Jie-Li Li

School of Nursing&Midwifery,University of South Australia,Adelaide SA 5000,Australia

1.Introduction

Recently,scholarly literature in Australia has focused on the issue of ensuring equitable access to healthcare for aboriginal Australians and Torres Strait Islanders,who are regarded as economically,socially,politically and culturally disadvantaged.1,2The goal of universal health coverage is to ensure that everyone attains his or her full health potential and has equitable,barrierfree access to healthcare regardless of social position or circumstances.5According to the World Health Organization,health equity implies a need for fairness in providing access to healthcare,regardless of an individual's social,economic,demographic,or geographic position.5However,despite significant effort by the Australian government,scholars,policy makers and communities to provide fair and equitable healthcare,this challenging and longstanding issue remains unresolved and needs to be addressed immediately.1,4In response,this paper seeks to address some factors that contribute to inequity in health service provision forindigenous Australians,particularly cultural barriers.Furthermore,this article presents ways for health professionals to take action on culture-induced health equity issues.Finally,this article addresses what nurses can do to support more operational interventions and enhance the quality of services for indigenous Australians and Torres Strait Islanders.

2.Discussion

2.1.Health inequity exists among aboriginal Australians and Torres Strait Islanders

Healthcare inequity clearly exists among aboriginal Australians and Torres Strait Islanders and it hinders their access to universal healthcare coverage.In 2011,the Australian Bureau of Statistics(ABS)concluded that‘for the aboriginal and Torres Strait Islander population in 2005-2007,life expectancy was estimated to be 11.5 years lower than that of the non-indigenous population for males(67.2 years compared with 78.7)and 9.7 years lower for females(72.9 years compared with 82.6)’.Due to remote,rural geographic conditions,as well as social-economic disparity and cultural differences,these indigenous populations tend to experience a substantially higher rate of infant and child mortality,perinatal mortality,low birth weight and age-standardized death rates.3The same is true for chronic diseases such as cardiovascular disorders and diabetes mellitus6and infectious diseases such as HIV/AIDS,hepatitis and sexually transmissible infections.7It is crucial to narrow this gap and ensure that everyone reaches his or her full health potential through equitable,barrier-free access to healthcare,regardless of social position or circumstances.

2.2.Cultural barriers are vital factors in addressing aboriginals'health inequity

Ensuring healthcare availability and accessibility requires not only a strong,efficient and well-run financial and geographical health system but also cultural/linguistic support.Cultural barriers in health workplaces refer to any obstacles that individuals might face,including differing languages,medical procedures and practices,or conceptions of gender and sexuality.These barriers,which can lead to serious miscommunication between parties of various cultural backgrounds,are the main cause of unsatisfactory outcomes of healthcare services among aboriginal Australians and Torres Strait Islanders.Such barriers lead to unequal health among indigenous people in Australia.8The literature shows that the different faith,beliefs,understanding and interpretations about value,health and identity make indigenous people less willing to use mainstream healthcare facilities.8Their fatalistic beliefs are closely related to delays in accessing free health checks,cancer screening and follow-up hospital appointments.9When Newman et al10conducted a research about HIV treatment among aboriginal people,he found that this population's greatest priority was to maintain everyday routines and follow ancient customs rather than focusing on individual health.10Therefore,cultural differences play a key role in causing unsatisfactory outcomes for healthcare services among aboriginal Australians and Torres Strait Islanders.

Given that language is the main component of culture,ineffective communication leads to dramatic failures in healthcare outcomes.Australia has developed the most sophisticated healthcare system in the world,but it provides little bene fit if patients and healthcare providers fail to communicate.Effectively communicating in a culturally appropriate way results in less confusion and misunderstanding,as well as higher quality healthcare.2For example,in the Northern Territory of Australia,aboriginals account for 97.5%of the population.Only 2.1%of them speak only English at home.11Linguistic and cultural discrepancies challenge equitable access to healthcare,as indigenous people speak more than 100 dialects.2The absence of a speech-language pathologist(SLP)for aboriginals in the rural Northern Territory who understands their linguistic and cultural background only exacerbates this problem.2More emphasis needs to be placed on addressing the cultural distance between healthcare professionals and their indigenous clients when considering potentially serious consequences.For instance,according to Lowell,2communication differences can lead to inappropriate interventions and even misdiagnoses.

Cultural identity refers to people's feeling of belonging to a group.Physical and biological differences might also prevent aboriginals from actively participating in their treatment.Undeniably,people tend to trust those who are from their same country,practice the same religion,come from the same social class,have the same ethnicity and share similar physiological features.It is more difficult to create a warm and comfortable environment,a better connection and a more intimate relationship with someone from a distinctly different cultural group.Therefore,it is understandable why some indigenous people refuse to seek health services from a ‘white doctor’,citing a lack of cultural safety.12

A rarer but nonetheless important issue is that some healthcare professionals maintain inappropriate cultural stereotypes of aboriginal Australians and Torres Strait Islanders.12Jennings,Spurling and Askew13conducted a qualitative study about barriers and enablers in urban aboriginal medical service.A semi-structured interview with clinic staff providing a Medicare-Funded Health Assessment(known as HC)for aboriginal Australians and Torres Strait Islanders revealed that low staff motivation,low staff con f idence,confusion about speci fic roles and cultural incompetency contributed partially to low HC rates.13Although an Aboriginal Interpreter Service and cultural training centers are accessible in aboriginal and Torres Strait Islander communities,cultural training for healthcare staff working with indigenous clients is too superficial.13It is impractical to expect staff to attain cultural and linguistic competence with this method,particularly when the utilization of such services by healthcare providers is‘far from optimal’.2

Regarding the highly praised Australian healthcare system,it is well known that a variety of government-supported community services throughout Australia deliver primary health care to aboriginal Australians and Torres Strait Islanders,though less than 40%of these community services have medical coverage.12Health clinics and centers are concentrated in metropolitan areas,with a ratio of 400 nurses per 100,000 people,or twice the distribution of nurses in remote areas where indigenous Australians and Torres Strait Islanders live.12Studies have revealed that the Australian healthcare system does not provide equal quality of healthcare to aboriginals and Torres Strait Islanders compared to non-aboriginal Australians.12The cultural factors discussed above contribute to inequitable access to healthcare for aboriginal Australians and Torres Strait Islanders.

