Aboriginal and Torres Strait Islander health

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Instructions

This section provides a summary of the area of practice for this unit and highlights the importance of this topic to general practice and the role of the GP.

Aboriginal and Torres Strait Islander peoples are the First Peoples of Australia, and have diverse, rich and continuing connections to culture, Country, traditional languages, family and community. These connections are powerful drivers of health and wellbeing.1-3 A skilled general practitioner (GP) respects and incorporates Aboriginal and Torres Strait Islander cultures and languages, so that patients are empowered to maintain their cultural identity while benefitting from primary healthcare tailored to their unique beliefs, context and needs. 

The source of health inequities

Aboriginal and Torres Strait Islander peoples continue to demonstrate resilience and determination. However, through intergenerational trauma and historical and ongoing dispossession and disempowerment, colonisation continues to have a profound impact on health outcomes.4 The existing health inequity is inexcusable, with an overall burden of disease among Aboriginal and Torres Strait Islander peoples more than double that of non-Indigenous Australians, and a life-expectancy gap that remains unacceptable.5  

This health inequity reflects the relative privileges that non-Indigenous people benefit from in socioeconomic and healthcare access, in comparison to Aboriginal and Torres Strait Islander peoples. Colonisation and systemic racism lead to structural disadvantage across all domains of socioeconomic determinants of health for Aboriginal and Torres Strait Islander peoples, with disparity in income, employment and education being particularly significant.5 Racism additionally directly affects both physical and psychological health.6,7 

Successive Australian governments have failed to adequately address the ongoing consequences of colonisation. Despite the implementation of some specific measures and a Commonwealth commitment to ‘Closing the Gap’ since 2007, there has been mixed progress towards equity in socioeconomic determinants and health outcomes.8 There remains a relatively significant underspend in health funding not commensurate to Aboriginal and Torres Strait Islander disease burden, and key health policy recommendations remain largely unfunded and unimplemented.9 

Cultural safety in general practice

Cultural safety is determined by Aboriginal and Torres Strait Islander individuals, families and communities. Culturally safe practice is the ongoing critical reflection of health practitioner knowledge, skills, attitudes, practising behaviours and power differentials in delivering safe, accessible and responsive healthcare free of racism.10

Healthcare services are not immune from reinforcing colonisation-based power imbalances.4,11 Additional to structural discrimination, reported experiences of interpersonal racism are common in healthcare contexts.12 Regardless of workplace location, GPs will likely see Aboriginal and Torres Strait Islander patients. Where available, dedicated Aboriginal and Torres Strait Islander medical services provide a significant level of care. However, in major cities fewer than 15% of patients usually attend such services, and even in very remote areas only 75% of patients usually attend a dedicated service, accessing available mainstream services instead.5 As such, the provision of culturally safe care in all primary healthcare settings is essential. This requires healthcare providers to acknowledge and address their own biases, attitudes and assumptions, as well as systems and policies, that might reinforce the colonialism, racism and privilege at the heart of health inequities.4,13,14

Cultural safety also requires healthcare professionals and organisations to understand their own cultural lens and examine the potential impact of their own culture on clinical interactions and healthcare service delivery.13 The majority of primary healthcare services are founded on non-Indigenous social and cultural norms. For Aboriginal and Torres Strait Islander peoples whose lived experience is of different social and cultural norms, unfamiliarity, discomfort and an expectation that patients will conform to the system’s norms can act as a barrier to healthcare.15,16 

Aboriginal community controlled health organisations provide care aligned with Aboriginal and Torres Strait Islander cultures, values and community-driven goals for health and wellbeing. Non-Indigenous primary healthcare providers can learn ways to improve cultural safety from these models. 

Cultural learning and self-reflective practice

Seeking to understand the cultural, historical and social fabric of the local community – and tailoring communication to local cultural communication styles and linguistic realities – can assist in building therapeutic relationships with communities, families and patients.16,17 In recognition of the significant diversity in language and cultural practices between and within urban, rural and remote Aboriginal and Torres Strait Islander communities, a focus on lifelong learning will contribute to ensuring care meets the specific beliefs, values and needs of each Aboriginal and Torres Strait Islander patient, as defined by them. Partnership building with local Aboriginal and Torres Strait Islander Elders, health professionals and organisations is an essential component for developing relevant knowledge and skills.15,17

In undertaking this learning, it is important to remember that no practitioner can ever know everything about all Aboriginal and Torres Strait Islander peoples’ cultures and communities, because cultural identity is complex, evolving and experienced uniquely by each Aboriginal and Torres Strait Islander person. Too much of an outward focus on the ‘other’ can reinforce stereotypes, assumptions and misunderstandings. A self-reflective focus creates humility, curiosity and a lifelong willingness to learn.16,18 It is not lack of cultural knowledge of Aboriginal and Torres Strait Islander peoples that most contributes to poor therapeutic relationships, but rather a failure to understand the local colonial and sociocultural context in which healthcare encounters are occurring.4,13 

Advocacy

Advocacy is also a required competency of the GP. Primary healthcare practitioners are uniquely placed to partner with Aboriginal and Torres Strait Islander patients, their families and communities, to advocate for support to mitigate barriers to equitable healthcare access. Additionally, GPs can be a powerful voice and ally in advocating for improved investment in culturally appropriate, structural responses to health inequity. 

