Embedding speech pathology in an Aboriginal community-controlled playgroup: Perceptions from the community

Colonisation in Australia has had long-term, pervasive, detrimental impacts on Indigenous Australians. When measured by national benchmarks, Indigenous children in Australia are currently at increased risk of developmental difficulties in comparison to their non-Indigenous peers. Community-led initiatives, such as playgroups, can provide safe and developmentally stimulating environments for Indigenous infants and young children, and deliver lasting benefits. These contexts also provide opportunities for collaborative approaches to develop children’s early communication skills. A participatory action research approach was applied to explore the parent/carer perspectives about incorporating speech pathology into an existing community-led Aboriginal playgroup in an urban context. The speech pathology service took the form of information sharing sessions between the speech pathologist and the playgroup members. Collaborative planning and implementation of the project was followed by discussion among the participants and co-researchers about the cultural safety and helpfulness of the speech pathology service. The complexity of incorporating services delivered by non-Indigenous people in an Aboriginal community-controlled playgroup was acknowledged. The information sharing sessions were regarded as helpful and acceptable by the community. However, in the planning and implementation of the service, cultural and community needs must be considered as a precedent and priority to ensure a culturally safe and strong environment.


Introduction
The current research 1 explored the community's perceptions about implementing evidence-based strategies for language development with an Aboriginal community in an urban Australian context.It is well recognised in the literature that the provision of early intervention and supports to vulnerable families can result in lasting benefits for the child (Chan et al., 2016;Daelmans et al., 2016;Doyle, 2020).Furthermore, the benefits are greatest when services collaborate to provide supports.Various interrelated factors contribute to a child's vulnerability so, of necessity, service providers need to respectfully acknowledge and address these factors collaboratively.For example, health, nutrition, housing, trauma and stress may all impact on a child's development (Mishra et al., 2017).Multidisciplinary, holistic interventions in the early years are evidence-based ways to support vulnerable children and families worldwide (Doyle, 2020;Richter et al., 2020).These interventions in the child's infancy are typically focused on equipping families and carers with the supports to nurture and cultivate the development of the children in their care.
In Australia, centuries of ongoing inequity have resulted in disadvantaged circumstances for many Indigenous children (Eckermann et al., 2010).Indigenous people in Australia have, since colonisation, endured social and political injustices, as a result of which Indigenous children today are at increased risk of developmental delays.Intergenerational trauma has also impacted the capacity of communities to provide the necessary nurturing and supports for young children's growth and development (Australian Institute of Health and Welfare, 2019;The Healing Foundation, 2021;Menzies, 2019).These combined factors have implications for children's language and literacy development.
Well-developed speech and language skills in the early childhood years are recognised as predictors to ongoing literacy and social progress later on (Dickinson & Tabors, 2001).For young children at risk of language and literacy delays, early language stimulation strategies are routinely implemented by speech pathologists as a preventative measure.Many young Indigenous Australian children are at risk of developing language and literacy difficulties due to environmental or personal factors, for example, increased risk of otitis media, low socioeconomic status and trauma.Findings from the Australian Early Development Census indicate that Indigenous children have increased vulnerability across domains of development compared to non-Indigenous children, with special impact on language and cognition (Commonwealth of Australia, 2019).Language and cognition develop symbiotically, so children's vulnerabilities in these domains have significant implications for their later academic and social success (Page et al., 2019).
Evidence-based interventions for speech and language development have been implemented with young Indigenous children and found to be effective.In particular, language stimulation strategies have been successfully shared with early childhood educators (Brookes & Taylor, 2016) and families of Indigenous children (Gapany et al., 2022;Page et al., 2019;Page et al., 2021;Williams et al., 2017).Across the nation, many Indigenous communities implement ante-and post-natal support groups for mothers and families within Aboriginal community-controlled health organisations (Campbell et al., 2018).Holistic, integrated, culturally sound, community-led, interdisciplinary solutions are needed to manage the variety of factors that may impact on a child's development (Campbell et al., 2018;Gapany et al., 2022;Staley et al., 2020;Ussher et al., 2015).Gapany and colleagues (2022) described how culture was incorporated into the approach implemented in the remote Indigenous community of Galiwin'ku, emphasising the centrality of Indigenous culture as integral to successful intervention.
Aboriginal English is spoken in the Awabakal community.It is worth noting that culturally safe speech pathology services should respect community language and not aim to alter an individual's dialect.Rather, speech pathology aims to support individuals to communicate in naturalistic contexts in order to enable participation in community (World Health Organization, 2007).
Existing evidence strongly supports parent/carer implementation of language stimulation strategies to support the early language development of vulnerable infants across international contexts (Heidlage et al., 2020;Roberts & Kaiser, 2011).This form of intervention has been explored thoroughly in the literature from the perspective of the researchers, for example, by measuring outcomes in children's development using Western-based tools.However, the perspectives of Indigenous parents and carers are missing from the literature.This research aimed to gather the perceptions of Aboriginal community and family members, such as parents, carers and teachers, about including speech pathology services in an existing community-controlled playgroup, as both collaborators and end-users of the project (Ball & Janyst, 2008).