2.3.The role of healthcare professionals in addressing aboriginal cultural barriers

Cultural competency has been broadly defined as a set of harmonious values,principles,attitudes and policies that enable people to work effectively across cultures.Healthcare that is culturally and linguistically tailored for indigenous populations is highly recommended.Strengthening the cultural competency of healthcare professionals and the healthcare system as a whole can be part of an effective solution for diminishing racial/ethnic disparities in healthcare.8Healthcare providers who are equipped with better cultural competencies and awareness can reduce healthcare disparities.8According to Mobula et al8responding appropriately to cultural barriers means‘incorporating culture into service delivery’,8or trying to understand a group's beliefs and combining them with clinical practices,skills and behaviors in the healthcare system.Nevertheless,according to Paez et al,14even in the USA,only one-third of healthcare providers report having attended cultural competency or diversity training,and less than half of professionals indicated their con fidence in the level of service provided to ethnic minorities.14In an attempt to offer solutions for developing cultural competencies,organizations and healthcare providers need to work together to create innovative solutions.Wylie et al15suggested that speech-language pathology professionals who understand the linguistic and cultural background of indigenous Australians and Torres Strait Islanders need to make meaningful contributions to how services are conceptualized,planned and supplied for these indigenous populations.15It has also been recommended to adopt cultural competency measurement tools to provide self-assessments.14Strategies linking policies to practice to reduce health disparities between aboriginal and non-aboriginal Australians are also needed.Mastering respectful and non-judgmental culture-oriented communication skills can help healthcare providers explain the healthcare system to aboriginal and Torres Strait Islanders and convince them to trust the system and the providers.

2.4.Different roles of nurses in addressing aboriginal cultural barriers

Together with specialists in public health workplaces,nurses play a significant role in improving the health of indigenous peoples by direct nursing care and upstream navigating.Upstream approaches seek to detect the original source of disease and avoidable in firmity and address complications through prevention rather than treatment,initiating care in advance to stop people from becoming ill.16Nurses also play a vital role in diminishing the impact of disorders,promoting health and wellbeing and helping people function well at home,at work,at leisure and in their communities.We need to consider the role of nurses in a larger capacity,as they consistently undertake patient advocacy,display a respect for culture,beliefs and traditions of all patients and promote ethical and effective cross-cultural healthcare for people with culturally diverse backgrounds.Some practical methods are already underway in Australia and could be considered in further developing these skills among different types of nurses(e.g.,nurse educators,clinical nurses,nurse researchers,nurse navigators).For example,some nurse educators periodically hold educational sessions17,18on aboriginal culture for students,new staff and international workers in medical institutions, hospitals and communities.In assessing the program of nursing and midwifery the University of Western Sydney,Hunt et al16concluded that education was playing a major role in transforming negative attitudes,breaking down misconceptions and stereotypes and enriching nursing students'acquaintance and respect for a culture that has endured significant adversities.Clinical nurses,apart from providing culturally considerate care for aboriginal populations,might also run a charitable club with volunteers to assist in breaking down misconceptions and stereotypes towards indigenous Australians and Torres Strait Islanders.Nurse researchers advocate the creation of some governmental or non-governmental healthcare organizations to provide culturally and linguistically appropriate services.18The successful implementation of an Advance Care Planning program among residents in nursing home in Singapore19has prompted discussion about a healthcare plan can that can be guided by nurses and social workers among aboriginals and their caregivers.Nurse managers play a vital role in cultivating well-trained nurses and providing operational and clinical leadership,management and coordination of holistic clinical services.In seeking to provide high-quality care and patient satisfaction,they are in a unique position to improve health outcomes for aboriginals.Finally,advocating for the health of indigenous peoples involves not only knowledge and systems but also empathy for those affected by disparities in access to healthcare.

3.Conclusions

Health equity is a basic human right and the core value of universal healthcare coverage.Interventions are necessary to help and protect disadvantaged aboriginal Australians and Torres Strait Islanders.It is unacceptable for cultural barriers to prevent universal healthcare coverage for aboriginal Australians and Torres Strait Islanders.All societies must strive to close the gaps in healthcare equity within a generation.More work and research needs to be performed in considering the roles of healthcare professionals and nurses in this process.Only by overcoming cultural barriers and ensuring cultural security with technical excellence can aboriginal Australians and Torres Strait Islanders fully attain equitable access to healthcare in the near future.

4.Limitation

As this is a problem-based discussion paper,any relevant published papers might be included(but not limited)to support my opinions without a rigorous systematic literature review.No standard critical appraisal instruments for speci fic study designs were used to critically appraise the level of evidence.

Conflicts of interest

There is no con flict of interest.

Acknowledgement

The author has to express her appreciation of the guidance and encouragement from supervisor Dr Luisa Toffoli from School of Nursing and Midwifery,University of South Australia.

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