Improving cultural respect in primary care

A mind that is stretched by a new experience can never go back to its old dimensions (Oliver Wendell Holmes)

There are many challenges in health services research, particularly for people working in Aboriginal and Torres Strait Islander (Indigenous) health. The randomised trial of the Ways of Thinking and Ways of Doing program reported in this issue of the Journal by Liaw and his co‐authors1 reflects these challenges. The aims of the program were to improve the rates of Indigenous health checks and recording of health risk factors, and to increase cultural respect in the participating urban general practices. The intervention was guided by cultural mentors, and included workshops, care system re‐design, and organisational partnerships for facilitating community engagement. It was implemented after years of developmental work, and its primary outcome measures were rates of Medical Benefits Schedule (MBS) item 715 billing (Indigenous health checks) and of the documentation of risk factors, and changes in a measure of cultural competency of clinic staff over 12 months. The program did not achieve significant changes in any of these outcomes. Nevertheless, the investigators identified important elements for improving care for Indigenous Australians and adopted a systems approach to implementing them in a real world setting. It joins other interventions targeting Indigenous Australian populations that have not significantly improved outcomes, often because of implementation failure,2 highlighting the need to accompany complex interventions with robust process evaluation.3

Despite this, there is much we can learn from this study. First, we might query the choice of outcome measures. MBS item 715 was introduced as part of a package of measures to improve prevention and management of disease by supporting comprehensive care assessments and care plans for Indigenous people throughout their lives. However, increased rates of billing for Indigenous health care plans do not necessarily reflect improved quality of care, nor are they proxy measures for holistic prevention and treatment. Primary health care practitioners with a major focus on Indigenous people know how difficult it can be to complete all the components required for item 715.

The lack of improvement in risk factor documentation is also unsurprising. This had not improved during the investigators’ intensive pilot study in ten practices, except for alcohol intake and fasting blood sugar.4 Evidence from other Indigenous Australian primary care settings underscores the challenges associated with consistently improving the assessment and management of a range of risk factors.5

Liaw and colleagues used a generic instrument to measure cultural intelligence, the cultural quotient (CQ) questionnaire, which assesses four domains: cultural strategic thinking (cognition and metacognition), motivation, and behaviour. Their preparatory study found that their program significantly improved cultural strategic thinking and overall CQ score, but not motivation or behaviour.4 The developers of the questionnaire argued that cultural competence complements cognitive intelligence and is important for establishing high quality personal relationships in cross‐cultural settings.6 However, the CQ questionnaire is not focused on Indigenous Australian history or culture, so this generic instrument may not be directly applicable in the Australian context. Further, we should acknowledge limitations in tools for assessing cultural competence, and also draw attention to the paucity of evidence that increasing cultural competence improves health outcomes for Indigenous Australians without also redressing broader social inequities.7

The outcome of the study by Liaw and colleagues does not mean that efforts to improve cultural competence in health care settings should be abandoned. However, we should wonder about the nature and intensity of interventions for developing cultural competence, while also recognising that trials are unhelpful if the resources required for a successful intervention will not be available in routine practice. The presence of Indigenous cultural mentor support, provided by phone and some face‐to‐face contact, may have been relatively limited in individual practices. Whether it was sufficient to achieve an effect might be questioned; the foreshadowed publication of qualitative findings may shed more light on this problem. Those with substantial experience of working with Indigenous people appreciate the value of the understanding that develops through informal learning from Indigenous colleagues who share their experiences and knowledge.

We can also ask how long it takes to become a culturally competent health practitioner and what experiences facilitate cultural understanding. Lessons from health training illuminate both challenges to and facilitators of the process. Challenges include limited understanding of the problems of Indigenous people, unacknowledged racism, and lack of self‐reflective practice as a critical element of clinical competence.8 Cultural immersion programs have proved particularly effective for transforming the understanding of Indigenous people and culture by shifting the participant outside their comfort zone.9,10,11

We must acknowledge the very real challenges in measuring, implementing, and improving health care for Indigenous Australians. And we should not underestimate the importance of studies such as that reported in this issue of the MJA for raising consciousness of cultural sensitivity and contributing to culturally safe care for Indigenous people.