ATSI – culturally respectful approach

from – https://www.racgp.org.au/afp/2014/january-february/aboriginal-cultural-mentors

culturally respectful approach was the most important attribute needed for effective relationships and healthcare. This includes:

• Attitudes and approach.
• Communication and consultation skills.
• Culturally aware practices.
• Applied knowledge.

Essential Knowledge for GPs

1. Understanding Aboriginal History (Including Local History):
   • Knowledge of Aboriginal history, especially local history, is crucial for GPs working with Aboriginal patients.
   • The historical context, including the past and lived experiences of Aboriginal people, strongly influences their interactions with healthcare systems and practitioners.
   • This learning need is often underappreciated by non-Aboriginal individuals.
2. Cultural Issues Impacting Healthcare:
   • GPs need to be familiar with cultural factors that affect patient care, recognizing that these vary between different Aboriginal and Torres Strait Islander communities.
   • Important cultural considerations include:
     • Bereavement or Sorry Business: Understand the significance of mourning rituals in Aboriginal and Torres Strait Islander communities, which may affect a patient’s ability to attend appointments or engage with healthcare during periods of loss. These rituals are deeply significant and should be respected in healthcare settings.
     • Men’s and Women’s Business: Be aware of gender-specific cultural practices, which may influence a patient’s comfort in discussing certain health issues. Some topics may only be discussed with healthcare providers of the same gender, and certain examinations might be inappropriate or uncomfortable.
     • Aboriginal Spirituality: Recognize that misunderstandings of spiritual beliefs could lead to misdiagnosis, such as mistaking spiritual experiences for mental health disorders. Sensitivity to spiritual practices and their role in health and well-being is important.
     • Family-Oriented Care / Kinship Structures and Decision-Making:
       • Aboriginal and Torres Strait Islander communities often have strong kinship ties, and healthcare decisions may involve family members or Elders.
       • GPs should be prepared to accommodate family consultations or input into decision-making processes.
       • It’s common for healthcare visits to involve multiple family members, and health decisions are often made collectively.
     • Traditional Healing Practices: Some patients may integrate traditional healing methods with Western medicine. It’s important to ask about any traditional treatments they are using and respect these practices while ensuring they don’t conflict with medical care.

Key Aspects of Aboriginal Communication Styles

1. Non-Verbal Communication

• Body Language: Aboriginal and Torres Strait Islander (ATSI) people often rely more on non-verbal cues such as gestures, facial expressions, and body posture. Observing these cues is essential as they may convey more meaning than spoken words.
• Silence: Silence is an important and natural part of communication in ATSI culture. It may signify respect, contemplation, or that the person is processing information. Allow silence without rushing to fill it.
• Eye Contact: In ATSI cultures, direct eye contact can be seen as confrontational or disrespectful, especially when interacting with Elders. A lack of eye contact should not be interpreted as disinterest or dishonesty.

2. Verbal Communication

• Indirect or Circular Communication: Rather than providing direct answers, ATSI individuals may use storytelling, metaphors, or examples to convey their point. This form of communication requires attentive listening to grasp the underlying message.
  • Storytelling: Stories are often used to provide insight into personal health or other situations, rather than directly answering questions.
  • Subtlety: Direct questioning may be avoided. Responses may be indirect, and the listener should focus on what is implied.
• Allowing Expression of Feelings: Patients need space to express their emotions. If they feel rushed or disrespected, it can negatively affect the doctor-patient relationship. Listening attentively and showing empathy are crucial.
• Yarning: This informal, conversational style helps build rapport. It often starts with casual, non-clinical conversation, easing the patient into more personal or clinical topics. Patients should be allowed to lead the conversation at their own pace.
• Culturally Appropriate Terminology:
  • Use inclusive terms like “Aboriginal and Torres Strait Islander peoples” to show respect and acknowledgment of cultural diversity.
  • Referring to specific groups (e.g., “Kaurna people”) shows recognition of individual identities and helps build trust.
• Plain and Respectful Language: It’s important to avoid medical jargon and use clear, respectful language that patients understand. Open-ended questions encourage patients to share more freely.
• Checking for Understanding: Employ the teach-back method to ensure that the patient understands the information by asking them to explain it back to you in their own words.

