Cultural safety
In Australia, there has been increasing recognition that improving cultural safety for Aboriginal and Torres Strait Islander health care users can improve access to health care and the quality of the health care received (AHMAC 2016). This in turn is likely to improve health outcomes and help to address gaps in health and wellbeing between Indigenous and non-Indigenous Australians.
Defining cultural safety
In Australian research there are various definitions of cultural safety and what it means in relation to the provision of health care.
The Cultural Respect Framework 2016–26 defines cultural safety as: ‘not [being] defined by the health professional, but is defined by the health consumer’s experience—the individual’s experience of care they are given, ability to access services and to raise concerns’.
The framework outlines the essential features of cultural safety, including:
- an understanding of one’s culture
- an acknowledgement of difference, and a requirement that caregivers are actively mindful and respectful of difference(s)
- it is informed by a theory of power relations
- an appreciation of the historical context of colonisation, the practices of racism at individual and institutional levels, and their impact on First Nations people’s living and wellbeing, both in the present and past (AHMAC 2016).
The AIHW developed the Cultural Safety in Health Care for Indigenous Australians: Monitoring Frameworkto bring together available data to assess progress in achieving cultural safety in health care for Indigenous Australians.
The framework has 3 reporting modules which each include measures focusing on culturally respectful health care services, patient experience of health care among Indigenous people, and access to health care as an indirect measure of cultural safety (see Table HS 4).
Table HS 4: Cultural safety monitoring framework modules
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Module 1 Culturally respectful health care services |
Module 2 Patient experience of health care |
Module 3 Access to health care services |
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Health care services
The cultural safety of Aboriginal and Torres Strait Islander health care users cannot be improved in isolation from the provision of health care, and the extent to which health care systems and providers are aware of and responsive to Indigenous Australians’ perspectives. The structures, policies and processes across the health system all play a role in delivering culturally respectful health care. Aspects of the provision of culturally safe health care include organisational commitments to provide culturally safe care, appropriate communication and services, Indigenous workforce development and training, client and community feedback and collaboration with Indigenous organisations.
Module 1 key findings
Among the Indigenous-specific primary health care organisations and maternal/child health services reporting to the OSR:
- In 2020–21, 47% of full time equivalent health staff were Indigenous—this proportion varied by type of health staff, with higher proportions for Aboriginal Health Practitioners/Aboriginal Health Workers (98%) and other health workers (55%) and lower proportions for General Practitioners (5%), nurses and midwives (15%).
- In 2017–18, 40% provided interpreter services, while around one third offered culturally appropriate services such as bush tucker, bush medicine and traditional healing.
From 2013 to 2020, national health workforce data shows the number of employed Indigenous:
- medical practitioners increased from 234 to 494
- nurses and midwives increased from 2,434 to 4,610.
From 2001 to 2020, higher education statistics from the Department of Education show the rate of enrolment in health-related course for Indigenous students increased from 26.9 per 10,000 Indigenous Australians to 70.1 per 10,000.
Patient experience
Respect for cultural identity is critical in providing culturally safe health care for Indigenous Australians. Aspects of cultural safety include:
- clear and respectful communication
- respectful treatment
- the inclusion of family members
- Empowerment in decision making.
‘Take own leave’, where Indigenous patients left against medical advice or were discharged at their own risk, is also measured as it may be linked to feelings of cultural safety.
Module 2 key finding
The National Aboriginal and Torres Strait Islander Health Survey shows that in 2018–19:
- 88% of Indigenous Australians aged 15 and over in non-remote areas reported that doctors always/often explained things in a way that could be understood
- 91% of Indigenous Australians aged 15 and over in non-remote areas reported that doctors always/often showed respect for what was said
- 32% of Indigenous Australians who did not access health services when required, indicated this was due to cultural reasons, such as language problems, discrimination and cultural appropriateness.
Data from the 2020 Australian Reconciliation Barometer indicate that 22% of Indigenous Australians or their families were racially discriminated against by doctors, nurses and/or medical staff in the last 12 months.
The differences in rates of Indigenous and non-Indigenous hospital patients who choose to leave prior to commencing or completing treatment are frequently used as indirect measures of cultural safety.
- In relation to admitted patient hospitalisations, Indigenous Australians were discharged against medical advice for 3.9% of hospitalisations in 2018–20. Based on age standardised rates, Indigenous patients were discharged against medical advice at over 5 times the rate of non-Indigenous Australians.
- In relation to emergency department care, based on age standardised rates, Indigenous patients left at own risk or did not wait at 1.5 times the rate of non-Indigenous patients.
Access
Indigenous Australians experience poorer health than non-Indigenous Australians and do not always have the same level of access to health services. Disparities in access may be due to factors such as remoteness, affordability and a lack of cultural safety. However, disparities in access may be due to a range of factors other than a lack of cultural safety.
Module 3 key findings
- In the two year period from 2018–2019, 27% of Indigenous women aged 40 and over received a free mammogram through BreastScreen Australia. Based on age-standardised rates, 26% of Indigenous women aged 40 and above received a mammogram, compared with 34% of non-Indigenous women.
- In 2019–20, Indigenous Australians waited longer to be admitted for elective surgery than non-Indigenous Australians—50% of Indigenous patients were admitted for elective surgery within 49 days, compared with 38 days for non-Indigenous patients.
- In 2019, the avoidable mortality rate for Indigenous Australians was 222 per 100,000. The Indigenous age-standardised rate was over 3 times that for non-Indigenous Australians (323 and 98 per 100,000 respectively).
- In 2019–20, the rate of potentially preventable hospitalisations for Indigenous Australians was around 3 times the rate for non-Indigenous Australians (68.4 compared with 23.3 per 1,000, based on age-standardised rates).
- In 2019, of 5,311 registered cases of rheumatic heart disease, 82% were Indigenous Australians compared with 18% non-Indigenous Australians.