Improving Access to Cancer Treatment Services in Australia's Northern Territory-History and Progress.

Cancer is the leading cause of death in the Northern Territory (NT), Australia's most sparsely populated jurisdiction with the highest proportion of Aboriginal people. Providing cancer care to the NT's diverse population has significant challenges, particularly related to large distances, limited resources and cultural differences. This paper describes the developments to improve cancer treatment services, screening and end-of-life care in the NT over the past two decades, with a particular focus on what this means for the NT's Indigenous peoples. This overview of NT cancer services was collated from peer-reviewed literature, government reports, cabinet papers and personal communication with health service providers. The establishment of the Alan Walker Cancer Care Centre (AWCCC), which provides radiotherapy, chemotherapy and other specialist cancer services at Royal Darwin Hospital, and recent investment in a PET Scanner have reduced patients' need to travel interstate for cancer diagnosis and treatment. The new chemotherapy day units at Alice Springs Hospital and Katherine Hospital and the rapid expansion of tele-oncology have also reduced patient travel within the NT. Access to palliative care facilities has also improved, with end-of-life care now available in Darwin, Alice Springs and Katherine. However, future efforts in the NT should focus on increasing and improving travel assistance and support and increasing the availability of appropriate accommodation; ongoing implementation of strategies to improve recruitment and retention of health professionals working in cancer care, particularly Indigenous health professionals; and expanding the use of telehealth as a means of delivering cancer care and treatment.

Perspectives of Aboriginal People Affected by Cancer on the Need for an Aboriginal Navigator in Cancer Treatment and Support: A Qualitative Study.

Aboriginal and Torres Strait Islander Australians suffer higher rates of cancer and poorer outcomes than the wider population. These disparities are exacerbated by rurality and remoteness due to reduced access and limited engagement with health services. This study explored the cancer journeys of Aboriginal patients and carers, and their views on the establishment of an Aboriginal Patient Navigator role within the Western Australian healthcare system to support cancer patients and their families. Sixteen Aboriginal participants were interviewed either face to face, by telephone, or via video conferencing platforms. The interviews were then recorded, transcribed, and thematically analyzed using standard qualitative techniques. Close consultation within the research team enhanced the rigour and robustness of the study findings. Patients and carers identified many gaps in cancer service delivery that made their experiences stressful and unnecessarily complex. Challenges included a lack of stable accommodation, financial burdens, constant travel, being "off-Country", and miscommunication with health professionals. Key sources of support and strength were the centrality of family and ongoing cultural connectedness. All participants were supportive of an Aboriginal Patient Navigator role that could address shortfalls in cancer service delivery, especially for patients from rural and remote communities. A culturally safe model of support has the potential to increase access, reduce anxiety and improve health outcomes.

Longitudinal Follow Up of Early Career Midwives: Insights Related to Racism Show the Need for Increased Commitment to Cultural Safety in Aboriginal Maternity Care.

Racism in health care undermines equitable service delivery, contributes to poorer health outcomes and has a detrimental effect on the Aboriginal workforce. In maternity care settings, Aboriginal women's perceptions of discrimination are widespread, with the importance of cultural practices surrounding childbirth often not recognised. Efforts to build midwives' cultural capabilities and address health disparities have seen Aboriginal content included in training programs but little is known about its application to clinical practice. This study reinterviewed midwives who had previously completed university midwifery training that aimed to increase understanding of Aboriginal people and cultural safety in health care. Participants were 14 non-Indigenous midwives and two Aboriginal midwives. Interviews explored the legacy of program initiatives on cultural capabilities and observations and experiences of racism in maternity care settings. Methods followed qualitative approaches for research rigour, with thematic analysis of transcribed interviews. Findings revealed the positive impact of well-designed content and placements, with non-Indigenous participants cognisant and responsive to casual racism but largely not recognising institutional racism. The Aboriginal midwives had experienced and were attuned to racism in all its guises and suggested initiatives to heighten awareness and dispel stereotypes. It is evident that greater attention must be paid to institutional racism in educational programs to increase its recognition and appropriate actions within health care settings.

