Aboriginal and Torres Strait Islander Health Performance Framework (HPF) 2012
Tier 3—Effective/appropriate/efficient—3.08 Cultural competency
Why is it important?:Cultural competency requires that organisations have a defined set of values and principles, and demonstrate behaviours, attitudes, policies and structures that enable them to work effectively cross-culturally.' (Dudgeon et al. 2010). The first of the nine principles underpinning the NSFATSIH is cultural respect—'ensuring that the cultural diversity, rights, views, values and expectations of Aboriginal and Torres Strait Islander Peoples are respected in the delivery of culturally appropriate health services' (AHMAC 2003).
In a review of the literature, Thomson (2005) found that generally, the mainstream health system has not adequately taken into account Aboriginal and Torres Strait Islander cultures, or their different views of health. This then impacts on how Aboriginal and Torres Strait Islander peoples make decisions to use health services and, in turn, their health outcomes (House of Representatives Standing Committee on Family and Community Affairs 2000). For example, if an Aboriginal and Torres Strait Islander patient has previously found health services uncomfortable, unwelcoming, or difficult to understand and navigate, this may contribute to avoidance or delays in seeking treatment (Jowsey et al. 2011; House of Representatives Standing Committee on Family and Community Affairs 2000). In turn this can lead to potentially preventable disease progression (see measure 3.07).
The NT Department of Health, in collaboration with the National Advisory Group on Aboriginal and Torres Strait Islander Health Information and Data (NAGATSIHID) and the National Aboriginal and Torres Strait Islander Health Officials Network (NATSIHON), are developing a cultural competence framework based around three elements:
- Organisational cultural competency: leadership and workforce, recruiting and supporting Aboriginal and Torres Strait Islander people in health professions and into leadership positions within health care systems, community engagement in planning and decision making and development of non-Indigenous staff.
- Systemic cultural competency: eliminating systemic and institutional barriers to Aboriginal and Torres Strait Islander people accessing care, including language barriers, trust, patient dissatisfaction and poor understanding of treatment.
- Clinical/professional/individual cultural competence: improving the cultural knowledge, skills and behaviours of individuals working in the health system, including clinical and administrative staff, to help patients navigate the health system and become a more active partner in the health care encounter.
Findings:The 2008 NATSISS found that 27% of Indigenous Australians had felt discriminated against in the last 12 months. The most common situation/places included by members of the public (11%), police/security/courts (11%) and at work (8%), while doctors, nurses or other staffs at hospitals/surgeries were identified by 4% of respondents. In 2004–05, 16% of respondents felt they had been treated badly when seeking health care in the last 12 months because they were Aboriginal or Torres Strait Islander. Thirty-three per cent of those respondents reported that they usually try to avoid the person/situation if they have been treated badly when seeking health care.
In 2008, 26% of Aboriginal and Torres Strait Islander peoples aged 15 years and over reported problems accessing health care. Approximately 7% of these identified 'service not culturally appropriate' as a barrier.
In 2008, 8% of people aged 15 years and over surveyed in the NATSISS disagreed or strongly disagreed with the statement 'Your doctor can be trusted'. In addition, 17% disagreed or strongly disagreed with the statement 'Hospitals can be trusted to do the right thing by you'.
Language can be a barrier in the health system, with 18% of Indigenous adults in remote areas and 6% in non-remote areas identifying having difficulty understanding and being understood by English speakers in 2008.
Between July 2008 and June 2010, there were 14,052 hospitalisations where Aboriginal and Torres Strait Islander people left hospital against medical advice or were discharged at their own risk. This represented around 2% of all hospitalisations for Aboriginal and Torres Strait Islander peoples, which compares with 0.4% for non-Indigenous Australians.
In 2006, there were 5,536 Aboriginal and Torres Strait Islander people employed in health-related occupations. Nursing (1,449) was the largest group followed by nursing support and personal care workers (974), and Aboriginal and Torres Strait Islander Health Workers (966). The occupations with the largest gap between numbers of Indigenous and non-Indigenous Australians were nurses, medical practitioners and allied health professionals.
In 2010, there were an estimated 1,766 Aboriginal and Torres Strait Islander tertiary students enrolled in health related courses and an estimated 5,100 Indigenous student enrolments in health-related courses in the VET sector.
