Cultural barriers to health care for Aboriginal and Torres Strait Islanders in Mount Isa

Objective: Access barriers to health care for minority populations has been a feature of medical, health and social science literature for over a decade. Considerations of cultural barriers have featured in this literature, but definitions of what constitutes a cultural barrier have varied. In this paper, data from recent interviews with Aboriginal and Torres Strait Islander people, Aboriginal Health Workers and other non‐Indigenous health professionals in north‐west Queensland assist to refine the meaning of this term and uncovered other issues disguised as ‘cultural’ difference. Design: Semistructured interviews with community and health professionals. Setting: Mount Isa, Queensland, Australia. Participants: Aboriginal and Torres Strait Islanders, Aboriginal Health Workers and other health professionals in Mount Isa between 2007 and 2009. Results: Cultural barriers were considered differently by Aboriginal patients and health practitioners. While Aboriginal patients focused heavily on social relationships and issues of respect and trust, most practitioners seemed more focused on making Aboriginal people feel comfortable with changes to physical environments and systems, with less emphasis on creating strong interpersonal relationships. Conclusions: For Aboriginal patients the focus on interpersonal relationships between themselves and health practitioners is paramount. Creating comforting physical environments and systems that are easier to navigate do assist in overcoming cultural barriers, but are often seen as little more than token gestures if trusting interpersonal relationships are not formed between patient and practitioner.     

Reducing racism in Aboriginal health care in Australia: where does cultural education fit?

Objective : This paper discusses whether educating health professionals and undergraduate students in culturally respectful health service delivery is effective in reducing racism, improving practice and lessening the disparities in health care between Aboriginal and non‐Aboriginal Australians. Approach : The paper supports the concept of race as a social construction that is discursively produced and reproduced. Studies on the effectiveness of cross‐cultural education for undergraduate students and health professionals to reduce racism and deliver culturally respectful health care to indigenous or minority populations are examined for evidence of sustained improvements to practice. Conclusion : Programs in culturally respectful health care delivery can lead to short‐term improvements to practice. Sustained change is more elusive as few programs conducted long‐term evaluations. Long‐term evaluation of programs in culturally respectful health care delivery is necessary to identify whether early changes to behavior and practices are sustained. Strategies linking policies to practice to reduce health disparities between Aboriginal and non‐Aboriginal Australians are also needed. Implications : Confronting the effects of racism in health services towards Aboriginal Australians is a priority requiring a multi‐tiered commitment to strategies linking policy to practice to reduce health disparities between Aboriginal and non‐Aboriginal Australians. Part of this strategy includes preparing undergraduates and health professionals for culturally respectful health care with education programs that are evaluated for long‐term improvements to practice.     

An evaluation of a public health nutrition workforce development intervention for the nutrition and dietetics workforce

Background: Workforce development is a key element for building the capacity to effectively address priority population nutrition issues. On‐the‐job learning and mentoring have been proposed as strategies for practice improvement in public health nutrition; however, there is limited evidence for their effectiveness. Methods: An evaluation of a mentoring circle workforce development intervention was undertaken. Thirty‐two novice public health nutritionists participated in one of three mentoring circles for 2 h, every 6 weeks, over a 7‐month period. Pre‐ and post‐intervention qualitative (questionnaire, interview, mentor diary) and quantitative (competence, time working in public health nutrition) data were collected. Results: The novice public health nutritionists explained the intervention facilitated sharing of ideas and strategies and promoted reflective practice. They articulated the important attributes of the mentor in the intervention as having experience in and a passion for public health, facilitating a trusting relationship and providing effective feedback. Participants reported a gain in competency and had an overall mean increase in self‐reported competence of 15% (range 3–48% change; P < 0.05) across a broad range of competency elements. Many participants described re‐orienting their practice towards population prevention, with quantifiable increases in work time allocated to preventive work post‐intervention. Conclusions: Mentoring supported service re‐orientation and competency development in public health nutrition. The nature of the group learning environment and the role and qualities of the mentor were important elements contributing to the interventions effects. Mentoring circles offer a potentially effective strategy for workforce development in nutrition and dietetics.     

