A Collaborative Indigenous-non-Indigenous Partnership Approach to Understanding Participant Experiences of a Community-Based Healthy Lifestyles Program.

We describe the approach of an Indigenous-non-Indigenous research partnership in the context of a qualitative study which aimed to understand barriers and facilitators to engagement in a community-based healthy lifestyles program in Aotearoa/New Zealand. Informed by Kaupapa Māori research principles and by "Community-Up" research values, this collaborative approach between the mixed Māori-non-Māori research team effectively engaged with Māori and non-Māori families for in-depth interviews on participant experience, including with non-service users. "Community-Up" research principles allowed for a respectful process which upheld the mana (status, dignity) of the interview participants and the research team. Challenges included maintaining flexibility in our conceptions of ethnicity to reflect the complexity of modern family life in Aotearoa/New Zealand. We were committed to ongoing communication, awareness, and attention to the relationships that formed the basis of our research partnership, which allowed effective navigation of challenges and was critical to the study's success.

Introduction

Ko koe ki tēnā, ko ahau ki tēnei kiwai o te kete.

You at that and I at this handle of the basket.

In this article, we describe the collaborative research approach undertaken by a team of Māori (the Indigenous people of Aotearoa/New Zealand) and non-Indigenous researchers involved in a project exploring the barriers and facilitators to engagement in Whānau Pakari, a home-based, family-centered healthy lifestyles program established to address weight issues among children and adolescents. We explore the partnership undertaken by the two researchers directly involved in interviews with program participants, as well as the wider approach taken by the research team, and identify aspects of the research process which were critical to the success of the wider project. The use of Community-Up research principles (Cram, 2001; L. T. Smith, 1999) provided values to guide the research team in respectful research practice and was an essential part of the reflective process required to navigate and negotiate the challenges and opportunities that emerged during the research.

Increasing obesity rates among adults and children are concerning. Indigenous peoples experience consistently inequitable health outcomes, including in rates of childhood obesity (I. Anderson et al., 2016). The high rates of children and adolescents experiencing obesity worldwide are reflected in Aotearoa/New Zealand (henceforth referred to as New Zealand), where 9% of children aged 2 to 14 years are affected. Māori children are 1.6 times more likely to experience obesity than non-Māori (Ministry of Health, 2020). The World Health Organization (2016) has recommended family-based, multicomponent lifestyle programs as the model of care for addressing childhood obesity. Equitable access to health services is a key guiding principle of the New Zealand Health Strategy (Minister of Health, 2016), and therefore healthy lifestyles programs addressing childhood obesity must be accessible and acceptable to the communities they serve.

Whānau Pakari

Whānau Pakari is a family-centered healthy lifestyles assessment and intervention program based in Taranaki, New Zealand. Whānau Pakari means “healthy, self-assured whānau [families] that are fully active” (Y. C. Anderson et al., 2015, p. 3). who . . .”] It is unique in that it provides a comprehensive medical assessment in the home, allowing participants to have any underlying weight-related comorbidities addressed without a hospital appointment (Y. C. Anderson et al., 2015). It also provides weekly sessions focusing on nutrition, physical activity, and psychology in a community setting in a positive, non-judgmental format. The focus is on healthy lifestyles rather than weight loss. The program is run by a multidisciplinary team, with physical activity specialist, dietitian, and psychologist input, and clinical oversight from a pediatrician. The program achieved high initial recruitment with Māori who comprised 47% of program participants (comparatively, Māori make up 17% of the Taranaki region’s population; Statistics New Zealand, 2014) with comparable recruitment as New Zealand European families (43%), as well as high representation from those residing in the most deprived areas (28%, compared with the background rate in Taranaki of 15%; Y. Anderson et al., 2017; Salmond et al., 2007; Statistics New Zealand, 2018). The greatest reductions in weight status were found in participants who attended ≥70% of program sessions; however, these participants were more likely to be of New Zealand European ethnicity (Y. Anderson et al., 2017).