Respect, Relationships, and "Just Spending Time with Them": Critical Elements for Engaging Aboriginal Students in Primary School Education.

While disparities in educational outcomes for Aboriginal children have narrowed in early childhood education and for Year 12 completions, these positive trends are not replicated in the intervening years where attendance, reading, writing, and numeracy targets have been missed. Erratic attendance in the primary years has the greatest impact on achievement; literacy and numeracy scores decline as absences increase. Family functioning and health, caregiver expectations, past encounters with the education system and socio-economic disadvantage are all implicated in poorer rates of attendance. In response to community concerns, an Aboriginal/mainstream partnership was forged in 2011 and began work in 2016 to address patterns of attendance and achievement among Aboriginal primary students in a regional city in Western Australia. This paper describes the innovative, community-led "More Than Talk" program and presents findings from teaching and support staff interviews two years after implementation. Qualitative methods were employed to analyse the data, develop themes, and ensure rigour. Findings highlighted the cascading impact of erratic attendance and the role of strong relationships, respect, and investment of time with children as critical elements in student engagement and wellbeing. Community-led, collaborative educational programs have the potential to positively impact Aboriginal students' engagement and contribute to culturally responsive environments. If sustained, such efforts can enable learning to flourish.

Cultural respect in midwifery service provision for Aboriginal women: longitudinal follow-up reveals the enduring legacy of targeted program initiatives.

BACKGROUND: Culturally competent maternity care provision to Aboriginal and Torres Strait Islander women was identified as a priority area by Australia's National Maternity Services Plan in 2011. While midwifery programs responded by including core Indigenous content and community placements in curricula, little is known about whether knowledge learned, and insights gained in response to these initiatives have endured and been applied in clinical practice. This follow-up study explores the impact of a compulsory Indigenous unit and a remote clinical placement on two cohorts of non-Indigenous midwives who were participants in an earlier 2012-14 study. METHODS: Fourteen non-Indigenous participants who were either students or recent graduates in 2012-14 were located and re-interviewed in 2019-20. In-depth interviews based on a semi-structured interview guide were conducted by telephone or face-to face; recordings were transcribed and thematically analysed using standard qualitative procedures. RESULTS: Exposure to Indigenous content and settings during training had an enduring impact on participants' midwifery practice; most felt better prepared to provide culturally safe care, build respectful relationships and advocate for improved services for Aboriginal women. Despite this positive legacy, they also expressed apprehension about causing offence and recognised their own knowledge deficits with regard to Aboriginal cultural practices. Organisational constraints, including restrictions on the number of family members accompanying a birthing mother were identified as barriers to optimal care; some positive organisational initiatives were also described. CONCLUSIONS: This follow-up study provides encouraging evidence that well-designed and delivered Indigenous content and community placement opportunities in midwifery programs can have a lasting impact on service provision to Aboriginal women, contribute to a more informed, empathetic and culturally competent maternity workforce and help catalyse health service changes towards more culturally safe care.

Learning from follow-up of student placements in a remote community: a small qualitative study highlights personal and workforce benefits and opportunities.

