“Too many white Australians think the door opens to opportunity from the outside, when you’ve got to be let into the door from the inside’.
Noel Pearson, Aboriginal activist, The Australian, 7 May 2015. (Bita, 2015)
“ The ‘AHW’ role was first established in the Northern Territory and recognized by the Western health system in the 1950s (Topp et al., 2018).
It was formally incorporated into Australia’s national health system in 2008 (National Aboriginal and Torres Strait Islander Health Worker Association, 2016).
Individuals can become an AHW if they are pursuing or hold a Certificate III, IV or higher degree diploma in, for example, primary health care, public health or a specific area of practice such as mental health.
In the mainstream health care sector, AHWs serve in ‘health worker’ or ‘outreach’ roles, providing clinical services, community outreach and education to improve access, health outcomes and the cultural appropriateness of services (McDermott et al., 2015).
Some also have specified AHW positions in prevention and health promotion. But the delivery of Indigenous health promotion in Australia is best exemplified by the work of Aboriginal Community Controlled Health Organisations (ACCHOs).
ACCHOs are primary health care services operated by the local Aboriginal community that they serve (NACCHO, 2018).
Their approach to providing comprehensive and culturally competent services draws on the cultural knowledge, beliefs and practices of their communities, and aligns with the Ottawa Charter principles aimed at enabling communities to take control of their own health care needs (WHO, 1986).
AHW positions within ACCHOs may, therefore, reflect the full range of role types outlined in Table 1.
It is primarily within ACCHO-developed community programmes that other types of CHW roles and models for their delivery have been implemented, for example, lay-leader or peer-to-peer education models (McPhail-Bell et al., 2017).
Yet many of these initiatives are only documented in programme reports within the ‘grey literature’ with much of the work undertaken in Aboriginal health promotion remaining under-researched and underreported ”
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MALLEE District Aboriginal Services (MDAS) is on the hunt for a “deadly hero” who will be the face of a campaign to encourage more Indigenous residents to visit the service for regular health check-ups.
MDAS regional tackling indigenous smoking worker Nathan Yates said the overarching aim of the campaign was to boost the health of the local indigenous population.
“Deadly Choices in our terminology is about making a good choice so for this it’s about making really healthy lifestyle choices because it’s all about trying to bridge the gap between life expectancy of indigenous and non-indigenous people,” Mr Yates said
Despite a clear need, ‘closing the gap’ in health disparities for Aboriginal and Torres Strait Islander communities (hereafter, respectfully referred to as Aboriginal) continues to be challenging for western health care systems.
Globally, community health workers (CHWs) have proven effective in empowering communities and improving culturally appropriate health services.
The global literature on CHWs reflects a lack of differentiation between the types of roles these workers carry out.
This in turn impedes evidence syntheses informing how different roles contribute to improving health outcomes.
Indigenous CHW roles in Australia are largely operationalized by Aboriginal Health Workers (AHWs)—a role situated primarily within the clinical health system.
In this commentary, we consider whether the focus on creating professional AHW roles, although important, has taken attention away from the benefits of other types of CHW roles particularly in community-based health promotion.
We draw on the global literature to illustrate the need for an Aboriginal CHW role in health promotion; one that is distinct from, but complementary to, that of AHWs in clinical settings.
We provide examples of barriers encountered in developing such a role based on our experiences of employing Aboriginal health promoters to deliver evidence-based programmes in rural and remote communities.
We aim to draw attention to the systemic and institutional barriers that persist in denying innovative employment and engagement opportunities for Aboriginal people in health.
Kirstin Kulka prepares fruit and salad wraps for children at Coen.
Aboriginal and Torres Strait Islander cultures in Australia are acknowledged to be the oldest living cultures in the world (Australian Government, 2017a), maintaining thriving and diverse communities for over more than 60 000 years, and implementing land management practices that are exemplary in their sustainability and productivity (Pascoe, 2018).
Hereafter, we use the term Aboriginal to describe the many different clans that make up this diverse peoples, including those from the Torres Strait. Following the British invasion and subsequent colonization of Australia, Aboriginal people across the nation suffered a sudden and complete rupture to all aspects of life including kinship, language, spirituality and culture.
The resulting health disparities experienced by Aboriginal people since colonization, and the inequalities that contribute to them, are well documented (AIHW, 2015). Despite the preponderance of evidence as to these inequities there has been only marginal progress in implementing effective strategies to improve health (McCalman et al., 2016).
Not enough research has focused on how Aboriginal knowledge is reflected in health programmes and services, and there are continued calls for Aboriginal people to be leaders of health-promoting endeavours (National Congress of Australia’s First People, 2016; NHMRC, 2018).
However, combatting systemic racism and reorienting the institutions of the dominant non-Aboriginal culture—i.e. government, health care, education—to include Aboriginal people in decision making and to enable their leadership is proving to be an ongoing challenge in both global and local health settings (George et al., 2015). The opening quote of this paper draws attention to this often-contested issue.