Method
A qualitative approach in the form of participatory action research (Baum et al., 2006) was adopted for this project.Participants were integrally involved in the planning and implementation of the speech pathology service, as well as the analysis of findings and evaluation of the project.The research design was collaboratively discussed and planned by the researcher and the participants.This fluid and contextualised research process acknowledged Indigenous ways of knowing, being and doing, and aimed to maintain cultural integrity throughout the research (Brewer et al., 2019;Ryder et al., 2020).Once the project had been conducted, the participants took action and implemented changes to practice.These changes were based on the observations and awareness that was developed during the project implementation.

Factors influencing the research methodology
The project was informed and planned in collaboration with the local Aboriginal community, who provided guidance on research methodology, prioritising culturally respectful practice.The methodology of this research relied on the decisions of the community, the Aboriginal participants and co-researchers.The researchers engaged in constant reflection throughout the project to reduce the impact of unconscious bias (Finlay, 2002) The lead researcher also attended regular mentoring sessions with members of the community who were very experienced in Aboriginal early childhood services.The mentors were Aboriginal early childhood educators.These processes ensured the ongoing collaborative nature of decision-making about the methodology of the program (Lowell, 2018).This collaborative approach included discussion about the needs of the community, who to co-lead the group, the roles of staff and how to pace the information (Aboriginal mentors suggested to "take it slowly").Other factors that could affect participants' uptake of the information, such as who had custody of children, family health, and personal and community wellbeing, were also discussed.At the time of the research Australia was suffering catastrophic bushfires and heat waves which were very upsetting and exhausting for many members of the community.The researchers, co-researchers and participants discussed openly how these factors might impact the implementation of the project and the research process.The data collection time frame was flexible within the calendar year of 2019.Similarly, the analysis and interpretation process was conducted collaboratively at times that suited the research team.Many meetings were scheduled and rescheduled to ensure that all voices were included.
Relationships between researchers and participants were a necessary underpinning of the project.Many of the participants knew the researchers or the collaborators in the research, due to long-term community connections.For example, the speech pathologist and/or the educators had often been involved in the education of siblings or relatives of the participants at the community-controlled preschool; therefore, many families were familiar with the researchers and co-researchers.These relationships helped to instil trust in the project for the participants and validate the program (Indigenous Allied Health Australia, 2015;Patton, 2015).
Researchers and collaborators brought a variety of valuable qualifications and experience to the project.For example, the playgroup coordinator had longstanding and close relationships with many of the families and staff who participated in the project.Co-researchers brought different perspectives to the project.For example, early childhood educators brought knowledge about child development and Aboriginal health workers brought cultural knowledge.Together these different knowledges and overlapping perspectives facilitated the development of the methodology.In the planning phase, researchers and co-researchers met informally, frequently within the community context, before or after playgroup, to discuss the research process.Co-researchers recommended suitable contexts for conversations with families, and also whether verbal/written/visual forms of communication would be most appropriate.

Participants
The project took place within Newcastle, a regional city on the eastern coast of Australia.Due to the close connections within the local Aboriginal community, many of the participants and researchers were known to one another.The participants included: • five adults (carers of Aboriginal children) who attended for the entirety of the program.Several additional families attended for part of the program.These families joined a few weeks after the information sharing sessions had commenced.The playgroup adopted an inclusive philosophy; any families who attended the playgroup were welcome to join the information-sharing sessions, so the group grew as the research progressed.All the children were Aboriginal, and were cared for by family members.Some of the participants were grandparents who were the main carers for their children in the playgroup.
• five Indigenous early childhood educators with diverse roles in the project, such as coordinator, cultural mentor, and so forth • an Aboriginal support worker.

