Twelve participants, (eight AHWs and four EPs) from four NSW-based ACCHS implementing BE WELL attended online education sessions between July and December 2020 (Table 1). At the time of the online education, no PTs were employed by ACCHS. The online education sessions were delivered to each of the four ACCHS separately, with timing of sessions based on their existing clinical responsibilities. Session length was between 30–60 min and sessions were delivered over 5 to 11 weeks.

Table 1 Participant demographics

Survey

Eleven, (7 AHW and 4 EPs) completed the survey (Table 1). All (100%) participants Strongly Agreed or Agreed the online sessions were easy to understand (mean (SD)) (1.8 (0.4)), had enough information about each topic (1.5 (0.5)), helped them understand COPD (1.5 (0.5)), and that their cultural perspectives (2.0 (0.0)) and opinions (1.8 (0.4)) were valued and that the resources were helpful for patients (1.5 (0.5)) (Fig. 1).

Almost all (91%) participants Strongly Agreed or Agreed the yarning sessions enabled them to gain knowledge and skills on how to help patients manage COPD (1.4 (0.7)). Almost all (91%) participants Strongly Agreed that the feedback received on the topics they presented was helpful (1.6 (1.2)).

All (100%) participants rated using VoIP technologies for the yarning education as Very Good or Good (1.4 (0.5)). All (100%) participants were Always or Mostly able to ask questions during the online sessions (1.8 (0.4)). Almost all (91%) participants Always and Mostly felt that the yarning sessions they prepared and delivered helped them to understand the topics better (1.5 (0.7)), that they were encouraged to incorporate their cultural knowledge into the topics they presented (1.8 (0.4)), and overall, that the sessions were useful (1.6 (0.7)). The majority (73%) of participants Strongly Disagreed or Disagreed that the sessions were too long (-0.9 (0.7)). Almost half (45%), Strongly Disagreed or Disagreed that the sessions were too often (-0.4 (1.3)), and 36% Agreed (Fig. 1).

Fig. 1
figure 1

Participants ranked the seven education topics from most to least useful. The most useful topic was How the lungs work and the least useful was Healthy Eating (Table 2). Free-text feedback consistently reported that responding to this question was difficult as participants found each topic was equally important.

Table 2 Ranking of the usefulness of the seven online education topics

Participants also responded to three open ended questions: What participants liked most; What needed improving; Any additional comments. Participants reported they liked learning about the function of the lung and COPD the most. The sessions increased their knowledge about how to present information and support patients with COPD in a culturally safe way.

“It really helped my team become more confident with delivering the content during the yarnings. Culturally I got a lot out of it.” (EP_02)

Several participants reported that they valued the structure of the weekly topics and presenting their own yarnings.

The whole session was great; everything was presented well. Yarning sessions are great, very helpful. Learnt more with the weekly sessions.” (AHW_11)

Suggested improvements included strengthening the formal structure of the first few online sessions, facilitators covering each topic over two sessions, further developing the role-playing by incorporating patients with COPD, delivering the education sessions over a whole day or block structure, and closely aligning education sessions with the roll out of BE WELL programs at each ACCHS.

Interviews

Interviews ranged from 15 to 29 min, with six interviews over 20 min. A total of 235 min with AHWs and EPs were recorded. Four themes were identified: 1. Revealing the Aboriginal lung health landscape; 2. Participating in online learning; 3. Structuring the online education sessions; 4. Co-designing with the facilitators. The themes were similar for AHWs and EPs. Variations mainly related to their differing roles within the broader BE WELL project and that none of the EPs were Aboriginal.

Revealing the Aboriginal lung health landscape

Professional experience

Most of the AHWs reported they had only commenced their role as an AHW in the last year, so had limited to no prior experience providing clinical care or delivering health programs. Four AHWs had completed nationally recognised training in Fitness, Mental Health or Aboriginal Health. All AHWs reported no previous education about COPD or experience providing PR programs before participating in the BE WELL project. Several AHWs stated they had not previously heard about COPD.

