Monash University
Department of Rural &
Indigenous Health
Indigenous Health Unit
www.med.monash.edu.au
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[email protected]
Indigenous Cultural Awareness /
Cultural Safety Training
for Health Professionals
Marlene Drysdale
Isabel Ellender
February 2009
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Objectives
To explore culture & cultural competence,
Examine why cultural competence is a desirable
skill for health professionals,
Examine events & policies that lacked cultural
safety & now impact on Indigenous health,
Reflect on your own values & perspectives to
become a culturally competent professional.
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Culture – why learn about it?
• Each of us is part of some culture or cultures.
• Sensitivity & curiosity to build competence
skills
• To provide better health care delivery.
• Equity
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Culture…..
• Beliefs
• Behaviours
• Attitudes
• Practices
……… all learned, shared, and passed
on by members of a group
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Culture shapes our…..
• experience of the world,
• environment,
• family life,
• lifestyle,
• work & play
• life in our communities.
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Culture is adapted through…..
• ethnic/racial environment,
• language and education,
• gender, age, personality
• socio/economic status,
• spirituality/religion,
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Every culture  defines health,
 determines disease aetiology,
 prescribes how distress is defined &
signalled,
 prescribes medical & social means of
treatment
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What is your culture?
Q
How would your culture affect your
service delivery?
Q
How do your values and norms affect
how you see the cultural practices of others?
Q
How do culture & health interact?
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What is Aboriginal Cultural
Awareness?
• Aboriginal Cultural Awareness means having
knowledge and understanding of Aboriginal
people’s histories, values, belief systems,
experience and lifestyles.
• It is not about becoming an expert on
Aboriginal culture.
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What is Cultural Safety?
• Cultural safety is the action that comes from
cultural awareness.
• Leads to cultural security.
• Appreciating and understanding difference
and accepting it.
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Definition of Aboriginality
An Aboriginal person is of Aboriginal descent
who identifies as such and who is accepted
by the Aboriginal community with which he
or she is associated
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SESSION ONE
Pre-European Settlement
•
•
•
•
60,000+ years Indigenous occupation
Strong traditional Indigenous societies
Complex and structured social organization
Self-sufficiency in tune with environment
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Dreaming
• Ungud
-
• Alcheringa • Tjukurpa • Wongar
-
• Bugari
-
Ngarinyin People from NW
Australia.
Aranda people
Pitjantjatjara People
Murngin People NE Arnhem
Land.
Broome Region of West Australia
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What the ‘Dreaming’ teaches us
• Our ‘dreaming stories’ are not myth and
legend but are both our past and present.
• Teaches rules for living in the physical and
spiritual worlds.
• Explains how the ‘spirit ancestors created the
world
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• Teaches us about all aspects of life our social
structure and relationships to one another
• Dreaming beliefs are passed on through story and
ceremony
• Importance of sharing and caring for our
environment
• Controls rules of marriage and behaviour
• The ‘Dreaming’ is creation, history, our bible and a
blueprint for life .
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Indigenous Occupation
• Kinship system
• 500 different languages and complex sign
language
• Highly complex and integrated spiritual belief
system
• Conservation of land and environment to
guarantee food and other resources-continuity
• Technology
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Kinship system
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Language
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Language (cont’d)
• In Victoria about 10 different languages
• Over 30 dialect groups e.g. Kulin nation of
Melbourne and surrounding areas was made of of
5 dialect groups- Woiworung, Jajowrong and
Taungurong.
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SESSION TWO
European Contact
•
•
•
•
1770 James Cook claims possession
1788 Captain Phillip raises Union Jack
1799 Aboriginal resistance – Parramatta
1835 Batman Treaty- estimated Aboriginal
population =11,500
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European Contact (cont’d)
• 1837 British parliament receives report on
genocide in the colonies
• 1838 First Aboriginal protectorate established
• 1841 Estimated Aboriginal population = 2000
• 1851 Colony of Victoria established
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European Control
• 1869 Act for protection and management of
Aboriginal natives is passed in Victoria
• 1908 Pensions for all Australians Except Aborigines
• 1912 Maternity allowance for all except Aborigines
• 1938 Aborigines forced to “play” re-enactment of
invasion of 1788
• 1941 Child endowment- no payments to nomadic or
“mission” dependent Aborigines
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Protection, removal, segregation
• Protection policies 1890-1937
• Assimilation policies –1938 1968
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Protection policies 1890-1937
What Happened?
