Title: Cross Cultural Workers for women and families from migrant and refugee backgrounds:
A mixed-methods study of service providers perceptions
Version: 1 Date: 20 Feb 2021
Reviewer:  Lisa Merry
Reviewer's report:
Thank you for the opportunity to review this paper. Overall I think it’s an important study since
there is a need to have more data on models of care for migrant women and their families during
pregnancy and early childhood. However, I do have a number of comments that I feel need to
be addressed, particularly in the methods and results’ sections. Please see below.
Abstract:
-Results: it would be clearer if the organizational factors were named or a link made to the
following sentence so it’s understood that ‘part time hours’ is the organizational factor (also
based on the results, it seems ‘part time hours’ is the only factor identified)
-Conclusion: it’s not clear exactly how the CCW model is ‘culturally’ responsive – the way the
results are presented in the abstract there is no mention of ‘culture’
Background
Overall clear, well written and complete. Study is well justified with relevant references.
Minor suggested edits:
In the first paragraph, the word ‘have’ could be removed (who left have their country… who
have fled their country)
Last sentence of the first paragraph- “significant implications for the planning and delivery of
quality maternal, child and family health services... Where?
Second paragraph- “women from migrant and refugee backgrounds…” –in the first paragraph,
migrants are defined as people outside of their country of birth, and includes refugees and asylum
seekers- so when you say “migrant” and “refugee”- who does migrant refer to?... Same issue in
third paragraph, and in other parts of the text throughout the manuscript.
Methods
Design: What type of mixed methods was used? Explanatory sequential?
Minor edits (Design paragraph): “its” potential to add rigour… “Service-providers’ experiences”
CCW model of care: fluent in their country of origin language – which languages?  What is their
background? What does ‘culturally appropriate’ support imply? Maybe provide an example or
two. It may also be helpful to know a bit more about the population who tend to be referred to
these services (countries of origin, languages spoken)- this would also help contextualize the
results.
Recruitment: was the survey anonymous (I think no based on reading the survey, but this should
be clearer in the text)? Since it wasn’t anonymous, was there any concern about getting ‘socially
desirable’ responses since the participants may have known the researchers? Did the service
providers have to have some interaction with CCW to be eligible (since the purpose of the study
was to evaluate CCW)? What was the sample goal – how many people were you hoping to
recruit (how did you decide you had enough participants)?
Recruitment for interview participants:  Does purposive sampling mean an email was sent
(similar to the recruitment approach used for the survey)? How many participants were you
hoping to have for the interviews (how did you decide you had enough participants)?
Data collection: what sort of literature was used to inform the development of the survey and
the interview guide (health service evaluation? Migration-sensitive care? Other?)
Minor edits: Data collection, first paragraph: “The exact email distribution is difficult to estimate
as service providers were encouraged to send to colleagues, and Service Managers to their staff,
approximately 450 people”- I think there is a word or two missing.
And “...two participants who provided an expression of interest via survey response, and 14 of
the 16 service providers who were suggested by HJR and AH”
Confidentiality/anonymity of interview data: HJR and AH still knew who the majority of the
interview participants were since they referred them...so they weren’t really anonymous. Maybe
just say that identifying information was removed as much as possible from the interviews to
limit linking interview responses to individual participants.
Data analysis: how were the quant and qual data integrated? Were they analysed together and
used to triangulate findings? Were data used in a complementary fashion? Or were the quant
data used to inform the interviews? Usually in mixed methods there should be mention of how
‘mixing’ (integration) occurred in the study (it can be done in the analysis phase and/or in other
phases of the study).
What does it mean DC cross-checked the analysis? Did DC also do coding?
Was the analysis really only inductive? It would seem that the coding would also be guided by
what was found in the quant survey (to validate or find contrasts), and also by the objectives
of the study (perceptions of effectiveness, satisfaction and recommendations for improvement)
and by what the CCW model sets out to do. Also, based on the description of how the analysis
was conducted (e.g., codes relevant to the study’s purpose were identified), it seems the process
was somewhat deductive.
When talking about qual analysis, we don’t usually say ‘patterns emerged’- it’s the researcher
that identifies the patterns.
Usually we don’t talk about ‘bias’ when discussing qual analysis, it’s assumed that there
is influence and subjectivity since qualitative research usually comes from a constructivist
paradigm. That being said mixed methods can also be used for more pragmatic purposes.
