Talking about the 'r' word: a right to a health system that is free of racism

Improving Breast Cancer Outcomes for Indigenous Women in Australia

In Australia, the incidence rate of breast cancer is lower in Indigenous* women than non-Indigenous women; however, the mortality rate is higher, with Indigenous women 1.2 times more likely to die from the disease. This paper provides practical and achievable solutions to improve health outcomes for Indigenous women with breast cancer in Australia. This research employed the Context-Mechanism-Outcome (CMO) framework to reveal potential mechanisms and contextual factors that influence breast cancer outcomes for Indigenous women, stratified into multiple levels, namely, micro (interpersonal), meso (systemic) and macro (policy) levels. The CMO framework allowed us to interpret evidence regarding Indigenous women and breast cancer and provides nine practical ways to improve health outcomes and survival rates.

Putting Indigenous Cultures and Indigenous Knowledges Front and Centre to Clinical Practice: Katherine Hospital Case Example

The inclusion of Indigenous cultures, known as the cultural determinants of health, in healthcare policy and health professional education accreditation and registration requirements, is increasingly being recognised as imperative for improving the appalling health and well-being of Indigenous Australians. These inclusions are a strengths-based response to tackling the inequities in Indigenous Australians' health relative to the general population. However, conceptualising the cultural determinants of health in healthcare practice has its contextual challenges, and gaps in implementation evidence are apparent. In this paper, we provide a case example, namely the Katherine Hospital, of how healthcare services can implement the cultural determinants of health into clinical practice. However, to be effective, health professionals must concede that Australia's Indigenous peoples' knowledges involving cultural ways of being, knowing and doing must co-exist with western and biomedical knowledges of health practice. We use the Katherine Hospital ABC Radio National Background Briefing interview, which was mentioned by two research participants in a 2020 study, as an example of good practice that we can learn from. Additionally, the six Aboriginal and Torres Strait Islander Health actions contained in the 2nd Edition of the Australian National Safety and Quality Health Service Standards provide governance and accountability examples of how to enable Indigenous people's cultures and their knowledges in the provision of services. The role of non-Indigenous clinical allies and accomplices is imperative when embedding and enacting Indigenous Australians' cultures in service systems of health. When Indigenous Peoples access mainstream hospitals, deep self-reflection by allies and accomplices is necessary to enable safe, quality care, and treatment that is culturally safe and free from racism. Doing so can increase cultural responsiveness free of racism, thereby reducing the inherent power imbalances embedded within mainstream health services.

A culturally safe referral service for at-risk mothers and infants in marginalised, Aboriginal, and Culturally and Linguistically Diverse families

This case study describes the development and implementation of a replicable early assessment and referral service for mothers experiencing minority group disadvantage and family violence in the perinatal period. The service aims to mitigate harms for at-risk mother-infant dyads that can lead to involvement in statutory child protection systems. In doing this, the service follows a culturally safe, restorative practice approach to supporting vulnerable families, which emphasises the relationship between worker and client to create a nurturing environment for change. The service model has been developed and refined since 2018 to now, involving stakeholders from the service team, the not-for-profit community organisation, and a university partner organisation, who provided evidence enrichment and support for clinical skill development. To date: the model has provided practitioners with structured and evidence-based ways of creating shared understandings with clients to prioritise cultural and relational needs; achieved culturally safe ways of engaging with Aboriginal and Torres Strait Islander and Culturally and Linguistically Diverse families; improved practitioners' confidence in detecting risk in parent-infant relationships; promoted effective communications with external providers; and enhanced therapeutic outcomes for vulnerable families at risk of entry into statutory child protection systems. The model may be suitable for uptake by practitioners and services seeking to improve cultural safety and therapeutic outcomes for diverse and vulnerable families. We share reflections on the scope and function of the model of care with reference to potential for broader application.

Change in health outcomes for First Nations children with chronic wet cough: rationale and study protocol for a multi-centre implementation science study

BACKGROUND

In children, chronic wet cough may be a sign of underlying lung disease, including protracted bacterial bronchitis (PBB) and bronchiectasis. Chronic (> 4 weeks in duration) wet cough (without indicators pointing to alternative causes) that responds to antibiotic treatment is diagnostic of PBB. Timely recognition and management of PBB can prevent disease progression to irreversible bronchiectasis with lifelong consequences. However, detection and management require timely health-seeking by carers and effective management by clinicians. We aim to improve (a) carer health-seeking for chronic wet cough in their child and (b) management of chronic wet cough in children by clinicians. We hypothesise that implementing a culturally integrated program, which is informed by barriers and facilitators identified by carers and health practitioners, will result in improved lung health of First Nations children, and in the future, a reduced the burden of bronchiectasis through the prevention of the progression of protracted bacterial bronchitis to bronchiectasis.

