Perspectives of Indigenous people in the Pilbara about the delivery of healthcare services

The Pilbara region comprises approximately 20% of the total land mass of Western Australia.¹ Much of the region is desert and sparsely populated with most of the population clustered around a few major towns.¹ In total there are approximately 50 000 residents, of whom around 16% are Indigenous.

Pilbara residents tend to experience poorer health than residents in most other parts of Western Australia. In part, the poorer health status of Pilbara residents owes to higher levels of smoking and alcohol consumption, higher levels of obesity, and low amounts of fresh vegetable and fruit consumption especially in remote Indigenous populations.^2–4 The other main factor that contributes to Pilbara residents experiencing poorer health is the lack of access to timely and effective primary healthcare that would have otherwise prevented the development of health conditions.⁵

For many remote communities, general health services fail to sufficiently address the particular needs of Indigenous people.^6,7 It has been shown that health services for Indigenous people are more effective when people with a positive manner and knowledge of Indigenous cultural issues provide the services.⁸ As such, Indigenous participation and ownership in the delivery of healthcare services is integral to successful outcomes.^3,8 Little is known about the views of Indigenous people regarding the delivery of healthcare services in the Pilbara. This article addresses a gap in the literature by examining the delivery of healthcare services from the perspective of three Indigenous language groups in the Pilbara. All are members of an Aboriginal Corporation, which represents the interests of these Aboriginal language groups, particularly through developing proposals for investments and community projects, and distributing income and other benefits to the traditional owners.

We sought to identify the Aboriginal Corporation members’ views about gaps and solutions, particularly practical solutions, in the delivery of healthcare services to Aboriginal people in the Pilbara.

We endeavoured to include all Aboriginal Corporation members (n = 1183). Invitation letters were mailed to all members by using postal details obtained from the Aboriginal Corporation member database. In addition, we invited members to participate through: public announcements at the Aboriginal Corporation’s general meetings; broadcasts on local radio; advertisements in local newspapers; and volunteer notices distributed as part of an earlier interrelated study.

Aboriginal employment agencies were engaged to recruit local Aboriginal community members to act as interviewers. We then trained those recruited in administering the interviews and the ethics involved in such situations. A review of the demographics of the Aboriginal Corporation members indicated that they were located mainly in townships. Accordingly, we concentrated on conducting face to face interviews in these locations, which included Newman, Tom Price, Port Hedland, Roebourne and Karratha. In addition, we sought to interview remotely located Aboriginal people by attending three general meetings of the Aboriginal Corporation. Aboriginal community members were also offered telephone interviews with our trained Aboriginal Corporation members. An interview guide, informed from an earlier survey, enquired about the following issues: access to healthcare professionals and services; access to transport; access to funding; health promotion initiatives; and self-empowerment (Appendix 1). The interview guide was also informed by a Steering Committee that had three Aboriginal representatives, two of whom were members of the Aboriginal Corporation. All responses were manually recorded verbatim by Aboriginal community members conducting the interviews.

The interview material was analysed with the use of content analysis, which may be undertaken in several different ways.⁹ In the present study, the content analysis was undertaken by counting the number of times either words or phrases occurred in the transcripts of the interviews. The words or phrases that occurred the most times were considered to be important issues. One of the authors initially developed the primary thematic framework, and it was then refined and augmented through several meetings involving all of the authors. Of note was the contribution of one of the authors, an Aboriginal person, who provided a personal perspective on issues encountered by Aboriginal Australians. In addition, important issues were identified by the research team through discussions about the responses, particularly as some important issues may be difficult to discuss or describe and hence occur infrequently in the responses. These important issues were then compared and similar issues were grouped together as themes.

Ethics approval was given by Murdoch University Human Research Ethics Committee, approval number 2011/221.

Of the 1183 Aboriginal Corporation members we contacted, 145 participated in the interviews. Approximately two-thirds of the interviews were held in person, and the remaining interviews were conducted by telephone. Most respondents were members of the Bunjima language group (n = 87). The remaining respondents were either from the Nyiyaparli language group (n = 29), Innawonga language group (n = 21), or non-defined language group (n = 7).

Six themes emerged from the analysis, namely: Access to Medical Doctors and Aboriginal Health Workers; Transport to Local Medical Services; Leaving Country for Medical Services; The Corporation’s Funding of Healthcare Services; Health Promotion Initiatives; and Self-Empowerment. Each theme will be explicated and supported by excerpts from the transcripts of the interviews.

Many respondents said that there were insufficient doctors, nurses and allied health professional near country. This was underlined by respondents listing ‘more doctors, more health workers’ as one of the most common suggestions for three things to improve health. Moreover, numerous respondents indicated that there were inadequate numbers of Aboriginal health workers:

There are minimal Indigenous health workers and no Indigenous doctors. We need more Indigenous health professionals.

The majority of respondents had adequate transport to reach doctors; however, it was also made clear that certain segments of the respondents’ communities required assistance to reach medical services, particularly the elderly, young children and those in remote communities. Some respondents thought that the Patient Assistance Transport Subsidy Scheme was useful, but others indicated that it was still unaffordable:

General community problem: capacity to pay is the issue.