References
  1. Bourke S, Wright A, Guthrie J, Russell L, Dunbar T, Lovett R. Evidence review of indigenous culture for health and wellbeing. Int J Health, Wellness & Society 2018;8(4). doi: DOI:10.18848/2156-8960/CGP/v08i04/11-27
  2. Jones R, Thurber KA, Chapman J, et al. Study protocol: our cultures count, the Mayi Kuwayu study, a national longitudinal study of Aboriginal and Torres Strait islander wellbeing. BMJ open 2018;8(6). doi: 10.1136/bmjopen-2018-023861
  3. Salmon M, Doery K, Dance P, et al. Defining the indefinable: Descriptors of Aboriginal and Torres Strait Islander peoples’ cultures and their links to health and wellbeing. Canberra: Aboriginal and Torres Strait Islander Health Team, Research School of Population Health, The Australian National University, 2019.
  4. Jones R, Crowshoe L, Reid P, et al. Educating for indigenous health equity: An international consensus statement. Acad Med 2019;94(4):512. doi: 10.1097/ACM.0000000000002476.
  5. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework 2020 summary report. Cat. no. IHPF 2. Canberra: AIHW, 2020.
  6. Larson A, Gillies M, Howard PJ, Coffin J. It's enough to make you sick: The impact of racism on the health of Aboriginal Australians. Aust N Z J Public Health 2007;31(4):322–29. doi: 10.1111/j.1753-6405.2007.00079.x.
  7. Paradies Y. A systematic review of empirical research on self-reported racism and health. Int J Epidemiol 2006;35(4):888–901. doi: 10.1093/ije/dyl056.
  8. Australian Government Department of the Prime Minister and Cabinet. Closing the Gap report 2020. Canberra: Department of the Prime Minister and Cabinet; 2020.
  9. The Close the Gap Campaign Steering Committee. A ten-year review: The Closing the Gap Strategy and Recommendations for Reset. 2018 [Accessed 28 October 2021].
  10. Ahpra. The National Scheme’s Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy 2020-2025. Melbourne: Ahpra, 2020 [Accessed 26 November 2021].
  11. Jennings W, Bond C, Hill PS. The power of talk and power in talk: A systematic review of Indigenous narratives of culturally safe healthcare communication. Aust J Prim Health 2018;24(2):109–15. doi: 10.1071/PY17082.
  12. Kelaher MA, Ferdinand AS, Paradies Y. Experiencing racism in health care: The mental health impacts for Victorian Aboriginal communities. Med J Aust 2014;201(1):44–47. doi: 10.5694/mja13.10503.
  13. Curtis E, Jones R, Tipene-Leach D, et al. Why cultural safety rather than cultural competency is required to achieve health equity: A literature review and recommended definition. Int J Equity Health 2019;18(1):1–7. doi: 10.1186/s12939-019-1082-3.
  14. Kendi IX. How to be an anti-racist. London, UK: Bodley Head, 2019.
  15. Davy C, Harfield S, McArthur A, Munn Z, Brown A. Access to primary health care services for Indigenous peoples: A framework synthesis. Int J Equity Health 2016;15(1):1–9. doi: 10.1186/s12939-016-0450-5.
  16. Freeman T, Edwards T, Baum F, et al. Cultural respect strategies in Australian Aboriginal primary health care services: Beyond education and training of practitioners. Aust N Z J Public Health 2014;38(4):355–61. doi: 10.1111/1753-6405.12231.
  17. Abbott P, Dave D, Gordon E, Reath J. What do GPs need to work more effectively with Aboriginal patients? Views of Aboriginal cultural mentors and health workers. Aust Fam Physician 2014;43(1/2):58–63.
  18. Watt K, Abbott P, Reath J. Cultural competency training of GP Registrars-exploring the views of GP Supervisors. Int J Equity Health 2015;14(1):1–10. doi: 10.1186/s12939-015-0226-3.

Instructions

This section lists the knowledge, skills and attitudes that are expected of a GP. These are expressed as core competencies that are required of a GP across all clinical consultations, interactions and contexts. These core competencies are further detailed as measurable core competency outcomes.

Communication and the patient–doctor relationship
Core competencies Core competency outcomes
  The GP is able to: 
  1. GPs communicate effectively and appropriately to provide quality care
 
  1. GPs use effective health education strategies to promote health and wellbeing
 

 

  1. GPs communicate in a way that is culturally safe and respectful
  1. communicate with Aboriginal and Torres Strait Islander patients in a culturally safe and respectful manner
  1. GPs provide the primary contact for holistic and patient-centred care
  1. establish an effective and culturally safe therapeutic relationship with Aboriginal and Torres Strait Islander patients
Applied knowledge and skills
Core competencies Core competency outcomes
  The GP is able to: 
  1. GPs diagnose and manage the full range of health conditions across the lifespan
  1. undertake screening for early identification of health issues in Aboriginal and Torres Strait Islander communities
  2. manage health conditions in a timely manner, including responding effectively to the complex needs of patients with multi-morbidity  
  1. GPs are innovative and informed by evidence
 

 

  1. GPs collaborate and coordinate care
  1. ensure care is relevant to Aboriginal and Torres Strait Islander peoples' social, cultural, economic and other unique needs
  2. work in respectful partnership with Aboriginal and Torres Strait Islander healthcare professionals
Population health and the context of general practice
Core competencies Core competency outcomes
  The GP is able to: 
  1. GPs practise in a sustainable and accountable manner to support the environment, their community and the Australian healthcare system
 