–
–
–
–
–
–
–
Mixing together of groups
Start welfare dependency
Stringent control of Aboriginal life
Loss of land
Forbidden to practice culture & speak language
European food & clothing introduced
Massacres & diseases
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Protection policies 1890-1937 (cont’d)
Effects
–
–
–
–
–
–
–
Destruction of kinship system
Families separated – loss of roles
Loss of spirit
Loss of culture
Loss of way of life-self-sufficiency
Heavy death toll
Disease epidemics
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Assimilation policies – 1938 -1968
What Happened?
– Children taken away from families
– Institutionalized & trained for menial work
– Further breakdown of family and clan
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Assimilation policies – 1938 -1968
The Effects
– Confusion, fear, anger
– Cultural dispossession
– Further loss of connection
– Increased welfare dependency
– Provision of cheap labor
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Self-determination/self-management 1968-90
What happened?
– 1957 Federal Council for The Advancement of
Aboriginals & Torres Strait Islanders established
– Aborigines Advancement League established in
Victoria
– Political activism-national level
– Re-emergence of Aboriginal leaders
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1967 Referendum
– sec127 of Constitution to include
Aborigines in the Census and
– sec 51 to enable the Federal Government
pass laws for Aboriginal people nationally
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Self-determination/self-management (cont’d)
The Effects
–
–
–
–
Aboriginal people gain new hope
Improvement in some aspects of life
Aborigines get right to vote
Government commitment to improving
economic status of Aboriginal people
– Department of Aboriginal Affairs
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Reconciliation 1990s onward
What Happened?
• Royal Commission into Aboriginal deaths in
custody 1991
• Council for Aboriginal Reconciliation established
1992
• National Inquiry into the separation of Aboriginal
& Torres Strait Islander children from their
families 1997
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Reconciliation 1990s onward
Effects
• National & State programs to reduce deaths in
custody
• National recognition of ‘Stolen Generations” of
Indigenous children
• Howard refuses to say sorry
• Community education programs introduced on
Indigenous culture & history
• Ongoing collaboration between Indigenous and
non-indigenous people on reconciliation
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Aboriginal Health Status
•
•
•
•
•
Life expectancy: 17 year less
Infant Mortality: 3 times higher
Diabetes: 20 -30 times higher
Renal Failure: 15 times higher
Birthweight: 209 grams less
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Health continued….
•
•
•
•
Death by injury : 4 times greater
Hospitalisation: rates 55% greater
Cardiovascular Disease: 1 in 3 deaths
Cancer: 70% higher death rates among
Indigenous women
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Issues Today
• Health conditions equal to third world
statistics
• 17 year less life expectancy
• No political power – no seats in Government
• No economic base to operate from
• High youth suicide etc.
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Continued…
•
•
•
•
•
Domestic violence
Child abuse
Government neglect
Loss of identity
Powerlessness
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Many Indigenous health issues lie
outside the health sector * cultural,
* spiritual
* economic
* social,
* historical
* physical environment.
If you don’t remove the cause,
you wont effect a cure!
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Good health requires • appropriate housing,
• Suitable, sufficient diet,
• clean drinking water and clean air
• land free of pollution,
• pest control and waste removal
• health education, information,
• communicable diseases control
• leisure facilities.
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“Health is not just the physical well-being of
the individual but the social, emotional and
cultural well-being of the whole community”
(NAHS Working Party, 1989:x)
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The Intervention
• Howard government response
• To eliminate violent & sexual abuse of
Aboriginal children & unacceptable living
standards in remote communities.
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The $1 billon Intervention
•
•
•
•
•
•
73 remote NT communities
acquired 99 year leases,
cancelled permit system
Enforced the alcohol legislation
Military taskforce
Quarantined 50% of all welfare payments.
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Pro Intervention
•
•
•
•
9000 child checks
rise in school attendance
drops in gambling, drinking & drug taking.
expanded schools, public housing
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Anti Intervention
•
•
•
•
•
•
•
On-going invasion!
Political manoeuvre
Land grab
Discriminatory
Broader issues neglected.
Undermined human rights.
Lacked consultation process
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Consider…….
•
•
•
•
All kids need protection!
Accusing all remote Indigenous parents.
Abuse in urban as well as remote.
Opening up closed remote communities Good or bad?
• Previously out of sight out of mind.
• A new assimilation and interference???
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The Apology
The Stolen Generations
Children of mixed descent, forcibly removed
from their families by government welfare or
church agents & placed in institutional care
or with non-Indigenous foster parents.
“Neglect” judged by presence of poverty,
mobility, or having few possessions.
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Some say …………
1. It’s too long ago!
2. I had nothing to do with it!
3. I didn’t know it was happening!
4. Why should I feel guilt & shame?
5. Saying sorry wont deliver results!
6. Saying sorry wont change the past!
But …….
