Examining the potential contribution of social theory to developing and supporting Australian Indigenous-mainstream health service partnerships.

INTRODUCTION: The substantial gap in life expectancy between Indigenous and non-Indigenous Australians has been slow to improve, despite increased dedicated funding. Partnerships between Australian Indigenous and mainstream Western biomedical organisations are recognised as crucial to improved Indigenous health outcomes. However, these partnerships often experience challenges, particularly in the context of Australia's race and political relations. METHODS: We examined the relevant literature in order to identify the potential role for social theory and theoretical models in developing and maintaining intercultural partnerships. Having identified relevant theoretical models, terms and possible key words, a range of databases were searched and relevant articles selected for inclusion. An integrative approach brought together theoretical models and practical considerations about working in partnership, to inform our analysis of the literature. FINDINGS: Considering partnerships between Australian Indigenous and mainstream health organisations as 'bi-cultural' is simplistic: rather they are culturally diverse across social and professional levels. As such, partnerships between Australian Indigenous and mainstream health organisations may be better conceptualised as 'intercultural', operating across diverse and shifting cultural frames of reference. Theories identified by this review as useful to guide partnerships include power relations, reflexivity and dialogue, borders and strangeness and the intercultural or third space. This paper examines how these theoretical approaches can develop understanding and improve intercultural engagement between mainstream and Australian Indigenous partners in healthcare. CONCLUSIONS: Rather than viewing partnerships merely as arrangements between disembodied entities, sometimes contractual in nature, they are better seen as activities between people and organisations and essentially dependent on relationships, occurring in an intercultural space that is complex, dynamic and subject to changes in power relations. Theoretical models aiming to understand and improve partnerships indicate the complexity of building and maintaining such partnerships and stress the importance of understanding factors that can strengthen or derail their effectiveness. While the theories presented here are by no means exhaustive, they nonetheless provide a series of entry points through which to engage with the issue and expand the discourse. This approach allows the transformative nature of Australian Indigenous-mainstream 'culture' to be explored and understood in its lived expression; rather than relegated to prescriptive categories.

Aboriginal-mainstream partnerships: exploring the challenges and enhancers of a collaborative service arrangement for Aboriginal clients with substance use issues.

BACKGROUND: Partnerships between different health services are integral to addressing the complex health needs of vulnerable populations. In Australia, partnerships between Aboriginal community controlled and mainstream services can extend health care options and improve the cultural safety of services. However, although government funding supports such collaborations, many factors can cause these arrangements to be tenuous, impacting the quality of health care received. Research was undertaken to explore the challenges and enhancers of a government initiated service partnership between an Aboriginal Community Controlled alcohol and drug service and three mainstream alcohol rehabilitation and support services. METHODS: Sixteen staff including senior managers (n=5), clinical team leaders (n=5) and counsellors (n=6) from the four services were purposively recruited and interviewed. Interviews were semi-structured and explored staff experience of the partnership including the client intake and referral process, shared client care, inter-service communication and ways of working. RESULTS & DISCUSSION: Communication issues, partner unfamiliarity, 'mainstreaming' of Aboriginal funding, divergent views regarding staff competencies, client referral issues, staff turnover and different ways of working emerged as issues, emphasizing the challenges of working with a population with complex issues in a persistent climate of limited resourcing. Factors enhancing the partnership included adding a richness and diversity to treatment possibilities and opportunities to explore different, more culturally appropriate ways of working. CONCLUSION: While the literature strongly advises partnerships be suitably mature before commencing service delivery, the reality of funding cycles may require partnerships become operational before relationships are adequately consolidated. Allowing sufficient time and funding for both the operation and relational aspects of a partnership is critical, with support for partners to regularly meet and workshop arrangements. Documentation that makes clear and embeds working arrangements between partners is important to ameliorate many of the issues that can arise. Given the historical undercurrents, flexible approaches are required to focus on strengths that contribute to progress, even if incremental, rather than on weaknesses which can undermine efforts. This research offers important lessons to assist other services collaborating in post-colonial settings to offer treatment pathways for vulnerable populations.