Although numerous respondents said that the Aboriginal Corporation provided medical travel assistance, some indicated that it could be accessed only in exceptional instances:

Depends on circumstances − Corporation may help if the issue is near death. Otherwise no.

A proposed mobile health clinic that has been mooted for several years for these language groups in the Pilbara was often cited as a solution for those who lacked sufficient transport to medical services and was thought to be particularly helpful:

It will make healthcare available when before it wasn’t. At least we will know our health will be in good shape knowing that we get weekly or monthly visit from the mobile clinic.

Moreover, a mobile health clinic was seen as a means by which the accessibility of healthcare could be improved as it would alleviate the travel burden even for those who were able to travel to medical services.

It’s easier for the services to come to the people in most circumstances. More accessibility the better, can access the remote communities.

About half of the respondents said they lacked accommodation if they needed to leave country for medical treatment, and slightly over one-third said a family member would be able accompany them for support. In light of the following response, it seems more than likely that many community members would need to leave country at some point to receive medical care and would struggle to find affordable accommodation in such cases:

People on remote communities need help. It’s often big problem finding somewhere, and if there’s no family we can’t pay.

It was apparent that the Corporation’s support was essential to most respondents’ ability to access healthcare as somewhat more than half said medical services would be unaffordable without financial assistance. Even so, the current level of financial assistance was not always deemed adequate for medical expenses over a particular period:

[Is the funding adequate?] Not really. Only to a certain amount. Once you use up funding and a family member gets sick you can’t help them

Another common funding issue concerned how medically related claims to the Corporation were processed, especially that the process was too slow. Other complaints included excessive and difficult paperwork, and some doctors failed to support purchase orders. Also, some respondents thought that it was unreasonable to have to produce letters to support their claims, others however indicated that the Aboriginal Corporation had to follow their guidelines.

Health promotion initiatives across several areas figured prominently in responses to the open-ended question enquiring about three things to improve their health. Of these areas, the most common was education about improved diet. Such education included information about cooking, hygienic food preparation and nutrition. For instance, one participant said:

We need an awareness of the difference in society between traditional foods and processed foods of these days. Teach and help each other about healthy food and how to cook.

Further initiatives that could help participants improve their diet were better access to healthy food and breakfast programs for school children. One participant noted:

We need access to the food: good food, fresh food, in the community store.

Another common health promotion initiative involved several avenues to improve the participants’ exercise levels, including providing gym memberships, education about the benefits of exercise, and the delivery of structured exercise programs:

Exercise programs would be great including payment of fitness centre fees and health centres i.e. Jenny Craig. This will enable individual goals and help meet personal targets, not a group, as we are all different.

The participants also saw substance abuse programs as an important health promotion initiative. As an example, one participant noted:

It should be a priority as there is a lot of drug and alcohol abuse. Something needs to be done about it.

Another common response to the open-ended questions regarding health promotion initiatives was the general need for health education programs, and that these programs must be easy to access. One participant stated:

There needs to be more availability of resources and programs to increase knowledge − being informed about health and how to adapt your lifestyle.

We also asked about where and how health promotion initiatives should be undertaken. The participants most often said that health promotion programs should be held within the local community and within schools as part of early education. The primary reason for conducting the health programs within local communities was because it was the most comfortable location. There was also a common desire for the whole family to participate together in workshops. For instance, one participant said:

They should be in the community, where they are most comfortable, with whole family in hands-on sessions.

It should be noted though that although participants expressed a keen desire for the whole family to participate, there was an acknowledgement that culturally sensitive issues should be taken into account. One participant indicated:

Some need to be done separately. Men’s group, women’s group, young women’s group, with Elders involved.

As the last statement indicates, some participants thought that elders should be involved in delivering health promotion initiatives. However, several members said that elders should be consulted but it was the responsibility of other community members to organise the workshops. As the following participant said:

It’s up to the young members to promote better health for and on behalf of the Elders. Seek their advice but get out and do the work.

Role models were viewed by the participants as the most important influence in leading people to take responsibility for improving their own health, thereby becoming self-empowered.

We need to lead and live life as an example.

However, some participants thought it was important but doubted whether suitable role models existed, as demonstrated by the following participant’s statement:

I believe the children are the main players − grandchildren telling their grandparents to look after themselves to see them grow up

When community role models were absent, it was thought that it would be beneficial to arrange to have other successful Indigenous people visit. These people should not necessarily have a high profile, but simply be successful in some way. Like one participant noted:

Mentors would be good but not just sports people: real people [from our community] who have been successful, even just in small things, like running a small business.

Lastly, an understanding of traditional diet, particularly the use of bush foods, was thought to be important to becoming self-responsible for health. As an example, one participant said:

They’re important [bush food] and could be included on bush camps and linked to culture. Should include local knowledge and production.

