3.08 Cultural competency
Why is it important?
Improving the cultural competency of health care services can increase Aboriginal and Torres Strait Islander peoples' access to health care, increase the effectiveness of care that is received, and improve the disparities in health outcomes (Freeman et al. 2014). 'Cultural competency requires that organisations have a defined set of values and principles, and demonstrate behaviours, attitudes, policies and structures that enable them to work effectively cross-culturally.' (Dudgeon et al. 2010). Seven key aspects of cultural competency include: respect and trust, transport, flexibility, time, support, outreach, and working together (Liaw et al. 2011).
Cultural competency can be measured directly (self-reporting on patient experience) or indirectly (discharge against medical advice). However, there is limited data available on the cultural competence of health services (Paradies et al. 2014) or on the effectiveness of interventions to address cultural competency (Truong et al. 2014). The Australian Health Ministers' Advisory Council has developed a framework for measuring cultural competence based on three elements:
- Organisational cultural competency: leadership and workforce, recruiting and supporting Aboriginal and Torres Strait Islander people in health professions and into leadership positions within health care systems, community engagement in planning and decision-making and development of non-Indigenous staff.
- Systemic cultural competency: eliminating systemic and institutional barriers to Aboriginal and Torres Strait Islander peoples accessing care, including language barriers, trust, patient dissatisfaction and poor understanding of treatment.
- Clinical/professional/individual cultural competence: improving the cultural knowledge, skills and behaviours of individuals working in the health system, including clinical and administrative staff, to help patients navigate the health system and become a more active partner in the health care encounter (NT Department of Health unpublished).
In the 2012–13 Health Survey, 16% of Indigenous Australians reported that they had been treated badly in the last 12 months because they are Aboriginal/Torres Strait Islander. Of those people who felt they had been treated badly, 8% reported this occurred 2–3 times per week and 5% reported this was a daily occurrence. The most common situation of unfair treatment was by members of the public (45%) and applying for work or while at work (29%). Doctors, nurses or other staff at hospitals/surgeries were reported as being discriminatory by 20% of those who felt they had been treated badly. Seven per cent of Indigenous Australians reported that they avoided seeking health care because of being treated unfairly. A study of 755 Aboriginal Victorian adults found one-third (29%) had experienced racism in health settings in the previous 12 months (Kelaher et al. 2014).
In 2012–13, 30% of Aboriginal and Torres Strait Islander peoples reported they did not access health care when they needed to. Of those people, reasons for not accessing care included: dislikes the service or professional/embarrassed/afraid (22%); felt it would be inadequate (9%); did not trust service or provider (9%); and discrimination/not culturally appropriate/language problems (4%). These types of barriers were higher for counsellors (45%) and hospitals (27%) compared with doctors and dentists (23%). Noting that cost (43%) was the major barrier to accessing dental services, dislike of service/professional/feeling embarrassed or afraid was also a key reason (19%), which has links to poor oral health outcomes (see measure 1.11).
In 2012–13, 70% of Indigenous Australians aged 15 years and over in non-remote areas gave an overall rating of the health care they received in the last 12 months as excellent or very good. However, some reported that their doctor only sometimes or never: listened to them (11%), showed respect for what was said (11%), explained things in a way that could be understood (13%), or spent enough time with them (15%). Comparable data for the total population showed that their doctor only sometimes or never: listened to them (11%); showed respect for what was said (7%); or spent enough time with them (12%) (SCRSP 2013). Indigenous Australians in the lowest income quintile were 1.7 times as likely as those in the top income group to report that their GP only sometimes/never showed respect for what was said. In 2013–14, Australians in the most disadvantaged areas were 2.4 as likely to report that their GP only sometimes/rarely/never showed respect compared with Australians who were in the least disadvantaged areas (ABS 2014i).
In the 2008 Social Survey, 8% of Indigenous Australians aged 15 years and over disagreed or strongly disagreed with the statement 'Your doctor can be trusted'. In addition, 17% disagreed or strongly disagreed with the statement 'Hospitals can be trusted to do the right thing by you'.
Between July 2011 and June 2013, there were 17,494 hospitalisations of Aboriginal and Torres Strait Islander people where they left hospital against medical advice or were discharged at their own risk. This represented around 5% of all hospitalisations for Aboriginal and Torres Strait Islander peoples compared with 0.5% for non-Indigenous Australians.
In 2011, there were around 8,500 Aboriginal and Torres Strait Islander people employed in health-related occupations. Nursing (2,189) was the largest group followed by nursing support and personal care workers (1,435), and Aboriginal and Torres Strait Islander Health Workers (1,256). Between 1996 and 2011 the rate of Indigenous Australians employed in the health workforce increased from 96 per 10,000 to 155 per 10,000 (see measure 3.12).
