“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
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
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.
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.3
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 2010–11.4 However, the proportion had increased by May 2012.5
The rebate for health assessments for Aboriginal and Torres Strait Islander People (Medicare Benefits Schedule [MBS] item 715),6 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%).7 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.8 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);8 38% lived in New South Wales (229 951) or Victoria (53 663).9 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.8
Indigenous Australians frequently encounter cultural disrespect in mainstream primary care services.10,11 The 2012–13 Australian Aboriginal and Torres Strait Islander Health Survey1 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.12 Lack of cultural respect in health care restricts access to and reduces the quality of care for Indigenous Australians.1
We have previously identified trust, access, flexibility, time, support, outreach, and working together as key aspects of cultural respect.13 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.14
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.15 The WoTWoD framework translates the systemic, organisational, and clinical elements of the Australian Health Ministers’ Advisory Council Cultural Competency Framework16 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.17 This is fundamental to Indigenous Australians’ right to the highest standard of health.11,18
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.