BACKGROUND: The maldistribution of the Australian health workforce contributes to restricted accessibility and poorer health outcomes for rural and remote populations, especially Aboriginal and Torres Strait Islander Australians. Student exposure to rural and remote settings is a long-term strategy that aims to reduce workforce shortages by encouraging rural career uptake, with well-supervised, positive placement experiences associated with rural practice intentions. Furthermore, placements can build students' cultural capabilities and foster interest in working with disadvantaged and underserved Aboriginal communities. However, little is known about the translation of rural practice intentions to career paths, and the factors influencing employment decision-making and application of clinical and cultural content to professional practice. This in-depth study reports on the second stage of an investigation into the longer-term impact of remote placements. Stage One identified factors that contributed to students' learning experiences and highlighted challenges encountered; Stage Two explored the impact on professional practice and employment decision-making amongst a subset of the original cohort. METHODS: Of 12 interviews with participants who completed a remote placement in 2013/4 (Stage One), eight graduates were located four years later and seven were re-interviewed. Telephone interviews used a semi-structured schedule; each interview was recorded, transcribed and analysed for recurring themes and meanings. RESULTS: At the time of interview, all participants were employed as health professionals and worked in Australia. The follow-up highlighted the enduring legacy of the student placement in terms of participants' personal and professional growth. The majority were employed in rural settings; some were attracted by a rural lifestyle and employment opportunities while others were drawn by a desire to reduce rural health disparities. Regardless of setting, all actively applied clinical and cultural learnings acquired on placement to their professional practice. Rural job security, professional support and opportunities for professional development were all influences on continuing rural practice. CONCLUSIONS: Despite the challenges of qualitative longitudinal follow-up, the findings of this study provide valuable information, which can inform scaled-up investigations into the role of placements in developing an expanded, more stable and culturally respectful rural workforce.

Applying a Midwifery Lens to Indigenous Health Care Delivery: The Contribution of Campus Learning and Rural Placements to Effecting Systemic Change.

STUDY BACKGROUND: Increasing cultural safety in health settings is essential to address stark health disparities between Indigenous and non-Indigenous Australians. Respect for cultural knowledge, better communication, and recognition of racism as a determinant of health are required for improved service delivery. How this knowledge is acquired in health professional training and translated to clinical settings is poorly understood. PURPOSE: Impacts of an innovative Indigenous health unit and remote clinical placements on knowledge acquisition and attitude change were explored among midwifery students to inform cultural competency initiatives in health professional training. METHODS: A multiphased, mixed methods research design used surveys, observations, and interviews. Qualitative analysis was strengthened through triangulation with quantitative data. RESULTS: A unit conceived with substantial Indigenous Australian input and which privileged these voices enhanced knowledge and shifted attitudes in a positive direction; however, immediate gains diminished over time. Remote placements had a profound effect on student learning. Exposure to Indigenous Australians in classrooms and communities, and the self-reflection generated, helped dispel stereotypes and challenge assumptions based on limited cultural knowledge and contact. CONCLUSION: Optimization of receptivity to Indigenous Australian content and opportunities for remote placements contributed to students' developing cultural capabilities with implications for all health professional training. Whether this heightened awareness is enough to address institutional racism identified in health service delivery remains unanswered. The focus must include those established health practitioners and administrators who influence organizational culture if real systemic change is to occur. Given appropriate on-going support, graduates can play a vital role in expediting this process.

Up close and real: living and learning in a remote community builds students' cultural capabilities and understanding of health disparities.

BACKGROUND: Rural and remote communities in Australia fare worse than their urban counterparts across major health indicators, with geographic isolation, restricted accessibility to health services, socioeconomic disadvantage, lifestyle and behavioural factors all implicated in poorer health outcomes. Health disparities, which are especially stark in Australian Aboriginal and Torres Strait Islander populations, underscore the urgent need to build a culturally responsive and respectful rural health workforce. Allied health student placements in settings with high Aboriginal populations provide opportunities for the development of cultural capabilities and observation of the causes and impact of health disparities. A service learning pedagogy underpinned by strong campus-community partnerships can contribute to effective situated learning. Positive placement experiences can also encourage future rural practice alleviating workforce shortages. This article reports on the first stage of a proposed longitudinal investigation into the impact of remote placements on clinical practice and employment choices. METHODS: In-depth interviews were undertaken with health science students and recent graduates from Australian universities who spent up to 4 weeks at the remote community of Mt. Magnet (Badimaya country) in Western Australia. Interviews, which occurred between two and 12 months following the placement were recorded, transcribed and thematically analysed for patterns of meaning. RESULTS: Factors which contributed to positive professional, personal and socially responsive learning experiences were identified. These included pre-placement cultural training to build understanding of the local Aboriginal community, peer support, community engagement, cultural exchanges and interprofessional collaboration. Highlights were associated with relationship-building in the community and opportunities to apply insights into Aboriginal cultural ways to clinical and community practice. The role of the Aboriginal mentor was integral to students' understanding of the social and cultural dynamics in the practice setting. Challenges related to the logistics of supervision in remote locations and workloads. CONCLUSIONS: The interprofessional placement offered students a unique opportunity to experience how isolation, socioeconomic disadvantage and cultural factors conspire to produce health inequities in remote Australian settings and to observe how communities respond to their circumstances. Despite difficulties encountered, learnings derived from the application of clinical, social and interprofessional skills, and rural employment opportunities that arose following graduation, were all highly valued.