METHODS

This study is a multi-centre, pseudorandomised, stepped wedge design. The intervention is the implementation of a program. The program has two components: a knowledge dissemination component and an implementation component. The implementation is adapted to each study site using a combined Aboriginal Participatory Action Research and an Implementation Science approach, guided by the Consolidated Framework of Implementation Research. There are three categories of outcome measures related to (i) health (ii) cost, and (iii) implementation. We will measure health-seeking as the proportion of parents seeking help for their child in a 6-month period before the intervention and the same 6-month period (i.e., the same six calendar months) thereafter. The parent-proxy, Cough-specific Quality of Life (PC-QoL) will be the primary health-related outcome measure.

DISCUSSION

We hypothesise that a tailored intervention at each site will result in improved health-seeking for carers of children with a chronic wet cough and improved clinician management of chronic wet cough. In addition, we expect this will result in improved lung health outcomes for children with a chronic wet cough.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry; ACTRN12622000430730 , registered 16 March 2022, Retrospectively registered.

Institutional racism: a discursive paper

The purpose of this paper is to provide discourse regarding awareness of institutional racism, from a non-Indigenous, Australian nursing student's perspective. The discussion has a focus on the presence of institutional racism in the Australian healthcare system, its impact on the health of First Nation Peoples and a commitment to ensuring culturally safe practice. It will be argued that institutional racism is pervasive in healthcare as a consequence of three factors: exclusion of First Nations Peoples from governance roles, inherent racism impacting on socio-cultural treatment bias, and institutional racism influencing key relationships in healthcare delivery.

Engage, understand, listen and act: evaluation of Community Panels to privilege First Nations voices in pandemic planning and response in Australia

Introduction

First Nations Peoples of Australia have not been included in the development nor prioritised in pre-2009 pandemic plans despite being a priority population in Australian health policy. Marginalised groups experience amplified barriers and systemic disadvantage in emergencies, however, their voices have not been heard in past pandemic responses. Through effective engagement with disadvantaged and oppressed groups, health authorities can gain a deeper understanding of how to design and implement pandemic control strategies. There have been limited studies with First Nations Peoples that has focused on pandemic planning and response strategies. Deliberative inclusive approaches such as citizens juries have been a way to uncover public perceptions.

Methods

Qualitative thematic research methods were used to conduct the study. We convened five First Nations Community Panels in three locations in Australia between 2019 and 2020. We used an Indigenist research approach, community-based Participatory Action Research framework and ‘yarning’ to understand whether Community Panels were an acceptable and appropriate way of engaging First Nations Peoples. Forty First Nations participants were purposively recruited through local and cultural networks. Panels heard evidence supporting various pandemic response strategies, and cross-questioned public health experts.

Results

All 40 participants from the 5 panels verbally indicated strong support of the Community Panels approach as an effective way of engaging First Nations Peoples in making decisions about pandemic planning and response strategies. The main theme of ‘respect’ centred on the overarching principle that First Nations Peoples are important in the context of continuation of culture and ongoing political resistance.

Conclusion

First Nations Community Panels are a way of enabling active participation of First Nations peoples, increasing knowledge and understanding, and a way for government and policymakers to respectfully listen to First Nations opinions and values.

Murradambirra Dhangaang (make food secure): Aboriginal community and stakeholder perspectives on food insecurity in urban and regional Australia

Background

It is widely acknowledged that the invasion by colonial powers of the Australian continent had profound and detrimental impacts on Aboriginal Communities, including food security. Policies of successive governments since European arrival have since further exacerbated the situation, with food insecurity now affecting 20–25% of Aboriginal and Torres Strait Islander people. Food insecurity contributes to long-term impacts on health, in particular diet-sensitive chronic diseases. This study aimed to describe Aboriginal community and stakeholder perspectives on food insecurity to get a better understanding of the key contributing factors and recommendations for potential strategies to address this issue in Aboriginal communities in urban and regional Australia.

Methods

Semi-structured interviews were conducted with 44 participants who were purposively selected. This included Aboriginal people in two communities and both Aboriginal and non-Aboriginal stakeholders from local food relief agencies, food suppliers, schools, and government in an urban and regional location in NSW. A conceptual framework was developed from literature on food security, and sensitizing concepts of availability, affordability, accessibility and acceptability or the lack thereof of healthy food were used to elicit responses from the participants. Interview transcripts were analysed thematically.