Aboriginal to non-Aboriginal differentials in 2-year outcomes following non-fatal first-ever acute MI persist after adjustment for comorbidity.

BACKGROUND: We investigated the relationship between Aboriginality and 2-year cardiovascular disease outcomes in non-fatal first-ever myocardial infarction during 2000-04, with progressive adjustment of covariates, including comorbidities. DESIGN: Historical cohort study. METHODS: Person-linked hospital and mortality records were used to identify 28-day survivors of first-ever myocardial infarction in Western Australia during 2000-04 with 15-year lookback. The outcome measures were: (1) cardiovascular disease death; (2) recurrent admission for myocardial infarction; and (3) the composite of (1) and (2). RESULTS: Compared with non-Aboriginal patients, Aboriginals were younger and more likely to live remotely. The proportions having 5-year histories of diabetes and chronic kidney disease were double and triple those of non-Aboriginals. When adjusting for demographic variables alone, the Aboriginal to non-Aboriginal hazard ratios for cardiovascular death or recurrent myocardial infarction were 3.6 (95% CI 2.5-5.3) in men and 4.5 (95% CI 2.8-7.3) in women. After adjustment for comorbidities, including diabetes, chronic kidney disease and heart failure, the hazard ratios decreased 36% and 47% to 2.3 (1.6-3.0) and 2.4 (1.5-4.0) in males and females, respectively. CONCLUSIONS: The high prevalence of comorbidities in Aboriginal people, including diabetes, kidney disease, heart failure, and other risk factors contribute substantially to the disparity in post-myocardial infarction outcomes in Aboriginal people, reinforcing the importance of both primary prevention and comprehensive management of chronic conditions in this population. Aboriginality remains a significant independent risk factor for disease recurrence or mortality, even after adjusting for comorbidity, suggesting the need for society-level interventions addressing social disadvantage.

Closing the (service) gap: exploring partnerships between Aboriginal and mainstream health services.

BACKGROUND: Although effective partnerships between Aboriginal and mainstream health services are critical to improve Aboriginal health outcomes, many factors can cause these partnerships to be tenuous and unproductive. Understanding the elements of best practice for successful partnerships is essential. METHODS: A literature review was conducted in 2009 using keyword searches of electronic databases. Sourced literature was assessed for relevance regarding the benefits, challenges, lessons learnt and factors contributing to successful Aboriginal and mainstream partnerships. Key themes were collated. RESULTS: Although there is much literature regarding general partnerships generally, few specifically examine Aboriginal and mainstream health service partnerships. Twenty-four sources were reviewed in detail. Benefits include broadening service capacity and improving the cultural security of healthcare. Challenges include the legacy of Australia's colonial history, different approaches to servicing clients and resource limitations. Recommendations for success include workshopping tensions early, building trust and leadership. CONCLUSION: Although successful partnerships are crucial to optimise Aboriginal health outcomes, failed collaborations risk inflaming sensitive Aboriginal-non-Aboriginal relationships. Factors supporting successful partnerships remind us to develop genuine, trusting relationships that are tangibly linked to the Aboriginal community. Failure to invest in this relational process and push forward with 'business as usual' can ultimately have negative ramifications on client outcomes.

Variable effects of prevalence correction of population denominators on differentials in myocardial infarction incidence: a record linkage study in Aboriginal and non-Aboriginal Western Australians.

