NACCHO Aboriginal Health #Racism and #CulturalSafety : Has the The Ways of Thinking and Ways of Doing #WoTWoD  program designed to improve cultural respect in general practice and improve health outcomes for Aboriginal patients failed

“Cultural respect reflects the attitudes and behaviour of the entire medical practice, from reception to consulting room.

In addition, general practice organisations must work in partnership with Indigenous community-controlled organisations to reduce health care disparities, address social determinants of poor health, and increase access to safe, effective and culturally respectful care. ” 

 Professor Siaw-Teng Liaw, professor of General Practice at the UNSW Sydney and and colleagues 

A YEAR-long program designed to improve cultural respect in general practice and improve health outcomes for Aboriginal patients, has failed to either increase the rate of Indigenous health checks or improve cross-cultural behaviours, according to the authors of research published in the Medical Journal of Australia.

Download 6 page copy of research 

Cultural respect in general practice

Read full report online at MJA 

Cover : The painting created for the Ways of Thinking and Ways of Doing (WoTWoD) study by Ashley Firebrace, a Wurundjeri man from Melbourne.

With the majority of Australia’s Aboriginal population living in cities, suburban doctors’ clinics are part of the front-line effort to close the gap in health inequalities.

There are efforts to improve the way general practices treat Indigenous patients, but progress is slow.

A new study into a program designed to make GP clinics more culturally sensitive has found little improvement after 12 months.”

ABC Radio AM Interview with Janine Mohammed. interim chief executive, Lowitja Institute : Teng Liaw, professor of general practice, University of New South Wales and Dr Tim Senior, Aboriginal and Torres Strait Islander health medical advisor, Royal Australian College of General Practice and GP, Tharawal Aboriginal Medical Service

Listen HERE 3 Minutes


Read over 50 Aboriginal Health and Cultural Safety articles here  

The Ways of Thinking and Ways of Doing (WoTWoD) program was developed by a team led by Professor Siaw-Teng Liaw, professor of General Practice at the UNSW Sydney and the Ingham Institute of Applied Medical Research.

It was designed to “translate the systemic, organisational, and clinical elements of the Australian Health Ministers’ Advisory Council Cultural Competency Framework into routine clinical practice”.

The WoTWoD program includes “a toolkit [comprising 10 scenarios that illustrate cross-cultural behaviour in clinical practice], one half-day workshop, cultural mentor support for the practice, and a local care partnership of participating Medicare Locals/PHNs and local ACCHSs for guiding the program and facilitating community engagement”.

In evaluating the program, Liaw and colleagues introduced WoTWoD to 28 intervention general practices and compared the results after 12 months with 25 control practices.

After 12 months “the rates of MBS item 715 claims (health assessment for Aboriginal and Torres Strait Islander People) and recording of risk factors for the two groups were not statistically significantly different, nor were mean changes in cultural quotient scores, regardless of staff category and practice attribute”.

Liaw and colleagues wrote that the negative results may be attributable to “variability in the fidelity of the intervention, especially the local care partnership … the clinical and organisational reasons for low usage rate [of the MBS item 715] … and the length of the trial”.

“The length of the trial (12 months) may not have been sufficient to detect significant changes in professional practice dependent on organisational changes that require time to formulate and implement.

“Nevertheless, it is encouraging and promising that the data trends over the 12 months within each group were positive and participant perceptions of the WoTWoD were very positive.

“Further collaborative and participatory mixed methods research is required to examine the complexities of co-creating, implementing, and evaluating programs that integrate ‘thinking and doing’ cultural respect in the context of the changing needs and priorities of general practice and Indigenous communities,” Liaw and colleagues concluded.

The known: The gap in life expectancy between Indigenous and non‐Indigenous Australians remains large. Urban Indigenous Australian‐controlled health services are under‐resourced, and mainstream primary care services are often not culturally sensitive.

The new: A practice‐based cultural respect program — including a workshop and toolkit of scenarios, with advice from a cultural mentor, and guided by a care partnership of Indigenous and general practice organisations — did not significantly influence Indigenous health check rates or cultural respect levels.

The implications: Cultural respect programs may require more than 12 months to increase Indigenous health check rates and the cultural quotient scores of general practice clinic staff.

Closing the health and care gaps between Aboriginal and Torres Strait Islander (Indigenous) Australians and non‐Indigenous Australians has been a longstanding challenge.,

In 2018, a decade after Australian governments committed themselves to Closing the Gap, mortality and life expectancy for Indigenous Australians had not markedly improved, and nearly 80% of the difference in mortality between adult Indigenous and non‐Indigenous Australians was attributable to chronic disease.

The Practice Incentives Program–Indigenous Health Incentive (PIP‐IHI), introduced in May 2010, assists general practitioners undertake chronic disease care planning for their Indigenous patients. Initial uptake was poor: only 64% of general practices expected to register (1275 of 2000) did so during 2010–11. However, the proportion had increased by May 2012.