  1. GPs advocate for the needs of their community
  1. identify and promote ways to achieve health equity for Aboriginal and Torres Strait Islander people
  2. identify and promote social, environmental and cultural determinants of health in the local community

 

Professional and ethical role
Core competencies Core competency outcomes
  The GP is able to: 
  1. GPs are ethical and professional
  1. GPs are self-aware
  1. implement an ongoing plan to overcome professional issues related to geographical isolation and boundaries
  2. be prepared, resourceful and adaptive to challenges that arise in geographic and professional isolation
  3. identify and acquire extended, or specific local knowledge to meet the healthcare needs of their community
  1. GPs mentor and teach
  1. engage with and support Aboriginal and Torres Strait Islander cultural education
  2. promote the professional development and support of the Aboriginal and Torres Strait Islander health workforce
  1. GPs participate in evaluation and research
  1. engage and support Aboriginal and Torres Strait Islander health research
  2. promote the use of Indigenous research methods and support the Australian Institute of Aboriginal and Torres Strait Islander Studies (AIATSIS) Code of Ethics for Aboriginal and Torres Strait Islander Research
Organisational and legal dimensions
Core competencies Core competency outcomes
  The GP is able to: 
  1. GPs use effective practice management processes and systems to continually improve quality and safety
  1. identify and implement models of primary healthcare delivery which meet the needs of Aboriginal and Torres Strait Islander peoples
  2. implement systems to support identification of Aboriginal and Torres Strait Islander patients
  3. facilitate timely and appropriate use of relevant Indigenous-specific health measures and MBS/PBS items
  1. GPs work within statutory and regulatory requirements and guidelines
  1. identify and implement appropriate policies and initiatives regarding Aboriginal and Torres Strait Islander health to optimise outcomes

Instructions

This section includes tips related to this unit from experienced GPs. This list is in no way exhaustive but gives you tips to consider applying to your practice.

Extension exercise: Speak to your study group or colleagues to see if they have further tips to add to the list.

  1. Working in Aboriginal and Torres Strait Islander health can be extremely rewarding. There are opportunities to learn about different cultures, build highly valued relationships with Aboriginal and Torres Strait Islander patients and communities, develop expertise from dedicated and skilled Aboriginal and Torres Strait Islander health practitioners, and contribute to improving one of the most significant areas of health need in Australia. The skills you develop in being able to work respectfully and effectively with Aboriginal and Torres Strait Islander patients will improve your care for all your patients.
  2. Learning in Aboriginal and Torres Strait Islander health is an ongoing, lifelong process. Self-reflection, an attitude of cultural humility and genuine interest, and an openness to unlearning and relearning are essential. Only patients can determine if the care you provide is culturally safe for them, so find ways to gather feedback (both explicit and from reflecting on interactions in the consultation).
  3. There is no stereotypical or representative Aboriginal or Torres Strait Islander person. There is significant diversity between and within communities, based on geography, culture, language, history and life experiences. While you might discover commonalities, such as experiences of colonisation or cultural themes, including connection to Country and family, remember that what is true for your interactions with one person might not be the case for your interactions with another.
  4. Experiences of interpersonal and systemic racism are common for Aboriginal and Torres Strait Islander people, and this includes experiences within healthcare. We all have biases, some unconscious and some we are aware of. Recognise that your biases stem from inaccurate media representations, colonial assumptions and unhelpful social narratives. Actively work to discover, understand and change your biases. It’s important not to discriminate, and equally important to identify, speak out and act if you see racism, either interpersonal or systemic.
  5. If you take a strengths-based approach, you will recognise the resilience in Aboriginal and Torres Strait Islander communities, and the role of culture, Country and kinship as positive drivers of wellbeing. It’s helpful to reflect on these strengths when considering statistics about disease inequality, or the disparities in socioeconomic determinants of health. Unfortunately, it’s easy to incorrectly assume that ‘being Indigenous’ is the problem. Understand that colonisation, discrimination and marginalisation from socioeconomic opportunities are all real and powerful external factors that impact on Aboriginal and Torres Strait Islander people and contribute to poor health outcomes and poor access to healthcare. Recognise that Aboriginal and Torres Strait Islander people and communities have survived these forces, and continue to build health and wellbeing for communities from a foundation of cultural strength.
  6. The majority of Aboriginal and Torres Strait Islander healthcare occurs in metropolitan areas. When working in rural and remote Aboriginal and Torres Strait Islander communities, there will likely be additional learning needs for those new to these areas. The cultural and linguistic differences between non-Indigenous people and local Aboriginal and Torres Strait Islander communities can be profound. There might be medical conditions endemic to or more common in these regions that you’re not familiar with. There are also the added challenges of geography and access to healthcare. Seek out specific induction and training if you choose to work with these communities.
  7. It can feel overwhelming to know where to begin. You might not see the relevance of learning about Aboriginal and Torres Strait Islander health, or believe that you won’t see Aboriginal and Torres Strait Islander people in your clinical practice. You might be afraid of making mistakes or unintentionally causing offence. Don’t let a lack of knowledge stop you from taking steps to learn more. Simple activities, such as reading a resource, attending a workshop or watching a movie, can lead to questions and reflections, and the next step will reveal itself.

Instructions

  1. Read this example of a common case consultation for this unit in general practice.
  2. Thinking about the case example, reflect on and answer the questions in the table below.

You can do this either on your own or with a study partner or supervisor.

The questions in the table below are ordered according to the RACGP clinical exam assessment areas and domains, to prompt you to think about different aspects of the case example.