Barriers and facilitators for health professionals referring Aboriginal and Torres Strait Islander tobacco smokers to the Quitline

Objective: To examine the barriers and facilitators among health professionals to providing referrals to Quitline for Aboriginal and Torres Strait Islander clients who smoke. Methods: A brief online survey, based on the Theoretical Domains Framework, was completed by 34 health professionals who work with Aboriginal and Torres Strait Islander people in South Australia and the Northern Territory. Results: Respondents who frequently made referrals had higher domain scores than less frequent referrers for ‘Skills and knowledge’ (M=4.44 SD=0.39 vs. M=4.09 SD=0.47, p<0.05) and ‘beliefs about capabilities’ (M=4.33 SD=0.44 vs. M=3.88 SD=0.42, p<0.01). Barriers to providing referrals to Quitline were lack of client access to a phone, cost of a phone call, preference for face‐to‐face interventions, and low client motivation to quit. Conclusions: Health professionals working with Aboriginal and Torres Strait Islander clients should be supported to build their skills and confidence to provide referrals to Quitline and other brief cessation interventions. Building capacity for face‐to‐face support locally would be beneficial where phone support is not preferable. Implications for public health: Engaging with health professionals who work with Aboriginal and Torres Strait Islander people to increase referrals to Quitline is strategic as it builds on their existing capacity to provide cessation support.     

Evaluation of an intervention to train health professionals working with Aboriginal and Torres Strait Islander people to provide smoking cessation advice

Objective : To investigate the effectiveness and cultural relevance of Quitskills training tailored for health professionals working with Aboriginal and Torres Strait Islander people who smoke. Methods : A retrospective analysis was conducted with data collected from 860 participants (54% Aboriginal and Torres Strait Islander participants) in tailored Quitskills training from 2012 to 2016. Course participants took part in a survey at pre‐training, post‐training and four‐six weeks post‐training to assess confidence in skills to address tobacco, and perceptions of the strengths, areas for improvement and cultural relevance of the training. Results : Confidence in skills and knowledge to address tobacco increased significantly from pre‐ to post‐training (all indicators of confidence in skills increased p<0.001) and remained high at follow‐up. Tailored Quitskills training was perceived as being culturally relevant by Aboriginal and Torres Strait Islander participants, and the training facilitators were the most commonly cited strength of the training. Conclusions : Quitskills is an appropriate course for increasing skills and confidence among health professionals working with Aboriginal and Torres Strait Islander people who smoke. Implications for public health : Training courses that are tailored for Aboriginal and Torres Strait Islander people can build the capacity of the health workforce in a culturally relevant manner.     

Beyond the barriers: family medicine residents' attitudes towards providing Aboriginal health care

Medical Education 2011: 45 : 400–406 Context Health care is one of many under‐resourced areas in Aboriginal communities in Canada. Aboriginal people have substandard health compared with the general population, yet have less access to health care services. Not only is there a paucity of Aboriginal doctors, but it also appears that few non‐Aboriginal doctors are willing or able to work in Aboriginal contexts. Objectives This study examines the attitudes of family medicine residents towards providing health care to Aboriginal patients. The goal of this study was to assess the willingness of family medicine residents to work in Aboriginal health care and to elucidate the major factors that inform these attitudes. Methods We conducted a cross‐sectional survey of an urban cohort of family medicine residents using a convenience sample. Our survey instrument consisted of a questionnaire comprising a mixture of open‐ended and closed questions. Results Although a majority (52%, n = 27) of the family medicine residents were willing to work in Aboriginal contexts, many felt underprepared to do so (40%, n = 21). Residents who have had some exposure to Aboriginal issues and have had community experiences are more likely to state an intention to work in Aboriginal settings. Conclusions The results of this study encourage the creation of educational experiences for medical residents that may promote a desire to work in Aboriginal communities.     

Increasing community participation in an Aboriginal health service

Objective: To increase Aboriginal participation with mainstream health professionals in an Aboriginal health and well‐being centre. Design: Participatory Action Research using Aboriginal traditional symbolism to depict aspects of the research process, interview surveys and a document review. Setting: A regional town with 629 Aboriginal and Torres Strait Islander residents and a newly established Aboriginal health and well‐being centre (Nunyara). Participants: Thirty Aboriginal community members were interviewed about their involvement with Nunyara and their health issues. Participants were selected through purposive ‘pass‐me‐around’ sampling to ensure that all family groups were included. Results: The results are presented in two areas: the structure of the Aboriginal community that affects participation and community views about health issues. Aboriginal people living in the town come from 10 or more different language groups and relate almost exclusively within their own groups. Activities at Nunyara were seen as individual family group events and not for everyone. Aboriginal community participants had a broad view of health as they reported problems that included smoking and alcohol use. Almost all would like more involvement in health issues through Nunyara. Conclusion: Aboriginal community members are willing to get involved in health issues in collaboration with Nunyara. However, fundamental to increasing participation is to bring people together from different family groups and increase social cohesion. This can be done through developing relationships with groups enabling different points of view to be heard and valued.     