Need an apology to move on.
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Bad things happen
when good people are silent!
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Lack of communication - the patient …
Lack of dialogue with a health professional can lead to
–
–
–
–
–
–
–
Compliance problems with prescribed treatment
Not understanding treatment purpose, side effects
Admitted to hospital without information
Lack of informed consent
Mistaken identity
Sent home with inadequate information.
Patients’ treatment at odds with their cultural beliefs.
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Lack of communication - the health professional
–
–
–
–
–
–
–
Barrier to diagnosing patients’ complaints
Difficult to inform patients, & gain informed consent
Getting gender issues wrong
Getting authorities wrong
Getting religious protocols wrong (death & birth)
Barriers to timely health prevention measures
Barriers to evaluating overall problem and
developing culturally sensitive solutions
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Cultural differences in communication
Verbal
Non-verbal Rules
Etiquette
tempo
taboos
address
tone
slang
gestures
body space
touching
eye contact
silences
greeting
respect
interrupting
acknowledging
conduct
prioritizing
avoidance
consent
observing time
decision making
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Reminder
You do not have to bear the guilt for the
actions of past practices but you have a
responsibility to ensure such practices do not
continue today
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Thank you
www.med.monash.edu.au/mrh
[email protected]
Cultural ways???
British
Japanese
Aboriginal German
American
Industrious
Gentle
Vicious
Artistic
Organised
Spiritual
Warlike
Passive
Aggressive
Intellectual
Narrow
minded
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What is your culture?
Q
How would your culture affect your
service delivery?
Q
How do your values and norms affect
how you see the cultural practices of others?
Q
How do culture & health interact?
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Your culture
♣ Describe your culture!
♣ In your culture, what protocols are associated
with birth?
♣ In your culture, what protocols are associated
with death, the dead body, disposal?
♣ Describe the indigenous people in your
country of birth?
♣ Describe something about their health?
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Indigenous culture
Name a behaviour or words likely to offend an
– Indigenous patient?
– A Moslem patient?
– A Jewish patient?
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Indigenous culture
♣ Have you met an Indigenous Australian?
♣ What does it mean to be aware of another’s
culture?
♣ Why would it be important to you as a
professional?
♣ What skills do you acquire from being aware of
Indigenous peoples’ history and their culture?
♣ What non-medical issues act as barriers to
Indigenous peoples’ use of mainstream health
facilities?
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Questions
♣ Proportion of Indigenous Australians in total
population?
♣ What is the life expectancy of a non-Indigenous
man?
♣ What is the life expectancy of an Indigenous
man?
♣ What is the life expectancy of a non-Indigenous
woman?
♣ What is the life expectancy of an Indigenous
woman?
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Institutional culture - ‘a culture of
no culture’???
What is the culture of the profession of Social Work?
How does it pass it on??
Truth of bio-medical knowledge - a real
knowledge.
What is the culture of Monash?
How does it pass it on?
Science is concerned only with timeless truths.
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DVD Stranger in town issues,
questions and model answers.
1.What support processes are in place for
Colin Murka’s remote community when
he gets sick?
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Q 1. Answers
• Aboriginal Health Worker (AHW). Familiar person in the
community, speaks the language, knows the people.
• AHW takes message from Colin’s nephew,
understands implications of message, acts on it.
• The clinic knows Colin.
• Female nurse has male AHW when she talks to and
questions Colin.
• The nurse gives Colin time to answer her questions.
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Colin in hospital
Q 2. What aspects of his hospital stay are
unfamiliar and scary for Colin?
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Q 2. Answers
• Clinical setting, confined situation, left alone in strange
environment for long periods.
• Unfamiliar procedures, gadgets around him.
• New faces, unfamiliar language.
• Everyone in a hurry.
• Wheelchair orderly shouts so he understands.
• Female nurses attend to him.
• Use of very direct approaches not his way.
• Fear of getting into a lift for the first time.
• Sleeps under stars not in formal bed in a clinical setting.
• Not told what’s happening next.
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Colin in hospital
Q 3. As a health professional in that
hospital what would you have done to
make Colin’s stay less scary?
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• Better communication.
• Appropriate explanations.
• Offer to contact hospital Indigenous liaison
officer or local Indigenous community.
• Culturally competent approaches.
• Offer to connect a phone call to his family
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Colin in hospital
Q 4. What caused Colin’s stay to improve?
Why did these things work?
• Contact with local Indigenous community
brought some familiarity and cultural safety.
• Contact person could liase with hospital staff
• A friendly face in a hostile environment.
• Speaking his language with a friend.
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Monash University School of Rural Health