As at 30 June 2011, over half (54% or 3,008) of the full time employment (FTE) paid positions in Aboriginal and Torres Strait Islander primary health care services were occupied by Aboriginal and Torres Strait Islander people. Seventy-four per cent of these services had a governing committee or board composed entirely of Aboriginal and Torres Strait Islander people.
Aboriginal and Torres Strait Islander Health Workers (ATSIHWs) have been recognised as playing an important role in contributing to improved cultural competency (House of Representatives Standing Committee on Family and Community Affairs 2000; Thompson et al. 2011). A small study in the cardiology unit of a WA hospital (Taylor et al 2009) found that these health workers improved the cultural security of the care provided, reduced the number of discharges against medical advice and increased participation in cardiac rehabilitation.Top of Page
Participation rates in cardiac rehabilitation have been lower for Indigenous Australians although it has been shown to be effective in reducing coronary death by up to 25% (National Heart Foundation and Australian Health Care and Hospitals Association 2010) (see measures 1.05, 1.23, 1.24). In 2009–10, 85% of Aboriginal and Torres Strait Islander primary health care services had an Aboriginal and Torres Strait Islander health worker on staff.
Health promotion through cultural groups was offered by half of Aboriginal and Torres Strait Islander primary health care services providing group activities (which constituted approximately 90% of services), while 60% offered services through women's groups and 57% services through men's groups. Twenty-one per cent of Aboriginal and Torres Strait Islander primary health care services offered bush tucker nutrition programs, 20% offered traditional healing and 12% offered bush medicine in 2010–11. Eighty-five per cent of Aboriginal and Torres Strait Islander substance-use-specific services ran cultural groups (e.g., art, hunting, bush outings).
A lack of local services that are culturally competent has been identified in the area of palliative care (McGrath et al. 2007), rehabilitation services (Kendall et al. 2004), and medicines information (Stoneman. J et al. 2007).
A recent study of a private GP practice in Qld found that by working in partnership with the Indigenous community the number of Indigenous patients increased from 10 to 147 with monthly attendances increasing from five to 40 Indigenous patients. Strategies introduced included bulk billing for all Indigenous patients, one session per week specifically for Indigenous patients, and a bus to the clinic. In addition, cultural safety training was undertaken by staff and an Indigenous health worker attended the clinic assisting with cultural safety and referrals. A monthly stakeholder meeting was also introduced, providing ongoing community ownership (Johanson et al. 2011).
Implications:The cultural competency of the health system impacts on Aboriginal and Torres Strait Islander people's access to health care, the quality and effectiveness of care that is received, and disparities in health outcomes (McDermott 2012). Cultural competency can be measured directly, e.g., through individuals self reporting on whether they find health services culturally competent, or indirectly, e.g., through rates of discharge against medical advice (National Heart Foundation and Australian Health Care and Hospitals Association 2010) (see measure 3.09).Top of Page
A WA report on cancer care (Thompson et al. 2011) made several practical recommendations to improve the cultural competency of care for Aboriginal patients including: providing a welcoming environment through welcome to country services, yarning places and access to traditional foods; facilitating the return of Aboriginal patients to their homelands for continued care where possible; ensuring that there is access to Aboriginal interpreters for Aboriginal people who are not confident speakers of English, and that staff understand differences in Aboriginal verbal and non-verbal communication styles; and ensuring service providers are familiar with, acknowledge and respect Aboriginal family structures, culture and life circumstances.
A Victorian study of Aboriginal diabetic patients found that a history of dispossession and racism were key barriers identified to access of health care. The study identified seven key aspects of cultural competency including respect and trust, transport, flexibility, time, support and outreach, and working together (Liaw et al. 2011).
Effective identification of Aboriginal and Torres Strait Islander people and accountability at all levels of the health system are vital to any initiative to improve cultural competency. Australian governments have focused on improving the cultural competency of health services in several ways.