A key part of the research program discussed in this article was understanding barriers (factors that prevent or limit engagement) and facilitators (factors that enable engagement) for participants accessing Whānau Pakari, to be able to understand how to improve ongoing engagement in the program with Māori in particular. While we anticipated that there might be some barriers unique to being referred to an obesity intervention program (e.g., widespread weight stigma), it was likely that many of the barriers experienced by whānau (families) were also applicable and relevant for understanding health care service use across a range of primary and community-based services (e.g., program logistics and relationships with staff; Kelleher et al., 2017). We undertook a qualitative research project involving 64 home-based, in-depth interviews with a diverse group of families who had been referred to the Whānau Pakari service (Wild et al., 2020b), with equal numbers of whānau and families with Māori and non-Māori children to ensure appropriate representation (Paine et al., 2013). This included participants who attended weekly sessions to varying degrees, those who had one assessment and decided not to continue, as well as those who declined further input from the service after their initial referral, to ensure representation from those who did not engage.

This diversity of participants called for a collaborative approach within the research team, which was comprised of both Indigenous and non-Indigenous researchers. This approach was developed to facilitate rich research findings from in-depth interviews while prioritizing participation (ideally, equal recruitment) from Māori families. This article focuses particularly on the partnership required of researchers involved in recruitment and data collection.

Method

Kaupapa Māori Informed Research

In New Zealand, all research involving Māori should be “responsive” to Māori under the Treaty of Waitangi (Hudson et al., 2010), establishing a strong impetus to work toward health equity for Māori (Reid et al., 2017). Before undertaking this project, the research team agreed that this research would take an approach informed by Kaupapa Māori methodological research principles and objectives (Malpas et al., 2017; Reid et al., 2017). There is considerable debate around the degree to which non-Māori can participate in Kaupapa Māori research (G. Smith et al., 2012), which is reflected in wider debates around the place of non-Indigenous researchers in decolonizing health research (Krusz et al., 2020). Kaupapa Māori research necessitates Māori ownership and control of the research process (Walker et al., 2006). Given the lead researcher and PhD student in this case were non-Māori, the approach of this research was considered “Kaupapa Māori informed,” as it centered whānau in the interview process and paid attention to broader contexts, considering power and structural issues (Malpas et al., 2017). This methodological approach was appropriate to the aim of the research, as there is a strong commitment in the research team to achieve health equity and reduce barriers to engagement within prevailing health care services by providing robust outcome data, to complement Kaupapa Māori service provision and research. We believed that this approach to the research would enable interview participants to positively engage in the research and would reduce many of the common barriers to research participation for Indigenous peoples, such as travel costs and a distrust of research (Glover et al., 2014).

“Community-Up” Research Process

The research process was informed by the “Community-Up” approach to research conduct developed by L. T. Smith (1999) and Cram (2001) which provides guiding principles for entering into respectful research processes with whānau, in ways which uphold their mana (status, dignity). These values included aroha ki te tangata (respect for people, allow people to define their own space and meet on their own terms); he kanohi kitea (meeting face to face and being a face that is known and seen in the community); titiro, whakarongo . . . korero (looking and listening to develop an understanding before speaking); manaaki ki te tangata (sharing, hosting, being generous); kia tūpato (be cautious, politically astute, reflexive about insider–outsider status); kaua e takahia te mana o te tangata (not trampling on the mana or dignity of a person); and kia māhaki (being humble, not flaunting knowledge). These values were important for the research team for guiding interactions with participants and with each other, and several key principles implemented in our research process are discussed in depth below.