Program and processes
The program was delivered as 10 weekly information sharing sessions, conducted as part of the Mums and Bubs playgroup at one site.The Mums and Bubs playgroup is a peri-natal support group run by the Awabakal Medical Service.
A series of processes that helped to shape the eventual content and format of the program preceded delivery.These processes are outlined below.
For several decades prior to this current research project, the Awabakal children's services had recognised the need for allied health (including speech pathology) in the community, and had been developing their relationship with a local early intervention service, Firstchance Inc.These two organisations had collaborated to trial and adapt different service delivery models of early intervention for Aboriginal children in the local area since the early 2000s.In 2008 an innovative government-funded program, Little Yarns, was implemented in the Aboriginal community-controlled children's services and ran effectively for eight years (Webb et al., 2011), at which time the funding was ceased.At the time of this current research project, the local formalised Aboriginal children's services focused mainly on 3-to 5-year-old children in preschools.Playgroups for children (aged 0-3 years, and sometimes older) also were run through the Awabakal Aboriginal community-controlled health service (ACCHS).These playgroups allowed families access to medical staff (e.g., doctors and nurses) and early childhood educators, however, allied health staff were not embedded in the playgroups.The playgroups were part of a long-term support model for mothers-to-be.The mothers received peri-natal support, which included attendance at Mums and Bubs (playgroup) meetings that were held weekly at several local sites.
In 2018, at a community event, the playgroup coordinator and the researcher discussed including speech pathology in existing playgroups.The researcher had provided speech pathology services to families through the Little Yarns program previously, so was known to the community.The ACCHS has an ongoing focus on the integration of services across domains, such as medical, health, education, housing, and so forth.
The term "information sharing sessions" was chosen collaboratively for this project, in preference to the more common term "parent training".It was felt that information sharing sessions better reflected the joint, two-way nature of the intervention, that is, the speech pathologist would be sharing information with the parents/carers, and the parents/carers would also be sharing information with the group.
The project team and participants decided to trial speech pathology information sharing sessions with the parents/carers in one of the existing playgroups.This particular playgroup was chosen in consultation with the coordinator because it was relatively small in terms of members and was held weekly at a spacious venue with indoor and outdoor facilities.The coordinator also felt that because this playgroup has been formed relatively recently, the members would be receptive to new services.A period of time was factored into the program plan to allow for building relationships and trust.However, the time frame was adjusted because more time was required to allow discussions with the management team (Table 1 describes the processes involved in the time frame for this project).
Discussions with the coordinator and management took place from January to March in 2019.The relationship-building phase of the program was from April to August 2019 when the speech pathologist attended the Mums and Bubs playgroup in a volunteer capacity each week.During this time there were changes in staffing at the centre.The relationship-building period was extended, thereby resulting in a shortened implementation time for the program.This extended time for relationship building also affected how the program was run.For example, the speech pathologist did not need to conduct "initial interviews" with the families, as originally planned, because they were already familiar with each other.The extended relationship-building phase was very beneficial in terms of getting to know each other and building awareness of each other's roles and circumstances.
The speech pathology service in the playgroup took the form of information sharing sessions, which were conducted weekly as part of the playgroup schedule in school terms 3 and 4 (September to December) of 2019.At the information sharing sessions, the speech pathologist provided information and education about language stimulation strategies such as modelling, contingent talk, reinforcement, repetition, expansion and extension of utterances (Owens, 2020).Resources from the You Make the Difference program (a Hanen Early Language program) including the DVD and the book (Manolsen et al., 1998) were used to support the application of learning.During these sessions, parents and carers also provided information to support the group.Topics such as behaviour management, setting up the environment to facilitate communication, planning realistic target words, access to a multidisciplinary team including audiology and occupational therapy, and early intervention were discussed.
The information sharing sessions were each approximately one hour long.The playgroup meetings typically ran from 10 a.m. to 1 p.m. Parents arrived by Awabakal bus or other transport and took time to socialise and settle into the group, with the speech pathology sessions commencing at approximately 11 a.m.This was followed by lunch.Several factors affected the progression of the group sessions, including: 1. custody issues -Whether the children were in the care of the parents or grandparents affected whether some were able to attend.
2. housing issues -Families needed to prioritise shelter and safety, and this affected the attendance of some children/carers.
3. transport issues -Sometimes the ACCHS bus was not available, so families could not attend.
4. staffing issues -There was a turnover of different staff, so the group sessions needed to be adaptable to these changes.
The pace of the program was adjusted in accordance with the abovementioned conditions.For example, sometimes the content took longer to progress, or repetition was required so that no one missed out on content.Families were also free to talk to the speech pathologist at any time during the playgroup meeting, which, as mentioned, ran from 10 a.m. to 1 p.m., one day per week.