3. Other Communication Styles

• Family Involvement:
  • During consultations, it’s important to acknowledge the entire family group, as family members may speak on behalf of the patient or assist in decision-making.
  •  Recognize the role of family and community in care.
• Respect for Elders:
  • Elders hold a special status in ATSI culture as decision-makers and cultural leaders. Show deference to their wisdom and experience. When speaking to Elders, engage respectfully and avoid a paternalistic approach.
• Avoiding Shame:
  • The concept of “shame” (a deep sense of embarrassment) is significant in ATSI cultures. Patients may disengage if they feel judged or embarrassed, especially on sensitive topics like mental health or sexual health.
  • A non-judgmental tone and confidential, discreet communication are essential to maintaining trust.
• Cultural Safety and Trauma-Informed Care:
  • Many ATSI patients may have experienced intergenerational trauma or discrimination. Being aware of these experiences and providing a safe space for discussion fosters trust.
  • Acknowledge the historical impacts of colonization and discrimination, and create a comfortable environment for discussing health matters.
  • Tailor care to minimize retraumatization and use open-ended, non-intrusive questions.
• Multigenerational and Family-Oriented Consultations:
  • Family involvement is common in ATSI health consultations. GPs should include family members in discussions, respecting their role in providing support or decision-making assistance.
• Facilitate Access to Interpreter Services:
  • Example: Establish a partnership with local or national interpreter services, such as the Aboriginal Interpreter Service (AIS) or TIS National (which offers interpreters for some Indigenous languages). Train reception staff on how to discreetly arrange these services, ensuring the patient’s comfort and privacy.
  • Additional Note: In remote communities, specific Indigenous languages may be spoken (e.g., Yolŋu Matha, Pitjantjatjara). Identify the most commonly spoken languages in your region to facilitate timely and culturally appropriate interpreter services.
• Visual Aids and Demonstrations:
  • Strategy: Use visual aids and practical demonstrations to clarify medical instructions and treatments, which can be particularly helpful in overcoming language barriers and ensuring understanding.
  • Example:
    • Use anatomical models to demonstrate joint movements or other physical processes during consultations, such as explaining arthritis or injury management.
    • Develop and distribute culturally relevant health information materials, incorporating ATSI languages and visual representations that align with the cultural contexts of your patients (e.g., using local art styles, symbols, or narratives familiar to the community).