An Indigenous–Non-Indigenous Research Team

The research team was comprised of both Māori and non-Māori researchers. Throughout this process, it was acknowledged that researcher positionality and values would influence the research process (Walter & Anderson, 2013). Acknowledgment of our researcher standpoints and specific skills allowed us to debate, challenge, and refine interpretations of the data with respect and openness. This was particularly important for the two researchers (R1 and R2) who formed a partnership as facilitators for the interviews. The interview process required us to engage in actively “working the hyphen” (Jones, 2012, p. 104), bringing the Indigenous–non-Indigenous relationship to the fore and requiring us to acknowledge our differences, rather than erasing them in the hope of a straightforward collaborative process. Jones (2012) argues that the “us” of the Indigenous–non-Indigenous research team must not replace the hyphen between the two worlds — rather, it identifies a relationship which is conditional, fluid, and constantly negotiated. In addition, as a wider Indigenous–non-Indigenous research team, we worked collaboratively, acknowledging our diversity within the research team and embraced the “productive tension of difference” (Jones, 2012, p. 104). This allowed space for multiple different realities and knowledge within the research team, and the view was taken that the collaboration should be a contested, negotiated process, which was ultimately reassuring.

Initial data analysis was undertaken by R1 as the doctoral student and then discussed, debated, and refined over several meetings with the wider research team in face-to-face and virtual meetings. Manuscript writing for reporting research findings was primarily undertaken by R1 with input and critical appraisal from all members of the research team. We agreed to apply the “Give-Way” rule throughout this research if there was disagreement over the interpretation of the data concerning Māori participants during the data analysis phase, and the final decision involving cultural interpretation of Māori participants’ experiences would pass to a Māori project team member (Airini et al., 2009; Curtis, 2016; Curtis et al., 2012). This allowed for a systematic and practical way of navigating differential interpretations within a diverse research team, with agreed parameters from the beginning (Naepi, 2015). Regardless of whether the “Give-Way” rule was required to be enacted in practice, its agreed importance was an essential aspect of the team’s collaboration.

In addition to the constant personal reflexivity required as a mark of researcher integrity, further layers of interpersonal collective reflexivity were required to deal with the complexities and “messiness” of collaborative research (Nicholls, 2009). This involved constant self-audit, as well as a reflexive approach to the dynamics of the relationships within the research team. Jones (2012) notes that to engage with a methodology as an outsider calls for a constant, restless, uncomfortable reflexivity. This required increased self-awareness and a willingness to introspectively investigate discomfort, as argued by Krusz and colleagues (2020). As both intermittent insiders and outsiders, we frequently questioned ourselves and each other, and the power dynamics at work within our relationship and in our interactions with interview participants.

Results

The application of “Community-Up” research principles allowed for a respectful research process which upheld the mana (status, dignity) of the interview participants and the research team (Cram, 2001; L. T. Smith, 1999). Three key “Community-Up” research principles which shaped our research process are discussed below, as well as the challenges we encountered.

Aroha ki te tangata—Respect for People, Allow People to Define Their Own Space and Meet on Their Own Terms

The interview participants were past Whānau Pakari program users, including those who had not had any further contact with the program aside from the initial referral. The non-Māori coordinating researcher took responsibility for recruitment of non-Māori participants, and the Māori researcher took responsibility for recruitment of Māori participants. Given that we were interested in talking with families who had not engaged highly with the service, especially non-service users, we were flexible in our approach and used a variety of recruitment strategies depending on the contact information at hand, including telephone calls, text messages, emails, and making use of whānaungatanga connections. Whānaungatanga is the process of establishing meaningful, reciprocal, and familial relationships through culturally appropriate ways, establishing connectedness and engagement and therefore a deeper commitment to other people (Bishop, 1996). For example, the interview encounter would ideally begin with making connections between the researchers and research participants, which built rapport and relationships based on shared experiences other than the research at hand. Therefore, while the interview itself was approximately 30 to 60 minutes, the whole encounter would usually last longer and would involve discussions around familial and community connections, sharing experiences, meeting whānau members, and cups of tea.

