Boosting cultural respect in mainstream health services

‘Obviously the gap isn’t really closing, so that’s a pretty obvious indication that we’ve got to do a lot more. And, as primary healthcare, we’re the first port of call.’
 
That is Dr Tanya Schramm, a GP, Palawa woman and lecturer in Aboriginal and Torres Strait Islander health at the University of Tasmania, as she spoke to newsGP on National Close the Gap Day this year.
 
According to Dr Schramm, cultural safety and respect is a vital part of the effort to improve Aboriginal and Torres Strait Islander access to primary healthcare.
 
‘If we, as Aboriginal people, are coming to a mainstream general practice, we should be able to expect culturally respectful and safe healthcare to the same standard we could receive at to the Aboriginal Health Service [AMS],’ she said.
 
‘It’s not as simple as just popping up a couple of flags and a bit of artwork in your waiting room. [Practices] need to go in behind that and make sure that they are providing culturally safe consultations within that context.’
 
The desire to make mainstream primary healthcare more accessible for Aboriginal and Torres Strait Islander people is the motivation behind research recently published in the Medical journal of Australia, ‘Cultural respect in general practice: A cluster randomised control trial’.
 
Professor Siaw-Teng Liaw, lead author and Professor of General Practice at the University of New South Wales, believes addressing this issue is vital because many Aboriginal and Torres Strait Islander people may not actually have access to Aboriginal Community Controlled Health Organisations [ACCHOs].
 
‘A substantial number [of Aboriginal and Torres Strait Islander people] live in urban areas – and that is a substantial number of Aboriginal people who should be better resourced,’ he told newsGP.
 
‘Because, when we look at the statistics for AMS and ACCHOs, there are relatively less in urban areas compared to rural and remote.
 
‘So we feel urban Aboriginal people are not as well looked after.’

Dr Tim Senior, Medical Advisor for RACGP Aboriginal and Torres Strait Islander Health, agrees more needs to be done to improve experiences within the mainstream.
 
‘Every Aboriginal and Torres Strait Islander health organisation tells us there are still too many Indigenous Australians experiencing racism in the health system,’ he told newsGP.
 
‘Many Aboriginal people expect they will have a bad experience in health services because they have usually had bad experiences in the past – there are many reasons why Aboriginal and Torres Strait Islander people may not want to attend our practices, and may not want to take our advice when they do.’


Dr Tanya Schramm and Dr Tim Senior participate in a Q&A about Aboriginal and Torres Strait Islander health on National Closing the Gap Day.

In order to help prevent further such experiences, Professor Liaw and his team created, in extensive consultation with the Aboriginal community, a toolkit to assist mainstream practices to provide culturally respectful care.

The researchers then conducted a randomised controlled trial over a 12-month period involving selected practices in Sydney and Melbourne, with some receiving the toolkit plus additional training and support.
 
‘We ran a half-day workshop [during which] the practice staff were taken through the toolkit and a background of Aboriginal history and dispossession,’ Professor Liaw explained.
 
‘At that workshop, they were introduced to the cultural mentors, who we recruited in each state to be available to the practice for a year to help them implement some of the things in the toolkit. The mentor was then available through an online discussion group or by phone number.
 
‘The other part of the intervention was at the PHN [Primary Health Network] level, which at that time was the Medicare Local, which we encouraged to form a care partnership with the local ACCHO.
 
‘So once we got the toolkit, the workshop and the cultural mentor in place, we implemented it as best as we could, and collected the data at baseline and compared it at 12 months.’
 
Professor Liaw and his team found the trial practices were extremely receptive to and engaged with the program, and that patients also had a positive experience of it.
 
‘We collected qualitative information from the practices and Aboriginal patients nominated by them, and the output was really positive from their perspective. Most of [the practices] wanted to continue with it,’ he said.
 
‘After we finished the trial, we also ran the workshops with the control practices, and they were all very keen as well.’
 
But despite these encouraging results, analysis revealed that quantitative outcomes – which were measured by the number of Aboriginal health checks carried out and recording of clinical risk factors such as cardiovascular, weight and blood sugar – did not differ significantly between participating and control practices.
 
While Professor Liaw was disappointed with these results, he also acknowledges the issues the researchers are trying to tackle may simply require more time to show significant change.
 
‘This is a complex intervention and to translate the toolkit, workshops and the cultural mentor suggestions into an organisational thing will probably require more than 12 months, because it might take a while to come to grips with it, and then work out a protocol to do it,’ he said.
 
However, another positive development has resulted from the research: buy-in from a participating PHN, which also means the research team can continue to monitor results on a much larger scale.
 
‘One of the PHNs involved in the study in Sydney is happy to roll it out,’ Professor Liaw said.
 
‘So we’re going to roll it out in one of the local government areas, and we will follow through what happened to the ones that participated in the trial, and also with this one, in the longer term. And then if they get more funding, we’ll roll it out to other local government areas, as well.’
 
Dr Senior is pleased with this news and is hopeful it is a signal of further engagement from PHNs with Aboriginal and Torres Strait Islander health.
 
‘The cultural respect program in this research may be a useful framework for PHNs, but the most crucial step will be for them to work on developing and enhancing true partnerships with their local Aboriginal communities, and local ACCHOs,’ he said.
 
‘It’s this local community engagement that will be crucial, and if the cultural respect program can be used in this context, then they may have some successes.’
 
Meanwhile, Professor Liaw and his team have been happy with the study’s results in terms of increasing cultural knowledge and respect within practices, and are hoping for improved quantitative results, as well, with a view to the long game.
 
‘We plan to do some interviews in about 12 months and see whether there’s any longer term changes,’ he said.

Aboriginal and Torres Strait Islander health cultural safety general practice research