Aboriginal and Torres Strait Islander Health Workers play an important role in improving cultural competency in health care delivery (Thompson et al. 2011). A small study in the cardiology unit of a WA hospital (Taylor, KP et al. 2009) found these health workers improved the cultural security of the care provided, reduced the number of discharges against medical advice and increased participation in cardiac rehabilitation. Participation rates in cardiac rehabilitation have been lower for Indigenous Australians although it has been shown to be effective in reducing coronary death by up to 25% (National Heart Foundation and Australian Health Care and Hospitals Association 2010) (see measures 1.05, 1.23, 1.24). In 2012–13, Aboriginal health workers represented 14% of all full-time equivalent (FTE) positions within Aboriginal and Torres Strait Islander primary health care services.
As at 30 June 2013, over half (54% or 3,611) of the FTE paid positions in Australian Government-funded Indigenous primary health care organisations were occupied by Aboriginal and Torres Strait Islander peoples (AIHW 2014a). In 2012–13, 74% of primary health care organisations had a governing committee or board of which all members were Indigenous Australians, 95% of services had formal mechanisms in place for client and community feedback, 86% had a formal organisational commitment to achieving culturally safe health care and 84% had mechanisms for gaining high-level advice on cultural matters affecting service delivery. Cultural group activities were provided by 36% of Indigenous primary health care organisations. Sixteen per cent of Indigenous primary health care organisations offered bush tucker nutrition programs and 11% offered bush medicine, while 57% of Aboriginal and Torres Strait Islander substance-use-specific services also ran cultural groups (e.g. art, hunting, bush outings).
A private GP practice in Qld found that by working in partnership with the Indigenous community the number of Indigenous patients increased from 5 to 40 Indigenous patients per month. Strategies introduced included bulk billing, one session per week specifically for Indigenous patients, and a bus to the clinic. In addition, cultural safety training was undertaken by staff and an Indigenous health worker attended the clinic assisting with cultural safety and referrals (Johanson et al. 2011).
Effective identification of Aboriginal and Torres Strait Islander peoples and accountability at all levels of the health system are vital to any initiative to improve cultural competency. Australian governments have focused on improving the cultural competency of health services in several ways.
Australian Government funding is provided to the Leaders in Indigenous Medical Education Network, which focuses on improving the quality and effectiveness of teaching and learning of Indigenous health in medical education through a nationally agreed curriculum framework and for promoting best practice in the recruitment and retention of Indigenous medical students.
The Department of Health is funding the Aboriginal and Torres Strait Islander Health Curriculum Framework project, which aims to develop a culturally inclusive, interdisciplinary Aboriginal and Torres Strait Islander health curriculum framework for integration into entry-level health profession training. The framework will improve the knowledge and capabilities of health professionals to work with Aboriginal and Torres Strait Islander peoples and subsequently contribute to better health outcomes.
The Practice Incentives Programme—Indigenous Health Incentive (PIP–IHI) aims to support general practices and Indigenous health services to provide better health care for Aboriginal and Torres Strait Islander patients including best practice management of chronic disease. Payments are made to practices that register for the PIP–IHI and meet certain requirements, including establishing and using a mechanism to ensure their Aboriginal and Torres Strait Islander patients aged 15 years and over with a chronic disease are followed up (e.g. through use of a recall and reminder system or staff actively seeking out patients to ensure they return for ongoing care) and at least two staff members from the practice (one of whom must be a GP) completing appropriate cultural awareness training. In 2013–14, 2,821 general practices and Indigenous health services had signed on to the incentive. Around 61,600 patients were registered in 2013.
The Australian Commission of Safety in Health Care is developing a guide on strategies and best practice for mainstream services (including acute care) in the delivery of care for Indigenous Australians.
The Australasian College for Emergency Medicine has developed a series of education tools and resources designed for doctors to enhance culturally competent communication and overall care for Aboriginal and Torres Strait Islander patients in the emergency department.
The Aboriginal and Torres Strait Islander Healing Foundation found that understanding and addressing trauma can have a positive effect on people's lives, relationships and workplaces. Recognising the need for a trauma informed workforce, the Foundation has invested $4 million in workforce and community development projects across almost 50 communities, including supporting accredited and non-accredited training to increase the capability, resilience and retention of social and emotional wellbeing staff (see measures 1.18 and 3.10).
In the NT, the Aboriginal Cultural Security Policy was launched in 2007 and is an ongoing commitment that the services offered to Aboriginal Territorians by the NT Department of Health respectfully combine the cultural rights and values of Aboriginal people with the best that health service systems have to offer.
In 2014, the NT Department of Health has been busy reviewing, developing and implementing a suite of initiatives that underpin the delivery of culturally secure services. They include the:
- development and implementation of the Cross Cultural Training Framework for staff
- Aboriginal Interpreter Policy
- Acknowledgement of Country and Welcome to Country Policy
- Aboriginal People and Communities Preferred Terminology Policy;
- Aboriginal and Torres Strait Islander and Health Practitioner Cultural Statement
- Cultural Competence Self-Assessment and Audit Tool continues to be trialled and further refined.