Consultation Management

1. Attitudes
   • Respectful and Non-Judgmental
     • Avoid labeling patients as “non-compliant” without understanding their circumstances.
     • Don’t make assumptions based on stereotypes, such as assuming an Aboriginal patient is a drinker.
     • Recognize that racism still exists in healthcare settings and can negatively affect care.
     • Build relationships by seeing patients as individuals beyond their medical conditions.
   • Interest in the Community and Individual
     • Show genuine interest in the patient’s background and community, not just performing a job and leaving.
     • Immerse yourself in the community, get to know its members, and learn about their culture.
     • Be open to feedback from the community, especially from Elders, and accept advice respectfully.
2. Professionalism
   • Maintain professional boundaries and understand the limits of what can be achieved.
   • Uphold a professional appearance and demeanor, as patients expect professionalism in their care providers.
3. Allow Time:
   • Time and Patience:
     • Building a therapeutic relationship, especially with ATSI patients, requires time.
     • Ensure consultations are not rushed to allow meaningful engagement between the patient and GP, despite time pressures.
     • Avoid rushing into clinical questions.
     • Acknowledge the person’s cultural background and family structure as this fosters rapport.
     • Show empathy without trying to immediately fix the problem
   • Multiple Visits
     • Manage complex needs and multimorbidities through multiple appointments, acknowledging that not all problems can be solved in one visit.
     • be patient and avoid trying to make immediate changes.
     • Example: “Rome wasn’t built in a day… You can’t solve all their problems in one consultation.”
   • Offer flexible scheduling
     • to accommodate cultural and familial obligations that may impact the patient’s ability to attend appointments.
     • Example: “If this appointment time doesn’t work, we can find another time that suits you.”
4. Engage Family and Friends During Consultations:
   • Be open to the presence of family members or friends, respecting this cultural practice within Aboriginal communities.
   • Involve family, extended kin, and community in the care process.
   • Examples: “That’s just the way the family is… and you’ve got to accept that.” “I’ll bring my grandkids in… but might not have [their mother] with them.”
5. Respect
   • Cultural Identity:
     • Land Acknowledgment: When consulting with an ATSI patient, acknowledging their connection to traditional lands, known as “Country,” is key. Showing understanding of this relationship and its significance can help foster trust.
       • Example: “I’d like to acknowledge that we are meeting on [traditional land name] and recognize its importance to your community and culture.”
     • Elders: Recognize the importance of Elders in ATSI culture. They are often consulted for decisions and guidance in matters of health.
       • It’s respectful to ask if an Elder or family member should be included in healthcare discussions.
       • Example: “Would you like to involve an Elder or family member in our discussion today?”
   • Addressing the Patient: It’s important to ask how the patient prefers to be addressed. This might include specific titles of respect.
     • Example: “How would you prefer me to address you?”
   • Patient Autonomy and Foster Shared Decision-Making:
     • Involve patients in healthcare decisions, empowering them to take an active role while respecting their autonomy and cultural beliefs.
     • “We’ll decide together what the best course of action is for you.”
6. Practice Cultural Safety with Awareness of Historical Context:
   • Ensure patients feel safe and comfortable in healthcare settings.
   • Acknowledge historical trauma, history of colonization and the Stolen Generation and distrust towards medical institutions, ensuring patients feel respected and secure.
     • “I understand there have been past experiences that can affect how you feel about healthcare. I’m here to listen and support you.”
     • “How do you think the past experiences of your parents or grandparents, like being part of the Stolen Generation, impact child’s sense of identity or emotional well-being?”
7. Adopt a Holistic, Whole-Person Approach:
   • Address health in a holistic manner including
     1. Biological Dimension:
        • Manage chronic conditions while respecting cultural healing practices.
        • Example: Incorporating traditional healing rituals into a child’s treatment plan.
     2. Social Dimension:
        • Assess living conditions
        • family dynamics
        • community connections
        • Example: Facilitating participation in cultural festivals to enhance social support
     3. Psychological Dimension:
        • Provide trauma-informed mental health support.
        • Example: Therapy for anxiety that incorporates cultural understanding.
     4. cultural Dimension:
        • Acknowledge the importance of traditional healing methods and be open to discussing how these practices can coexist with Western medicine.
        • This can include acknowledging the role of
          • Elders
          • Traditional healers
          • Bush medicine
        • collaborate with Indigenous healers and allow for traditional practices to be used as part of the patient’s healing journey, recognizing the importance of cultural practices in overall health.
8. Involve Aboriginal Health Workers or Cultural Support Workers:
   • Employing Aboriginal staff is highly recommended.
   • It helps build trust with Aboriginal patients and provides opportunities for Aboriginal community members (e.g., traineeships).
   • Example: “Would you like me to involve one of our Aboriginal Health Workers to support you during the consultation?”
9. Cultural Competence Training. Culturally Aware Staff:
   • All staff, including receptionists and nurses, should be educated on cultural issues to ensure respectful interactions with Aboriginal patients.
10. Commitment to Identification of Aboriginality:
    • Practices should clearly explain the reason for asking about Aboriginal identity, to connect patients with specific health services.
    • Example “We’re asking this question because there may be unique services that could be provided for this Aboriginal person.”
11. Creating a Welcoming Environment:
    • Gestures like acknowledging the traditional owners of the land or displaying Aboriginal posters in GP practices can create a welcoming atmosphere and safe environment for Aboriginal patients.
    • However, these visible signs need to be accompanied by culturally competent care throughout the practice to truly impact patient care.
12. provide access to Aboriginal Health Programs:
    • Knowledge of Aboriginal health, culture, and the specific programs aimed at reducing health disparities is essential for GPs to support Aboriginal patients effectively.
    • GPs should be familiar with programs such as
      • Closing the Gap
      • Aboriginal health checks which are designed to decrease the health disadvantages faced by Aboriginal people.
      • Providing Culturally Appropriate Support Services:
        • Example: Referring a child to an Aboriginal health service.
13. Identifying Barriers to Care
    • Access to Culturally Sensitive Care: Refer the child and carer to Aboriginal-controlled health services where they can receive culturally appropriate care.
    • Logistical Support: If transportation is an issue, explore telehealth options or arrange for transport assistance.
    • Social Services Navigation: Connect the family with a social worker who can help them navigate complex systems and access support for schooling, healthcare, and financial aid.