“I’ve never had no idea, or understanding of COPD, or what it was about; but you know being a part of this BE WELL Program, I’ve learnt so much.” (AHW_11)

In contrast with AHWs, EPs had a much longer work experience, but each stated their current employer was the first ACCHS in which they had worked. All EPs reported little to no prior experience providing clinical care or programs for Aboriginal people with COPD.

Perspectives of lung health literacy

AHWs and EPs consistently perceived there was low lung health literacy within their respective Aboriginal communities. Some AHWs mentioned when lung disease was discussed, the community focused on asthma or smoking. An AHW stated that when attending smoking cessation appointments with Aboriginal patients, many reported a smoking history of 20 + years, but displayed limited lung health knowledge.

EPs perceived asthma, smoking and asbestosis were discussed in the community, but thought key information about these conditions may be missing. An EP stated lung health is openly discussed due to asbestos mining in the area, with many Aboriginal people dying from asbestos-related lung disease. EPs also spoke about competing priorities for Aboriginal people’s attention such as a focus on other chronic health conditions such as diabetes and heart disease rather than chronic lung diseases. This has resulted in Aboriginal patients often presenting to the ACCHS with breathlessness, unsure of the reason for their symptoms.

“They will come into me and say, Look, I can’t breathe very well and I don’t know what’s going on. And you look at their notes and they’re smokers or have a diagnosis of COPD”. (EP_01)

Perspectives of access to lung health services

AHWs and EPs perceived Aboriginal people have low access and limited knowledge of lung health services provided by ACCHS and mainstream health services, such as PR. AHWs perceived an ACCHS would be the first point of contact for Aboriginal people with COPD, but acknowledged their ACCHS had low numbers of existing patients diagnosed with COPD. The ACCHS in the BE WELL project had only recently commenced offering PR and most previous clinical discussions related to lung disease focussed on quitting smoking and nicotine replacement therapy.

“We actually haven’t got many clients with [ACCHS] that I know that are diagnosed, but I think they should be diagnosed since starting the BE WELL project.” (AHW_05)

Since participating in the BE WELL project several AHWs reported they were now able to identify existing ACCHS patients at risk of COPD and able to refer them to PR.

“And you know, ever since being able to learn more about the lungs and COPD, I’m able to identify the patients when they do come into the clinic.” (AHW_11)

EPs mentioned delivering PR by their ACCHS was important, considering mainstream health services struggle to engage Aboriginal people because those services are perceived as culturally unsafe.

“I don’t think they go too often [to hospital]. It’s not their meeting place.” (EP_01)

An EP also spoke about needing to work with Aboriginal patients to overcome fear and avoidance of breathlessness during exercise training and maintaining their ongoing participation in an 8-week PR program.

“The hardest thing for us now [at ACCHS] is to get participants and then get them to regularly attend.” (EP_01)

EPs also spoke of the need to strengthen the cultural component of lung care by delivering programs on Country away from the clinical environment, spending additional time listening to and allowing Aboriginal people to share their ‘story’, and increasing access to care by improving referral processes within their ACCHS for assessment and management.

Participating in online learning

Experiences of VoIP technologies

Overall AHWs reported the education sessions were successfully adjusted to an online delivery mode using VoIP technologies. AHWs positively described their experience using VoIP technologies as it enabled the educational content to be packaged into small manageable topics around other work demands. This approach supported thorough explanation of each of the seven COPD topics and enabled AHWs to ask questions and revisit educational material.

“I think the shorter sessions are probably better.” (EP_07)

AHWs mentioned some technical challenges such as limited Wi-Fi connectivity and using a work computer with a broken camera.

“I enjoyed it. – [Facilitator] went through the sessions really well. [Facilitator] explained every bit, you know, every detail, bit by bit, in the way that I was able to understand.” (AHW_ 11)

The EPs perception of the use of VoIP technologies varied. Two EPs reported that although online delivery ran smoothly and they got a lot out of the online sessions, their preference would be for face-to-face delivery to enable practical and interactive education. One of these EPs also mentioned they had initially suggested that the education sessions could be provided as a one-day refresher. Positive perspectives about using VoIP technologies were that they were nearly as good as attending in person because information and pictures could be brought up on the computer screen, and questions could always be asked of the facilitators. An EP mentioned using VoIP technologies was better than providing the information quickly face-to-face over two days. From their perspective, the best aspect was having a one week break in between each session to develop yarning scripts. The same EP also reflected on the experience of VoIP technologies for AHWs.

