Cultural Perspective of Health and Illness

Cultural Perspective of Health and Illness

(Readings and student online activities)

Learning Outcomes for Module 3

Upon                        successful completion of the tutorial and online activities, you                   should be able to:                                                       Discuss                                 perspectives of health and illness;                                                                 Discuss                            Aboriginal and Torres Strait Islander and Western definitions of                             health;                               Describe                           and discuss two Aboriginal holistic models of health and                                 wellbeing                           Define                              culture and discuss how it impacts health and wellbeing                                                               Discuss                            the nature of collective/individual societies.

Module 3 is divided into 7 sections

1:                       The Importance of culture                                        2:                       Definitions of health                                                                 3:                          Models of health                                                     4:                       Primary                    Healthcare in the Australian Healthcare System                         5:                       Traditional Aboriginal healing and Western medicine                          6:                       Birthing on Country                                                  7:  Implications for                     practice

Please note: Aboriginal and Torres Strait Islander people should be aware that some of this content may contain images, voices or names of deceased persons in photographs, film, audio recordings or printed material.

Readings for Module 3 :

Kingsley, J., Townsend, M., Henderson-Wilson, C., & Bolam, B. (2013). Developing an exploratory framework linking Australian Aboriginal peoples’ connection to country and concepts of wellbeing. International Journal of Environmental Research and Public Health, 10 (2), 678-698.

Brown, A. E., Middleton, P. F., Fereday, J. A., & Pincombe, J. I. (2016). Cultural safety and midwifery care for Aboriginal women–A phenomenological study. Women and Birth , 29 (2), 196-202.

N.B. These weekly readings are incorporated into the notes and activities in this module.  Complete the Module 3 student online activities. read the notes, review the PowerPoint slides and then attempt the online quiz.

Lecture: This week’s lecture will be played during the tutorial and is presented by Paul Callaghanwho is a proud member of the Ridgeway and Manton mobs, born and bred in Karuah surrounded by his extended Aboriginal family.

Section 1:  The Importance of Culture

Thackrah and Scott (2011) suggest that there are many definitions of culture most referring to:

‘systems of shared meanings or guidelines that are passed from one generation to the next and provide a lens through which the world is viewed and understood’.

Culture is dynamic and it exists within social, economic and historical frameworks and care needs to be taken not to over-read culture in that it is used to explain health and health behaviours.  Culture is frequently identified as an explanation for poor Aboriginal and Torres Strait Islander health.  For example, overcrowding is associated with Aboriginal families who tend to live in multi-family households. The preference to live in family groups may not be perceived as a problem by Aboriginal and Torres Strait Islander people but there is not a preference to live in poverty and inadequate housing (Saggars, Walter and Gray, 2011).

‘Culture can influence Aboriginal and Torres Strait Islander people’s decisions about when and why they should seek health services, their acceptance of treatment, the likelihood of adherence to treatment and follow up, and the likely success of prevention and health promotion strategies’.  (Australian Government, National Aboriginal and Torres Strait Islander Health Plan 2013 – 2023, (2013), p.9).

Houston (2009, p.106) makes an important point that health professionals need to remember that:

‘the movement towards culturally secure health services must proceed with a strong appreciation of the fact that the cultural life for Aboriginal people, be they Ngaanyutjarra, Nynoogars, Pintubi or Badi is not the same.  The is not a single homogenous Aboriginal culture, there are regional variations that are important’.

THIS IS VERY IMPORTANT.  ABORIGNAL COMMUNITIES ARE ALL DIFFERENT.  THIS MEANS THAT THERE ARE DIFFERENT CULTURAL PROTOCOLS.  THIS IMPACTS HOW NON-ABORIGINAL HEALTH PROFESSIONAL ENGAGE WITH THEM.  YOU NEED TO CONSULT WITH LOCAL ABOROGINAL LAND COUNCILS FOR ADVISE.

Section 2:  Definitions of Health

Many definitions of health exist and most acknowledge the need to consider physical, psychological, social issues and wellbeing to gain a comprehensive view of health.  The following offer Western and Aboriginal and Torres Strait Islander perspectives:

The World Health Organisation initially defined Health as:

‘a state of complete physical, emotional and social wellbeing, and not merely the absence of disease or infirmity’ (WHO, 1946).

