“For many Aboriginal people in the bush, hospital is code word for ‘the place you go to die.’ People are used to seeing friends and relatives go off to hospital but never coming home.”
A resident of Mataranka in the Northern Territory
First Nations peoples in Australia have deep knowledge and a connection to Country going back over 65,000 years. This deep cultural connection and wisdom continues to provide a foundation of strength, resilience and knowing.
The current disparity in health outcomes for First Nations peoples is well documented. The Australian Institute of Health and Welfare reports that, in 2018, after accounting for differences in age structures in the populations, the overall death rate for First Nations peoples was almost twice the rate for non-Indigenous Australians.
Cancer, heart disease and diabetes are leading causes of death in First Nations communities. These are all chronic and progressive health conditions that often eventually require hospital treatment such as surgery, dialysis or chemotherapy. Yet, for many historical and cultural reasons, time in hospital can be traumatising, or re-traumatising, for First Nations peoples.
What could your hospital or healthcare organisation do differently to improve outcomes for First Nations peoples? A great deal, according to Donna Burns, a proud Wiradjuri descendant and Board Director at Q-bital Healthcare Solutions. Donna urges healthcare organisations to adopt an inclusive, strengths-based approach.
“What is well known is First Nations peoples have better outcomes (health, social, financial) when healthcare is:
- Co-designed with First Nations peoples
- Received on or close to home
- Delivered in a culturally safe and respectful environment
- Delivered by staff who understand the impacts of intergenerational trauma and their important role in intergenerational healing.”
This article will explore the concept of a strengths-based approach to First Nations healthcare and then discuss practical ways for healthcare organisations to move forward in this area.
A strengths-based approach to First Nations healthcare
We noted above that the overall death rate for First Nations peoples is twice the rate of other Australians. That could be considered an example of ‘deficit discourse’, which the Lowitja Institute defines as ‘disempowering patterns of thought, language and practice that represent people in terms of deficiencies and failures.’
They argue that,
A subtle way deficit discourse is reproduced is evident in deficit statistics, such as in Closing the Gap reports. The reports systematically compare Aboriginal and Torres Strait Islander Australians, in the aggregate, to non-Indigenous Australians. In almost all the chosen statistical indicators the status of Aboriginal and Torres Strait Islander people appears to ‘fall short’ of national norms.
Deficit discourse can negatively affect First Nations peoples’ sense of identity, educational achievement, health and wellbeing and contribute to both internalised and external racism.
In contrast, a strengths-based approach:
- Does not deflate the systemic disadvantage experienced by First Nations people, which affects many aspects of life, including health
- Recognises the role of history and context
- Harnesses the strength of First Nations peoples in different ways, such as:
- Building on positive attributes of an individual or group
- Emphasising strength to withstand adverse circumstances
- Tailoring programs to be culturally appropriate
- Shifting the perspective from Western or European in order to privilege First Nations ways of knowing and being
- Highlighting protective factors
- Positive psychology.
When it comes to healthcare, privileging First Nations ways of knowing and being may involve recognising that:
- Wellbeing is a ‘whole of life’ view that is not compartmentalised into different components
- Health refers to relationships between people, land, environment, families and ancestors.
Improving the hospital experience for First Nations peoples
While many reported positive experiences with doctors, 32% of First Nations peoples who did not access health services when they needed to, indicated this was due to cultural reasons, such as language problems, discrimination and cultural appropriateness.
According to the AIHW, First Nations peoples are more likely than non‑Indigenous Australians to leave hospitals without completing treatment. The age-standardised proportion of patients who left hospital against medical advice or were discharged at their own risk from 2017-2019 was 6 times higher for First Nations peoples than non-Indigenous Australians (3.0% compared with 0.5%).
Royal Adelaide Hospital
Royal Adelaide Hospital’s Aboriginal & Torres Strait Islander Liaison Health and Wellbeing Hub works to raise awareness and advocate on behalf of First Nations patients to assist in providing culturally appropriate services and to achieve improved health outcomes.
The Hub:
- is a welcoming and peaceful environment for patients and visitors from diverse First Nations backgrounds
- helps patients understand their condition, decide on treatment options and access an First Nations interpreter if needed
- advocates for patients
- provides practical support through computer and telephone access and refreshments
- features a dedicated garden with First Nations artwork and native plants that promote healing and connection to culture and country
- supports continuity of care after discharge by linking the patient to local culturally sensitive services.
Royal Adelaide Hospital has also brought a 60,000-year-old First Nations healing tradition into the hospital setting. Ngangkari healers offer smoking ceremonies, bush medicines or spirit realignment within the hospital setting working alongside mainstream clinicians.
Lighthouse Hospital Project
Begun in 2012, the Lighthouse Hospital Project is a joint initiative between the Heart Foundation and the Australian Healthcare and Hospitals Association (AHHA) to improve health and care outcomes for First Nations peoples with coronary heart disease.
Over the last decade, with 18 participating hospitals across Australia, it has enabled better in-hospital and post-hospital cardiac care, through improved hospital systems and fostering cultural competence in acute care staff.
It has helped participating hospitals to:
- Increase engagement with local First Nations community organisations
- Increase the prominence of First Nations peoples culture and values in the hospital environment
- Integrate First Nations peoples workers into acute coronary syndrome teams
- Improve staff capacity to provide culturally appropriate care
- Improve processes relating to the admission, identification, discharge and post-discharge care for First Nations patients admitted with an acute coronary syndrome.