Robust data to close the gap: current vascular and maternal/newborn indicators as measures of progress in Aboriginal health in New South Wales

Objective: Focussing on maternal/newborn health and vascular diseases, to review NSW Health's reporting, by Aboriginal status, against national performance indicators relevant to preventable chronic diseases. Methods: We reviewed seven indicator documents and the Australian Institute of Health and Welfare Chronic Disease Indicator Database to identify national indicators. Indicators from six NSW Health reports were then compared with these national indicators to assess reporting by Aboriginal status and region. Results: NSW Health routinely reports against six maternal/newborn indicators and fourteen vascular national indicators. Five of the former report performance by both Aboriginal status and region. Eight of the latter report by Aboriginal status, one of which (diabetes hospitalisations) also reports by region. Indicator quality and breadth was substantially limited by under‐enumeration of Aboriginal status, small or potentially unrepresentative samples, inadequate longitudinal or regional data and few primary health care indicators. Notwithstanding these limitations, we found wide and persistent disparities in outcomes for Aboriginal people for all indicators in all regions. Conclusions: NSW Health reports adequately, by Aboriginal status, for maternal/newborn health monitoring (albeit constrained by under‐enumeration), but provides limited information about vascular health. A minimum, national chronic disease indicator dataset against which all jurisdictions would report performance by Aboriginal status and region is needed. Improved monitoring requires sustained efforts to address under‐enumeration, better survey sampling, and population representative data from the primary care system.     

Australia and New Zealand's contribution to Pacific Island health worker brain drain

Objective: The paper aims to quantify Australia and New Zealand's contribution to the brain drain of Pacific Island health workers and to contribute firm evidence to the ongoing, highly‐contested health professional migration issue. Methods: The study uses the Australian and New Zealand 2006 census data to examine the number of Pacific Island born health professionals living in Australia and New Zealand and uses World Health Organization data to compare it against the numbers of health workers in Pacific Island countries. Results: Six hundred and fifty‐two Pacific Island born doctors and 3,467 Pacific Island born nurses and midwives are working in Australia and New Zealand, more than half of whom are from Fiji with significant numbers from Papua New Guinea, Samoa and Tonga as well. There are almost as many Fiji‐born doctors in Australia and New Zealand as there are in Fiji. There are more Samoa, Tonga and Fiji‐born nurses and midwives in Australia and New Zealand than in the domestic workforce. Conclusions: Migration of Pacific Island health professionals to Australia and New Zealand is very high and contributes to the shortage of health workers in Pacific Island countries. Implications: Australia and New Zealand are encouraged to actively address the issue in collaboration with Pacific Island partners with a number of solutions proposed.     

A phase II clinical trial of a dental health education program delivered by aboriginal health workers to prevent early childhood caries

ABSTRACT: BACKGROUND: Early Childhood Caries (ECC) is a widespread problem in Australian Aboriginal communities causing severe pain and sepsis. In addition dental services are difficult to access for many Aboriginal children and trying to obtain care can be stressful for the parents. The control of dental caries has been identified as a key indictor in the reduction of Indigenous disadvantage. Thus, there is a need for new approaches to prevent ECC, which reflect the cultural norms of Aboriginal communities. METHODS: This is a Phase II single arm trial designed to gather information on the effectiveness of a dental health education program for Aboriginal children aged 6 months, followed over 2 years. The program will deliver advice from Aboriginal Health Workers on tooth brushing, diet and the use of fluoride toothpaste to Aboriginal families. Six waves of data collection will be conducted to enable estimates of change in parental knowledge and their views on the acceptability of the program. The Aboriginal Health Workers will also be interviewed to record their views on the acceptability and program feasibility. Clinical data on the child participants will be recorded when they are 30 months old and compared with a reference population of similar children when the study began. Latent variable modeling will be used to interpret the intervention effects on disease outcome. DISCUSSION: The research project will identify barriers to the implementation of a family centered Aboriginal oral health strategy, as well as the development of evidence to assist in the planning of a Phase III cluster randomized study.Trial registrationACTRN12612000712808.     

POST OPERATIVE PAIN EXPERIENCES OF CENTRAL AUSTRALIAN ABORIGINAL WOMEN. WHAT DO WE UNDERSTAND?