Activity Time frame Phase of research
Longstanding relationships were developed between services and individuals.

Prior to 2018 Pre-program consultation
Discussions about speech pathology in the playgroups commenced between the speech pathologist (researcher), preschool educator and playgroup coordinator.

July 2018
Consultations took place between ACCHS management and playgroup coordinator.Discussions considered how the speech pathology service would be implemented within the existing Mums and Bubs playgroups.

January -March 2019
Relationship-building phase between speech pathologist, staff and families of the Mums and Bubs playgroup.

April -August 2019
Cultural mentoring for the non-Indigenous researcher was sought and provided by community personnel.

April -December 2019 Implementation
Implementation of speech pathology information sharing sessions.

September -December 2019
Data collection in the form of focus groups and interviews.December 2019 Analysis involved consultation and collaboration between researcher and co-researcher.The time frame for the analysis and interpretation process was affected (extended) by COVID-19.

Data collection and analysis
As described in Table 1, data was collected in the final stage of the project.This took the form of group and individual conversations with participants.The conversations were very informal, guided by general questions such as "What did you think about including speech pathology in the Mums and Bubs playgroup?","What did you find helpful?","What suggestions do you have for improvement?","How culturally appropriate was the program?".The researcher asked the initial question and participants discussed their perceptions about including speech pathology information sharing sessions in the group setting.At the recommendation of one of the participants, a talking stick was introduced during the data collection process to allow the voices of all participants to be heard (Indigenous Corporate Training Inc, 2015).The talking stick was passed around the circle of participants so that all could contribute and everyone's voice was valued; this reduced the likelihood that one person could dominate the conversation.Some staff chose to complete written feedback on the project rather than participate in verbal conversations in consideration of time efficiency.These processes of data collection were selected at the recommendations of the participants, who felt most comfortable with informal processes (Munro et al., 2019).The data was transcribed, de-identified and stored in the secure university system.
The data was analysed thematically by the researcher (lead author) and one of the participants (who became a co-researcher and the second author) using inductive thematic analysis, based on the steps outlined in Braun and Clarke (2006).Data from the individual and group conversations was coded into categories.The researchers discussed the analysis and collaboratively assigned the themes.The second author who, as a member of Awabakal staff, had been involved since the early relationship-building phase of the project utilised visual means to interpret and express the themes in the data (see Figure 1).