Note that these are examples only of questions that may be asked in your assessments.

Extension exercise: Create your own questions or develop a new case to further your learning.

Aboriginal and Torres Strait Islander health

Jonathon is a 40-year-old Wadi Wadi man who has recently moved to the outer suburbs of Melbourne from rural southwest NSW and presents for a health check. He lives with his wife and three young children, and works as an office manager.

Jonathon tells you he recently spent some weeks back on Country for ‘Sorry Business’ after his older brother’s sudden and unexpected death from a heart attack at the age of 47. Many of his family members talked about needing to look after their health so there would be less Sorry Business for their community. This has motivated him to attend, despite a bad experience he had with a GP some years before where his Aboriginal identity was questioned, which put him off.

Jonathon says he generally feels well. He felt renewed by being back on Country and participating in ceremony with his community, and one of the Elders treated everyone with some traditional medicines (mixed plant-based tea) to support good health for the whole family. At the last check-up he had, the GP told him he needed to start taking a medication, the name of which he can’t remember. When the script repeats ran out after six months, he did not get it renewed, as he felt the GP hadn’t really explained to him what it was for or whether he needed to keep taking it.

Questions for you to consider Clinical exam assessment area Domains

If this was the first time you had met Jonathon, how would you ask how he identifies himself or his cultural heritage? What are the barriers to a patient identifying as Aboriginal and/or Torres Strait Islander? Why might an Aboriginal or Torres Strait Islander person choose not to identify?

How might you build rapport with Jonathon?

Consider what assumptions you have made about Jonathon (including biases and stereotypes). Where do these come from? How might you adjust your perspective?

Do you know what ‘on Country’ and ‘Sorry Business’ mean? How might you find out more about terminology commonly used by Aboriginal and Torres Strait Islander people in your community?

Thinking about the different geographical locations where you might see a patient such as Jonathon, how might you need to tailor your communication; for example, to adapt to local cultural communication styles or language differences? What is your own cultural communication style? How might you adjust your natural style to accommodate your patients?

  1. Communication and consultation skills
1,2,5
 

What are your priorities for this first consultation? Consider priorities beyond clinical investigation and management.

How would you tailor your history-taking to explore important sociocultural elements of this consultation?

What might you need to consider if Jonathon was a member of the Stolen Generations or had only recently discovered his Aboriginal heritage?

What is trauma-informed care? How might repeated episodes of grief and trauma impact on Jonathon’s social and emotional wellbeing or mental health? How might that impact on your engagement with him?

What strengths can you identify in Jonathon?

  1. Clinical information gathering and interpretation
2   

How would your health check be different if this patient was seven years old or a 62-year-old woman?

How do the preventive health assessment guidelines differ for Aboriginal and Torres Strait Islander people compared with non-Indigenous people? What are the population-level drivers of health inequities and why do these exist?

How might you respectfully incorporate knowledge about population-level risk factors for Aboriginal and Torres Strait Islander people into your assessment, without stereotyping the individual patient?

What additional conditions would you consider screening for if Jonathon lived in a remote community in Far North Queensland?

How would you approach the complex interplay of potential multimorbidity?

  1. Making a diagnosis, decision making and reasoning
2   

What are some cultural determinants of health, and how might these be incorporated into your management through a strengths-based approach?

How might you respectfully incorporate Aboriginal and Torres Strait Islander models of health and wellbeing into your management plan, including use of traditional medicines, if patients choose? What is your approach to navigating differences between your own and your patient’s priorities (such as family or cultural obligations) when developing shared management plans?

What differences in clinical management guidelines exist for specific conditions in Aboriginal and Torres Strait Islander communities, including for patients who live rurally or remotely?

  1. Clinical management and therapeutic reasoning
2   

What do you need to learn about Jonathon’s local community both here and on Country?

What local services exist in your area that might support your care of Jonathon, including dedicated Aboriginal and Torres Strait Islander services, and how would you partner with them in your care?

How would you provide culturally safe care if Jonathon was unable, or preferred not, to access an Aboriginal community controlled health organisation, Aboriginal and Torres Strait Islander health worker/practitioner, or Aboriginal and Torres Strait Islander liaison officer?

If appropriate, how might you incorporate a family-centred approach to care?

What is your role in helping patients to develop biomedical health literacy, without judging existing health beliefs? How will you assess and support this patient’s health systems literacy (the ability to navigate and access health services and systems)?

What is your role as an advocate for Jonathon and the broader Aboriginal and Torres Strait Islander community regarding socioeconomic determinants of health and healthcare access?

  1. Preventive and population health
1,2,3      
 

What are your own cultural values and beliefs, and how might these impact on how you relate to or understand your patient’s values and beliefs, and therefore priorities for healthcare and wellbeing? Is there a time you can think of when someone has held a belief about health/causation of disease that was different to that of the biomedical model of disease? How might you navigate these differences?

How might you endeavour to approach this consultation through a lens of anti-racism?

How will you respond to Jonathon’s disclosure about culturally unsafe care in previous healthcare interactions?

  1. Professionalism
4   

What care elements can you identify that might have been culturally unsafe for Jonathon in the past? What barriers might exist in your clinic that inhibit cultural safety? What if this were an 18-year-old woman from an urban area?

What Aboriginal and Torres Strait Islander-specific PBS or MBS items is Jonathon eligible for? What is the rationale for these population-specific measures?

What are some practical barriers to accessing healthcare services that Jonathon might have? How might you help overcome or reduce these?