OBJECTIVES: To investigate the impact of prevalence correction of population denominators on myocardial infarction (MI) incidence rates, rate ratios, and rate differences in Aboriginal vs. non-Aboriginal Western Australians aged 25-74 years during the study period 2000-2004. STUDY DESIGN AND SETTING: Person-based linked hospital and mortality data sets were used to estimate the number of prevalent and first-ever MI cases each year from 2000 to 2004 using a 15-year look-back period. Age-specific and -standardized MI incidence rates were calculated using both prevalence-corrected and -uncorrected population denominators, by sex and Aboriginality. RESULTS: The impact of prevalence correction on rates increased with age, was higher for men than women, and substantially greater for Aboriginal than non-Aboriginal people. Despite the systematic underestimation of incidence, prevalence correction had little impact on the Aboriginal to non-Aboriginal age-standardized rate ratios (6% and 4% underestimate in men and women, respectively), although the impact on rate differences was more marked (12% and 6%, respectively). The percentage underestimate of differentials was greater at older ages. CONCLUSION: Prevalence correction of denominators, while more accurate, is difficult to apply and may add modestly to the quantification of relative disparities in MI incidence between populations. Absolute incidence disparities using uncorrected denominators may have an error >10%.

'I don't know why they don't come': barriers to participation in cardiac rehabilitation.

OBJECTIVES: To describe health professionals' perceptions of Aboriginal people's access to cardiac rehabilitation (CR) services and the role of institutional barriers in implementing the National Health and Medical Research Council (NHMRC) guidelines Strengthening Cardiac Rehabilitation and Secondary Prevention for Aboriginal and Torres Strait Islander peoples. DESIGN: Qualitative study. SETTING: Metropolitan and rural tertiary and community-based public CR services and Aboriginal health services in WA. PARTICIPANTS: Thirty-eight health professionals working in the CR setting. METHOD: Semistructured interviews were undertaken with 28 health professionals at public CR services and 10 health professionals from Aboriginal Medical Services in WA. The participants represented 17 services (10 rural, 7 metropolitan) listed in the WA Directory of CR services. RESULTS: Emergent themes included (1) a lack of awareness of Aboriginal CR patients' needs; (2) needs related to cultural awareness training for health professionals; and (3) Aboriginal health staff facilitate access for Aboriginal patients. CONCLUSIONS: Understanding the institutional barriers to Aboriginal participation in CR is necessary to recommend viable solutions. Promoting cultural awareness training, recruiting Aboriginal health workers and monitoring participation rates are important in improving health outcomes.

Incidence of and case fatality following acute myocardial infarction in Aboriginal and non-Aboriginal Western Australians (2000-2004): a linked data study.

BACKGROUND: Despite Coronary Heart Disease exacting a heavy toll among Aboriginal Australians, accurate estimates of its epidemiology are limited. This study compared the incidence of acute myocardial infarction (AMI) and 28-day case fatality (CF) among Aboriginal and non-Aboriginal Western Australians aged 25-74 years from 2000-2004. METHODS: Incident (AMI hospital admission-free for 15 years) AMI events and 28-day CF were estimated using person-based linked hospital and mortality data. Age-standardised incidence rates and case fatality percentages were calculated by Aboriginality and sex. RESULTS: Of 740 Aboriginal and 6933 non-Aboriginal incident events, 208 and 2352 died within 28 days, respectively. The Aboriginal age-specific incidence rates were 27 (males) and 35 (females) times higher than non-Aboriginal rates in the 25-29 year age group, decreasing to 2-3 at 70-74 years. The male:female age-standardised incidence rate ratio was 2.2 in Aboriginal people 25-54 years compared with 4.5 in non-Aboriginal people. Aboriginal age-standardised CF percentages were 1.4 (males) and 1.1 (females) times higher at age 25-54 years and 1.5 times higher at age 55-74 years. CONCLUSION: These data suggest higher CF and, more importantly, AMI incidence contribute to the excess ischaemic heart disease mortality in Aboriginal Western Australians. The poorer cardiovascular health in Aboriginal women, particularly in younger age groups, should be investigated.

Health information system linkage and coordination are critical for increasing access to secondary prevention in Aboriginal health: a qualitative study.