Aboriginal and Torres Strait Islander spiritual and cultural beliefs

1. Connection to Land and Nature

• Belief: Aboriginal and Torres Strait Islander peoples have a deep spiritual connection to the land, often referred to as “Country.” Land is not just a physical place but a source of identity, wellbeing, and spiritual significance.
• Healthcare Impact: Many Indigenous patients may feel uncomfortable or disconnected in large, sterile, urban hospitals that are far from nature or “grounded” environments. The separation from nature in these environments can cause distress. For example:
  • Hospitals and Big Buildings: ATSI patients may feel uneasy or reluctant to enter large buildings like hospitals because they are high above the ground and disconnect them from the earth, which they believe is essential for spiritual and physical healing.
  • Walking Barefoot: Some Indigenous patients prefer to walk barefoot because it allows them to stay connected to the earth, which they believe promotes grounding and a sense of spiritual balance.

Aspect	Connection to Land and Nature	Impact on Healthcare (Western Medicine)
Healing from the Land	Land provides physical and spiritual healing; time on Country restores balance and wellbeing.	Preference for outdoor settings in healthcare; preference for bush medicine alongside or instead of pharmaceuticals.
Walking on Country	Walking barefoot connects individuals to the earth, promoting grounding and spiritual balance.	Discomfort in shoes or indoor settings; desire to return to Country for healing and recovery.
Sacred Sites and Healing	Certain areas of land are sacred and possess spiritual healing properties.	Indigenous patients may seek healing at sacred sites, avoid healthcare facilities built on spiritually significant land, or express reluctance to enter certain areas.
Nature as Part of Spiritual Wellbeing	Natural elements (plants, animals, water) are integral to spiritual and physical health.	Environmental damage can cause spiritual distress. Access to natural settings, like rivers, can enhance healing, but absence may cause discomfort.
Respect for Animals and Ecosystems	Animals and ecosystems are spiritually significant, often serving as totems or spiritual guides.	Symbolic presence of animals may influence perceptions of health. Traditional practices like hunting are considered part of maintaining health.
Seasonal and Cyclical Connection	Health decisions and lifestyle practices align with natural cycles and seasons, considered essential for balance.	Indigenous patients may prefer to time medical interventions with natural cycles, which may conflict with standard treatment schedules.
Returning to Country for Healing/Death	Returning to ancestral lands is essential for spiritual peace, especially at end of life.	Indigenous patients may wish to leave hospitals for end-of-life care at home, fearing spiritual harm if they die away from Country.
Use of Bush Medicine	The land provides traditional healing remedies (bush medicine), passed down through generations.	Preference for natural remedies over or alongside prescribed medications. May combine traditional and Western medicine.
Sacred Trees and Places for Reflection	Certain trees and landmarks serve as places for spiritual reflection and mourning, aiding emotional healing.	Hospitals away from sacred or natural sites may feel isolating. Indigenous patients may seek time in nature for emotional or spiritual healing.

2. Concept of Health and Holistic Wellbeing

• Belief: In many Indigenous cultures, health is seen as a holistic concept. It encompasses not only the physical body but also the spiritual, emotional, and social aspects of life. Wellbeing is closely tied to family, community, and the environment.
• Healthcare Impact: This broader view of health may not align with Western medicine’s focus on treating specific illnesses or symptoms. Indigenous patients may seek treatment for spiritual or emotional imbalances, such as grief, trauma, or disruption of relationships, which are not always recognized in Western medical models. For instance:
  • A person may describe feeling unwell due to a spiritual imbalance, such as a disconnection from their land or ancestors, which Western medicine might not address.