Results

All participants felt strongly that food insecurity was a major problem experienced in their local Aboriginal communities. Five core areas impacting on food security were identified: trapped in financial disadvantage; gaps in the local food system; limitations of non-Aboriginal food relief services; on-going impacts of colonization; and maintaining family, cultural and community commitments and responsibilities. Participants suggested a number of actions that could help ease food insecurity and emphasized that Aboriginal values and culture must be strongly embedded in potential programs.

Conclusions

This study found Aboriginal families in urban and regional Australia are experiencing food insecurity on a regular basis, which is impacted by a range of socio-economic, environmental, systemic and cultural factors, as reported by the participants. Study findings highlight the need to address system level changes in the food environment and acknowledge Aboriginal history, culture and food preferences when considering the development of programs to alleviate food insecurity among Aboriginal people.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13202-z.

The Bunya Project: Protocol to develop culturally informed curriculum (Preprint)

BACKGROUND

Indigenous peoples live across all continents, representing approximately 90 nations and cultures and 476 million people. There have long been clear statements about the rights of Indigenous peoples to self-determine services, policies, and resource allocations that affect our lives, particularly via the United Nations Declaration on the Rights of Indigenous Peoples. An area for urgent improvement is curricula that train the predominantly non-Indigenous health workforce about their responsibilities and that offer practical strategies to use when engaging with Indigenous peoples and issues.

OBJECTIVE

The Bunya Project is designed to advance Indigenous community-led teaching and evaluation of the embeddedness of strategies to achieve an Indigenous Graduate Attribute in Australia. The project centers the relationships with Aboriginal community services to lead education design relating to Indigenous peoples. The project aims to articulate community recommendations for university education in allied health in the usable format of digital stories to create culturally informed andragogy, curriculum, and assessment measures for use in teaching. It also aims to understand the impact of this work on student attitudes and knowledge about Indigenous peoples' allied health needs.

METHODS

Multilayered project governance was established, along with a 2-stage process using mixed methods participatory action research and critical reflection, using the reflective cycle by Gibbs. The first stage, preparing the soil, used community engagement, drew on lived experience, encouraged critical self-reflection, embodied reciprocity, and demanded working collectively. The second stage, planting the seed, requires more critical self-reflection, the development of community data through interviews and focus group discussions, the development of resources with an academic working group and community participants, the implementation of those resources with student feedback, the analysis of the feedback from students and community members, and reflection.

RESULTS

The protocol for the first stage, preparing the soil, is complete. The results of the first stage are the relationships built and the trust earned and gained, and it has resulted in the development of the planting the seed protocol. As of February 2023, we have recruited 24 participants. We will analyze data shortly and expect to publish the results in 2024.

CONCLUSIONS

The readiness of non-Indigenous staff to engage with Indigenous communities has not been ascertained by Universities Australia, nor can it be assured. Staff preparation and skills to support the curriculum, create a safe learning environment, and develop teaching and learning strategies to guide academics to recognize that how students learn is as important as the content students learn. This learning has broad implications and benefits for staff and students within their professional practice and for lifelong learning.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/39864.

'Teaching in Circle' with student nurses contributes to experiential understanding of cultural safety

BACKGROUND

Cultural safety is mandated for Australian nursing practice and education. Cultural safety privileges the knowledge of the client, who determines whether healthcare is culturally safe. Understanding, and learning cultural safety requires critical self-reflection to expose clinicians' assumptions, unconscious biases, beliefs and actions and their impact on clients. More research is required on best-practice strategies on how students learn about cultural safety in nursing education. Experiential pedagogical methods may be one such strategy to promote understanding of principles that underpin safe environments.

OBJECTIVES

To explore the influence of 'Teaching in Circle' to enhance students' understanding of cultural safety within the classroom environment.

METHODS

Students in first year undergraduate Bachelor of nursing units participated. Teachers facilitated tutorials using a respectful adaptation of 'Teaching in Circle' methodology; was underpinned by principles of Yarning, an Aboriginal and Torres Strait Islander Peoples way of learning and communicating in groups. Students developed principles to guide the facilitation of a more culturally safe classroom, providing written feedback on the environment and their participation in the circle.

RESULTS

Student feedback was reflected in three themes: 'Journey through unfamiliar territory'; `More personable way of learning and sharing' and 'Relational engagement creates safety'. Student perspectives resonated strongly with the principles of cultural safety or lack of, within healthcare settings. The method both disrupted normative classroom/learning environments and supported experiential learning about the principles of cultural safety.

CONCLUSIONS

'Teaching in circle' provided an experiential means of enhancing first year nursing students understanding of the principles of cultural safety. This learning should be embedded in nursing curriculum and ongoing education, to prepare nurses to provide culturally safer care to Aboriginal and Torres Strait Islander Peoples. The study supports similar research calling for innovative learner-focused, experiential methods for the development of the practice of cultural safety in Australian nursing education.

