To the Editor: The Australian Government is seeking to reduce Indigenous disadvantage through its “Closing the Gap” strategy.1 One challenge, however, is incomplete identification of Indigenous status in health and administrative data collections and the necessary caution in interpreting statistics because of such underestimates.2-5 For planning, expenditure, access to and equity of health services, governments need to ensure that Indigenous data collections are accurate. A key area of interest is self-reported Indigenous identification in mainstream general practice settings. Research has focused on general practitioners’ perspectives,6 but not those of Indigenous patients.
We conducted a qualitative study that explored the views of Indigenous Australians residing in the Australian Capital Territory who were recruited through a range of Indigenous organisations and differed in age, sex and social background. Participants gave written informed consent to face-to-face interviews, in which they were invited to describe their experiences of being asked their Indigenous status in mainstream general practice settings — including their understanding of why people are asked about their Indigenous identity and views on how they should be asked.
Of the 28 participants (age range, 18–78 years), 12 were men, 18 were Aboriginal, five were Torres Strait Islander, and five identified as both Aboriginal and Torres Strait Islander. All had used mainstream general practice services in the ACT. Six reported ever having identified as Indigenous in that setting, although it is unclear how many were asked their Indigenous status. Some reported having been mistaken for being either from another country or non-Indigenous. All stated they would identify as Indigenous if asked, but felt it was essential to be provided with information explaining the rationale for the question — in particular, how it would benefit them if they did identify as such. It was suggested that pamphlets or posters explaining the benefits of identifying could create cultural safety. Participants emphasised the need for appropriate training of practice staff on the rationale for asking the identifier question and how to ask it respectfully.
Several themes reflecting issues that would influence an individual’s decision to identify as Indigenous emerged: previous racism in the community; the patient–doctor relationship; the perception that discussing identity would lengthen consultation times; practice staff’s assumed motives for asking; and recognition of the culture and diversity of Indigenous Australians (Box). The principal message was that the process for asking needs to be kept brief and simple. An acceptable form of words was agreed by all participants to be: “For the purpose of providing the best care possible, can you please tell me if you are Aboriginal and/or Torres Strait Islander?”
This research highlights the need for GPs to “Just ask!” and to ensure that the Indigenous identifier question and explanation are conveyed consistently and appropriately. Further research in other primary care settings could evaluate the approach that we advocate. Aboriginal medical services provide culturally secure services based on Aboriginal preferences.7 Participants in this study have provided guidance on how similarly culturally secure services could be provided in mainstream general practice.
Themes identified from interviews with 28 Indigenous respondents about identifying as Indigenous in mainstream general practice
Importance of the patient–doctor relationship “I think it is important to start building relationships between medical professionals and Indigenous people, so that Indigenous people can start becoming more informed about their health and be more proactive in managing it more.”
Rationale for asking about Indigenous identity “. . . I can understand why a mainstream service would see if a person wants to identify or not so that they can get those Medicare items. So it needs to be done without someone getting offended. I know that I would be offended if it was done in a mainstream area and a big deal made of just for the money. It’s how you portray it to the Indigenous person so that they don’t get offended.”
Creating cultural safety in general practice “When you see posters and pamphlets and information then you think, ‘Oh, so maybe this surgery is OK’. You’re more comfortable in coming back and volunteering information. It is all about creating an environment that enables that.”
Mistaken identities of Aboriginal and Torres Strait Islanders “Some of them have asked if I was from PNG [Papua New Guinea], and um [I’m] . . . not really a Torres Strait Islander, I don’t know, it must be my features. They naturally assume that I am from PNG.”
Who should ask the question? “I think the doctor. Because then they get an idea of your background and . . . it gives them a good idea of where you come from and what sort of illnesses are around the place.”
- 1. Council of Australian Governments. Communiqué. Council of Australian Governments’ meeting, 2 July 2009. National integrated strategy for closing the gap in indigenous disadvantage. http://www.coag.gov.au/coag_meeting_outcomes/2009-07-02/ (accessed Mar 2010).
- 2. Australian Bureau of Statistics. Experimental estimates of Aboriginal and Torres Strait Islander Australians, Jun 2006. Canberra: ABS, 2006. (ABS Cat. No. 3238.0.55.001.)
- 3. Australian Institute of Health and Welfare. Indigenous identification in hospital separations data: quality report. Health services series no. 35. Canberra: AIHW, 2010. (AIHW Cat. No. HSE 85.)
- 4. Australian Institute of Health and Welfare. National Advisory Group on Aboriginal and Torres Strait Islander Health Information and Data: strategic plan 2006–2008. Canberra: AIHW, 2006. (AIHW Cat. No. IHW 19.
- 5. Australian Institute of Health and Welfare. Improving identification of Aboriginal and Torres Strait Islander peoples in health data. Working paper. Canberra: AIHW, 2009. http://www.aihw.gov.au/indigenous/iiatsiphd.pdf (accessed Mar 2010).
- 6. Kehoe H, Lovett RW. Aboriginal and Torres Strait Islander health assessments — barriers to improving uptake. Aust Fam Physician 2008; 37: 1033-1038.
- 7. Henry BR, Houston S, Mooney GH. Institutional racism in Australian healthcare: a plea for decency. Med J Aust 2004; 180: 517-520. <MJA full text>