Objective: The aim of this study was to explore the postoperative pain experiences of Central Australian Aboriginal women and the subsequent interpretation of that pain experience by non‐Aboriginal female nurses. Design: Qualitative study using grounded theory methodology. Setting: Postoperative surgical setting of a Central Australian regional hospital. Subjects: Five Aboriginal female clients who had undergone a surgical procedure, eight non‐Aboriginal female nurses and four Aboriginal female health workers employed by a Central Australian regional hospital. Results: Aboriginal women have culturally appropriate ways of expressing and managing pain that are not well understood by non‐Aboriginal female nurses. In addition, the Aboriginal women inappropriately endow non‐Aboriginal nurses with the same powers and skills expected of healers from their culture. This phenomenon resulted in the non‐Aboriginal nurses lacking the cultural insight and the appropriate knowledge and tools required to assess and manage the postoperative pain of Central Australian Aboriginal women effectively or efficiently. Conclusions: Non‐Aboriginal nurses have a profound knowledge deficit about the postoperative pain experiences of Central Australian Aboriginal women. This deficit is evident through the use of culturally inappropriate and unreliable pain assessment strategies and tools and the misinterpretation of traditional pain relief strategies, such as the use of pituri, rubbing and centreing. The findings of this study suggested that nurse/client interactions related to language and role interpretation were in cultural conflict. The nurses expected the Aboriginal women to adopt pain behaviours as understood from the nurses’ culture. The nurses anticipated that the client would contribute to their own care by communicating pain experiences in ways that are familiar and are believed to be universal. The Aboriginal women expected the nurses to conduct business similar to that of their own traditional tribal healers, ‘to see within’ and to ‘just know’. What is known on this subject: The National Health and Medical Research Council claim there is a dearth in systematic studies of pain issues for Aboriginal and Torres Strait Islander people. 1 Previous studies conducted suggest that Aboriginal people do not feel pain and have an extraordinary high pain tolerance. 2 , 3 However, no significant studies exist in the area of pain management that address the cultural needs of Aboriginal people. What this paper adds: Statistical evidence gathered from the informal Acute Pain Service operational within a Central Australian regional hospital, revealed that although the hospital clientele were predominately of Aboriginal descent, the service catered for a greater proportion of non‐Aboriginal people. The misconception that Aboriginal people have a high pain tolerance requiring less pain relief is outdated and erroneous, as this paper will reveal.     

Screening for diabetic retinopathy in remote Australia: a program description and evaluation of a devolved model

Objectives: To describe the diabetic retinopathy screening program operating in the Kimberley and evaluate recruitment into and the quality and timeliness of, the screening procedure. Method: Review of the documents relating to the Kimberley diabetic retinopathy screening program and analysis of Kimberley diabetic retinopathy screening database. Results: The Kimberley Public Health Unit developed and maintains a program of training, credentialing and ongoing professional development for retinal camera practitioners and a Kimberley‐wide database of retinal photographs taken for diabetic retinopathy screening. As a result of this program, diabetic retinopathy screening is available in or close to most diabetics’ home towns/communities and 58% had undergone retinopathy screening in the preceding 2 years. Over 90% of sets of photographs were of excellent or adequate quality. There was a positive relationship between credentialing and photograph quality and timeliness of photographs being sent away for reporting. Conclusions: Quality diabetic retinopathy screening, at prevalences comparable to, or higher than, other urban and rural populations, can be achieved in a remote area. What is already known: Screening and early treatment of diabetic retinopathy can prevent visual loss associated with diabetes. However, there is little published literature about the operational aspects of diabetic retinopathy screening programs in remote area settings. What this study adds: Diabetic retinopathy screening in remote areas can be successfully implemented using non‐mydriatic retinal photography performed by credentialed local health professionals, such as Aboriginal health workers and nurses.     

Public Health System Partnerships: Role for Local Boards of Health in Preparing the Future Public Health Workforce

The Institute of Medicine’s report, Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century, recommended that public health education be accessible to undergraduate students. Promoting access to public health education will ideally contribute to a well-educated public health workforce, thus assuring the fulfillment of the public health mission. In response to this call to action, the authors examined the current practice, feasibility, and value in developing a functional partnership between academic institutions and local boards of health in preparing future public health professionals. Local boards of health in New England were surveyed to: (1) establish a baseline of existing working relationships between them and nearby academic institutions; (2) examine the barriers that inhibit the development of their collaborations with academic partners; and (3) assess how they jointly advance public health workforce development. Despite the main barriers of a lack of time, staff, and funding that are often cited for the absence of collaborations between institutions, one New England state, in particular, reported that their academic institution and local board of health partnerships were important and effective. The authors discuss how academic-practice collaborations hold the potential to combine basic public health principles with leadership and governance experience offered by local boards of health. Such partnerships are underutilized and have the potential to integrate core public health concepts while facilitating applied experiential learning opportunities in a professional public health setting, thus contributing to the development of the future public health workforce.     