(There are many definitions, they change over time).

The WHO (1946) moved away from a medical definition of health that is associated with the ‘absence of disease’ towards a broader more holistic view of health, related to a sense of emotional and social wellbeing but the global dominance of the Western medical system and biomedicine, which is disease orientated, remains dominant.  It does not interrogate the political, economic, historical and social factors that impact health. The value of biomedicine and its positive impact on population health is acknowledged and valued, but it contrasts with an Aboriginal definition of health which is based not on the ‘sick individual’ but on the individual as part of the much wider community and is culturally defined (Neumayer, 2013).

Aboriginal and Torres Strait Islander definitions of health

The following two Aboriginal definitions of health offer a different perspective

‘it means not just the physical wellbeing of an individual but refers to the social, emotional and cultural wellbeing of the whole Community in which each individual is able to achieve their full potential as a human being, thereby bringing about the total wellbeing of their Community. It is a whole-of-life view and includes the cyclical concept of life-death-life.”  (NACCHO Constitution, 2011. P5).

‘The Aboriginal concept of health is holistic, encompassing mental health and physical, cultural and spiritual health. Land is central to wellbeing. This holistic concept does not merely refer to the ‘whole body’ but in fact is steeped in the harmonised inter-relations which culturally constitute wellbeing. These inter-relating factors can be categorised largely as spiritual, environmental, ideological, political, social, economic, mental and physical. Crucially it must be understood that when the harmony of these interrelations is disrupted, Aboriginal ill-health will persist.’ (Swan & Raphael, 1995, p13).

Concern for Country

Land is critical to Aboriginal and Torres Strait Islander peoples’ wellbeing.  It is a powerful protector that influences wellbeing and the perception of a community’s wellbeing is closely intertwined with the health of their Country:

‘Country is multi-dimensional – it consists of people, animals, plants, Dreamings, underground, earth, soils, minerals and waters, air…People talk about country in the same way that they would talk about a person: they speak to country, sing to country, visit country, worry about country, feel sorry for country, and long for country’ (Rose, 1996 p.8).

The Dreaming has been adopted by some Aboriginal people to discuss matters of lore and spirituality. However, it is a Western term that has different meanings for different Aboriginal clan groups. At its heart are a series of protocols that govern Aboriginal societies and to the relational nature of Aboriginal and Torres Strait Islander kinship structures. In different ways across the continent Aboriginal people experience their connection to culture through walking and being present on country, through stories, songs, and dances related to a place, an object e.g. a tree, or an activity, e.g. hunting. This sense of connection is protective of health and wellbeing (a holistic connection of body, mind and spirit).  The opposite of health and wellbeing is therefore linked to disconnection from the land and culture.

This holistic view is captured in the colors of the Aboriginal flag

Black – represents the Aboriginal      people of Australia

Yellow circle – represents the Sun ,     the giver of life and protector

Red – represents the red    earth , the red   ochre used in ceremonies and Aboriginal peoples’ spiritual       relation to the land

Ganesharajah (2009, p.7) cites Willis, Pearce and Jenkins (2004), who offered an example of how Country and health are connected.  Aboriginal people in the Murray River region attributed aspects of their own poor physical or mental health to the poor health of the Murray River.  Legally restricted access and environmental degradation resulted in the Aboriginal communities being unable to pass on traditional knowledge or activities connected with the river system.  This loss of connection to land negatively impacted on perceptions of health and wellbeing.  This view of health can be misunderstood and omitted by health professionals when Aboriginal health is discussed, so it is important for you to take some time to consider how it may differ from your own perception of health.

The colors of the Aboriginal flag

Black – represents the        Aboriginal people of Australia

Yellow circle – represents   the Sun, the giver of life and protector

Red – represents the red    earth, the red ochre used in ceremonies and Aboriginal peoples’    spiritual relation to the land

Section 3:  Models of health

The biomedical model of health is disease focused and ignores the complexities of health and illness.  It has an individual focus, health and illness are regarded as objective biological states.  Cure is the goal. The model fails to consider the social determinants of health and individuals are responsible for their health (Germov, 2014).