  1. General practice systems and regulatory requirement
5   

Are there cultural considerations you might need to respond to during examinations and procedures; for example, gender preferences (sometimes known as ‘women’s business’ or ‘men’s business’)?

How would you negotiate what is or is not acceptable to Jonathon in the consultation? What creative solutions might you use to manage patient preferences?

  1. Procedural skills
2   

How will you approach the issue of not knowing the previous medical history, in a culturally respectful manner?

How will you approach limitations in your cultural knowledge about Jonathon? For example, how might you find out more about his use of and access to traditional medicines?

  1. Managing uncertainty
2   

How will you assess the severity of a patient’s illness in situations where cultural differences might change the presentation of symptoms; for example, pain? Are you aware of the published coroners’ case reports on Aboriginal and Torres Strait Islander deaths due to misinterpretation of illness severity and systemic racism?

Do you understand the local cultural considerations for communicating with family members, and how would you approach this with the family of a patient who is critically unwell if needed?

What might you need to consider if your patient requires an urgent medical retrieval from your clinic, including in rural and remote contexts?

  1. Identifying and managing the significantly ill patient
2

Instructions

This section has some suggestions for how you can learn this unit. These learning suggestions will help you apply your knowledge to your clinical practice and build your skills and confidence in all of the broader competencies required of a GP.

There are suggestions for activities to do:

  • on your own
  • with a supervisor or other colleague
  • in a small group
  • with a non-medical person, such as a friend or family member.

Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.

On your own

Attend a cultural immersion opportunity, such as a cultural camp or a local cultural workshop/seminar, or research some local information about the Country your practice is on.

  • Who are the Traditional Owners of the local area?
  • Find out some local history about your area. The local library, land council or traditional owner group websites are good places to start.
  • What did you learn about your local community? What did you learn about yourself?
  • How can you strengthen your relationships with local Aboriginal and Torres Strait Islander people you met during your immersion?
  • What is the next step in your learning journey to build on this experience?
Invite an Aboriginal or Torres Strait Islander patient to attend for an MBS item 715 health check (see learning resources section for a guide and health check templates).
  • Before the health check, prepare by writing in a journal. Reflect on a previous interaction with an Aboriginal or Torres Strait Islander patient (or a consultation you have observed). How did you identify them? What assumptions did you make, if any? How did you feel after the consultation? How might you learn more about what was important to them and their cultural identity?
  • Plan your health check consultation. What will be your priorities? How will you build rapport? What sociocultural history will you consider incorporating? What assumptions and biases are you going to leave behind?
  • After the health check, ask your patient for feedback on your consultation skills to help improve your work with Aboriginal and Torres Strait Islander patients. Was there anything they thought you could have done differently? Return to your preparation and reflect on your approach in the consultation based on your own feelings and the feedback you received. What will you do differently next time?
  • Repeat this reflective process a few times with other Aboriginal and Torres Strait Islander patients.
Practise asking every patient about their identity: ‘Are you of Aboriginal or Torres Strait Islander origin?’. The learning resources section lists supporting documents to help with this learning activity.
  • How do you record in your practice software if someone is Aboriginal, Torres Strait Islander, both or neither? How do you seek appropriate consent to record this information and why is this important? How did it feel to incorporate this into your consultations? How did your patients respond? Were you able to answer any questions about why you were asking?
  • What types of services or programs might you discuss with them? How would you manage unexpected responses?
  • How would you continue the consultation once someone has identified as Aboriginal and/or Torres Strait Islander?
Audit five of your own and/or your supervisor’s Aboriginal or Torres Strait Islander patients, checking if screening activities are up to date for each patient, as per the RACGP National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people. If you can’t find five patients, reflect on why patients might not be identifying at this practice. You could also audit five non-Indigenous patients and consider how preventive health activities would be different if this patient were an Aboriginal or Torres Strait Islander. Alternatively, you could do one of the RACGP clinical audit quality-improvement activities in Aboriginal and Torres Strait Islander health (available on gplearning).
  • Reflect on your audit activity. What did you learn from this activity? What surprised you most? What are three ways you will change your practice from now on?
  • How are the preventive health activities different if you change each patient’s age or gender?
  • Reflect on the communication and consultation skills you or your supervisor used with each of these patients. What can you do to check if your patients feel culturally safe?
  • To extend your learning, present your findings to your supervisor and discuss their approaches to preventive health checks and consultations with Aboriginal and Torres Strait Islander patients.
With a supervisor

With support from your supervisor, identify a local cultural mentor or cultural educator and arrange to meet them. Cultural mentors and educators are respected individuals from the local community (they might be health professionals and/or community members) who can help you develop cultural competency by teaching you about local history, cultural beliefs, values and practices, including appropriate communication and body language. They might know about local primary healthcare, including allied health services, and the local community’s relationship with them.