More justification and information on the mixed methods design being used is needed. The
methods section should also include a bit more information on how rigour was maintained for
the respective qual and quant phases of the study.
Results:
The results (qual and quant) from those who are ‘insiders’ (CCWs and others who are part of
the managerial team and clinical governance group) vs. ‘outsiders’ I think should be reported
separately (or there should have been some analysis to identify contrasts) since those who work
in the service are likely to have a vested interest in providing a more positive evaluation. This
may have been done for the qual results (CCW results are presented separately)- it’s not clear if
some of the service providers were ‘insiders’... That being said, for the qual results if the CCWs
are the only insiders, I’m not sure their data should be reported separately since there are only
three of them and everyone in the community knows who they are, so easier to individually
identify them.
The objective of the study was to report on the perceptions of effectiveness, satisfaction
and recommendations for improvement- the survey results only reports on perceptions of
effectiveness and satisfaction- there’s nothing about recommendations?
To maintain confidentiality, the quotes shouldn’t indicate who said the quote (it’s a small
community, so just saying ‘CCW’ or ‘manager’ makes the participants potentially identifiable).
There seems to be some disconnect between the survey results and the interview themes.
“Improved experiences and care” seems coherent across the survey and interview results, but
“bridge to health” doesn’t seem to fully align with the survey results- 30% of survey respondents
did not see the service of having a positive effect on women’s outcomes (i.e., not effective or no
effect). Moreover, 26% didn’t see it as having an impact on “engagement between communities
and services”- so the “bridge” concept and the sub-category of “supporting access to services”
don’t seem completely consistent.
The “culturally appropriate care” theme doesn’t seem well supported. First, it’s not clear what
is meant by culturally appropriate care (does it mean the CCWs ‘know’ what to do because
they are from the same cultural background (this is what is implied based on the quote); or
does it mean that they act as mediators to help identify what women may want in terms of
‘culturally appropriate care’ (because they know what it is like to be ‘culturally different’ even
if not from the same background and as such they provide a means for ensuring a ‘culturally
safe’ environment...) Secondly, it seems that not everyone sees the CCWs as being able to
provide culturally appropriate care because of incongruence between their cultural background
of the CCWS and some of the women they assist. As mentioned above, it would be helpful to
understand who the CCWs are, whose the population mostly served by them, and what is meant
by ‘providing culturally appropriate care’
It’s not clear how “Supporting capacity building of service providers to provide culturally
responsive care” is a separate theme from “CCW part-time hours and capacity to fulfil role”-
they seem overlapping
The qual results doesn’t say much about how the CCW model may be improved (other than
increasing their hours)- yet, this was one of the study goals.
Discussion
I’m not sure the following statement is fully supported by the results: “to support service
navigation, enhance communication between service providers and women, enable continuity
of care, and culturally appropriate support, which resulted in trust in the healthcare system and
empowered women to consider their health needs” (as per my comments made in the results
section). On a related note, there should be some discussion on how the qual and quant results
relate to each other (complement vs. contrast each other).
There should be some discussion on ‘culturally appropriate care’- this was raised as an issue
by some of the care-providers- Do CCWs necessarily need to be from the same cultural
background as the women they support? I think there are arguments to say yes, they should be,
but also arguments that suggest it may not be necessary. And from a manager/program organizer
standpoint, what is feasible? In the same vein, it may be worthwhile to have a discussion point
on what the role should be for a CCW- it seems like there is an expectation that they do it all.
There is also some misunderstandings around their role. If we want to develop these types of
positions and have them acknowledged (and valued) as professionals (and advocate for them to
have more hours), then a more defined role may be warranted.... Or maybe there are drawbacks
to have a more defined role....
Limitations: how do you know that the participants were representative? If I understand
correctly, the main researcher HR is the manager of the CCW- so I think this should be
mentioned in the limitations section. Responses may have been more ‘socially desirable’ given
the researcher’s position.
There should be more details on recommendations (this was one of the goals of the study). For
example, it seems like there are some misunderstandings about the role of CCWs (acting as
interpreters)- so could something be done to improve understanding? Also, migrant seem to
need help with immigration- is it possible to somehow address this need? The survey results
show that an important number of care-providers don’t see a link between the CCWs improved
outcomes, or community development, or engagement between communities and services-
recommendations for addressing this?...
There is nothing on future research... or other implications (policy level?)