3. Fear of Death and Spirits

• Belief: Many Aboriginal and Torres Strait Islander people hold specific beliefs about spirits and the afterlife, which influence how they perceive hospitals and death.
• Healthcare Impact: Hospitals, particularly Western hospitals, may be seen as places where people go to die, leading to a fear of these environments. Some Indigenous people believe that the spirits of those who die in hospitals may not be able to return to their ancestral lands, causing great distress.
  • Dying in Hospital: Many ATSI patients and their families prefer to return home to die rather than staying in a hospital because they believe the spirit must return to Country (ancestral land) for peace.
  • Avoidance of Death-related Discussions: In some communities, talking about death is taboo and considered to invite bad luck. Western medicine often involves detailed discussions about prognosis, terminal illness, and end-of-life care, which may make Indigenous patients uncomfortable or anxious.

4. Kinship and Community

• Belief: Kinship and strong family ties are central to the health and wellbeing of Indigenous peoples. Decisions about health are often made collectively, involving the broader family or community.
• Healthcare Impact: Western medicine typically focuses on the individual and encourages personal responsibility for health. However, Indigenous patients may feel that health decisions must be made with the input of family, elders, and community members.
  • Group Decision Making: Indigenous patients might not make quick decisions about treatment without consulting family members, which can be seen as a delay in Western medical practice.
  • Presence of Family: Large family gatherings in hospitals, including extended family, can occur, as many feel the need to support the patient and ensure culturally appropriate care. This may be challenging in hospital settings with visitor restrictions or limited space.

5. Spiritual Healing and Traditional Healers

• Belief: Traditional healing practices are important for many Aboriginal and Torres Strait Islander people. Traditional healers (e.g., Ngangkari in some communities) play a key role in maintaining spiritual and physical health through the use of natural remedies, rituals, and spiritual guidance.
• Healthcare Impact: Indigenous patients may seek out both Western medical treatments and traditional healing practices. They may rely on bush medicine or the intervention of a traditional healer before or alongside seeking Western medical care.
  • Use of Traditional Medicine: Indigenous patients may prefer or trust traditional medicines and remedies (e.g., bush plants) over pharmaceuticals. In some cases, there may be reluctance to use prescribed medications because of these preferences.
  • Combination of Healing Approaches: Some patients may choose to see both a doctor and a traditional healer, and they may expect the healthcare system to respect and incorporate their traditional practices.

6. Fear of Removal and Historical Trauma

• Belief: Many Aboriginal and Torres Strait Islander peoples carry the trauma of historical policies such as the Stolen Generations, where Indigenous children were forcibly removed from their families.
• Healthcare Impact: This historical trauma can manifest as a mistrust of healthcare institutions and government services, leading to delayed healthcare-seeking behavior.
  • Fear of Child Removal: Indigenous parents may fear that hospitals or healthcare services could result in their children being taken away, a fear rooted in past practices. This may lead to avoidance of hospitals or medical services, especially in cases involving child health.
  • Mistrust of Healthcare Providers: Some Indigenous patients may be hesitant to engage with healthcare providers due to a perceived lack of understanding of their cultural needs or fear of discrimination.

7. Spiritual Healing through Ceremony

• Belief: Ceremonies, including smoking ceremonies or cleansing rituals, are an important part of healing and maintaining spiritual wellbeing for many Indigenous Australians.
• Healthcare Impact: These ceremonies may be performed before or after a significant event like surgery, illness, or death. However, such practices may not always be accommodated or understood in Western medical settings.
  • Smoking Ceremonies: These involve burning native plants to cleanse a space or person spiritually. Patients may request permission to perform a smoking ceremony before undergoing a medical procedure or upon leaving a hospital.

8. Belief in “Sorry Business”

• Belief: “Sorry Business” refers to the Indigenous mourning and funeral practices, which are deeply significant and involve extended periods of grieving, often involving the entire community.
• Healthcare Impact: Western medical systems may not fully recognize the importance of “Sorry Business,” leading to potential conflicts when Indigenous patients need time off work, leave from school, or an extended stay away from healthcare facilities.
  • Prioritization of Mourning: Family members may prioritize participation in “Sorry Business” over medical appointments or treatments, which can be misunderstood by healthcare providers as non-compliance or neglect of health.