Promoting women's health in remote Aboriginal settings: Midwifery students' insights for practice.

OBJECTIVE: To describe midwifery students' insights on promoting health to Aboriginal women in remote Australia following a supervised clinical placement. DESIGN: Semistructured, in-depth interviews were conducted with all midwifery students who undertook the placement between 2010 and 2013. SETTING: Aboriginal communities on the Ngaanyatjarra Lands, Western Australia. PARTICIPANTS: Undergraduate and postgraduate midwifery students from a Western Australian university. INTERVENTIONS: Remote cultural immersion clinical placement. MAIN OUTCOME MEASURES: Student learning related to culturally respectful health care delivery and promotion of health. RESULTS: Students observed that, despite vast distances, high rates of participation in a breast screening program were achieved due to the informal provision of culturally relevant information and support. Opportunistic encounters in communities also enabled sexual health messages to be delivered more widely and in less formal settings. The role played by Aboriginal Health Workers and female family members was vital. The importance of culturally respectful approaches to sensitive women's business, including discretion, the use of local language and pictorial representations of information, was recognised as was the socio-cultural context and its impact on the health and well-being of the community. CONCLUSIONS: Although short in duration, the Ngaanyatjarra Lands clinical placement provided midwifery students with a rare opportunity to observe the importance of local contexts and cultural protocols in Aboriginal communities, and to adapt health promotion strategies to meet local needs and ways of doing things. These strategies embraced the strengths, assets and capacities of communities, yet students also witnessed challenges associated with access, delivery and acceptance of health care in remote settings.

Exploring undergraduate midwifery students' readiness to deliver culturally secure care for pregnant and birthing Aboriginal women.

BACKGROUND: Culturally secure health care settings enhance accessibility by Aboriginal Australians and improve their satisfaction with service delivery. A culturally secure health service recognises and responds to the legitimate cultural rights of the recipients of care. Focus is upon the health care system as well as the practice and behaviours of the individuals within it. In an attempt to produce culturally secure practitioners, the inclusion of Aboriginal content in health professional programs at Australian universities is now widespread. Studies of medical students have identified the positive impact of this content on knowledge and attitudes towards Aboriginal people but relatively little is known about the responses of students in other health professional education programs. This study explored undergraduate midwifery students' knowledge and attitudes towards Aboriginal people, and the impact of Aboriginal content in their program. METHODS: The study surveyed 44 students who were in their first, second and third years of a direct entry, undergraduate midwifery program at a Western Australian (WA) university. The first year students were surveyed before and after completion of a compulsory Aboriginal health unit. Second and third year students who had already completed the unit were surveyed at the end of their academic year. RESULTS: Pre- and post-unit responses revealed a positive shift in first year students' knowledge and attitudes towards Aboriginal people and evidence that teaching in the unit was largely responsible for this shift. A comparison of post-unit responses with those from students in subsequent years of their program revealed a significant decline in knowledge about Aboriginal issues, attitudes towards Aboriginal people and the influence of the unit on their views. Despite this, all students indicated a strong interest in more clinical exposure to Aboriginal settings. CONCLUSIONS: The inclusion of a unit on Aboriginal health in an undergraduate midwifery program has been shown to enhance knowledge and shift attitudes towards Aboriginal people in a positive direction. These gains may not be sustained, however, without vertical integration of content and reinforcement throughout the program. Additional midwifery-specific Aboriginal content related to pregnancy and birthing, and recognition of strong student interest in clinical placements in Aboriginal settings provide opportunities for future curriculum development.

