As are Aboriginal worldviews generally, Aboriginal perspectives on health have been described as ‘holistic’. The term ‘holistic’ means that such perspectives take account of a wide variety of factors, including social, emotional, mental, physical and spiritual factors (Mussell, Nicholas & Adler, 1993). Put differently, a holistic approach considers ‘upstream’ (general socio-economic) factors, ‘midstream’ factors (contemporary socio-cultural practices and circumstances), and ‘downstream’ factors (people’s unique lives). Al these factors are important to consider, particularly because they all play a role in explaining the current health status of Aboriginal people.
Aboriginal worldviews are worldviews that emerge from Aboriginal culture. For example, Aboriginal worldviews include regarding family relationships and land ownership as central to Aboriginal identity.
A critical fact, too, is the British colonisation of Australia, compounded with racism, discrimination and social exclusion (Reading & Wien, 2009). All this has contributed to the loss of Aboriginal language, culture and self-determination, and this, in turn, has had negative impacts on Aboriginal people’s health and disease patterns.
- culture
the values, norms and practices that groups of people have in common, and with which these people identify themselves.
Our point of departure is that communication and relationship breakdown in health care is common, but avoidable, when working with Aboriginal patients (Campbell, 1995; Shannon, 1994). Creating culturally safe environments is vital – not only for patients and healthcare staff, but also within the staff team. This chapter focuses on working with Aboriginal and Torres Strait Islander (from now on, Aboriginal) patients and colleagues. The strategies highlighted in this chapter can also be used by those working with people from other non-Western cultures and with different worldviews.
- communication
the process of people engaging in the exchange of knowledge, information, feelings and meanings. Communication can encompass spoken and written language, but it also includes many other kinds of meaning-making, including bodily gestures and the disembodied meanings of visual displays and architectural designs.
Introduction
Holistic health encompasses not just biophysiological well-being, but also social and emotional well-being. Holistic health is achieved and maintained by connections to land or country, culture, ancestry, family, community and spirituality (Department of Health and Ageing Social Health Reference Group, 2004). Aboriginal health critically depends on connections to land, spirit, ancestry and country (the land to which family is connected), but this dependence is sometimes poorly understood by Western society (Garvey, 2008). In Western society, spirituality is often ignored in healthcare provision as it has been excised from the Western medical model. Western medicine operates according to the dictates of science, and dismisses aspects of our life world that are not framed in the discourse of scientific evidence as ‘subjective’, ‘arbitrary’ and ‘ungeneralisable’. This creates a disregard for spirituality, and it downgrades Aboriginal people’s priorities and concerns when having to cope with illness and when seeking health care.
Also well documented in literature are the worrying health disparities between the Aboriginal and non-Aboriginal populations (Alderete, 1999). Low life expectancy figures are often cited to emphasise Australian Aboriginal populations’ health disadvantage. The 20-year gap in life expectancy between Caucasian Australian and Aboriginal peoples is in large part a result of mortality in Aboriginal adults from non-communicable disease and injury (Marmot, 2005). In response to this life expectancy gap between the two populations, however, policy and research commonly adopt a ‘deficit perspective’ – that is, a perspective that posits that Aboriginal peoples are not doing the right thing with regard to how to live and how to treat their health.
This chapter presents a different perspective, highlighting the strengths and positives that are evident in Aboriginal peoples’ lives and approaches to their health. To capitalise on these strengths and positives, Aboriginal peoples need to play a central role in empowering healthcare workers, policy-makers and researchers to work effectively with them. Specifically, guidance from Aboriginal health professionals is critical to enable others to value an Aboriginal person’s lived experience. Such guidance also emphasises that an Aboriginal person’s ‘worth’ does not equate with their level of education attainment, their type of employment, or their income. Such guidance focuses on enabling people to acknowledge the uniqueness of an Aboriginal person’s daily social and family activities, as a carer, a parent, an advocate or a mentor.
Understanding Aboriginal culture
Above all, what is valued in Aboriginal culture is the importance of family, cultural identity, community obligation and a connection to country (including ancestor and spiritual links). Virtues that are highly esteemed include an individual’s sincerity, trustworthiness and helpfulness. Positive experiences in the health system are created by healthcare workers who know how communicate and to act according to these values. Genuine relationships between healthcare workers and patients can facilitate the informal reconciliation required for social and emotional well-being. To achieve this, we first and urgently need to overcome the historical legacy of mistrust between Aboriginal people and those working in the health sector in Australia (Garvey, 2008).
To project this challenge onto a broader canvas, ‘upstream’ factors must be considered when addressing these matters. Upstream factors are those that occur at a macro level. Global forces such as world economics and industrialisation may affect local land use and destabilise cultural practices; think of how mining and natural gas projects are affecting Aboriginal–government relationships. Then there are federal government policies pertaining to education, employment, income, living and working conditions, many of which have challenged Aboriginal well-being since colonisation. It is noteworthy in this regard that the experiences for Indigenous peoples in other countries, such as New Zealand and Canada, have been quite positively influenced thanks to federal treaties, policies ensuring social and government recognition, and the incorporation of traditional Indigenous approaches to medicine in healthcare provision. Historically, Australia has a poor track record in addressing and accommodating these upstream factors (Marmot, 2005).