BACKGROUND: Aboriginal Australians have low rates of participation in cardiac rehabilitation (CR), despite having high rates of cardiovascular disease. Barriers to CR participation reflect multiple patient-related issues. However, an examination of the broader context of health service delivery design and implementation is needed. AIMS: To identify health professionals' perspectives of systems related barriers to implementation of the National Health and Medical Research Council (NHMRC) guidelines Strengthening Cardiac Rehabilitation and Secondary Prevention for Aboriginal and Torres Strait Islander Peoples. METHOD: Semi-structured interviews were conducted with health professionals involved in CR within mainstream and Aboriginal Community Controlled Health Services in Western Australia (WA). Thirty-eight health professionals from 17 services (ten rural, seven metropolitan) listed in the WA Directory of CR services and seven Aboriginal Medical Services in WA were interviewed. RESULTS: Respondents reported barriers encountered in health information management and the impact of access to CR services for Aboriginal people. Crucial issues identified by participants were: poor communication across the health care sector and between providers, inconsistent and insufficient data collection processes (particularly relating to Aboriginal ethnicity identification), and challenges resulting from multiple clinical information systems and incompatible technologies. CONCLUSIONS: This study has demonstrated that inadequate information systems and communication strategies, particularly those representing the interface between primary and secondary care, contribute to the low participation rates of Aboriginal Australians in CR. Although these challenges are shared by non-Aboriginal Australians, the needs are greater for Aboriginal Australians and innovative solutions are required.

Are the processes recommended by the NHMRC for improving Cardiac Rehabilitation (CR) for Aboriginal and Torres Strait Islander people being implemented?: an assessment of CR Services across Western Australia.

BACKGROUND: Cardiovascular disease is the major cause of premature death of Indigenous Australians, and despite evidence that cardiac rehabilitation (CR) and secondary prevention can reduce recurrent disease and deaths, CR uptake is suboptimal. The National Health and Medical Research Council (NHMRC) guidelines Strengthening Cardiac Rehabilitation and Secondary Prevention for Aboriginal and Torres Strait Islander peoples, published in 2005, provide checklists for services to assist them to reduce the service gap for Indigenous people. This study describes health professionals' awareness, implementation, and perspectives of barriers to implementation of these guidelines based on semi-structured interviews conducted between November 2007 and June 2008 with health professionals involved in CR within mainstream health services in Western Australia (WA). Twenty-four health professionals from 17 services (10 rural, 7 metropolitan) listed in the WA Directory of CR services were interviewed. RESULTS: The majority of respondents reported that they were unfamiliar with the NHMRC guidelines and as a consequence implementation of the recommendations was minimal and inconsistently applied. Respondents reported that they provided few in-patient CR-related services to Indigenous patients, services upon discharge were erratic, and they had few Indigenous-specific resources for patients. Issues relating to workforce, cultural competence, and service linkages emerged as having most impact on design and delivery of CR services for Indigenous people in WA. CONCLUSIONS: This study has demonstrated limited awareness and poor implementation in WA of the recommendations of the NHMRC Strengthening Cardiac Rehabilitation and Secondary Prevention for Aboriginal and Torres Strait Islander Peoples: A Guide for Health Professionals. The disproportionate burden of CVD morbidity and mortality among Indigenous Australians mandates urgent attention to this problem and alternative approaches to CR delivery. Dedicated resources and alternative approaches to CR delivery for Indigenous Australians are needed.

Exploring the impact of an Aboriginal Health Worker on hospitalised Aboriginal experiences: lessons from cardiology.

To enhance Aboriginal inpatient care and improve outpatient cardiac rehabilitation utilisation, a tertiary hospital in Western Australia recruited an Aboriginal Health Worker (AHW). Interviews were undertaken with the cardiology AHW, other hospital staff including another AHW, and recent Aboriginal cardiac patients to assess the impact of this position. The impact of the AHW included facilitating culturally appropriate care, bridging communication divides, reducing discharges against medical advice, providing cultural education, increasing inpatient contact time, improving follow-up practices and enhancing patient referral linkages. Challenges included poor job role definition, clinical restrictions and limitations in AHW training for hospital settings. This study demonstrates that AHWs can have significant impacts on Aboriginal cardiac inpatient experiences and outpatient care. Although this study was undertaken in cardiology, the lessons are transferable across the hospital setting.