The biopsychosocial model of health and illness is a more extensive model of health than the medical model – it incorporates social and psychological elements. An example of this is the association between cancer and tobacco use.  Elevated levels of stress are associated with an increase in risk taking behaviors and smoking becomes a coping mechanism.  The social determinants of health are associated with many high-risk behaviors.  This model originally based on physical, psychological and social elements of health.  It has been expanded to incorporate culture and reflects the complex interaction of multiple elements and their relationship to health (McInerney, 2015).

Figure 1.   Biopsychosocial Model – Engle (1977) Used under CC BY 3.0

Aboriginal models of health and wellbeing

Two Aboriginal holistic models of health will be discussed (these models do not relate to Torres Strait Islander people).

The Dance of Life:  An Aboriginal   understanding of health and wellbeing

It is acknowledged that Aboriginal communities are unique, so any model needs to appreciate the uniqueness of different communities (Kingsley et al., 2013).  The model is a multi-dimensional, holistic model of health and wellbeing from an Aboriginal perspective.

Milroy, Helen. 2002. The Dance of Life.

Many thanks to Professor Helen Milroy for allowing us to use her beautiful painting.

This model of health has been developed by Professor Helen Milroy and is illustrated through ‘The Dance of Life’ which is the last of a series of paintings.  It has five circles that represent the physical, psychological, social, spiritual and cultural dimensions which are influenced by historical, traditional and contemporary views and gaps in knowledge.  This interconnection is related to a whole-of -life approach to Aboriginal wellbeing.

Student                    Activity 1: Access the                        following link to: The                   Dance of Life Read about the five circles of Helen Milroy’s model The Dance                      of Life:  an Aboriginal understanding of health and wellbeing and                     make some notes.  Physical                             health  Psychological                            health  Social                                health & wellbeing  Spirituality  Cultural                             integrity  Student                    Activity 2: Reflect and write   What                    is your definition of health?  How does it relate to your                   perceptions of health?  Do different perceptions of health matter?

‘ Our         Wellbeing’ developed by the Rumbalara Aboriginal Cooperative         (2008)

“Our wellbeing” A holistic model of wellbeing (Rumbalara Aboriginal Cooperative 2008 cited in .

Kingsley et al 2013 pp. 685) Used under CC BY 3.0.

This model is an example of an exploratory framework linking Australian Aboriginal peoples’ connection to Country and concepts of wellbeing. The Rumbalara Aboriginal Cooperative (an ACCHS in Victoria) developed a model that explores ‘the interrelated nature of wellbeing and the environment’.  The model explores the ‘broad elements that affect Aboriginal peoples’ wellbeing, such as connectedness, sense of control, and history, and visually shows how these factors interrelate’ (Kingsley, p 685).  The importance of the Barmah Forest which is the Country of the Rumbalara Aboriginal corporation members and Melbourne City at the bottom are captured in the model highlighting the conflict that Aboriginal people face in terms of ‘being urbanised but wanting to still connect to their Country’.

Kingsley et al (2013) acknowledge the role of Aboriginal Community Controlled Health Services (ACCHS’s) as taking the lead in the development of ‘holistic and culturally appropriate models in primary healthcare settings in Australia’.

The next section will discuss the key role they take in creating culturally safe holistic care for Aboriginal people and distinct communities.

Section 4:  Primary Healthcare in the Australian Healthcare System

Providers of primary healthcare services include:

General     practices

Community       health services; and

Aboriginal Medical Services        including Community Controlled Aboriginal Health Services

Aboriginal Community Controlled Aboriginal Health Services (ACCHS)

The ACCHS were set up 1971 (the first one was in Redfern, Sydney); there are now over 143 located all over Australia in remote, rural, regional and urban locations. The National Aboriginal Community Controlled Health Organisation (NACCHO) is the peak body that represents them.  All ACCHS areAboriginal Medical Services (AMS), but the reverse is not the case. An Aboriginal Medical Service (AMS) is a health service funded principally to provide services to Aboriginal and Torres Strait Islander individuals. An AMS is not necessarily community controlled.  If an AMS is not community controlled, it will be a government health service run by a State or Territory government.

