Communicating medical information with Aboriginal patients: lessons learned from GPs and GP registrars in Aboriginal primary health care

Introduction

Australia, home to the oldest continuous culture, is one of the most culturally diverse countries in the world (AHRC 2014). Indigenous Australians place importance on balancing their individual connections with their body, spirit, and mind, alongside their collective relationships to family, land, and community (Gomersall et al. 2017).

Effective communication is crucial in a cross-cultural medical context, where cultural differences can significantly impact the patient-doctor relationship. Language barriers, cultural differences, or even historical distrust of the healthcare system can all pose challenges. To overcome these obstacles, healthcare providers need to adapt their communication style to suit the patient’s language, literacy level, and cultural background (AMA 2022). In cross-cultural situations, healthcare providers must continuously develop their cultural competence by acquiring knowledge, skills, and attitudes, as well as examining their own cultural beliefs, attitudes, and assumptions (AIHW 2015; McKivett et al. 2019).

Aboriginal communities view time as circular, with the individual at the centre and important life events placed closer to them on the concentric ‘time circles.’ This contrasts with the linear western concept of past, present, and future. In Aboriginal culture, the importance of an event determines its placement on the ‘time circles,’ rather than its chronological order (Janca and Bullen 2003). In Western culture, the linear concept of time emphasises the individual within the timeline. However, in Aboriginal culture, the focus is on the individual’s context, which includes their family, history, and connection to the land, represented by the concentric circle of time. Therefore, it is important to understand this cultural difference and avoid misinterpreting it as lack of interest in personal health or disrespectful to the medical structure (Janca and Bullen 2003; McKivett et al. 2019).

Health literacy is elemental for effective communication and health outcomes. It refers to an individual’s understanding of health information, and their capacity to navigate the health system and formulate their health-related decisions and actions (ACSQHC 2019). The World Health Organization (WHO) has identified health literacy as a priority cost-effective factor in achieving sustainable development goals in the battle against non-communicable diseases (Liu et al. 2020). Spoken languages correlate significantly with health literacy, with over 50 actively spoken Australian Indigenous languages with limited access to interpreters (Diversity of Language – Australia’s Cultural Diversity 2021). Unfortunately, there are no national data describing the health literacy levels in Aboriginal and Torres Strait Islander people, but we know that 59% of non-indigenous Australian adults reported low levels of health literacy (Rheault et al. 2019). This indicates how complex it may be for even the general population to understand health information. Healthcare providers can use communication strategies to improve health literacy in Aboriginal health such as using plain language and visual aids, showing respect, adopting a holistic approach, and building trust. This may require extra effort and time from both patients and providers (Davy et al. 2016).

Aboriginal Community Controlled Health Organisations (ACCHOs) were established in Australia to address the health disparities experienced by Indigenous Australians. These community-led organisations provide culturally appropriate primary healthcare services that prioritise a holistic approach to health, community involvement, and the employment of a range of health professionals that can provide additional services beyond clinical care to address social determinants of health (Campbell et al. 2018). The rise of ACCHOs has significantly reduced the burden of chronic disease and increased the engagement with health services among Aboriginal and Torres Strait Islander people (Gomersall et al. 2017; Rheault et al. 2019). However, we recognised a gap in the literature about the experiences of GPs, and GP registrars training in those clinics, therefore we aim to address this gap in the present study.

Methods

This study adopted a qualitative model via semi-structured interviews. Given the nature and sensitivity of the topic and our belief in the importance of collaboration and inclusiveness, an advisory group was formulated early in the process. This included representatives from the Aboriginal Health Council of South Australia (AHCSA), an Aboriginal health practitioner, an Aboriginal health medical educator, GPs experienced in Aboriginal health, and Aboriginal cultural mentors from the South Australian regional training organisation for general practice (GPEx). The role of the advisory group was to guide and steer the project as well as to provide expertise in a culturally safe environment. The Aboriginal cultural mentors were a male and a female elder from the community recruited by GPEx. Their roles included cultural education and support for registrars undertaking placements in Aboriginal health, as well as to help maintain a strong working relationship with the Aboriginal health training posts and the local Aboriginal communities.

The advisory group was formed in the early stages of the project and prior to the ethics application. The primary ethics application was made to AHCSA given that it is the peak body representing the ACCHOs in South Australia (AHCSA, n.d.). Approval was granted by AHCSA (AHREC protocol number: 04-21-929) and Flinders University (Project ID: 4629) ethics committees. The speed of the ethics approval has set a precedent, which was mainly a result of the inclusive mindset and the deep consultations (support letters from all stakeholders) made in preparation for this project following the famous motto ‘nothing about us without us’ (Charlton 1998). Meanwhile, given the limited scope of the study, which only involved GPs (not Aboriginal patients or an Aboriginal workforce), the recommendation from the AHCSA ethics committee was that, in order to develop resources and recommendations out of this study, there would need to be wider engagement and collaboration with the Aboriginal workforce. Therefore, we deliberately avoided producing any recommendations or resources as outcomes of this project.

Two cohorts were invited to participate in the research: experienced GPs (cohort A – seven participants) who had worked in Aboriginal health for more than 10 years; and GP registrars or new GP fellows (cohort B – five participants) who had completed a placement in Aboriginal health during their training.

Recruitment occurred via email invitations to experienced GPs listed on the AHCSA database; and to GP registrars, via GPEx, who undertook Aboriginal health placements between 2019 and 2021.