The PIP Indigenous Health Incentive, funded by the Australian Government, aims to support general practices and Indigenous health services to provide better health care for Aboriginal and Torres Strait Islander patients, including best practice management of chronic disease. This incentive is a key part of the COAG National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes. Payments are made to practices that register for the PIP Indigenous Health Incentive and meet certain requirements, including establishing and using a mechanism to ensure their Aboriginal and Torres Strait Islander patients aged 15 years and over with a chronic disease are followed up (e.g., through use of a recall and reminder system or staff actively seeking out patients to ensure they return for ongoing care); and at least two staff members from the practice (one of whom must be a GP) completing appropriate cultural awareness training. As at 30 April 2012, more than 2,900 practices and Indigenous health services have signed on to the PIP Indigenous Health Incentive. Around 40,000 patients were registered for this incentive in 2011.
The Department of Health and Ageing, as the main funder of Aboriginal Community Controlled Health Organisations (ACCHOs), has developed a funding agreement that, in setting out the terms and conditions for project funding for the provision of health care services to Aboriginal and Torres Strait Islander peoples under the OATSIH Program, re-affirms the commitment to community control. The funding agreement's Head Agreement includes an emphasis on increasing the access of Aboriginal and Torres Strait Islander peoples to quality primary care services that respect cultural safety and are planned and delivered according to a transparent needs assessment. This is to reinforce that the organisation must be responsive to local priorities. The Department of Health and Ageing is also currently developing a wide range of culturally appropriate training resources for Aboriginal and Torres Strait Islander aged and community care workers.
The NT Department of Health and Community Services has developed an Aboriginal Cultural Security Policy (The NT Government n.d.) which will be implemented at a regional level to assist all parts of the system to become culturally competent. Key focus areas include workforce development, workplace reform, monitoring and accountability, and community engagement.Top of Page
The NSW Health Aboriginal Health Impact Statement is designed to ensure the needs and interests of Aboriginal people are embedded into the development, implementation and evaluation of all NSW Health initiatives. The Impact Statement Guidelines (NSW Government 2007) recommend considering questions such as whether a policy includes initiatives that reflect Aboriginal health principles such as a whole of-life view of health, a holistic approach to health, Aboriginal self determination, working in partnership, and cultural respect; and whether recommendations for policy implementation include the adaptation of programs, campaigns and materials that are culturally respectful to the needs of Aboriginal communities. The Guidelines also recommend that evaluation plans for health policies and programs affecting Aboriginal people should include indicators on issues such as cultural security and responsiveness of services to community needs.
The Victorian Department of Human Services has established Building Aboriginal Cultural Competence Training Programs that aim to embed cultural respect and understanding into policy development, service delivery and people management. Program participants will gain a range of insights, including a better understanding of:
- historical and contemporary Aboriginal leadership;
- the strengths of Aboriginal identity, culture and people;
- the impact of past and current government policies and practices on the lives and outcomes of Aboriginal people; and
- how government and Aboriginal community networks can engage in the process of policy and partnership development.
The Victorian Department of Health established the Improving Care for Aboriginal and Torres Strait Islander Patients (ICAP) program in 2004 in recognition that many Aboriginal people are reluctant to attend hospitals and under-identification of Aboriginal patients continues to hamper policy and service development based on service access and health needs (Victorian Government 2009). ICAP is underpinned by a 30% loading on health service funding for Aboriginal inpatients. To demonstrate the provision of quality care for Aboriginal patients, health services are required to report progress against four key result areas in their annual quality of care reports: relationships with Aboriginal communities, culturally aware staff, discharge planning, and primary care referrals.
Figure 164—Aboriginal and Torres Strait Islander people employed in selected health-related occupations, 1996, 2001 and 2006Top of Page
Source: AIHW analysis of the ABS Census data
Figure 165—Proportion of those with problems accessing health care who identified 'service not culturally appropriate' as a barrier, by selected services, Aboriginal and Torres Strait Islander peoples, 2008Top of Page
Source: ABS and AIHW analysis of 2008 NATSISSTop of Page
Figure 166—Aboriginal and Torres Strait Islander primary health care services, by proportion of governing committee or board who were Aboriginal or Torres Strait Islander, 2008–11
Source: AIHW OSR data collectionTop of Page
Figure 167—Treatment of Indigenous Australians when seeking health care in the last 12 months, by remoteness, 2004–05
Source: ABS and AIHW analysis of 2004–05 NATSIHSTop of Page