Four practical steps your hospital can take
The examples above show how Australia’s major hospitals, in both cities and large regional towns, are committed to working with First Nations peoples to improve health outcomes.
So, where could your hospital start? Here are four approaches that can help to create more accessible and affirming healthcare for First Nations people.
1. Co-design healthcare with First Nations peoples
Services should be co-designed with First Nations peoples.
As the National Aboriginal Community Controlled Health Organisation (NACCHO) argues,
‘This means a genuine partnership process where there is equal weight given to the sector’s voice at the table alongside that of governments and agencies. It is important that this is not just the sort of consultation process that has existed previously, but a meaningful partnership where the sector has equal decision-making authority.’
The Birthing on Country movement provides a powerful example of co-designed and First Nations-driven service planning.
Many First Nations women fear giving birth in hospital when so many babies were (and still are) removed from their families. A birthing centre with First Nations peoples governance and continuity of care linked to the local community can offer the safety of a hospital birth without the fear or the distance from family and community.
The Birthing on Country movement:
- Incorporates traditional birth practices and a holistic approach to health
- Enables First Nations women to give birth on ancestral country
- Ensures services are community-based and governed.
In 2013, the Mater Mothers Hospital in Brisbane established an urban Birthing on Country service co-designed with First Nations peoples in an action research project. A 2021 study found that First Nations women receiving the Birthing on Country service were:
- More likely to attend 5+ antenatal visits
- Less likely to have a premature birth
- More likely to breastfeed exclusively when discharged.
2. Support First Nations peoples to receive care on or close to home
Rates of end-stage kidney disease are high among First Nations peoples. The need for frequent hospital-based dialysis means many patients have to leave communities and relocate to cities or large centres for treatment.
That causes a great sense of grief and loss. As one patient explained,
“Some of us have grandchildren and we can’t teach them in Port Augusta and Adelaide [because] we’re not in the right Country.”
A mobile service can alleviate this. In South Australia, the Mobile Dialysis Truck enables patients to have dialysis on Country for a few weeks. It means First Nations patients can be reunited with family and take part in cultural activities without compromising healthcare.
The service has been shown to improve social and emotional wellbeing, which has significant clinical implications, foster connections to land and family, and improve relationships with healthcare providers.
Flexible mobile and modular healthcare infrastructure can enable healthcare providers to deliver a wide range of services on Country, improving health outcomes through more accessible care that reflects the importance of the land to First Nations peoples.
3. Deliver care in a culturally safe and respectful environment
Hospitals can improve their engagement with First Nations peoples by creating a more inclusive environment where First Nations people are recognised and welcomed, and prioritised.
Many hospital environments would benefit from a facelift to create a comfortable and familiar feeling rather than a sense of sterility. Displaying First Nations artworks, welcome messages, or a healing garden, designed with local community members, can all help to create a more welcoming environment that makes First Nations peoples feel included.
4. Ensure staff understand and mitigate the impact of intergenerational trauma
Hospitals are large institutions run by governments – and that alone can make them seem culturally unsafe to First Nations peoples still living with the trauma of the Stolen Generations.
Hospitals that employ First Nations doctors, nurses, midwives and staff observe the value of a clinical team that instinctively connects with First Nations peoples.
Aboriginal Community Controlled Health Centres and Aboriginal and Torres Strait Islander Health Workers have reshaped primary care for their communities with evidence suggesting that they help to:
- overcome key cultural and communication barriers for Indigenous people accessing health care
- improve attendance at appointments and acceptance of treatment and assessment recommendations
- reduce discharge against medical advice
- increase patient contact time
- enhance patient referral linkages
- improve patient follow-up practices.
The 2022 Federal Budget included $13.9 million to expand the number of health scholarships offered under the Puggy Hunter Memorial Scholarship Scheme by up to 300 additional places for First Nations peoples.
Other staff may benefit from cultural sensitivity training to help them understand the customs of local First Nations peoples groups and the holistic concept of health as well as to improve their cross-cultural communication skills. It is helpful for staff to understand culturally significant behaviours, for example, why First Nations family obligations may take priority, making a patient late for an appointment or how First Nations men and women may reveal more to a clinician of their own gender.
The role of flexible mobile and modular infrastructure
Mobile facilities offer a way to provide acute care closer to regional and remote communities, helping to make the experience less disruptive for patients who remain near to their support systems.
Supplemental mobile and modular infrastructure could be a solution for rural and remote healthcare systems and for city hospitals seeking to create a First Nations peoples’ health hub.
A flexible Healthcare Space facility could be used in many different ways:
- Provide a culturally safe birthing suite for First Nations communities that enables Birthing on Country with the best of modern midwifery and the capacity for an onsite caesarean if needed
- Create a specialist First Nations peoples’ coronary care unit that overcomes barriers of distance, maintains community connections and features imagery and language from local First Nations groups.
Q-bital Healthcare Solutions are open and committed to working alongside First Nations Communities, Aboriginal Community Controlled Healthcare Organisations and healthcare providers, to help make positive change in healthcare outcomes.
Contact Q-bital Healthcare Solutions to learn more about mobile and modular healthcare facilities
Disclaimer: All information is general in nature.