“I think particularly for the Aboriginal Health Worker they are a little bit quiet and… felt a bit of shame. I suppose both, you know, when you’re talking on video conferencing and particularly in the beginning. In the end, they just opened up completely…I think it was really quite good.” (EP_01)

Perspectives of the education sessions and developing yarning scripts

All AHWs reported that engaging with the education sessions, preparing their own yarning scripts, applying the stimulus questions and demonstrating how they would deliver their own yarning sessions to colleagues and the facilitators reassured to them they had interpreted the seven COPD topics correctly. The sessions were reported as being a culturally safe and a self-paced learning environment, where AHWs were driving their own knowledge development, enabling them to confidently design their own yarnings. Several AHWs also spoke about the structured, clear and culturally safe way the scripts they developed enabled them to yarn about complex lung health information simply with Aboriginal people.

“This isn’t like a GP just reading off a piece of paper. Look, we made it into a good discussion, but we [AHWs] made it. So there’s feedback, there’s input to start more yarnings and kind of branch off each other. Yeah, I think yarning will be a good thing.” (AHW_03)

For the EPs, the education sessions were reported as helpful and more as a refresher, complimenting their existing lung health clinical skills and strengthening their Aboriginal cultural knowledge. Consistently EPs expressed professional respect for the AHWs, emphasising the value of collegiality, shared decision-making and autonomy. An EP observed that an AHW found it confronting initially to allocate time and to prepare yarning scripts. As a result, the EP supported the AHW to better prepare and deliver their yarning scripts. EPs also reported that the education and yarning sessions enabled them to have confidence that AHWs were seeing good examples of patients with lung disease and were aware of what to look out for clinically.

“We worked together and I let her present it [the yarning script], cause it’s her mob [Aboriginal community], her program. So I was really supporting her delivering the program.” (EP_01)

Structuring the online education sessions

Perspectives of the education topics

Delivering information into manageable topics was reported to increase comprehension and reduce complexity. Subsequently this scaffolding approach was reported as enabling the AHW to make greater sense of the COPD information.

“Yeah, especially the medications. That was so far out of my scope at the time.” (AHW_03)

EPs consistently reported the topics were pitched appropriately and included the right amount and type of information for AHWs, Aboriginal patients and covered everything they needed to know.

“I think, medication wise, that’s one for me that I still definitely need a little bit more assistance with, so that was good to be able to go over them again”. (EP_07)

Perspectives of the resources

AHWs provided consistent positive feedback about the range of resources used during the online sessions. Resources were described as ‘clear’ and ‘culturally safe’. Resources defined as useful were the pictures, diagrams, booklets, medication charts, PowerPoint slides and videos of the correct use of inhalers and of patients with lung disease. An AHW mentioned practical teaching aides, such as placebo inhalers and spacers were resources that should be used more often in future sessions. Some AHWs stated using videos particularly helped them learn about the symptoms of lung disease.

“I have not seen anyone with COPD before. Well, I may have, but I didn’t know what it is. So, I thought [using videos of patients with lung disease] was great.” (AHW_03)

All EPs mentioned the resources were useful in their role as supervisors of AHWs. The EPs also perceived the resources as culturally appropriate and helpful. An EP reported the resources had been valuable to their role and ACCHS beyond the BE WELL project and patients with COPD, as the format can be applied across other health programs. Future sessions could be enhanced by incorporating additional resources such as real-life scenarios and videos of patients at the beginning of each session.

Perspectives about the frequency and length of the education sessions

AHWs and EPs agreed that the number, length and frequency of each topic and the education sessions were broadly right. Short 30-min sessions were preferred as these allowed staff to maintain focus. An EP mentioned the timing of the education sessions made it hard for them to attend and support AHWs, and that over time attending became more of a chore.