In practice, this process would sometimes be limited by time constraints, and would often be an ongoing process throughout the interview as the relationships between the interviewers and participants evolved, rather than taking place at the beginning. This sometimes meant that the interview dynamic changed in accordance with the establishment of whānaungatanga and rapport. To try and mitigate this, the interview questions began with general experiences before turning to more specific and sensitive topic areas, which required more rapport to elucidate open, genuine participant experiences and rich interview data.

As well as being used to establish linkages and rapport in the interview encounter, whānaungatanga was also used as a recruitment methodology, whereby some participants were able to be contacted and recruited via existing relationships and networks (Paine et al., 2013). This was particularly effective when contact information on record was incorrect or had changed and allowed connections to be established early in the interview process. However, it was also highly complex in terms of the existing trust between participants and the researchers involved in recruitment. This required treading delicately so as not to overstep and tarnish relationships that existed independent of the research. For example, some participants were unwilling to be involved precisely because they knew the researchers; one interview was complicated further by a historical employment relationship between the interviewer (the employee) and the participant (the employer).

However, this approach was potentially helpful in recruiting participants with a mistrust of the health system. For example, after trying to make contact with a potential participant, the researcher and potential participant met by chance in the community where they knew each other as parents, where the potential participant was able to ask further questions and discuss the research in an informal capacity.

In the interview, the researcher who had made the initial contact with the participant led the interview, with the other researcher contributing to the interview as appropriate. Interview times and locations were chosen by the participant, to overcome travel and timing barriers, and frequently took place in the participant’s home. Other whānau and family members were sometimes present, which was accepted as part of the participant terms of the research process.

Kia tūpato—Be Cautious, Politically Astute, Reflexive About Insider–Outsider Status

As well as being a critical aspect of the data analysis process, we also found the underlying principle of the Give-Way rule to be a useful tool during data collection. R1 and R2 worked together to establish rapport with the interview participants and develop a comfortable environment for the sharing of experiences and stories. Practically, this meant that, in some cases, R1 as the non-Māori researcher and doctoral student “gave way” to the relationship already established between the R2 and the participant—The interview was led and conducted primarily by R2, with R2 there to assist and contribute when appropriate. This ability to “sit outside the circle,” as articulated by Waddell and colleagues (2020), allowed for a more engaged interview encounter, with the prioritization of participants rather than researchers. This required an acknowledgment and negotiation of the cultural (Pākehā and Māori) and other power dynamics (PhD student, and undergraduate student and tutor, respectively) between the two researchers, as well as a certain degree of humility (Krusz et al., 2020; Waddell et al., 2020). This was an instinctive, dynamic process which evolved as the interview progressed and involved a constant negotiation of the multiple and subtle ways in which we were both insiders and outsiders to participants, as Indigenous and non-Indigenous, as women, parents, and students, and as people with varying backgrounds and life experiences (L. T. Smith, 1999).

Given the diversity of participants, both interviewers held insider status at different times. We were aware that we both held multidimensional identities, allowing us varying levels of insider–outsider status, depending on the interview participant, the context, and which shared experiences became more relevant and important during the course of the interview (Dwyer & Buckle, 2009; Serrant-Green, 2002). Interviews were semi-structured to allow for this flexibility. Conducting the interviews as a partnership gave us a greater shared ability to connect with and position ourselves alongside the interview participants according to shared identities, ethnicities, backgrounds, life stages, relationships, and experiences. This also benefited the research collaboration by relieving some of the pressure on the interviewers to connect with participants based solely on our initial insider–outsider status and be open to discovering additional ways in which we connected with participants.