Results
The general themes from the data are expressed in Figure 1 and presented in more detail in the text that follows.This results section consists predominantly of direct quotes from the community/participants, the parents/carers and educators.These have been structured with thematic sub-headings and some explanatory notes to enhance the reader's understanding of the context.The intent of this section is for the voices of the community to be shared as clearly as possible.In the interests of confidentiality, pseudonyms are used in the quotes when participants were referred to by name.The importance of culture is emphasised, as it is situated at the core of the model.Emphasis was placed on children, families and community as decision-makers who decided the supports and services that were necessary and how these were implemented.Participants indicated that the community context enhanced the learning opportunities for the group, as described in the following quotes from participants: All of us are here because we've got some sort of Aboriginal in us.(parent/carer 4) I liked the community feel, like in a group of others.So, if say one wasn't understanding something, someone else might be able to explain it.It worked really well.(parent/carer 2) So, I liked pretty much the same as Justine, just the, um, acceptance of others' thoughts and opinions in a positive manner, rather than, like, even I've never felt judged by anyone in the Mums and Bubs and I love that community feel.I love that connection.(parent/carer 3) Oh, yeah, just, um, coming and meeting with the elders and hanging around, whatever.Yeah, just basically the same as the other ladies; learning what we haven't been taught and told, and, yeah, it makes a big difference in, yeah, rearing your kids.(parent/carer 4) What I like about the program the most is that it is so understanding and it's not "has to be this way".It's what's working for you and your kid.So there's no: has to do this, has to do that.If something's working, you can go with the flow.(parent/carer 1) Be respectful of home language "Aboriginal Australian".(written response, educator 2) Parents can be teachers, implementing own family culture.(written response, educator 3) The participants valued and respected contributions from all members of the group, both the professionals and the other parents/carers from the community, as shown in the following quotes: It's good with feedback from the other ladies too because what, yeah, like Meggie said, she likes my opinion whereas I might like one of the ladies' opinions, and their experiences.
(parent/carer 4) People identifying their issues and those, so we could work on them as a group together.
Because everybody knows a little bit different how to deal with their kids.(parent/carer 1) Participants felt that it was helpful that the sessions were conducted in a culturally safe space.
[It's a] safe place for all to learn, with Aboriginal educators role modelling.(parent/carer 4) But it's good to have a group as well.And, well for me, it's always been really hard.Like it's nice to have the other mums here that are in the community.We've always been welcomed, and welcoming of each other's children's behaviours, more so just like how helpful everyone can be.It's not like you need to cry for help, someone's just always there and can help.Like, everyone sort of works together so well.And the kids learn that, like especially her [child], like, she's a really mummy's girl and she's learned that she can branch out and she can make new friends.And I was sort of, like, well if the kids can do it, maybe I can too, so I've learned not to be so anxious.And yeah, it's great.(parent/carer 3) Quality services, such as speech pathology, surrounding the children and community (see Figure 1) were important.
Well, we've learned a lot since we been here and [child] have come out of her shell, a bit more.And she's starting to talk really lots now, like, different things, like.(parent/carer 5) It gave so many mums knowledge and information in regards to their children's speech.So many children in the program had speech problems and difficulty so this was a huge benefit.
(educator 1) The people and agencies involved in providing services to the playgroup are selected with care by the community, engaged through trusting relationships with external agencies.Community members expressed their approval of the services.
Yeah, it's been great learning and we want you back! (parent/carer 4) I've been taking a lot of what we've been learning here back [home] and doing it with my sister who's 10 and was born with a cleft palate so she will speak very fast, and we've learnt through this that we can slow her down and it's actually helped her talking.So, she's pronouncing words better, so this book will be able to help heaps with her too.She'll be able to see it herself and take it on board herself too.(parent/carer 1) Adequate funding was mostly mentioned by educators who were more aware of the funding and resources required for provision of services than parents/carers.Considerations included: Access to funding, transport, a customised cultural space, adequate ratios of staff for children so that parents/carers can spend time learning and relating without worrying about their young children.In this ideal environment, everyone feels more comfortable; the parents/carers, children, staff, visitors and so forth.(educator 1) Participants specifically acknowledged the importance of empowering families, as shown in the following quote: Parents feel more comfortable and confident.Families are taught possible early warning signs in other family members … to help bridge the gap.(educator 1) This model is filtered through a lens that considers pervasive factors that could be affecting the families, such as trauma, racism, mental health issues, housing concerns and socioeconomic issues.The participants spoke about these issues from a strengths-based perspective, as shown in the following quote: So, it's, it's all very, not in your face, but, like, it opens your eyes to it all.So when you have the group sessions you can see that everybody's having the sort of same issues in the same age groups and kids so you're not feeling so alone.And then independently it's like you're learning more to be able to, like, cope with yourself personally.(parent/carer 1) Services must be implemented with a holistic focus, acknowledging the many potential different factors affecting families and communities.In the following quotes, factors such as transport and other health issues are considered: Transport at times for parents sometimes made consistency in attendance difficult.
(educator 3) Very important, our children are … commonly have ear problems which lead to speech problems.(Aboriginal support worker) Participants (educators and staff) offered some extension ideas for future implementations of allied health services within an Aboriginal community.These included the importance of building trusting relationships, prioritising the ongoing sustainability of programs, and supporting rural and remote communities.The following quotes illustrate these ideas, and offer some cultural guidance: Ensuring [that] relationships are trusting and supportive is essential before delivering a session.(educator 1) The program needs to be … ongoing so it can be part of [a] routine for families.(educator 3) More access to speech in remote areas is a MUST!!!More education with early childhood staff with speech, especially in remote communities.(written response, educator 2) Provide training for non-Indigenous workers on how to approach and socialise with Indigenous peoples to make both parties more comfortable.(educator 3)