Interviews were conducted via Zoom and recorded as audio files only. They were based on pre-written scenarios of common Aboriginal health primary care presentations. Initially, five scenarios were formulated based on the most common causes of mortality for Aboriginal people as per the Australian Institute of Health and Welfare (AIHW 2023), which were subsequently reduced to three scenarios due to time restraints noted in the trial interviews. The three scenarios covered topics relating to polypharmacy in the context of chronic kidney disease and multiple other comorbidities; cancer screening in the time of the COVID-19 pandemic; and grief in the context of family-related suicide (Supplementary material 1). All interviewees signed a consent form prior to the interviews and were informed of their rights to withdraw or abstain from participating at any stage of the project.

Experienced GPs were interviewed by the primary researcher, whereas the GP registrars were interviewed by a co-researcher who was a fellowed GP, to avoid any coercion with the primary researcher who was a registrar. All interviews started with a brief introduction about the participant followed by sharing the scenarios. All three scenarios had a similar format covering questions on: knowledge and thoughts prior to reviewing the patient, approaches and methods that would be considered during the consultation, and the use of physical or community resources.

Interviews ranged from 26 to 51 min. There were seven experienced GPs and five GP registrars/new fellows. Audio-recordings were sent to an independent external provider (Pacific Transcription) for transcription and checked by the primary researcher. The co-researcher was offered AUD90 per hour for their time and participants were offered AUD125 gift cards after completion of the interviews as an honorarium for their time.

Transcripts were de-identified and uploaded to Nvivo (ver. 1.6). The data was systematically analysed using the inductive thematic analysis approach, following the Braun and Clarke method. This involved text analysis, categorising key words and ideas into themes, and generating a codebook (Supplementary material 2). As the analysis progressed, the codebook was updated and refined to improve accuracy (Braun and Clarke 2006). An inter-rater reliability check was conducted independently by another researcher to improve reliability and validity of the codes generated while eliminating individual biases and interpretations.

Results

It was noted that there were strong themes emerging from the codes, which covered patient–doctor relationship (107 references), health literacy (139 references), and the engagement with the health system (85 references) (Table 1). Furthermore, there was strong emphasis on the importance of Aboriginal Health workers (AHWs) in the communication and rapport process.

Discussion and conclusions

Aboriginal people are highly interested in their health and well-being (Canuto et al. 2019), but wellness may be defined differently to a conventional understanding of health. The WHO defines health and wellbeing as being physically, mentally, and socially well, not only disease-free (WHO 2023). These interviews revealed how GPs within Aboriginal health services think, connect, and implement therapeutic management plans within an Aboriginal health context.

Both cohorts discussed how a consultation in Aboriginal health is multifaceted and complex. Understanding the patient’s context was an excellent starting point for clinicians who had multiple issues to cover, but then were usually guided by the work of the AHWs who do the initial introductory screening. The involvement of AHWs is not only for screening or follow-up purposes, but also to bring better structure to the consultation, overcome cultural barriers and gender sensitivities, and improve health literacy for patients and their families on the short and long term. Aboriginal patients may experience barriers that are not as prevalent in non-Aboriginal contexts. These barriers could include feelings of shame, guilt, fear, and mistrust, as well as issues with judgment, misunderstandings, past trauma, and changing priorities. Some of the key communication skills highlighted by both cohorts include active listening, understanding patients’ context, allowing patients to lead during the consult, non-verbal communication, and approaching patients using a relaxed demeanour (Table 1). While both cohorts valued the importance of building rapport, experienced GPs emphasised body language as part of this process.

A strong patient–doctor relationship is the cornerstone for any forward steps during a consultation in Aboriginal health. Aboriginal people come from a multitude of backgrounds, languages, and bio-psycho-social constructs, and therefore it is essential to listen to the context, address the concerns, work harder on building trust, find common ground, establish priorities, provide clear information, and involve the right teams for follow-up. This is described in Aboriginal health as ‘therapeutic yarning’ which is a culturally sensitive approach to communication and relationship building that involves storytelling and listening with empathy and respect, creating a safe and supportive space for people to share their experiences and feelings (Bessarab and Ng’andu 2010). It facilitates finding a medium/metaphor of shared understanding with the patient and using that as a common ground to explain diagnosis and the importance of complying with a treatment plan (Lin et al. 2016). Finally, while developing the codebook, it was observed that themes could be more easily discerned from interviews conducted with experienced general practitioners (GPs). Despite variations in clinical backgrounds and experience, the responses of experienced GPs were concise yet exhibited similar ideas to those of less experienced GPs.

This research has multiple limitations that may have impacted the results. Despite using similar interview questions, the two cohorts had different interviewers which may have affected the type and depth of information gathered. It was also difficult to ensure a head-to-head comparison of the findings given the interviews had a different flow of conversation between participants. Furthermore, data interpretation was done primarily by a GP registrar who might have unintentionally extracted richer content from the experienced GPs’ interviews. This was addressed by having a senior supervisor in the project with extensive experience in research and Aboriginal health to review the findings and address this bias. Moreover, these findings are not intended as recommendations to change current practices, as we did not test the approaches discussed nor validate them with Aboriginal and Torres Strait Islander patients. However, a GP training placement in Aboriginal health has been shown to have taught registrars the complexity and challenges in this field, as well as having an impact on the way they think about working with Aboriginal people. It continues to remain unclear whether clinicians’ concerns were of significant importance to patients, as they have not been tested or validated with them. Furthermore, it was unclear how the clinicians developed and consolidated their thoughts and approaches in those practices and whether it was purely from personal experiences or from feedback they had from Aboriginal patients and AHWs. Further research including collaboration and leadership by the Aboriginal community is required to determine the effectiveness of all strategies used in a clinical rather than theoretical context in order to validate the above findings.

Supplementary material

Supplementary material is available online.