  • Discuss your goals for meeting and working with your cultural mentor.
  • Consider the cultural and linguistic differences between you and your mentor. What skills might you need to navigate these differences and develop an ongoing working relationship? What approach has your supervisor used to develop a relationship with a mentor?
  • Note that it might be appropriate for the cultural mentor role to be remunerated – please discuss this with your supervisor.
Undertake a cultural safety audit of your clinic. Use the RACGP Five steps towards excellent Aboriginal and Torres Strait Islander healthcare resource to guide your audit (see link in the learning resources section). You might want to talk with your practice manager, nurses, administration staff, supervisor and other GPs at the clinic to work through this activity.
  • Discuss what the clinic is currently doing well and what could be improved.
  • What does your supervisor believe are the barriers to implementing additional cultural safety strategies? What are the possibilities? What difference to patient care has your supervisor seen from measures that have been put in place?
  • What first step for change or improvement will you implement or advocate for?
Do a role play where your supervisor or cultural mentor plays the patient, and practise tailoring your communication skills to build rapport. Include the ‘identity question’ – Are you of Aboriginal or Torres Strait Islander origin?
  • Consider questions, such as: Would you be willing to tell me a bit about where you are from and your Country? What languages do you speak? Can you tell me a bit about your family and who you live with? What are your responsibilities at home and in community? Remember that it can be helpful to share some things about yourself to build rapport.
  • Ask your supervisor how they build rapport and what questions they ask about cultural identity. What has been their experience of developing relationships with Aboriginal and Torres Strait Islander patients?  
In a small group

Read a book written by an Aboriginal and/or Torres Strait Islander person about their lived experience of cultural safety and racism. Alternatively, watch a documentary or movie produced/directed by Aboriginal and Torres Strait Islander people about their lives.

  • Share with each other how it felt to engage with the resource you chose. What was new for you? What surprised you? What challenged you? What questions or uncertainties do you still have?
  • How will this inform future conversations you have with Aboriginal and Torres Strait Islander people?
Choose one of the journal articles listed in the learning resources section and review it together. Undertake a ‘journal club’ to discuss the article as a group.
  • Questions for discussion include: Who are the authors of this article and what are their backgrounds? Why do you think they did this research/wrote this paper? What was the most interesting aspect of the article for you? What findings were unexpected?
  • Discuss three ways in which this paper will change your practice. What next step will you take in your learning?
  • Consider presenting this resource as a journal club discussion with your clinic team.
  • Consider discussing the article with your cultural mentor or educator and/or supervisor.
Create a list of local Aboriginal and Torres Strait Islander organisations and services. Arrange a group visit for a lunch time ‘meet and greet’ (for example) to either a local Aboriginal community controlled health service or an Aboriginal and Torres Strait Islander community organisation. (Doing this activity as a small group of learners will be less taxing for the local services.) Tip: The local primary health network (PHN) could be a good starting point for this activity.
  • What services are available at the clinic/organisation? How might these be of benefit to your patients? How might you incorporate these into your care plans? How do you refer patients to them? How can you build an ongoing working relationship with the organisation and its staff? Are there activities you can get involved in?
Find a local or national Aboriginal and Torres Strait Islander health or social justice campaign (eg Close the Gap campaign, National Sorry Day). Learn more about it and develop a deeper understanding of the community and the challenges they might face.
  • As a group, discuss the challenges the community faces (in relation to the campaign). How does learning about this campaign make you feel? What new understanding do you have about the historical and contemporary lived experience of Aboriginal and Torres Strait Islander peoples?
  • What type of advocacy skills would be helpful for you to develop? Consider these in relation to your work with individual patients, and also how you might get involved at a systemic level.
With a friend or family member

With a friend or family member, attend an Aboriginal and Torres Strait Islander gallery exhibition, watch a movie, performance, or documentary, or listen to some poetry or music, to expand your knowledge of the lived experience of Aboriginal and Torres Strait Islander peoples. TV networks and mobile phone apps often have search functions for Aboriginal and Torres Strait Islander content, or do an internet search to find what is available in your local area. Your supervisor, cultural mentor, cultural educator, or medical educator might have some excellent suggestions of resources you can engage with.

  • What ideas were new or challenging for you? What ideas were new or challenging for your friend or family member? Did their response surprise you in any way?
  • Talk about where our understanding of Aboriginal and Torres Strait Islander communities and experiences comes from.
  • How has your learning about colonisation and anti-racism changed how you consume media?
  • How would you approach a conversation about racism and privilege with your friend or family member? 

Participate in the annual national days of importance to Aboriginal and Torres Strait Islander peoples, for example, NAIDOC Week or National Sorry Day.

  • Ask your friend or family member what their understanding is of these national days. Are there events that either of you were not familiar with? Discuss why you think this might be. Were you surprised by your friend’s response?
  • Research the history of a day or event and discuss your learning together. Discuss what is important to you about being a part of these events and what you will do to participate. 

On your next holiday in Australia, take part in a cultural tourism activity run by the Traditional Owners of the local Country you are visiting.

  • What is the name of the Country and Traditional Owner group(s) of the place you visited? What did you learn about local history, cultural/sacred sites, traditions and kinship?
  • How did it feel to experience a holiday destination from a different point of view?
  • What local language words did you pick up?

Instructions

These are examples of topic areas for this unit that can be used to help guide your study.

Note that this is not a complete or exhaustive list, but rather a starting point for your learning.

