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.

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.