Type of Business	Meaning	Significance	Cultural Considerations	Health Implications
Sorry Business	Mourning practices and ceremonies after a death	Brings the community together for grieving and support	Avoidance of certain names/images of the deceased suspension of work/routines during the mourning period	Emotional and mental health impacts, including grief and stress. Long mourning periods can affect mental well-being, social participation, and access to healthcare.
Men’s and Women’s Business	Gender-specific cultural knowledge and ceremonies	Involves initiation rites and passing down of cultural roles and knowledge	Sacred and secretive; strictly limited to the respective gender groups	Restricted access to gender-specific healthcare if cultural boundaries are not respected. Gender-sensitive care is crucial.
Ceremonial Business	Ceremonies marking life events (e.g., initiation, marriage)	Central to maintaining cultural traditions and spiritual beliefs	Deeply spiritual, involving song, dance, and rituals; sacred in nature	Physical and emotional well-being may be influenced positively through community support but also through potential stress or physical strain during lengthy ceremonies.
Kinship and Family Business	Business involving family gatherings, dispute resolution, and kinship ties	Fundamental to social structure, influencing relationships and responsibilities	Complex obligations that are governed by traditional kinship rules	Family and community responsibilities may lead to stress or mental health challenges, especially if there is conflict or high expectations.
Cultural Business	Preservation and sharing of traditional knowledge (language, art, spirituality)	Vital for maintaining cultural identity and traditions	Involves storytelling, oral histories, and respect for Elders who hold the knowledge	Positive impact on mental and emotional well-being due to a sense of belonging and cultural continuity. However, loss of cultural knowledge may lead to feelings of isolation or identity issues.

9. Different Interpretations of Health Symptoms

• Belief: Some symptoms may be interpreted as signs of spiritual distress rather than physical illness. For instance, feeling unwell could be attributed to a spiritual cause, such as a curse or breach of cultural law.
• Healthcare Impact: Indigenous patients may describe symptoms differently, emphasizing the spiritual or emotional aspects of their illness rather than physical symptoms, which can lead to misunderstandings with healthcare providers focused on physical diagnoses.

Aboriginal Colloquial terms related to health and their respective health contexts:

Term	Meaning	Health Context
Deadly	Colloquial term meaning excellent or great	“Deadly health programs” or “deadly doctors” refer to excellent health services or professionals.
Djukurrpa (Dreaming)	Spiritual belief system, explaining the creation and cultural laws	Holistic health is tied to spiritual and cultural beliefs, encompassing mind, body, and spirit.
Yarning	Informal conversation or storytelling	Used in healthcare to build trust and understanding; “yarning circles” in mental health or counselling settings.
Liyan (Kimberley Region Term)	Inner sense of well-being or gut feeling	Refers to emotional and spiritual wellbeing. A “good” liyan means feeling balanced and healthy.
Marngrook	Traditional Aboriginal football game or physical play	Physical activity is essential for maintaining physical health and wellbeing, especially for youth.
Koori, Murri, Nunga, Yolngu, Palawa	Regional names for Aboriginal groups (e.g., Koori in NSW/VIC, Murri in QLD)	Used in health services to provide culturally safe care (e.g., “Koori Health Services”).
Mob	Family, group, or community	Health programs often focus on supporting the “mob” or community’s collective health and wellbeing.
Ngurra	Home or country	Connection to country is essential for mental, emotional, and spiritual wellbeing.
Birthing on Country	Culturally safe birthing practices on ancestral land	Programs integrate cultural values into maternal and infant healthcare for better health outcomes.
Strong Spirit, Strong Mind, Strong Body	Holistic view of health (balance of physical, mental, emotional, spiritual)	Concept used in health programs to promote overall wellbeing.
Dadirri (Deep Listening)	Deep listening or inner quiet	Promotes mental and emotional healing, often used in therapeutic settings to support mental health.
Sorry Cuts	Self-inflicted cuts during mourning (part of “Sorry Business”)	Culturally significant but requires sensitive medical care to prevent infection and promote healing.
Bush Medicine	Traditional plant-based medicine used for healing	Often integrated with or used as an alternative to Western medicine in ATSI communities.