Undergraduate nursing students' experiences in a rural clinical placement

Objective: This paper draws on questionnaire findings and analysis of students' comments to demonstrate the aspects of rural placements that were effective in engaging students in the learning process. It also examined how a primary health care clinical placement in Aboriginal communities can provide nursing students with a rich and varied learning experience and an insight into the complex aspects of rural life including Aboriginal health. Design: A cohort of eight second‐year nursing students from the Australian Catholic University, North Sydney, in partnership with the Broken Hill University Department of Rural Health (BHUDRH), participated in a 4 weeks' rural placement in far western New South Wales. A pre‐test/post‐test questionnaire was used to capture their experiences with the students completing the questionnaires before and after their clinical placements. Such placements offer students opportunities to deepen their understanding of issues related to rural health in clinical, professional, social and community contexts. Results: The results suggest that clinical experience in rural areas can positively influence attitudes, preparedness for practice and engage students on many levels, deepened their understanding of rural communities and issues related to rural health. Conclusion: This group of undergraduate nursing students indicated they all had a positive learning experience in their rural clinical placement. The value of rural placements as a method for increasing nursing student's practical experience should be promoted.     

South Australian four-year-old Aboriginal children: residence and socioeconomic status influence weight

Objective: Obesity rates have increased in children in Australia in the past 15 years. However, there is little available population data describing rates of overweight and obesity in Aboriginal children. Methods: Anthropometric data of four‐year‐old children (n=11,859) were collected by trained nurses at routine statewide preschool health checks during 2009. Weight status (underweight, healthy weight, overweight and obese) was determined using age and gender specific International Obesity Task Force (IOTF) cut‐points. Results: There were 337 Aboriginal children (3%) in the study population. Aboriginal children had significantly higher rates of overweight and obesity compared to non‐Aboriginal children (28% compared to 18% respectively, χ²p=0.0001). A statistically significant association between BMIz score and identifying as Aboriginal remained after controlling for rural/urban residence and socioeconomic status using multiple regression analyses. Conclusions: Aboriginal children have higher rates of overweight and obesity compared to their non‐Aboriginal peers by the time they are four years of age. Aboriginal children have higher BMIz scores compared to non‐Aboriginal children after controlling for rural/urban residence and socioeconomic status. Implications: A significant investment is required to optimise the health of Aboriginal women before pregnancy and throughout pregnancy. A rethink may be necessary in the approach to dietary management and catch‐up growth of Aboriginal children of low birth weight or having growth failure in early childhood.     

Undergraduate public health education: a workforce perspective

OBJECTIVE: To describe the career paths of students who majored in public health at the undergraduate level and to assess the skills and knowledge these graduates believed were most useful to them in the public health workforce. METHOD: A telephone survey was conducted of all graduates from Adelaide University's Bachelor of Health Sciences degree from 1992-99 who had majored in public health (124 graduates). RESULTS: The response rate to the graduate survey was 71%. Using the definition of public health functions from the National Delphi Study on Public Health Functions to delineate the public health workforce, 59% of respondents were employed in public health. Graduates working in public health valued generic skills such as communication and collaboration more highly than more specific public health skills and knowledge areas. However, they also believed their undergraduate course would have been improved by a more practical orientation. CONCLUSIONS: A high proportion of graduates from this generalist degree who major in public health find employment in the public health workforce. They greatly value the generic skills associated with their undergraduate public health education and believe their entry into the workforce would have been further facilitated by stronger links between their academic program and the working environment of public health professionals. Implications: Studies of workforce training programs in public health must differentiate between the educational needs of undergraduate and postgraduate students. In particular, strategies need to be developed to provide stronger links between undergraduate students and the public health workforce.     

Capacity building in rural mental health in Western Australia

ABSTRACT: A regional success story in capacity building in terms of workforce development in rural Western Australia is described. A rural and remote distance education program in mental health was delivered in 1999 across 10 rural sites to 31 health professionals (26 general nurses, four allied health and one Aboriginal health worker) who are in contact with mentally ill patients at the primary level in country areas. Evaluation on completion of the program and at 4 months postprogram was extremely positive, with participants reporting that they have gained knowledge of mental health management regimens, developed mental health assessment skills and enhanced their clinical practice. Both participants and their line managers identified that the program had greatest impact on improving relationships with the mental health team. The program has also been an example of capacity building in terms of innovative resourcing to address a statewide need in mental health education for those at the forefront of rural practice.