ACCHS were set up because Aboriginal and Torres Strait Islander people have a holistic view of health that is not adequately met by the biomedical model of health care (The National Aboriginal Community Controlled Health Organisation (NACCHO), 2018). The aim of ACCHS is “to deliver holistic, comprehensive, and culturally appropriate health care to the community which controls it.” (NACCHO, 2017).  This is based upon the principle of self-determination which enables Aboriginal communities to determine their own affairs, protocols and procedures.

Aboriginal communities have long argued the vital role of ACCHSs in improving Aboriginal health and recent review of the evidence suggests that ACCHSs are making important contributions to improving Aboriginal health through several pathways (Campbell, Hunt, Scrimgeour, Davey & Jones, 2017).

The notion of ‘community’ is an essential component of the Aboriginal view of the self and therefore strongly related to health and well-being (see definitions at the end of this document).  ACCHS provide a comprehensive primary health care approach and the services they provide are broader than those of mainstream services.  They emphasise the need for a multidisciplinary care team approach and aim to establish long-term relationships with patients in their care.  They create culturally safe and secure environments that, ‘allows Aboriginal people to draw strength in their identity, community and culture.  Health and wellbeing – not just white coats’(NACCHO, 2018).

Comprehensive primary care services include:

home        and site visits;

provision   of medical,

public       health and health promotion services;

allied        health,

nursing     services;

assistance with making appointments and transport;

help accessing child care or dealing with the justice system;

drug and alcohol services; and

providing help with income support.

Local control is vital as not one community is the same and needs vary (NACCHO, 2018).

Aboriginal Healthcare Workers

Aboriginal Healthcare Workers are central to the ACCHS model of care.  They act as cultural brokers, assisting Aboriginal and non-Aboriginal health care providers and organisations to ensure that engagement with Aboriginal people and communities is appropriate. They also act as cultural mentors to non-Aboriginal health professionals.   Clinically, they perform immunisations, pap smears and health assessments and engage in health promotion.  Aboriginal health care workers also work in mainstream hospitals (Ware, 2016).

Student                    Activity 3: Access the                        following link and watch the following video: Closing                      the Gap – video for Melbourne Health Staff

One of the problems that all healthcare services experience is that Aboriginal and Torres Strait Islander peoples are significantly under-represented in the health workforce.  Like Aboriginal healthcare workers other Aboriginal and Torres Strait Islander health professionals can align their unique knowledge to improve patient care, improve access to services and ensure culturally appropriate care in the services that they and their non-Aboriginal colleagues deliver (West, Usher & Foster, 2010; Anderson, Ewen & Knoche, 2009).

Section 5:  Traditional Aboriginal healing and Western medicine

Indigenous knowledge and practices, ways of seeing, knowing, doing and being in the world are culturally grounded.  The United Nations Declaration on the Rights of Indigenous Peoples (2008)

Article 24.1 states:

‘Indigenous peoples have the right to their traditional medicines and to maintain their health practices, including the conservation of their vital medicinal plants, animals and minerals.’

Traditional Aboriginal and Torres Strait Islander healing cannot be learned by those who do not possess this culture and heritage.  There is a need for health professionals from other cultural backgrounds to develop an understanding of the Aboriginal and Torres Strait Islander holistic view of health and wellbeing.  There has been a lack of integration of traditional medicines with Western medicine and partnerships with Aboriginal traditional healers need to occur so that the two systems can exist ‘side by side’ (Indigenous Health Network POCHE, 2016; National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing 2017-2023).

The important role of cultural healers (like the Ngangkari – traditional healers of the Ngaanyatjarra Pitjantjatjara Yankunytjatjara Lands), Elders, and others recognised by community play an important role when working with spiritual wellbeing in health.  There are Healing centres in Western Sydney:  These are the Baabayn healing centre and the Marrin Weejali Aboriginal Corporation

Student                    Activity 4: Access the                        following link and read Maringka Burton and Noami Kantjuriny’s                     stories and listen to Frank Ansell’s story Ngangkari                    Traditional Healing  Student                    Activity 5: Read and reflect.  What                     do you think about traditional Aboriginal healers?  Is there                      anything similar in your culture?