Cultural safety: Teachers engagement with an Indigenous pedagogical method in undergraduate nursing education

BACKGROUND

Given the continued disparity between the health of Indigenous Australian people's health and that of the broader Australian population, cultural safety is mandated as a component of undergraduate education as a strategy to improve health care. Evidence suggests that academics are not confident to teach cultural safety to undergraduate nursing students.

OBJECTIVES

To explore the efficacy of an Indigenous teaching method (Teaching in Circle) to create culturally safe classrooms and to build the capacity and confidence of teachers to teach about cultural safety.

DESIGN

An Indigenous pedagogy was adapted for use in tutorials by teachers, with mentorship provided by an Indigenous knowledge expert. Teaching in Circle (TiC) methodology was implemented by teachers in tutorials.

METHODS

All nurse academics teaching in the Bachelor of Nursing program at a small regional Australian university were eligible to participate. Information about the project was provided in team meetings, with invitations to participate. Teachers provided written reflection on the method and participated in regular on-line mentored support meetings throughout the teaching session. Data was analysed, using a reflective, inductive systematic process.

RESULTS

Final themes were "Sticking with initial disconcertment and discomfort"; "A renewed enjoyment of teaching"; "Learning and adapting", "The influence of the method on safety" and "Shifts in classroom dynamics".

IMPACT STATEMENT

'Teaching in Circle', underpinned by respectful practice, positively influences culturally safe teaching and learning environments. The method enhances academics' confidence to teach cultural safety to undergraduate nursing students and supports an understanding of the essential components of culturally safe health care.

CONCLUSIONS

Evidence suggests the method built capacity to teach and foster experiential learning of safety, and thus what is required to create a culturally safe teaching and learning space.

The Barriers and Facilitators of Sport and Physical Activity Participation for Aboriginal Children in Rural New South Wales, Australia: A Photovoice Project

Participating in physical activity is beneficial for health. Whilst Aboriginal children possess high levels of physical activity, this declines rapidly by early adolescence. Low physical activity participation is a behavioral risk factor for chronic disease, which is present at much higher rates in Australian Aboriginal communities compared to non-Aboriginal communities. Through photos and ‘yarning’, the Australian Aboriginal cultural form of conversation, this photovoice study explored the barriers and facilitators of sport and physical activity participation perceived by Aboriginal children (n = 17) in New South Wales rural communities in Australia for the first time and extended the limited research undertaken nationally. Seven key themes emerged from thematic analysis. Four themes described physical activity barriers, which largely exist at the community and interpersonal level of children’s social and cultural context: the physical environment, high costs related to sport and transport, and reliance on parents, along with individual risk factors such as unhealthy eating. Three themes identified physical activity facilitators that exist at the personal, interpersonal, and institutional level: enjoyment from being active, supportive social and family connections, and schools. Findings highlight the need for ongoing maintenance of community facilities to enable physical activity opportunities and ensure safety. Children held strong aspirations for improved and accessible facilities. The strength of friendships and the family unit should be utilized in co-designed and Aboriginal community-led campaigns.

Unique knowledge, unique skills, unique role: Aboriginal and Torres Strait Islander Health Workers in Queensland, Australia

Aboriginal and Torres Strait Islander Health Workers (A&TSIHWs) are a professional cadre of Australian health workers typically located in primary care clinics. The role is one of only two that is ‘identified’— that is, it must be occupied by an Aboriginal and/or Torres Strait Islander person — and holds specific responsibilities in relation to advocating for facility-level cultural safety. However, lack of understanding of the distinctive skills, scope and value associated with the A&TSIHW role remains pervasive in the broader health workforce. Positioned to represent the perspective of those working as A&TSIHWs, and drawing on 83 in-depth interviews with A&TSIHWs and others, this qualitative study reports on the core functions and distinctive orientation of the role, and seeks to articulate its distinctive value in the modern Queensland health service. Findings highlight the multifaceted (generalist) nature of the A&TSIHW role, which comprises three core functions: health promotion, clinical service and cultural brokerage. Underpinning these cross-cutting functions, is the role’s unique orientation, defined by client-centredness and realised through Indigenous strengths based ways of knowing, being and doing. The findings highlight how the A&TSIHW role is one of the only mechanisms through which Aboriginal and Torres Strait Islander knowledge can be brought to bear on context-specific adaptations to routine health service practices; and through which the impacts of lack of cultural or self-awareness among some non-Indigenous health professionals can be mitigated. The complexity of such work in a government health system where a dominant biomedical culture defines what is valued and therefore resourced, is under-recognised and undervalued and contributes to pressures and stress that are potentially threatening the role's long-term viability.