"Listening to the silence quietly": investigating the value of cultural immersion and remote experiential learning in preparing midwifery students for clinical practice.

BACKGROUND: Cultural immersion programs are increasingly offered to medical and health science students in an effort to provide experiential learning opportunities that focus on 'the self' as well as 'the other'. Immersion programs encourage self-reflection on attitudes towards cultural differences, provide opportunities to build relationships and work with community members, and allow students to apply knowledge and skills learned in training programs in a supervised practice setting. The aim of this paper is to describe midwifery students' reflections on a remote Aboriginal clinical placement that has been offered at a Western Australian university since 2010. METHODS: Interviews were conducted over a period of 15 months with the first seven participants who completed the program. At the time of interview, four participants were in the final year of their undergraduate degree and three were practicing midwives. In addition, access was given to a detailed journal kept by one participant during the placement. Interviews also were conducted with midwifery staff at the university and practice setting, although the focus of this paper is upon the student experience. RESULTS: Student selection, preparation and learning experiences as well as implications of the placement for midwifery practice are described. The remote clinical placement was highly valued by all students and recommended to others as a profound learning experience. Highlights centred on connections made with community members and cultural knowledge learned experientially, while challenges included geographic and professional isolation and the complexities of health care delivery in remote settings, especially to pregnant and birthing Aboriginal women. All students recognised the transferability of the knowledge and skills acquired to urban settings, and some had already incorporated these learnings into clinical practice. CONCLUSIONS: Cultural immersion programs have the potential to provide students with rich learning experiences that cannot be acquired in classroom settings. In Aboriginal communities on the Ngaanyatjarra Lands students gained valuable insights into the impact of isolation on health service delivery, the extent and strength of cultural traditions in the region, and a heightened awareness of the difficulties encountered by pregnant and birthing Aboriginal women in remote locations.

Refining the concept of cultural competence: building on decades of progress.

Cultural competence strategies aim to make health services more accessible for patients from diverse cultural backgrounds. Recently, such strategies have focused on specific groups, and particularly Indigenous Australians, where services have failed to address large disparities in health outcomes. Limitations of cultural competence largely fall into three categories: lack of clarity around how the concept of culture is used in medicine, inadequate recognition of the "culture of medicine" and the scarcity of outcomes-based research that provides evidence of efficacy of cultural competence strategies. Narrow concepts of culture often conflate culture with race and ethnicity, failing to capture diversity within groups and thus reducing the effectiveness of cultural competence strategies. This also hampers the search for evidence linking cultural competence to a reduction in health disparities. Attention to cultural complexity, structural determinants of inequality and power differentials within health care settings not only provide a more expansive notion of cultural competence and a nuanced understanding of the role of culture in the clinic, but may assist in determining the contribution that cultural competence strategies can make to a reduction in health disparities.

Confronting uncomfortable truths: receptivity and resistance to Aboriginal content in midwifery education.

OBJECTIVES: The emotional responses of students undertaking a new, compulsory unit on Indigenous cultures and health were investigated as part of a broader study looking at culturally secure practice in midwifery education and service provision for Aboriginal women. METHODS: Classroom observations were conducted on a first year midwifery cohort from July to October 2012 and students completed 'before and after' questionnaires. RESULTS: A spectrum of emotional responses was identified and found to be consistent with studies of medical student exposure to Aboriginal content. While stereotypes were challenged and perceptions altered as a result of the content, issues surrounding racism remained unresolved, with some students expressing dismay at the attitudes of their peers. CONCLUSION: This study confirmed the need for content on Aboriginal health and cultures to extend beyond one unit in a course. Learning and knowledge must be carefully integrated and developed to maximise understanding and ensure that unresolved issues are addressed.