In summary, understanding the holistic definition of Aboriginal health and related models; along with an acknowledgement of the role of Community Controlled Health Organisations, Aboriginal and Torres Strait Islander health professionals, and the need for traditional healers working in collaboration with Western health systems and medicine, is a framework from which new health initiatives can be developed which align with the Close the Gap campaign.  One example of this is birthing on Country.

Section 6: Birthing on Country

The Birthing on Country (BoC) Project’s main focus is improving birth outcomes for Aboriginal and Torres Strait Islander mothers and babies; the aim is to bring together community members and health services – two systems existing side by side.  The goal is to establish Aboriginal Birthing on Country models of maternity care; whether Aboriginal Midwifery Group Practices, birthing in hospital with a known Midwife or stand-alone Aboriginal birth centres.  This project is in collaboration with community members, and is supported by health services, health professionals and state and national governments.

*It is important to note that midwifery care needs to be individualised.  There needs to be consultation with every individual woman in terms of their birth plan and how they would like to engage with services.  Women’s choices need to be respected.  Some Aboriginal and Torres Strait Islander women may want to birth on-Country but some will not; the following is one example relevant to one specific group within a culturally diverse population.

Student                    Activity 6: Access                      the following link: Aboriginal                         Birthing on Country and watch this                     video.  Access                      the following link Brown,                    Middleton, Fereday & Pincomb (2016).  Cultural safety and                        midwifery care for Aboriginal women Read the ‘Background’ section (p. 196 -197) and answer the                         following questions.  Q.                      How do you think midwives ensure the social and emotional                         wellbeing of Aboriginal women when attending hospital during                         birthing?  Q.                      Why might Aboriginal women feel unsafe?  Q.                      What do you think might be the consequences for maternity service                      use if Aboriginal women feel unsafe?  Student                    Activity 7: Reflect and write:  How                      has Aboriginal Birthing on Country impacted you?  What do you                        think about it?

Section 7:  Implications for practice

To work effectively with Aboriginal and Torres Strait Islander peoples it is vital that you understand and adopt ‘the principles for working with Aboriginal Communities’.

These include;

1. Trust and cultural respect;

2.  Recognition of the cultural values and traditions of Aboriginal communities;

3. Holistic approaches to the health of Aboriginal people;

4. The valuable and unique role of Aboriginal Community Controlled Health Services;

5. The participation of Aboriginal people at all levels of Health service delivery and management;

6. Partnerships with Aboriginal communities through Aboriginal Community Controlled

Health Services (ACCHS) and the Aboriginal Health & Medical Research Council of New South Wales (AH&MRC);

7. Recognition of the contribution the health system can make to the social determinants of Health (NSW Agency for Clinical Innovation (2013)

Student                    Activity 8: This                  activity will assist you to structure a critical reflection.                       Your first of two critical reflections is due in Week five (see                         Learning Guide for details).  Identify                     an issue/topic in the Module 1 and critically reflect over it.                      This is not for submission.  Use the following sequence based on Gibbs                   reflective Cycle to guide your writing.  Gibbs (1988)                                              The                   issue you select may relate to one of those listed below or                   something else that has caught your attention/effected how you                     think about Aboriginal and Torres strait islander people.  This                        may be something current in the press?                                                  The                   following are some possible areas on which to base this week’s                  reflection but you need to decide which ones are relevant to you,                     what has impacted you?                                                    The                          Importance of culture                                                 Definitions                               of health                                                                                   Models                            of health                                                           Primary                            Healthcare in the Australian Healthcare System                                  Traditional                                Aboriginal healing and Western medicine                                      Birthing                            on Country Description:  Feelings:  Critical                     Evaluation:  Analysis                   and conclusion:  Action                      plan:

References

Anderson, I., Ewen, S., & Knoche, D. (2009). Indigenous medical workforce development: current status and future directions. Medical Journal of Australia , 190 (10), 580-1.