The rebate for health assessments for Aboriginal and Torres Strait Islander People (Medicare Benefits Schedule [MBS] item 715), constitutes an additional strategy for improving the access of Indigenous Australians to primary health care matched to their needs. GPs can engage suitably qualified practice nurses or Aboriginal Health Workers to assist with the assessment, including patient history‐taking, clinical examination and investigations, and with providing patients with education and resources for managing their own health.

The proportion of Indigenous Australians for whom payment for MBS item 715 was claimed increased from nearly 11% in 2010–11 to nearly 29% in 2016–17 (New South Wales, 26.8%; Victoria, 17.1%). However, the rate is still low and access to comprehensive care planning for Indigenous Australians is poor

Aboriginal Community Controlled Health Services (ACCHSs) are important providers of primary health care to Indigenous communities. However, most Indigenous Australians living in urban areas also use standard primary care and GP services.

In 2016, Indigenous Australians comprised 3% of the Australian population (744 956 people); 38% lived in New South Wales (229 951) or Victoria (53 663). About one‐third of Indigenous Australians live in major cities, but only 16 of 138 ACCHSs are in major cities; urban ACCHSs have lower staff/client ratios than regional and remote ACCHSs.

Indigenous Australians frequently encounter cultural disrespect in mainstream primary care services., The 2012–13 Australian Aboriginal and Torres Strait Islander Health Survey reported that 16% of Indigenous Australians had experienced racism in health settings; 20% of these respondents reported that doctors, nurses and other hospital or clinic staff were discriminatory, and 7% avoided seeking health care because of unfair treatment.

Of 755 adult Indigenous Victorians surveyed in 2011, 29% had experienced racism in health settings. Lack of cultural respect in health care restricts access to and reduces the quality of care for Indigenous Australians.

We have previously identified trust, access, flexibility, time, support, outreach, and working together as key aspects of cultural respect. Although the Indigenous Chronic Disease Package (2009–2014) supported increased cultural awareness training for health workers, it did not change attitudes or behaviour sufficiently to bridge the cultural gap between health professionals and Indigenous people.

We developed the Ways of Thinking and Ways of Doing (WoTWoD) cultural respect program with a trans‐theoretical approach, harmonising many similar conceptual frameworks and the terminology applied to Indigenous and cross‐cultural health in Australia. The theoretical underpinnings of WoTWoD were described in the article describing our pilot study. The WoTWoD framework translates the systemic, organisational, and clinical elements of the Australian Health Ministers’ Advisory Council Cultural Competency Framework into routine clinical practice. Cultural respect reflects the attitudes and behaviour of the entire medical practice, from reception to consulting room. In addition, general practice organisations must work in partnership with Indigenous community‐controlled organisations to reduce health care disparities, address social determinants of poor health, and increase access to safe, effective and culturally respectful care. This is fundamental to Indigenous Australians’ right to the highest standard of health.,

We undertook a cluster randomised controlled trial to examine whether the WoTWoD program improves clinically appropriate anticipatory care in general practice and the cultural respect of medical practice staff.


NACCHO Aboriginal Health and #Smoking : @TheMJA #npc Mass-reach #anti-smoking campaigns must return

Disadvantaged groups are and should be a key focus of action to reduce smoking further. This has long been recognised, including in the report of the National Preventative Health Taskforce, which specifically called for action in relation to Aboriginal and Torres Strait Islander people and other highly disadvantaged groups, such as people with mental health problems,”

The evidence tells us that we need a mix of approaches. We need whole-of-community approaches, with measures such as tax increases and strong mass media campaigns, which benefit disadvantaged groups disproportionately. We also need specific targeted approaches, as this article notes: the Talking About the Smokes project and the Tackling Indigenous Smoking program have played valuable role in complementing mainstream activity.”

 Professor Mike Daube, professor of health policy at Curtin University, welcomed calls for further action on smoking prevalence in disadvantaged groups, and said that a mix of approaches was needed. Professor Daube told MJA InSight.

Read over 100 NACCHO Smoking articles published in past 5 years

NACCHO Aboriginal Health and Smoking : Download Tackling Indigenous Smoking Program prelim. evaluation report

TARGETED tobacco control strategies are urgently needed to tackle the “remarkably high” smoking rates in some high-risk groups, according to Australian authors, but leading public health experts say reinstatement of mass-reach campaigns should be a priority.

Writing in the MJA, Professor Billie Bonevski, a health behaviour scientist and researcher at the University of Newcastle, and co-authors said that the overall smoking prevalence in Australia was now 14%, but among population subgroups, such as those with severe mental illness and those who had been recently incarcerated, the rates were upwards of 67%.