  • Develop:
    • an openness and desire to learn about Aboriginal and Torres Strait Islander health, from a place of cultural humility
    • a holistic approach to healthcare that incorporates social, emotional, physical, spiritual and cultural aspects
    • respect for, and willingness to learn from, cultural mentors and cultural educators
    • an understanding of your own cultural identity, cultural lens and worldview, beliefs, values, behaviours and communication styles, and how these impact consultations and relationships with Aboriginal and Torres Strait Islander patients, staff and community members
    • an understanding of the culture and worldview of Western healthcare systems, and the impact of this on Aboriginal and Torres Strait Islander peoples’ healthcare experiences and access.
  • Practise anti-racism in healthcare by:
    • examining own conscious and unconscious biases and prejudices towards Aboriginal and Torres Strait Islander peoples and actively work to transform them
    • describing the negative impact of stereotyping on therapeutic relationships and Aboriginal and Torres Strait Islander health outcomes
    • recognising and act in response to witnessed interpersonal discrimination
    • recognising and addressing systemic discrimination within general practice and healthcare systems
    • recognising, and committing to mitigating, one’s own privilege as a non-Indigenous person, and power imbalances inherent within the patient–doctor relationship.
  • Understand and recognise population health considerations, such as:
    • relevant screening guidelines for a preventive health assessment for Aboriginal and Torres Strait Islander patients
    • the increased relative risks of certain health conditions within the Aboriginal and Torres Strait Islander community
    • the increased relative risk of chronic disease at a younger age
    • the increased relative risk of multimorbidity
    • the colonial and socioeconomic determinants of health, and explain how they underpin and drive differences in healthcare access and health inequities:
      • colonial:
        • systemic and interpersonal racism
        • exclusion and marginalisation from access to socioeconomic opportunities
        • disempowerment and lack of self-determination/self-governance
        • forced removal of children and disruption of families (Stolen Generations, child protection)
        • intergenerational trauma
        • forced loss of language and cultural practices
        • disproportionate incarceration rates (racial profiling within law enforcement)
      • socioeconomic:
        • housing pressures
        • income and employment
        • education
        • understand local barriers to accessing healthcare (eg transport, geography, availability of Aboriginal and Torres Strait Islander-specific healthcare services, cultural safety of local primary healthcare and social services), and describe approaches to mitigating these factors.
  • Use a strengths-based approach in all aspects of Aboriginal and Torres Strait Islander health:
    • Describe cultural determinants of health, and appreciate their benefit in enhancing and maintaining health and wellbeing:
      • family and kinship
      • traditional languages, including language revitalisation
      • cultural practices, traditions, ceremony, spirituality, lore and law
      • connection to Country
      • resilience and survival (of colonisation).
  • Understand cultural safety, including:
    • how a lack of cultural safety at individual and systemic levels acts as a significant barrier to healthcare access
    • the measures that can be implemented in general practice and primary healthcare to improve cultural safety, including but not limited to:
      • creating a welcoming environment
      • giving an Acknowledgement of Country (and know how this differs to a Welcome to Country)
      • cultural safety training for all staff
      • ensuring all staff know of, and routinely use, relevant Aboriginal and Torres Strait Islander clinical and preventive health guidelines
      • registering the clinic for the Practice Incentives Program – Indigenous Health Incentive (PIP IHI)
      • accurately recording Aboriginal and Torres Strait Islander identity in patient records (and having culturally appropriate and respectful policy, procedures and training in place to ensure this)
      • ensuring staff know of, and routinely offer patients access to, relevant Aboriginal and Torres Strait Islander-specific MBS and PBS items; for example:
        • Aboriginal and Torres Strait Islander MBS health checks and subsequent access to allied health services and Aboriginal and Torres Strait Islander healthcare providers
        • Closing the Gap PBS Co-Payment Program
        • Aboriginal and Torres Strait Islander PBS eligibility for medicines
    • appreciate the diversity of Aboriginal and Torres Strait Islander peoples and cultures, and know that what is appropriate in one community might not be appropriate in another.
  • Use effective communication skills; for example:
    • respectfully ask all patients about their Aboriginal and Torres Strait Islander identity and explain why this is important, and be aware of the complex historical and contemporary contexts in which people interact with questions about identity
    • develop trust and rapport with Aboriginal and Torres Strait Islander patients and understand the time and skill that this takes
    • use appropriate terminology in reference to Aboriginal and Torres Strait Islander peoples, including community preference for naming protocols for local language/tribe/group/nation
    • know the name of the Traditional Owner group(s) of the land on which you live and work
    • know about local Aboriginal and Torres Strait Islander language and words in common use (eg Sorry Business, men’s and women’s business, deadly, mob, yarning) and how these might differ across Australia
    • appreciate the importance of tailoring communication to the local context, including:
      • understand and use cultural communication styles, including verbal and non-verbal cues (eg use of silence, eye contact, indirect communication), and know where and when these are appropriate or not appropriate; know how these differ to your own cultural communication styles and how to be adaptive
      • work with Indigenous language interpreters if patients do not speak English as a first language, and recognise the challenges of working with them, including lack of access to appropriately trained interpreters in all Indigenous languages, lack of linguistic knowledge to translate medical concepts into Indigenous languages, and poor understanding of even commonly used English health words, despite good conversational translation ability
      • use health promotion materials that are appropriate and tailored to the local community
    • appreciate the diversity of health beliefs and the use of traditional medicines; consider how these might differ from biomedical health frameworks and consider patients’ biomedical health literacy; navigate the impact of this diversity on presentation, diagnosis and management plans
    • understand the diversity of cultural protocols, including gender considerations, death and dying, kinship structures, and cultural and family obligations, and be aware of those locally relevant to your practice
    • incorporate the sociocultural context into history-taking, assessment and shared management plans, and respond appropriately to patient preferences, priorities and needs
    • appreciate the impact of miscommunication on health outcomes.
  • Understand the importance of partnerships:
    • describe the unique role of, and develop effective working relationships with:
      • Aboriginal community controlled health organisations (ACCHOs) and Aboriginal medical services (AMS) (including knowing the difference between these types of organisations)
      • Aboriginal and Torres Strait Islander liaison officers
      • Aboriginal and Torres Strait Islander health practitioners and health workers
      • Indigenous language interpreters
    • know appropriate local referral pathways for patients to access primary and allied healthcare and social services specific to Aboriginal and Torres Strait Islander communities
    • understand the importance of family, kinship and community for Aboriginal and Torres Strait Islander people, and incorporate family-centred care into practice, where appropriate
    • be aware of the role of peak Aboriginal and Torres Strait Islander health organisations, including:
      • National Aboriginal Community Controlled Health Organisation (NACCHO) and state and territory affiliates
      • Australian Indigenous Doctors’ Association (AIDA)
      • Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINAM)
      • Indigenous Allied Health Australia (IAHA)
      • National Association of Aboriginal and Torres Strait Islander Health Workers and Practitioners (NAATSIHWP)
      • Indigenous General Practice Registrar Network (IGPRN).
  • Advocate for Aboriginal and Torres Strait Islander peoples by:
    • understanding the impact of local and national historical events, and contemporary local, state and federal government policies on local community self-determination and wellbeing, and the flow-on effects on engagement with healthcare services
    • supporting and promoting self-determination, community involvement, self-governance, and local Aboriginal and Torres Strait Islander models of primary healthcare
    • appreciating the importance of allies in advocating for improvement in health equity and social justice
    • understanding the policies and laws that promote health equity and address colonial and socioeconomic determinants of health; being familiar with the National Aboriginal and Torres Strait Islander Health Plan 2013–2023
    • engaging with and supporting community initiatives and participating in days of national importance, such as Sorry Day, NAIDOC Week, Close the Gap Day and Reconciliation Week
    • understanding the importance of workforce parity for Aboriginal and Torres Strait Islander doctors, nurses, allied health and ancillary staff, and committing to providing culturally safe workplaces for Aboriginal and Torres Strait Islander colleagues.  
  • Be aware of issues relating to research:
    • the historical research harm done to Aboriginal and Torres Strait Islander communities, and the ongoing impact of these on contemporary research
    • the Australian Institute of Aboriginal and Torres Strait Islander Studies (AIATSIS) Code of Ethics for Aboriginal and Torres Strait Islander Research.