The NSW Health Aboriginal Health Impact Statement is designed to ensure the needs and interests of Aboriginal peoples are embedded into the development, implementation and evaluation of all NSW Health initiatives. The Impact Statement Guidelines (NSW Government 2007) recommend considering questions such as whether a policy includes initiatives that reflect Aboriginal health principles such as a whole-of-life view of health, a holistic approach to health, Aboriginal self-determination, working in partnership, and cultural respect and whether recommendations for policy implementation include the adaptation of programs, campaigns and materials that are culturally respectful to the needs of Aboriginal communities. The guidelines also recommend that evaluation plans for health policies and programmes affecting Aboriginal people should include indicators on issues such as cultural security and responsiveness of services to community needs.
The Victorian Department of Human Services has established Building Aboriginal Cultural Competence Training Programs that aim to embed cultural respect and understanding into policy development, service delivery and people management. Programme participants will gain a range of insights, including a better understanding of:
- historical and contemporary Aboriginal leadership
- the strengths of Aboriginal identity, culture and people
- the impact of past and current government policies and practices on the lives and outcomes of Aboriginal people
- how government and Aboriginal community networks can engage in the process of policy and partnership development.
The Victorian Department of Health established the Improving Care for Aboriginal and Torres Strait Islander Patients, which is underpinned by a 30% loading on health service funding for Aboriginal inpatients. To demonstrate quality care for Aboriginal patients, health services are required to report progress against four key result areas in annual quality of care reports: relationships with Aboriginal communities, culturally aware staff, discharge planning, and primary care referrals.
A WA report on cancer care (Thompson et al. 2011) made several practical recommendations to improve the cultural competency of care for Aboriginal patients including: providing a welcoming environment through welcome to country services, yarning places and access to traditional foods; facilitating the return of Aboriginal patients to their homelands for continued care where possible; ensuring that there is access to Aboriginal interpreters for Aboriginal people who are not confident speakers of English, and that staff understand differences in Aboriginal verbal and non-verbal communication styles; and ensuring service providers are familiar with, acknowledge and respect Aboriginal family structures, culture and life circumstances. 'Moorditj Koort' (Aboriginal Health and Wellness Centre) was a vision of the local WA Aboriginal community that recognised the need for culturally appropriate services at a local level. Hundreds of Aboriginal people have registered and attended regularly for medical care, self-management, referral and follow-up.
Figure 3.08-1 shows that 95% of Indigenous primary health care services have client and community feedback mechanisms and 95% employ local Aboriginal and Torres Strait Islander peoples.
Source: AIHW OSR data collection
Figure 3.08-2 shows rates of Aboriginal and Torres Strait Islander people employed in selected health-related occupations. Data is presented separately for 1996, 2001, 2006 and 2011. Data is presented separately for nurses, Aboriginal and Torres Strait Islander health workers, nursing support workers and personal care workers, health diagnostic and promotion professionals, allied health professionals, dental and dental allied workforce, ambulance officers and paramedics, drug and alcohol counsellors, medical practitioners, health service managers, and other. Refer to the findings section of this measure for a description of key results found in this figure.
Source: AIHW analysis of the ABS Census data
Figure 3.08-3 shows the proportion of Aboriginal and Torres Strait Islander peoples who had problems accessing health care who identified 'service not culturally appropriate' as a barrier in 2012–13. Data is presented separately for dentists, doctors, other health workers, hospitals, and mental health services. Refer to the findings section of this measure for a description of key results found in this figure.
Note: more than one response allowed, sum may exceed 100%
Source: ABS and AIHW analysis of 2012–13 AATSIHS
|Dentist||Doctor||Other health professional||Hospital||Counsellor||Total health services|
|Did not access service when needed to in last 12 months||21||14||9||6||9||30|
|Reason(s) did not access service|
|Discrimination/not culturally appropriate/language problems||2†||3†||2†||4†||4†||4|
|Dislikes service/professional, embarrassed, afraid||19||14||13||14||27||22|
|Felt it would be inadequate||1†||9||5||9||18||9|
|Does not trust service provider||4||6||3||8||12||9|
|Cultural appropriateness of service (subtotal)||23||23||18||27||45||32|
Note: Comprehensive significance testing results are published in the Detailed Analyses
† Estimate has a relative standard error between 25% and 50% and should be used with caution.
Source: ABS aand AIHW analysis of 2012–13 AATSIHS
Figure 3.08-4 shows the proportion of Aboriginal and Torres Strait Islander peoples aged 15 years and over who rated whether their doctor spent enough time with them, whether their doctor showed respect for what the patient said, whether their doctor explained things in a way that could be understood and whether their doctor listened. The majority of people reported positive patient experiences.
Source: ABS and AIHW analysis of 2012–13 AATSIHS