Tobacco use among Aboriginal and Torres Strait Islander people also remained high, with the prevalence among Indigenous people aged 15 years and older being about 39% in 2014–15.

Listen to Podcast HERE

The authors said that a truly comprehensive approach to tobacco control should include targeted campaigns in high smoking prevalence populations.

“If we are truly concerned about this issue, we must focus more attention on the groups that are being left behind,” they wrote.

Novel, targeted interventions and increased delivery of evidence-based interventions was needed, the authors said, noting that tobacco harm reduction strategies, such as vaporised nicotine, should also be further investigated.

In an MJA InSight podcast, lead author Professor Bonevski said that smoking was still “almost … socially acceptable” in some subgroups, such as those from low socio-economic populations.

“People who have lower incomes end up smoking from a younger age and, by the time they reach adulthood, they are more heavily nicotine dependent and … it becomes much harder to quit,” she said. “This is a vicious cycle in terms of socio-economic status contributing to high smoking rates, and then high smoking rates contributing to poor health, and then poor health keeping you in that low socio-economic status group, and so on.”

Professor Simon Chapman, Emeritus Professor in the University of Sydney’s School of Public Health, said that targeting high smoking prevalence subgroups sounded sensible “until we unpack what targeting involves”.

“The world-acclaimed, highly successful Australian national Quit campaign has been scandalously mothballed since 2013. So, talk of fracturing what is now a zero-budgeted, non-operational population-wide campaign into multiple targeted campaigns is currently a ‘brave’ call,” he said.

Professor Chapman said that Australia’s main goal should be to restore our “family silver”: properly funded, mass reach campaigns that reach all subgroups.

He pointed to research, published in 2014, that found that the decline in smoking prevalence in Australia – from 23.6% in 2001 to 17.3% in 2011 – was largely due (76%) to stronger smoke-free laws, tobacco price increases and greater exposure to mass media campaigns.

Professor Chapman said that higher smoking rates among disadvantaged groups were more likely to be explained by higher uptake, than by failure to quit.

He noted that 22.7% of the most disadvantaged people were ex-smokers, versus 26.9% of the least disadvantaged. “But only 53.5% of the least disadvantaged people have never smoked, compared with 62.9% of the most advantaged,” he said.

Professor Chapman said that labour-intensive interventions were inefficient in preventing uptake among young people.

“It remains the case that most kids who don’t start smoking and most smokers who quit do not attribute their status to a discrete intervention,” he said.

Professor Mike Daube, professor of health policy at Curtin University, welcomed calls for further action on smoking prevalence in disadvantaged groups, and said that a mix of approaches was needed.

See opening statement


Professor Daube said that strong action at the public policy and health system levels was crucial.

“At the policy level, this should include immediate resumption by the federal government of national mass media campaigns, which have, incomprehensibly, been absent over the past 4 years; and action to combat the tobacco industry’s cynical strategies to counter the impacts of tax increases and plain packaging,” he said.

“We also need more than lip service within health systems about the physical health of people with mental health problems, not least through support and assistance in quitting smoking. There are some who try, but they are the exception.”

Professor Daube said that the suggestion that vaporised nicotine may play a role in reducing smoking was “very speculative”, and still “some way ahead of the evidence”.

“[We] should await any determination by the [Therapeutic Goods Administration] as to their safety and efficacy,” he said.

Earlier in 2017, the TGA decided to uphold the ban on vaporised nicotine in e-cigarettes in Australia

NACCHO Aboriginal Health #NAIDOC2017 @TheMJA —Embedding cultural safety in Australia’s main health care standards

 ” Cultural safety requires embedding in not only course accreditation for each health profession — including measures to reduce resistance — but also in the standards governing clinical professionalism and quality, such as the Royal Australian College of General Practitioners Standards for general practices,19 and the Australian Commission on Safety and Quality in Health Care National safety and quality health service standards.20

Such commitment will need investment in clinician education and professional development, together with measures for accountability. The stewards of the National Aboriginal and Torres Strait Islander Health Plan5 (ie, the Department of Health and their expert implementation advisory group), accreditation bodies, and monitors of the existing frameworks of safety and quality standards in health care need to formally collaborate on a systematic revision of standards to embed culturally safe practice and develop health settings free of racism.”

Martin Laverty, Dennis R McDermott and Tom Calma

Originally published by MJA here

Download a PDF of this Report Paper for references 1-20

MJA Cultural Safety

Read 20 + previous NACCHO articles Cultural Safety  

In Australia, the existing health safety and quality standards are insufficient to ensure culturally safe care for Indigenous patients in order to achieve optimum care outcomes.