Instructions

The following list of resources is provided as a starting point to help guide your learning only and is not an exhaustive list of all resources. It is your responsibility as an independent learner to identify further resources suited to your learning needs, and to ensure that you refer to the most up-to-date guidelines on a particular topic area, noting that any assessments will utilise current guidelines.

Journal articles
In-depth qualitative research on Aboriginal perspectives on how GPs can develop cultural safety in their practices. Current thinking on culturally safe practice. How Aboriginal and Torres Strait Islander patients perceive communication in healthcare, the role of communication in reinforcing or removing power imbalances, and culturally safe approaches to communication. A useful article for supervisors and medical educators that provides context for the foundations of Aboriginal and Torres Strait Islander health education. A useful article for supervisors and medical educators on important factors to support learning in Aboriginal and Torres Strait Islander health.
Textbooks
A framework for creating a culturally safe environment and enhancing health outcomes.
  • Taylor K, Guerin P. Health Care and Indigenous Australians: Cultural safety in practice, 3rd edn. UK:Macmillan Science & Educ. 2019. (Available from the RACGP library.)
The relationship between the social and political environment and health. Essential reading for anyone working in Aboriginal and Torres Strait Islander health. 
  • Carson B, Dunbar T, Chenhall RD, Bailie R, editors. Social determinants of Indigenous health. Crow’s Nest, NSW: Allen & Unwin, 2007. (Available from the RACGP library.)
Best practice clinical and policy management of the major health problems facing Aboriginal and Torres Strait Islander peoples. A definitive guide.
  • Couzos S, Murray R. Aboriginal primary health care: An evidence-based approach. Oxford University Press, 2008. (Available from the RACGP library.)
The evidence for the impact of racism on health.
Online resources
Comprehensive, gold standard guidelines for preventive health activities for Aboriginal and Torres Strait Islander peoples. Templates for undertaking a health check in various age groups. Resources to help general practice clinics implement cultural safety practices, policies and procedures. A brief guide to understanding identity and asking the question, ‘Are you of Aboriginal or Torres Strait Islander origin?’. A guide to appropriate and respectful behaviour with Aboriginal and Torres Strait Islander peoples, including background information and guidance on Aboriginal and Torres Strait Islander perspectives, and understanding important protocols and other cultural issues. Evidence-based information and resources for providing healthcare in Aboriginal and Torres Strait Islander communities. Resources to understand the lived experiences of the Stolen Generations, and strategies for working safely with Stolen Generation survivors.
Learning activities
gplearning has many valuable learning resources for this unit. Search by ticking ‘Aboriginal and Torres Strait Islander health’ under topics. Modules include a comprehensive introduction to Aboriginal and Torres Strait Islander cultural awareness.
  • The Royal Australian College of General Practitioners. gplearning.
Webinars on Aboriginal and Torres Strait Islander healthcare.
  • The Royal Australian College of General Practitioners. RACGP Events.
Other
The RACGP Aboriginal and Torres Strait Islander Health faculty is a network of GPs with a special interest in Aboriginal and Torres Strait Islander health. It has a focus on policy and advocacy, education, resources and supporting the work of the RACGP to be culturally safe.
Back to units Report issue for this unit

Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/aboriginal-and-torres-strait-islander-health 27/09/2022