In Australia, health inequalities continue to create a disadvantage for Aboriginal and Torres Strait Islander people despite generally higher standards of healthcare in place. The paper will discuss a range of strategies and principles that aim to eliminate and reduce the health inequalities experienced by First Nations people.
Part 1: Role of ACCHSs
Self Determination and ACCHSs
The right to self-determination is widely accepted as a human right and carries a particular application in the case of Aboriginal and Torres Strait Islander people. It is an on-going process which involves affirming the right to manage one’s own affairs, make one’ own decisions, and to decide one’s own nature and pace of future development CITATION Rob04 \l 1033 (Roberts, 2004). It provides the First Nation's people with an ongoing process of decision-making in a manner which ensures that the people's cultural, social, and economic needs are met. Moreover, the right to self-determination acknowledges the fact that Aboriginal and Torres Strait Islander people are Australia’s first nation and their right to live according to their own beliefs and common values has to be respected by everyone. It serves as a critical factor in enabling the First Nation’s people to overcome the legacy of dispossession and colonization, and thereby eliminate inequalities CITATION AHR13 \l 1033 (AHRC, 2013).
The Aboriginal Community Controlled Health Services (ACCHS) in Australia are based on the principle of self-determination and are grounded on the idea that the only means of solving the health inequality crisis is to enable local Indigenous communities to control their own affairs. As a result, the health services offered by local ACCHSs are grounded upon local Indigenous approaches towards preventative and primary health care in a manner which redresses the power imbalance that resulted from colonization, and approaches healthcare from an Aboriginal perspective and understanding CITATION Ode16 \l 1033 (Mazel, 2016). The ACCHS provides community support, primary clinical care, advocacy, and special needs programs that focus on cultural complexities in a way which is not catered to by mainstream health services. Thus local needs, cultures, and priorities underpin ACCHS services to achieve favourable outcomes for the First Nations CITATION Mic133 \l 1033 (Weightman, 2013).
ACCHSs improving local health outcomes
The Dandenong and District Aborigines Co-operative Ltd (DDACL) is an ACCHS centre in Dandenong, Victoria which was established by local Indigenous families in the area to address the changing needs of the Koori community. The Yarning Group runs a DDACL anti-smoking program which organizes weekly sessions to support and encourage the local Indigenous community to quit smoking or to continue their status as ex-smokers. The program involves experts and health professionals to educate members of the community and to provide them with a culturally safe and supportive space with special access to resources and quit educators CITATION DDA14 \l 1033 (DDACL, 2014). Smokers are supported and assisted during their quit journey, and other ex-smokers help enable other community members to maintain quit status and reduce social isolation for the people.
Several studies highlight the necessity of smoking cessation interventions to bridge health inequality gaps between Australia’s native and non-native population CITATION Gil091 \l 1033 (Gould, McGechan, & Zwan, 2009). Indigenous people suffer from disproportionate rates of smoking-related diseases compared to the non-native population which underscores the need to develop collaborative and culturally acceptable and appropriate interventions for the Indigenous communities as the DDACL yarning group aims to achieve CITATION Mic112 \l 1033 (DiGiacomo, et al., 2011). Effective strategies in this regard include expert advice on smoking cessation, nicotine replacement pharmacotherapy, multi-component anti-tobacco programs and culturally training health professionals to deliver culturally appropriate cessation advice CITATION Row11 \l 1033 (Ivers, 2011).
Part 2: Role of Hospitals
Action 1.2 of the NSQHS Clinical Governance Standards states that “The governing body ensures that the organization’s safety and quality priorities address the specific health needs of Aboriginal and Torres Strait Islander people” CITATION ACS171 \l 1033 (ACSQHC, 2017). For this purpose, hospital management and governing bodies should review demographic profiles of their indigenous patient’s population and track the health issues faced by their communities to inform their strategies and decision to address the special needs of the First Nation’s People. Moreover, Aboriginal and Torres Strait Islander communities, as well as providers, should be consulted for devising referral processes, and any performance data and figures related to the number of patients under care must be periodically reviewed to remain abreast of any changes in their needs CITATION ACS171 \l 1033 (ACSQHC, 2017).
Implementing these strategies will benefit the Aboriginal and Torres Strait Islander people by meeting their Individual needs to improve patient experiences and outcomesCITATION Mar081 \l 1033 (Marmot, Friel, Bell, Houweling, & Taylor, 2008). It will create an atmosphere of engagement for communities and create a sense of being valued, while also changing the perception of hospitals as places of trauma by the Indigenous people CITATION Pat10 \l 1033 (Dudgeon, 2010). Moreover, they will see their unique advice informing health care processes and see their local priorities aligned with that of the state. In addition, it will also promote effective use of resources as Indigenous communities will be keener to participate and engage in care processes.
The Action 2.13 of the NSQHS standards involves working in partnerships with consumers and requires “building effective and ongoing relationships with Aboriginal and Torres Strait Islander communities, organizations and groups that represent or service this population” CITATION ACS171 \l 1033 (ACSQHC, 2017). In this respect, hospitals should attempt to promote a better understanding of Indigenous populations within the organizational catchment and referral system. This would require engaging Aboriginal and Torres Strait Islander liaison services under discussions alongside other health workforce personnel and Indigenous health organizations. Furthermore, the hospitals should review important performance measures with regards to Aboriginal and Torres2 Strait Islander health promotion and wellbeing for their organization by collecting information on their discharge rates, health status, unplanned re-admissions and re-presentations to emergency departments. In addition, hospitals should partner with Indigenous organizations and services by obtaining advice on maintaining relationships, appropriate processes, and developing partnerships with the Indigenous community representatives and local workforce. Hospitals can further engage Indigenous organizations to agree on mechanisms, responsibilities, and structure of their partnerships which aims to promote effective communication and mutually beneficial and sustainable relationships with the organizations CITATION NSQ18 \l 1033 (NSQHS, 2018).