Where “business as usual” health care is perceived as demeaning or disempowering — that is, deemed racist or culturally unsafe — it may significantly reduce treatment adherence or result in complete disengagement,1,2 even when this may be life-threatening.3

Peak Indigenous health bodies argue that boosting the likelihood of culturally safe clinical care may substantially contribute to Indigenous health improvement.4 It follows that a more specific embedding of cultural safety within mandatory standards for safe, quality-assured clinical care may strengthen the currently inadequate Closing the Gap mechanisms related to health care delivery.

The causes of inequitable health care are many. Western biomedical praxis differs from Indigenous foundational, holistic attention to the physical, emotional, mental and spiritual wellbeing of the person and the community.5 An article published in this issue of the MJA6 deals with the link between culture and language in improving communication in Indigenous health settings, a critical component of delivering cultural safety.

Integrating cultural safety in an active manner reconfigures health care to allow greater equity of realised access, rather than the assumption of full access, including procession to appropriate intervention.

As an example of the need to improve equity, a South Australian study found that Indigenous people presenting to emergency departments with acute coronary syndrome were half as likely as non-Indigenous patients to undergo angiography.7 More broadly, Indigenous people admitted to hospital are less likely to have a procedure for a condition than non-Indigenous people.8

Cardiovascular disease is the leading cause of death in Indigenous Australians.9 Cancer is the second biggest killer: the mortality rate for some cancers is three times higher for Indigenous than for non-Indigenous Australians.10 Clinical leaders in these two disease areas have identified the need for culturally safe health care to improve Indigenous health outcomes.

Cultural safety is an Indigenous-led model of care, with limited, but increasing, uptake, particularly in Australia, New Zealand and Canada. It acknowledges the barriers to clinical effectiveness arising from the inherent power imbalance between provider and patient,11 and moves to redress this dynamic by making the clinician’s cultural underpinning a critical focus for reflection.

Moreover, it invites practitioners to consider: “what do I bring to this encounter, what is going on for me?” Culturally safe care results where there is no inadvertent disempowering of the recipient, indeed where recipients are involved in the decision making and become part of a team effort to maximise the effectiveness of the care. The model pursues more effective practice through being aware of difference, decolonising, considering power relationships, implementing reflective practice, and by allowing the patient to determine what safety means.11

Along with an emphasis on provider praxis, cultural safety focuses on how institutional care is both envisaged and delivered.12 Literature on cultural safety in Australia is scant but growing.13 Where evidence is available, it identifies communication difficulties and racism as barriers not only to access but also to the receipt of indicated interventions or procedures.11

There is evidence of means to overcome these barriers. An Australian study undertaken across ten general practices tested the use of a cultural safety workshop, a health worker toolkit, and partnerships with mentors from Indigenous organisations and general practitioners.13 Cultural respect (significant improvements on cultural quotient score, along with Indigenous patient and cultural mentor rating), service (significant increase in Indigenous patients seen) and clinical measures (some significant increases in the recording of chronic disease factors) improved across the participating practices.

In addition, a 2010 study by Durey14 assessed the role of education, for both undergraduate students and health practitioners, in the delivery of culturally responsive health service, improving practice and reducing racism and disparities in health care between Indigenous and non-Indigenous Australians. The study found that cultural safety programs may lead to short term improvements to health practice, but that evidence of sustained change is more elusive because few programs have been subject to long term evaluation..

Newman and colleagues10 identified clinician reliance on stereotypical narratives of indigeneity in informing cancer care services. Redressing these taken-for-granted assumptions led to culturally engaged and more effective cancer care. In a similar manner, Ilton and colleagues15 addressed the importance of individual clinician cultural safety for optimising outcomes, noting that provider perceptions of Indigenous patient attributes may be biased toward conservative care.

The authors, however, went beyond the clinician–patient interaction to stress the outcome-enhancing power of change in the organisational and health setting. They proposed a management framework for acute coronary syndromes in Indigenous Australians.

This framework involved coordinated pathways of care, with roles for Indigenous cardiac coordinators and supported by clinical networks and Aboriginal liaison officers. It specified culturally appropriate warning information, appropriate treatment, individualised care plans, culturally appropriate tools within hospital education, inclusion of families and adequate follow-up.

Willis and colleagues16 also called for organisational change as an essential companion to individual practitioner development. Drawing on 12 studies involving continuous quality improvement (CQI) or CQI-like methods and short term interventions, they acknowledged evidence gaps, prescribing caution, and argued for such change to be undertaken in the service of long term controlled trials, as these would require 2–3 years to see any CQI-related changes.

Sjoberg and McDermott,17 however, noted the existence of barriers to change: the challenge (personal and professional) posed by Indigenous health and cultural safety training may not only lead to individual but also to institutional resistance.17 Dismantling individual resistance requires the development of a critical disposition — deemed central to professionalism and quality18 — but in a context of strengthened and legitimating accreditation specific to each discipline. The barriers thrown up by institutional resistance, manifesting as gatekeeping, marginalisation or underfunding, may require organisational change mandated by standards.