‘Midstream’ factors are intermediate; that is, they include health behaviours and psychosocial attitudes and beliefs. Midstream factors are intermediate in that they pertain to the habits and practices that define societies and cultures, and are at the same time enacted by individuals in the ‘here and now’. Midstream factors are at issue when people seek health care, offering opportunities for public health education and health behaviour change.
‘Downstream’ factors operate at a micro level, including an individual’s personal physiological and biological status, and their genetic make-up (Northern Territory Department of Health, 2012). When communicating with Aboriginal patients and families, each of these factors needs to be brought in view to ensure respectful and effective treatment.
The challenge we face, however, is that, in Australia, Indigenous groups make up only approximately 3% of the population, a low figure compared to other countries such as New Zealand. Not surprisingly, the percentage of Aboriginal health workers also remains small compared to that of the general population. As a result, Aboriginal health workers in systems such as hospitals and other services can be overburdened, faced with the challenge of dealing with the detrimental consequences of upstream factors, and the dual task of tackling midstream (socio-cultural) and downstream (individual) factors.
Sadly, the pressures on Aboriginal healthcare workers as representatives or consultants can have negative effects on their own health. These pressures and effects reverberate within their families and their community network, as the health of the individual is intrinsically linked to the health of their extended family and community, and vice versa. This may produce a vicious cycle, resulting in burnout on the part of members of the Aboriginal healthcare workforce, and greater isolation from the healthcare system.
As noted above, what adds to all these challenges is that Western health care and medicine embody a worldview that privileges material, scientific and technological values at the expense of social, relational and spiritual values. That is, the Western medical worldview is not just anchored in scientific evidence, but actively shuns extra-scientific knowledge, such as narratives, experiences, emotions and the like. Here, the term ‘scientific’ presupposes that we erase personal experiences and spiritual connections. The term ‘scientific’ encourages us to construe science as if it is somehow blessed with ‘a view from everywhere’. Such a ‘scientific’ view, it is assumed, yields truths that naturally hold for everyone everywhere. If science fails to recognise its own limits, however, it risks becoming unscientific – a realisation that is now increasingly argued by contemporary philosophers of science (Prigogine, 1996).
Alternative healing practices, which have been shown to be beneficial, are often dismissed as unscientific, and sometimes even seen as detrimental to people’s health. Nevertheless, it is not uncommon for people to have powerful spiritual experiences and healing outcomes that are not explained by science (Benedetti & Amanzio, 2011), and which are therefore not accommodated in existing healthcare communication and practice.
In our interactions with Aboriginal patients, families and staff, Aboriginal values, experiences and worldviews should shape our clinical care approach and our communication styles. By understanding similarities and differences between Aboriginal and non-Aboriginal perspectives, and by exploring these differences and keeping them in mind when communicating, we may be able to create ‘culturally secure spaces’ for Aboriginal patients and families. Achieving cultural safety means remaining attuned to and counterbalancing the potentially adverse effects of the ‘power relationships between the service provider and the people who use the service’ (Anderson et al., 2003). Here safety issues forth from Aboriginal people knowing that the health care they receive is anchored in a deep appreciation of their socio-economic circumstances, their socio-cultural practices, and their personal actions and values.
- cultural safety
the fact (or the feeling) that I and my worldview are respected by the people with whom I interact.
This practice example is about the challenges faced by an Aboriginal family when responding to the deterioration of their Aunt Mabel.
Geoffrey is a middle-aged Aboriginal man living in a metropolitan city in Australia. His older aunty, Mabel, who lives in a regional town, is very unwell. Mabel is a well-respected woman in her community and has been battling cancer for a number of years. Geoffrey, along with other family members around the state, make plans to drive to this town, some travelling as far as seven hours by car to be there. For this regional visit Geoffrey drives with his brother, sister, eldest son and niece to the town. He leaves his wife and youngest daughter in the city for this trip. Many members of the extended family make a considerable, but common effort, to visit her – taking time off work, and arranging for care of younger dependants where needed and travelling across the desert at the height of summer.
On arrival Geoffrey is united with extended family members from other regions. Some relatives have arrived outside of visiting hours and have been waiting in and around the hospital. Aunt Mabel’s immediate family in the town is hosting a large number of visitors in their homes. Over the next week, most of the family members meet and congregate under a tree directly next to the hospital. Geoffrey comes to the hospital daily with an insulated drink cooler of cool drink and water, as midday summer temperatures are high.
A hospital staff member, Helen, has noticed this group converging over the last few days, and on the third day asks the group to disperse. Helen informs Geoffrey that patients and other community members are displeased with the group loitering and smoking. As Mabel’s condition has worsened since his arrival, Geoffrey makes no apology for his family’s presence and tells Helen they will be there as long as Aunt Mabel is in hospital. Helen leaves and informs the hospital’s security guard Roger, who is a Torres Strait Islander. Roger approaches the group and notices the group, some smoking, and all drinking out of the cooler. He informs the group to move on or police will be called. Geoffrey is frustrated and tells Roger what he told Helen. Roger does not make any concession for the family, however, and there is a disagreement that leads to a fight. The police are called and three of the 12 family members present are arrested, including Geoffrey. During this time Aunt Mabel’s health rapidly deteriorates and she passes away.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