The implementation of these strategies will bring about a range of benefits for Aboriginal and Torres Strait Islander communities and health services by firstly improving communication between the community and health service organization and promoting a better understanding of hospital processes and systems within Indigenous communities CITATION Org14 \l 1033 (Howitt, et al., 2014). In addition, it will enhance compliance with care plans and treatment programs and improve the overall health literacy of the communities. More importantly, it will preserve and enhance the self-determination of the Indigenous communities as their leaders’ and organizations’ perspectives are integrated into health services which will help promote a greater sense of connection between the people and the health care organization, while also fostering cultural brokerage among various groups of people CITATION Lia16 \l 1033 (Liaw, Wade, Lau, Hasan, & Furler, 2016).
Part 3: The role of individual nurses and midwives
Delivering culturally safe care will involve nurses and midwives follow two important principles of cultural safety. Among these principles, seeking to minimize power differentials is particularly important because the relationship between patients and nurses is one in which power plays an important contributive role, especially in influencing the ability of the nurses to delivery culturally safe care to Indigenous communities. Power imbalance may occur intentionally or unintentionally, therefore nurses should remain aware of how power balance can shift within the practice setting. For instance, the use of terms such as ‘non-compliant’ by nurses implies that the patient is not following the instruction of the nurse, yet, the term itself indicates an imbalance between the nurse and the patient’s power CITATION Ker12 \l 1033 (Taylor & Guerin, 2012). Thus, nurses and midwives should prevent the use of terms that emphasize a sense of power over Indigenous clients. Secondly, nurses should be trained to minimize power differentials by creating a greater acceptance within them regarding combined therapy, developed by Indigenous communities, and its efficacy. This would involve fostering recognition of the value of traditional healing and health-promoting elements with medicinal properties such as eucalyptus oil and tea tree oil, that have been in use to treat certain illnesses and infections effectively for a long period of time. Thus the acknowledgement of Indigenous practices remains a powerful strategy in minimizing power imbalance between the nurse and the Indigenous patient.
Implementing these strategies would create greater mindfulness among nurses with regards to delivering culturally safe care by minimizing a sense of power difference between Indigenous patients and nurses. Furthermore, Aboriginal and Torres Strait Islander communities that have previously been subject to a culturally unsafe form of care in hospitals will be likely to have their expectations regarding health care changed. It would promote a sense of connection with the provider as they will not feel their values, attitudes, and beliefs challenged or ignored by their care providers, and will consequently also accept using a combination of traditional and Western medicine as treatment.
The second important principle with respect to delivering culturally safe care is to "undertake a process of decolonization". Implementing this principle will involve acknowledging that the process of colonization has been detrimental to the health of indigenous populations and that the effects of the colonization have to be challenged and eliminated in favour of complete self-determination for the Aboriginal and Torres Strait Islander people. In this regard, nurses should be trained to appreciate the value of traditional Indigenous practices and to reclaim these practices where appropriate. Besides acknowledging the role of colonization, nurses should be taught the history of the Indigenous people and communities, alongside their own personal history and the history of the health care system in which they would work in. It will also involve learning about the impact of that history on consumer health, which will help nurses affirm the notion that both health models are equally good and complementary to one another. The use of alternative health care services, where appropriate, would also be promoted while inculcating the importance of nurse advocacy for the First People’s right of self-determination CITATION Ode14 \l 1033 (Best & Fredericks, 2014).
Implementing these strategies would begin the process of decolonizing the attitudes, mindsets, and practices of health care providers, foster better understandings of alternate health systems, and enable the development of collaborate models of healthcare which can combine between indigenous health care and medicine, with modern western medicine in managing the care of patients CITATION Sim18 \l 1033 (Nemutandani, Hendricks, & Mulaudzi, 2018). Finally, a decolonized attitude towards healthcare would enable nurses to deliver culturally safe and appropriate care to First Nations’ people in a more sensitive and effective manner.
BIBLIOGRAPHY ACSQHC. (2017). National Safety and Quality Health Service Standards Guide for Hospitals. Sydney NSW: Australian Commission on Safety and Quality in Health Care.
AHRC. (2013, April 30). Right to self determination. Retrieved June 21, 2019, from Human Rights: https://www.humanrights.gov.au/our-work/rights-and-freedoms/right-self-determination
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Nemutandani, S. M., Hendricks, S. J., & Mulaudzi, M. F. (2018). Decolonising the mindsets, attitudes and practices of the allopathic and indigenous health practitioners in postcolonial society: An exploratory approach in the management of patients. African journal of primary health care & family medicine, 10(1), 1518-1525.
NSQHS. (2018, May 28). Action 2.13: Working in partnership. Retrieved June 20, 2019, from User Guide for Aboriginal and Torres Strait Islander Health: https://nationalstandards.safetyandquality.gov.au/topic/user-guide-aboriginal-and-torres-strait-islander-health/action-213-working-partnership
Roberts, D. (2004). Self-determination and the Struggle for Equality. In C. Bourke, E. Bourke, & B. Edwards (Eds.), Aboriginal Australia, An Introductory Reader in Aboriginal Studies (2nd ed.). St. Lucia, QLD: University of Queensland Press.
Taylor, K., & Guerin, P. (2012). Health care and indigenous Australians: cultural safety in practice. South Yarra, VIC: Palgrave Macmillan.
Weightman, M. (2013, July 24). The role of Aboriginal Community Controlled Health Services in Indigenous health. Retrieved June 20, 2019, from Australia Medical Student Journal: http://www.amsj.org/archives/3012
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