Australian Government, National Aboriginal and Torres Strait Islander Health Plan 2013 – 2023,

Department of Health, Canberra, 2013, p.9.  Accessed 2/3/19 from http://www.health.gov.au/internet/main/publishing.nsf/content/B92E980680486C3BCA257BF0001BAF01/$File/health-plan.pdf

Brown, A. E., Middleton, P. F., Fereday, J. A., & Pincombe, J. I. (2016). Cultural safety and midwifery care for Aboriginal women–A phenomenological study. Women and Birth , 29 (2), 196-202.  Accessed 2/3/19 from http://www.womenandbirth.org/article/S1871-5192(15)00333-9/pdf

Campbell, M. A., Hunt, J., Scrimgeour, D. J., Davey, M., & Jones, V. (2017). Contribution of Aboriginal Community-Controlled Health Services to improving Aboriginal health: an evidence review. Australian Health Review .

Ganesharajah, C. (2009). Indigenous health and wellbeing: the importance of country . Native Title Research Unit, Australian Institute for Aboriginal and Torres Strait Islander Studies.  Accessed 2/3/19 from https://aiatsis.gov.au/sites/default/files/products/report_research_outputs/ganesharajah-2009-indigenous-health-wellbeing-importance-country.pdf

Germov, J. (2014). Second opinion: An introduction to health sociology (5th ed.).  South Melbourne, VIC: Victoria Oxford University Press.

Gibbs, G. (1988) Learning by doing: a guide to teaching and learning methods. [London]: FEU.

Houston, S. (2009, ‘Cultural security as a determinant of Aboriginal health’.  In Kelher H & MacDougall, understanding health.  A Determinants Approach, 2 nd ed. South Melbourne, Vic: Oxford University Press.

Kingsley, J., Townsend, M., Henderson-Wilson, C., & Bolam, B. (2013). Developing an exploratory framework linking Australian Aboriginal peoples’ connection to country and concepts of wellbeing. International Journal of Environmental Research and Public Health, 10 (2), 678-698.  Accessed:  2/3/19 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3635170/pdf/ijerph-10-00678.pdf

Indigenous Health Network POCHE (2016).  Key Thinkers Forum.  Opinion Paper.  Traditional Aboriginal Healing & Western Medicine.  Accessed 2/3/19.

http://pochehealth.edu.au/wp-content/uploads/2015/05/POCHE_Opinion-Paper_Close-the-Gap-Ten-Year-Anniversary.pdf

McInerney, S. (2015). Introducing the Biopsychosocial Model for good medicine and good doctors. BMJ 324 (1533). Access 2/3/19 from http://www.bmj.com/rapid-response/2011/10/29/introducing-biopsychosocial-model-good-medicine-and-good-doctors National Aboriginal Community Controlled Health Organisation (NACCHO) (2018).Aboriginal Community Controlled Health Services are more than just another health service they put Aboriginal health in Aboriginal hands.  Accessed 27/2/2019 from http://www.naccho.org.au/wp-content/uploads/Key-facts-1-why-ACCHS-are-needed-FINAL.pdf

NACCHO Constitution (2011).  Constitution for the National Aboriginal Community Controlled Health Organisations for the National Aboriginal Community Controlled Health Organisation.  Accessed 2/3/19 from http://www.naccho.org.au/wp-content/uploads/NACCHO-CONSTITUTION-Ratified-Ver-151111-for-ASIC-.pdf

NACCHO (2017).  Definitions.  Accessed 2/3/2019 from http://www.naccho.org.au/about/aboriginal-health/definitions/

Neumayer, H. (2013). Changing the Conversation: Strengthening a rights-based holistic approach to Aboriginal and Torres Strait Islander health and wellbeing.  Accessed 2/3/19 from http://iaha.com.au/wp-content/uploads/2013/10/Changing-the-Conversation-Strengthening-a-rights-based-holistic-approach-to-Aboriginal-and-Torres-Strait-Islander-health-and-wellbeing.pdf

NSW Agency for Clinical Innovation (2013).  A Framework for Working Effectively with Aboriginal people.  Accessed 2/3/19 from https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0010/203788/ACI-Aboriginal-Framework.pdf

 

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