Titiro, whakarongo . . . korero—Looking and Listening to Develop an Understanding Before Speaking

The time spent traveling to and from interviews unexpectedly became a significant and vital part of the data collection and analysis process. Having not worked together previously, R1 and R2 traveled to and from interviews together, and the time spent in these car trips became a place for collective knowledge-building, sharing, discussion, reflection, debrief, debate, and challenge. While it did not necessarily change the content of the interviews, the interview team became more familiar and comfortable with each other, which made the interviews a much more instinctive process. This was invaluable for the success of the partnership and the research. It facilitated us knowing ourselves and each other in the context of the research project, allowing us to develop an instinctive knowledge of our dynamic insider–outsider status with different participants. We were also able to immediately peer debrief if an interview experience was surprising or unplanned, or if sensitive material was raised. The success of the interviews, in terms of facilitating a positive experience for participants and resulting in rich research findings, was highly dependent on this partnership between R1 and R2, which required significant time and effort to cultivate.

Challenges and Limitations

Our interview recruitment strategy was based on obtaining equal numbers of interviews with Māori and non-Māori whānau and families, to ensure adequate representation from Māori whānau. However, we occasionally found that ethnicities on hospital records did not align with how participants self-identified at initial contact or at the interview. For example, a participant may have had their ethnicity recorded simply as “New Zealand European” on the hospital electronic record, but in reality, they also self-identified as Māori. This meant that sometimes we only became aware of how a participant currently self-identified when meeting them face to face or speaking on the phone, which sometimes meant that our insider/outsider status shifted. This required flexibility during the interviews to develop genuine rapport and allow the best interview experience for the participant and reiterates the value of making whānaungatanga connections prior to commencing the interview.

As well as flexibility in our conceptions of ethnicity, this process required us to question our assumptions and understandings of what it meant to be a Māori whānau, rejecting notions of cultural essentialism (Curtis, 2016) and shifting away from binary modes of thinking (Krusz et al., 2020). For example, there were multiple families in which the parent and child did not identify as the same ethnicity; half of the interviews with Māori families were with non-Māori parents and/or caregivers of Māori children. We subsequently broadened our inclusion criteria to respect the preferences of participants and allow for diversity, which resulted in interviews with grandparents, caregivers, extended whānau and non-Māori parents and/or caregivers of Māori children. While this added complexity and challenged our original research protocol, the research team agreed that this simply reflected the complexities and fluidity of whānau in New Zealand today (Ministry of Health, 2017).

An additional challenge to and limitation of this partnership approach was the process taken when compiling the research findings, whereby manuscript writing was primarily undertaken by R1 as part of their obligations as a doctoral student. This meant that initial drafts of the manuscripts were produced by a non-Indigenous member of the research team, and critical appraisal from Indigenous members of the team was undertaken in the revision stages. This is likely to remain an ongoing challenge for researchers engaging in collaborative research partnerships, particularly when these relationships are complicated by multiple competing obligations such as doctoral program requirements. However, this project resulted in a richness of data that spoke to many issues relating to the need for health systems change and the addressing of institutional racism as a barrier to engagement for Indigenous participants (Wild et al., 2020a, 2020b, 2020c).

Conclusion

Our research team comprised of both Indigenous and non-Indigenous researchers adopted a collaborative partnership approach for the interview process, based on principles informed by a Kaupapa Māori approach (Malpas et al., 2017; Reid et al., 2017). The experience resulted in rich research findings from in-depth interviews with participants who were willing to be open and generous with their time and experiences. The research team held a strong unifying belief in the importance of the work, a commitment to health equity, and mutual respect, as well as a willingness to be intellectually challenged, to learn from one another, with humility demonstrated from all parties, with professional growth as researchers. A partnership approach to interviewing effectively enabled the researchers to engage with a diverse participant group, while prioritizing Māori voice through intensive recruitment efforts and a thoughtful interview process which was responsive to Māori participants. This approach could be applied in similar research with mixed Indigenous and non-Indigenous research teams working together to be responsive to the community. The Community-Up principles (Cram, 2001; L. T. Smith, 1999) provided a solid foundation that guided the interview process and decision making, and ultimately allowed us to effectively navigate any challenges that emerged. While there is not one “best practice” for respectful, effective Indigenous–non-Indigenous health research, our team was committed to ongoing communication, awareness, and attention to the relationships that formed the basis of our research partnership.