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Cultural awareness workbook for GPs |
BACKGROUND
About 1.8% of the Northern Rivers area (NRA) population is made up of
Aboriginal and Torres Strait Islander (ATSI) residents, but this population represents 4.2% of our clients, 4.3% of all births and by health statistics, is the group in greatest need of attention.
Mortality: In brief, crude death rates for males have remained stable here in the last decade, at a level significantly higher than non-indigenous males, whose rates have decreased, while female death rates have actually increased by 3.5-4%. This translates into an average life expectancy of 57-60 for men, versus ~75 years for non-indigenous males, and 60-65 for females, versus ~81 years of age for non-indigenous females.
Causes are most commonly circulatory disease, cancer, respiratory disease and injury and poisoning, especially in the younger age groups of 25-34 where death rates are actually 6-8 times higher. Cancer incidence rates are actually similar but due to access and service problems in our area, indigenous people who get cancer are more likely to die from it.
Infant mortality rates continue to be 3-5 times higher by maternal indigenous status, while birth weights and breastfeeding rates remain lower by comparison.
Morbidity: Hospital admission rates are persistently higher for indigenous people, ~60% higher for men and 50% higher for women, where the differences were highest in infancy and older ages greater than 50 years. Respiratory diseases, injury, pregnancy and childbirth are the most common reasons for admission, while circulatory diseases, diabetes and GIT/GUT problems contribute significantly to morbidity in the community.
Rates for infectious diseases have also remained significantly high in the
NRA Goori community (a locally accepted term rather than Koori) including ear, eye, skin, respiratory and STD infections when compared to non-indigenous population; ~8.6% versus 2.5% in males and 7.3% versus 1.8% in females as a cause for hospital separation.
Lifestyle risk factors for chronic degenerative diseases are also rife in our
Goori community:
Obesity: 60% of males, 57% of females.
Smoking: 52-56% of males, 41-52% of females.
Alcohol: About 65% of the indigenous population drink alcohol compared to ~85% of non-indigenous residents, but ~22% of those that do drink do so at harmful levels versus 10% of non-indigenous people.
Illicit Drugs: Commonly young males using marijuana 24% versus 15% in the general population.
Mental illness: 4.25% of mental illness admissions are indigenous people versus 2.85% of the NRA non-indigenous population. This difference is again more evident in males.
Employment: The mean individual income for indigenous people in 65% of the general population.
Education: Only 33% of ATSI children complete schooling (ie. Year 12) versus the national average of 77%, and only 2.2% of indigenous people have tertiary degrees compared to 8.7% in the general population.
CULTURE
Generally defined as what is accepted as the norm in the community, i.e. the learned proportion of human behaviour. If we start by understanding our own cultural viewpoint, we can then see the challenges of another culture accessing and using the offerings we have and the difficulties we have extending help to this other paradigm of belief. For example, it is very difficult to offer advice on how to improve lifestyle factors if we are not aware of the social conditioning influencing that person, or the motivation to change behaviours against prevalent cultural beliefs, or the stereotypes that person has unconsciously invested in.
We then need to remember that we are health-orientated in our thinking, subconsciously assuming that everyone wants to be healthy, whereas this person has only ever learnt gratification-thinking or has a fatalistic cultural paradigm of deserving ill health. Only by realising and treating our patients in the holistic understanding of their culture can we avoid non compliance and victim-blaming.
We also need to remember that these people are not aware of what cultural beliefs construct their behaviour, nor which culture they actually belong to.
Not having a sense of belonging has been shown to contribute to a sense of powerlessness and subsequent ill health. These issues are often familial, embedded in the structure of the community in which they were born, weaned and live, and so remain unconscious, as do the negative stereotypes which were enforced over generations. Shame, self-doubt, and withdrawal from either culture are common reactions, causing isolation and the inability to self-advocate on matters of health.
This is why the illness often has to be severe or progressed before help is sought. The survival instinct literally has to push against a wide variety of barriers, including the guilt factor that there may be something wrong in a spiritual or social justice sense to cause the disease. Again this stems from the conceptual differences between the cultures, where the western viewpoint on health has been based on a biomedical model whereas Aboriginal society nests illness in a socio-spiritual framework, often involving the community and its connection to God or the land.
Other factors preventing early or timely presentation include:
Distance: Goori clans have centred themselves in traditional meeting places, as well as the outer edges of towns, all which tend to be strategically further from available service centres.