Discussion
This project sought to explore community perspectives about including speech pathology services in an Aboriginal community-controlled setting in a regional city centre.Community supported the inclusion of speech pathology in the playgroup, under the condition that the services were guided by, and responsive to, the needs of the community.
Generally, the community believed that the program was culturally acceptable; parents and carers valued the support and acceptance from the group.They valued the knowledge gained from the information sharing sessions.
One limitation of the research was the limited time frame, which was constrained by funding.The flexibility of the researchers and the collaborators helped to overcome this issue; as described in the methodology, the information sharing sessions and final data collection were pushed back to occur later in the year.All collaborators worked together to enable the completion of the project in the required time frame.
Many factors affected the implementation of speech pathology services in the playgroup.These included transport, child custody, facilities and location, staff availability and training, resources (e.g., food, culturally sensitive toys, learning resources such as books and videos, technology, space to conduct the group sessions), access to a multidisciplinary team, physical and mental health of parents and carers, the transient nature of the workforce and the compatibility of the individuals who provided the services.These findings are consistent with literature that refers to the integrity of culture at the core of a service, and also the importance of empowering parents and carers in the community to facilitate their child's development (Gapany et al., 2022;Page et al., 2021).
Note that this was a small research project with a local community where the researchers were known to the community.The findings that were generated from the research are relevant and directly applicable to this particular context (Braun & Clarke, 2021).It is also noted that some findings may also be relevant to Indigenous communities in other urban/regional locations.Further, broader research with a variety of communities would provide more information that could extend the findings of this project.
Families and staff involved in this project spoke Aboriginal English dialect and adhered to cultural values.There is a need for further research in this area, owned and led by Indigenous people.The importance of cultural collaboration when implementing services and programs is relevant across communities.Non-Indigenous researchers/organisations cannot predict what will be valued by the community.Information provided by the community members in the information sharing sessions during this project was different to that provided by the health professional, and the content from both these sources was valued by the participants.
This research provided unique contributions consistent with a participatory action research approach.As a result of the research, supported playgroups are now established as part of the Awabakal children's services model.These supported playgroups now include allied health and early intervention services through Firstchance Inc. (an organisation that has a longstanding relationship with the community).

Conclusions
This research found that the careful and collaborative inclusion of speech pathology services was well received in an Aboriginal community-controlled playgroup.Crucial messages from this research are that community personnel have an abundance of valuable cultural knowledge to share.Non-Indigenous professionals need to be open to receiving knowledge and insights from the community.Also, the building of trust and relationships during the pre-program consultation phase was pivotal to the success of the implementation of this project.
Some key messages from this research: • The inclusion of speech pathology in a playgroup was valued by the parents/carers of the Aboriginal children.
• The service delivery required culturally specific adaptations to best meet the needs of the Aboriginal community.
• Holistic, interdisciplinary, integrated support is essential when delivering services.
• Participants appreciated both the community context and contributions from community that enhanced the service delivery.

Figure 1 :
Figure 1: Considerations for including allied health service within an Aboriginal communitycontrolled playgroup Informed written consent was gained from all participants.The research was approved by the University of Newcastle Human Research Ethics Committee (approval number: H-2019-0066) and Awabakal as a member of the Aboriginal Health & Medical Research Council of NSW (AH&MRC).In planning the project, the potential impact of the research on the participants was considered and the National Health and Medical Research Council's (NHMRC) Values and Ethics: Guidelines for Ethical Conduct inAboriginal  and Torres Strait Islander Health Research (2003)were respected and adhered to.This research process was guided by the principles laid out in the National Statement on Ethical Conduct in Human Research(NHMRC  et al., 2007(NHMRC  et al.,  , updated 2018)).The research interpretation was guided by the Australian Institute of Aboriginal and Torres Strait Islander Studies (AIATSIS) Code of Ethics for Aboriginal and Torres Strait Islander Research (AIATSIS, 2020).