Insufficient numbers of doctors, nurses, allied health and Aboriginal health workers was one of the respondents’ main concerns. The Pilbara Health Network has recently moved to address the issue, mainly through offering incentives to corporate healthcare practices to focus on the needs of local community members (Chris Pickett, pers. comm.). Apart from three Aboriginal Medical Services, all but one of the healthcare practices in the Pilbara are corporate practices. These corporate practices focus on occupational healthcare services that primarily address the needs of mining sector employees (Chris Pickett, pers. comm.). However, the new incentives obligate corporate practices to provide chronic disease management services, which should shift the focus from the mining sector to the local community (Chris Pickett, pers. comm.)

The lack of Aboriginal health workers, another main concern, has been an issue over numerous years. Recent Western Australia Country Heath Care Service initiatives have increased the number of Aboriginal workers at both the management and health professional level.⁵ However, the mining sector targets the recruitment of Aboriginal health workers because they are viewed as a reliable source of labour (Chris Pickett, pers. comm.). The willingness of Aboriginal health workers to enter the mining sector is entirely understandable as the salaries are substantially larger than health professional earnings. Hence, it appears that incentives need to be offered to retain Aboriginal health workers; however, whether current health budgets allow for such incentives remains unclear.

The lack of adequate transport to medical services was a notable problem. There was some doubt among members about whether, and in what circumstances, the Aboriginal Corporation covered travel expenses, which suggests that it would be beneficial to clarify the issue through a communication strategy. The Pilbara Health Network has recognised that inadequate transport presents as a substantial problem for local communities in the Pilbara. To help alleviate this problem, care coordinator positions have been recently established and part of the role involves transporting clients to appointments (Chris Pickett, pers. comm.). However, it was acknowledged that it would be difficult to fill all care co-ordinator positions and there would be gaps in service delivery (Chris Pickett, pers. comm.). There are Government plans to acquire several small mobile health clinics, which will assist in addressing health service shortfalls (Chris Pickett, pers. comm.). But the success of these strategies needs to be evaluated once fully implemented to identify ongoing gaps in healthcare provision.

The dearth of adequate accommodation available to Indigenous people who need to leave country for healthcare is unacceptable. This has been highlighted by the situation at Port Hedland in which Aboriginal people camp in the park outside the hospital.¹⁰ The State government initiated a feasibility study to build a hostel. Whether the situation is similar in other regions is uncertain, but our findings suggest it is difficult to find short-term accommodation throughout the Pilbara. The Patient Assistance Transport Scheme does cover some of the cost of short-term commercial accommodation.¹¹ Even so, the likely high cost of such accommodation would probably prove unaffordable for the overwhelming majority of Indigenous people.¹²

The issues raised by respondents about processing medically related claims were brought to the attention of their Aboriginal Corporation. Unfortunately, the required paperwork and delays in approving claims were largely unavoidable due to an obligation to follow guidelines established under the Corporation’s Foundation Trust Deed (Laura Coe, pers. comm.). It was apparent that not all respondents appeared to be aware of these guidelines and it was accordingly recommended that communication about entitlements could be improved and one on one assistance offered.

Education about better eating and exercise were the two health promotion areas of most interest to the respondents. Numerous studies have been undertaken in these areas to determine what types of initiatives work best in Indigenous communities.^13,14 These studies have shown that in order for physical activity and dietary programs to be effective they must be community initiated and managed.^13,14 In addition, programs are also ineffective if they fail to address broad structural issues such as poverty and an inadequate supply of healthy food.¹⁵ Examples of demonstrated effective physical activity and dietary programs, which could potentially be implemented in the Pilbara, include ‘Looma Healthy Lifestyle’¹⁶ and ‘Waist-Loss’¹⁷.

The respondents viewed the use of bush foods as promoting self-empowerment and a way in which they could improve their health, which has been identified in previous research.¹⁸ Indigenous Australians have reported that gathering and consuming bush foods may help restore and protect culture.¹⁸ In addition, it was thought that the use of bush foods would to some extent foster a return to traditional dietary patterns, which had been disrupted by colonisation and supplanted by poor nutrition influenced by Western culture.¹⁸ Importantly, it was recognised that to sustain behavioural change the use of bush foods needs to be based on local knowledge.¹⁸ Given these benefits, it appears that restoring the widespread use of bush foods could substantially lead to improving the health and wellbeing of Indigenous communities in the Pilbara.

This study provides Indigenous perspectives from three language groups about gaps and solutions in healthcare service delivery in the Pilbara. Although initiatives have commenced to address the shortfall in health professionals and inadequate transport to healthcare, there are still likely to be gaps in service provision. Mobile health services may be integral to addressing these gaps and there was strong community support for such measures. Given the inherent difficulties of providing adequate primary healthcare in remote areas, it is imperative that secondary healthcare interventions are implemented well. Such interventions, based on this study’s findings, should focus on health promotion activities that improve diet, increase exercise levels and reduce substance abuse. In particular, conducting camps in country to foster knowledge about traditional bush foods may be important in improving diet and strengthening ties to traditional culture. Finally, a notional limitation of the study was the sample size; however, given the commonality of responses we believe we have exhausted the major themes likely to occur in a larger sample of the population.

The authors declare there are no competing interests.