Transport: Challenges here include availability of private or public transport, including drivers, as Goori women often do not have a license, and conditions of the road, especially in our flood prone areas.
Finances: This features in every detail from telephone or radio access, to payment for transport and medical services.
Social Supports: Childcare is especially important in these communities, as the cost and ability to take the whole family along is often impossible. Cultural or family responsibilities are often obligations greater than the individual need.
Disability: A further possible limitation, not provided for at many levels.
Cultural appropriateness: An often cited cause for hesitation, including the degree of indigenous involvement in the facility, how aware and how trusted the health practitioners are, and of course language and gender issues.
Timing: All of the above have to then coordinate with service availability and an understanding of appointment systems.
Paperwork: Attainment of appropriate identification such as Medicare card, Healthcare card or license, are made especially difficult if they have no birth certificate or are unable to fill in the paperwork due to illiteracy.
Fear: Fear of big buildings, especially when having to go up flights of stairs away from the earth’s force; fear of hustle and bustle and confusion; fear of judgment; fear of misunderstanding; fear of pain; fear of poor prognosis; fear of death; fear of embarrassment or having to discuss private or taboo subjects; and basic fear of western culture including medicines or invasive treatments.
With all these barriers to navigate, it’s a wonder anyone makes it to the front door! Remember we are working from the context of a dominant culture and it is hoped this day out will help you experience that difference rather than distant intellectual understanding. The compliance of our patients is a reflection of our awareness of their context and our appropriateness as practitioners.
CONSULTATION
An effective consultation with a Goori patient begins in early preparation.
Aboriginality should be part of the appointment making process and all reception staff should have instruction on cultural appropriateness. This initial contact could quickly turn the most needy person away if they receive the wrong impression. Goori understanding is often greatly intuitive, and attitude through body language, eye contact or wording will be quickly noted. This of course applies to the health practitioner also, so take these simple tips to heart.
Be COMFORTABLE: have extra time scheduled for your ATSI patients. It will be worth the correct diagnosis, treatment and appropriate follow up in the long run.
Be GENUINE: Admit your experience and the limitations of your knowledge concerning their culture and time. Honesty and trust are essential for history taking and compliance with treatment.
Be CASUAL: They will also know if you’re trying too hard and see information gathering as an exchange rather than answering a whole lot of cop questions. Please sit at eye level, even though you may not establish eye contact, and put your pen down for some moments.
Be AWARE of what it has taken for this person to see you, and what social/community supports this person will return to. Be also aware that the schemata of any conversation is culture bound and that this person may not have the appropriate language cues we unconsciously depend on to allow complete understanding and correct recall.
In general, KEEP IT SIMPLE:
Don’t talk too fast or say too much at once.
Don’t use complicated words or medical jargon.
Don’t raise your voice or speak down to the person.
Make sure you listen as carefully as you speak.
Now that we’ve covered the authoritarian ‘don’ts’, we’ll talk about what to ‘do’ with your questions. Essentially, encourage the patient to tell his or her own story and allow time for response with space left for silent contemplation. Goori people will deliberate rather than make immediate decisions and their words will depend on the level of trust, so this involves the health practitioner being comfortable with a little silence.
What I usually start things off with are general questions like “How have things been for you?” Direct questioning is often inconsistent with Aboriginal culture and negatives (especially double negatives) used in questioning are confusing. Be careful also with yes or no questioning, as the person may simply answer what she/he thinks you want to hear or what seems correct.
So what questioning is left I hear you ask? What appears to work is what is
called strategic questioning. Offer suggestions or choices for them to agree
with or refute like “Have you had a productive cough or is it dry?” or “Have you had this for few days or more time than that?” Also ask open questions around their experience like “What has happened to worry you?” or “How has this affected your body and/or mind?” or “Is there anything else you can tell me about that?”
Be careful with the interpretation of “I don’t know” or “I don’t remember” as this may be a statement about the method of questioning. If more precise information is sought, ask about happenings and their sequence by equating this with distinct occurrences in time. A Goori person may not be able to answer “How long has this been occurring?” but will be able to identify if it started at lunchtime, or on the weekend, or at Christmas time.
The concepts of time, numeracy, intensity and specificity are often cited as major cultural differences, but people often understand the type of information you seek if you can orientate them by a reference point, for example the severity and quality of pain can be related to another physical experience, like fire, or a knife, or someone sitting on you.