Co-designing with the facilitators

Perspectives of the facilitators’ attributes

AHWs perspectives of the facilitators were overwhelmingly positive. AHWs consistently described the facilitators as ‘knowledgeable’ and perceived them as ‘culturally competent’ and ‘professionally respectful’ and ‘understood’ the demands of the AHWs roles and their learning needs. All AHWs felt that their cultural knowledge and perspectives were respected by the facilitators. They also reported the facilitators had created a culturally safe learning environment for Aboriginal organisations and staff to engage in learning by incorporating Aboriginal protocols, such as an Acknowledgement of Country and using resources depicting Aboriginal people.

AHWs described the facilitator (JA) as explaining information in ways the AHWs could understand, which increased AHWs self-reported knowledge. The facilitator had engaged the AHWs in relaxed discussions and provided feedback about the yarning scripts that the AHWs had created. This allowed AHWs to share their perspective, knowledge and yarning approaches openly and deeply. An AHW reported one occasion when the facilitators seemed ‘unapproachable’. The AHW stated this occurred when minimal staff from their ACCHS attended the first online session which made the session confronting for a lone AHW. The experience resulted in the ACCHS regrouping and identifying how all staff could attend future sessions around clinical responsibilities.

EPs described the facilitators’ attributes similarly to the AHWs. They felt the facilitators supported their learning and encouraged them to contribute to discussions exploring the applicability and adaptation of the educational content and material and the overall BE WELL program to fit the local Aboriginal community context. The EPs also stated the facilitators were responsive to the EPs and AHWs ideas and ways of being, such as how they and the ACCHS worked with community.

“You know, they were really good at facilitating us to create our own yarn, and also our own ideas for how the program should be run.” (EP_01)

Perspectives of the facilitators’ expectations

Most AHWs described the facilitators’ expectations to attend the online sessions, prepare and present their yarnings as realistic and reasonable. AHWs felt encouraged to make choices and changes to adapt the education sessions.

“[The facilitators] pretty much gave us free rein…. Well, not to talk us up, but, you know, they [the facilitators] loved what we came up with. So, yeah, like they literally gave us a lot of wriggle room.” (AHW_ 03)

Two AHWs from different ACCHS highlighted the intensity and demands of the AHW role, while participating in the online education sessions.

“Because our transport driver called in sick that day, so I had to fill in [and missed a session].” (AHW_08)

Three of the four EPs mentioned the facilitators were flexible, accommodating and did not expect too much when the EPs were attending the session or helping the AHWs prepare their yarning scripts. The other EP acknowledged the role of an AHW is ‘tough’ and agreed with an AHW at their service that expectations were too high.

“The expectation felt too much on a couple of the health workers, but that’s not the facilitator’s fault. That’s just, once again time management, and just being super busy, and juggling lots of things. It can just feel like another thing to have to do.” (EP_06)

Perspectives of co-design

All AHWs and EPs agreed co-design occurred. AHWs reported feeling supported by the facilitators and were able to transform the COPD educational material into their own words to better engage the local Aboriginal community.

“It [using co-design] was just trying to get it more culturally appropriate. So it’s not just going to be like the typical GPs talk. Because that’s when you lose people, that’s when your gonna lose community. So it’s just a yarn.” (AHW_03)

AHWs simplified the clinical information and incorporated local knowledge, terms and phrases, as well as their personal experiences of the local Aboriginal community. This approach made the yarning resources their own and was reported as relieving the pressure and expectation they initially felt co-designing the educational material. However, they felt that there were more Aboriginal cultural references that could be included in the future as they developed their knowledge and confidence and began to deliver yarnings sessions within their respective BE WELL programs.

“We haven’t as of yet [included local Aboriginal stories or language], because there was a lot of new information for someone learning about COPD.” (AHW_05)

In addition, EPs commented the facilitators asked enquiring questions of the team about the format, session frequency, timing, topics and whether the local BE WELL teams’ needs were being met, which supported co-design and local adaptation.

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