Community ownership of decision making for health has long been recognized as key to addressing the social determinants of health that underlie health disparities (WHO, 1978). Internationally, community health workers (CHWs) enable community involvement in health systems—particularly among minority communities—and contribute to positive health outcomes in a variety of settings (Goris et al., 2013; Kim et al., 2016).
In the USA, for example, the Indian Health Service has funded American Indian ‘Community Health Representatives’ since 1968 (Satterfield et al., 2002).
These health workers provide links between communities and health services, and build trust, relationships and culturally appropriate education and care. Maori CHWs play a similar bridging role in New Zealand by linking community members with health interventions and clinical services, providing health education and also working alongside traditional healers and supporting tribal development (Boulton et al., 2009).
In Australia, CHWs are largely operationalized as Aboriginal Health Workers (AHWs), although there is considerable variation in the kinds of roles they perform. The result is that some AHWs experience inflated role expectations that can contribute to unmanageable workloads and stress, reduced job satisfaction, and barriers to integration with other members of the health workforce (Bailie et al., 2013; Schmidt et al., 2016).
Yet variations in role definition for CHWs, and the associated problems, are not unique to Australia (Topp et al., 2018) and are well documented in the broader global CHW literature (Olaniran et al., 2017; Taylor et al., 2017). This variation is problematic as it impedes research into how CHWs influence health outcomes.
In this paper, we explore the lack of differentiation in the global literature between the types of CHW roles both internationally and within the Australian context. Differentiating the various types of CHW roles has enabled us to articulate the need for a specific community health promotion role, one that is distinct from, but complementary to, that of AHWs in clinical settings.
The impetus for writing this paper came from the experiences of two of the authors (NT and JG), an Aboriginal and a non-Aboriginal woman, who have worked in partnership for more than 15 years delivering and evaluating health promotion programmes in Australia.
The challenges we experienced in creating Aboriginal CHW-type positions within two mainstream health promotion programmes caused us to question whether the focus on AHW roles had created unintended barriers to involving Aboriginal people in other opportunities to address health.
By detailing our experience in creating community-based, Aboriginal CHW positions in health promotion, we aim to draw attention to the systemic and institutional barriers that impede expanding employment opportunities for Aboriginal people wanting to work in health.
The National Tackling Indigenous Smoking Workers Workshop was held from Tuesday 2 April to Thursday 4 April 2019 in Alice Springs. This workshop was one of the largest gatherings of TIS workers, partners, experts and supporters of the TIS program.
CHWs AND AHWs
Broadly, CHWs are individuals who may or may not be paid, who work towards improving health in their assigned communities and who often share some of the qualities of the people they serve. These may include similar cultural, linguistic or demographic characteristics; health conditions or needs; shared experiences or simply living in the same area.
However, the degree to which CHWs demographic or experiential profiles ‘match’ the target population also varies. And while most bring cultural and community knowledge to the role, many CHWs have little or no training in Western medicine or in navigating its health systems prior to becoming CHWs (Olaniran et al., 2017).
There is less agreement on the specifics of the CHW role including what they do, how they are trained, how these parameters link to outcomes, and even the titles they are given. One review evidenced 120 terms used to describe CHW roles including variants of ‘lay health educators’, ‘community health representatives’, ‘peer advisors’ and ‘multicultural health workers’ (Taylor et al., 2017).
Syntheses of literature on CHWs illustrate that the tasks they undertake are highly varied but often inadequately or inconsistently defined (Jaskiewicz and Tulenko, 2012; Kim et al., 2016). These issues, coupled with a general lack of contextual information about the role of CHWs, make it difficult to determine patterns or predictors of success.
This lack of clarity is documented as an ongoing barrier to the sustainability of CHW programmes, sometimes causing negative impacts on the workers themselves including burnout due a lack of appropriate training and mentoring support (Jaskiewicz and Tulenko, 2012; Schmidt et al., 2016). One review concluded that ‘the [CHW] role can be doomed by overly high expectations, lack of clear focus, and lack of documentation’ [(Swider, 2002), p. 19].
Previous research has classified CHW roles into typologies of main tasks and activities performed (Olaniran et al., 2017; Taylor et al., 2017). These include providing: (i) social support, (ii) clinical care, (iii) service development and linkages, (iv) health education and promotion, (v) community development, (vi) data collection and research and (vii) activism.
In practice, CHW activities overlap substantially, and tasks regularly extend across categories—both formally and informally (Jaskiewicz and Tulenko, 2012). In Table 1, we present different CHW role types alongside the theoretical models that underpin each.
Linking roles to theory can help differentiate and specify the mechanisms by which CHWs are meant to influence health through the core tasks they perform, and the specific skills related to each task.