This is also part of the two way process that can be helped by explaining why you need the information. In general, don’t get too caught up on specifics if you’ve already got the gist of what they are saying. This will only frustrate the patient as they think they are being misunderstood, and slow down the whole process.
Procedures of any kind including urinalysis or venepuncture, also need to be explained as all parts of the body and its functions are seen as private and/or sacred. Similarly, if you need to admit an Aboriginal person to hospital, explain why, for how long and what is likely to happen, as this is often one of their greatest fears. Such places are reserved for dying or severe illness in their past experience, and healing is often seen as best done at home. Goori people particularly don’t like being sent to hospitals outside their normal region, as they do not want to pass away in someone else’s land.
If you are unable to attain the information you require from the person, he/she may be amenable to you asking family members or involving Aboriginal health workers. There is a concept that illness takes over a person and he or she is not responsible for his/her utterances while ill, so some Aboriginal people, especially the elderly, would prefer a close relative to speak for them. It is important to know who to contact if you are having difficulty and in general, there is often a huge family, which is integral to ensuring follow up and compliance and is a valuable resource.
You may have witnessed this with the large number of children who are attended by their auntie or grandmother. Once a child is born, these people are automatically involved in the responsibility of mothering. This safety mechanism has ensured Aboriginal survival over many generations.
Other traditions, like the limited contact between a man and his mother-in-law are also in place to ensure survival! Older people are expected to remain independent for as long as possible, and be involved and active in the family. This sense of independence is strongly encouraged from childhood and Koori women will not molly-coddle their children as in western culture.
This draws me to a few points about treating children. It is especially important that the carer be well informed and has come to trust you by observing your interaction with themselves and the child. Inflicting or being the cause of pain to a child is taboo for mothers and they will often not be able to attend immunisations or the like.
This is also one of the reasons why they generally do not stay with their children in hospital, apart from their own discomfort about western surroundings, hustle and bustle, lights and noise, big buildings and being eight flights above the ground. Their innate sense of helplessness and shame contributes here too, so it is vital that the person be reassured that this is not their fault and that they have done everything they can. This positive reinforcement is integral to treatment compliance and follow up in all cases.
Reward achievements and notice any effort being made, with the knowledge that a big effort was often required just to get there.
TREATMENT
Treatment is very much dependent on the individual and the plan is most often successful when the patient is involved in the decision making and understands clearly, why, how and what to do. All the access problems previously discussed here also apply. Ask yourself these questions:
- Can the patient even get to the chemist, let alone afford the medication, or treatment method, eg. nebuliser, you prescribe?
- Do they understand the quantities, ie. 5 ml = 1 tablespoon, and have you referenced their timing to identifiable times in the day, like when you first get up, or breakfast, lunch and dinner etc.
- Do they have an adequate diet or drink or take anything that may interact with what you prescribe?
- Do they need family support or reminders by their local health workers?
- Can they get to the specialist, or even make an appointment and do they understand about waiting times in hospitals.
- What do they think they can do to improve things?
- Do they understand that the illness can be given to others? (This is sometimes a difficult concept).
- Do they comprehend what will happen to them over time, ie, either with their illness, habit or treatment?
I find using hands on experiential explanations the best way to describe both the sequelae of illness and treatment, like injecting an orange with saliva to show the ‘rot’ inside of diabetes. Inside health and outside appearances are often difficult to separate in Goori concepts and in general these people live very much in the present moment. For an indigenous person, tomorrow doesn’t much matter when survival today is in question, and this may mean having another smoke or drink in order to cope with the next 10 minutes. So draw them a picture of what they will be like when they are their grandmother’s age, and use constant reminders as a rule, especially using people and things they can relate to.
Basically, remember how much of our daily lives and knowledge we take for granted and work up from first principles. Again, keep the treatment regime as simple as possible, and use the support networks that are available. If notification etc needs to occur, it is advisable that this is done through your local Aboriginal health worker. The concept of cultural safety is that these people have the right to think, feel and deal with things differently to us, and we need to accustomise to their ways if we want to treat them.
Good luck, relax and enjoy the ride!
Copyright 2000 Dr Jacqueline Boustany MBBS (Hons), Dip Paeds, MPH
This workbook was put together for the Goori Cultural Awareness trips for local doctors to meet Aboriginal communities on their land, which were organised by Dr Boustany and the Northern Rivers Division of General Practice in 1999 and 2000.
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