ATSI – culturally respectful approach
from – https://www.racgp.org.au/afp/2014/january-february/aboriginal-cultural-mentors
Adapted from RACGP AFP 2014, cultural mentors, and national best practice principles
1. Core Principle: Cultural Respect
A culturally respectful approach is central to effective clinical relationships and improved outcomes. It involves:
- Attitude: Humility, openness, non-judgment.
- Communication: Respectful, indirect, story-based where appropriate.
- Cultural Awareness: Sensitivity to spiritual beliefs, kinship, history.
- Applied Knowledge: Local history, social determinants, family roles, community norms.
2. Foundational Knowledge for GPs
Understanding Aboriginal History (National & Local)
- Colonisation, dispossession, the Stolen Generations, and discriminatory policy have lasting impacts.
- Local history matters: knowing local traditional owners, historical trauma, missions, and policies specific to the area fosters rapport.
- Health system mistrust is often intergenerational and valid.
- Avoid minimising past injustices—acknowledge them openly when appropriate.
Clinical Information Gathering & Interpretation
- Biopsychosocial-cultural history – explore Country connection, traditional healing use, kinship obligations.
- Trauma-informed lens – screen gently for trauma triggers; normalise mental health discussion.
- Function & Well-being – ask about impact on work, cultural roles, family responsibilities.
- Risk & Protective Factors – housing, food security, cultural strengths (community, spirituality).
Patient-Centred Management & Therapeutic Reasoning
| Step | Action |
|---|---|
| Shared Decisions | Present options with visual aids; allow time for family consultation. |
| Holistic Plan | Combine biomedical Rx with traditional practices (check interactions). |
| Prevention | MBS 715 health check, immunisation (NIP + ATSI-specific schedules), “Closing the Gap” scripts. |
| Review & Escalation | Set review date; agree on red-flag triggers for earlier contact. |
Addressing Barriers to Therapeutic Alliance
| Barrier | Recognition cue | Strategy |
|---|---|---|
| Shame (deep embarrassment) | Avoidance, quiet voice, missed appointments | Offer private entrance, allow AHW to lead discussion, normalise sensitive issues. |
| Racism in system | Patient recounts negative ED experience | Validate feelings, apologise, outline complaint pathways, offer to accompany. |
| Power Imbalance | Quick “yes” answers, minimal questions | Use teach-back, sit at same eye level, share notes on screen. |
| Historical mistrust | References to “government taking kids” | Acknowledge truth; explain confidentiality limits, mandate of care. |
3. Key Cultural Considerations in Healthcare
“Sorry Business” (Bereavement Practices)
- Important ceremonies for death and grieving.
- May impact attendance at appointments for extended periods.
- Patients should not be pressured to explain absence during mourning.
- Respect collective grief—don’t require formal documentation.
“Men’s and Women’s Business”
- Cultural rules may restrict discussion of health matters with opposite-gender practitioners.
- E.g., reproductive health, sexual health, certain traditional knowledge.
- Offer same-gender clinician, private space; use plain language; reassure confidentiality
Aboriginal Spirituality
- Some beliefs involve ancestral spirits, sacred sites, and connections to Country.
- May be misinterpreted as psychiatric symptoms (e.g., hearing voices ≠ psychosis).
- Always ask and explore context before interpreting unusual symptoms.
Kinship & Collective Decision-Making
- Extended family and Elders often involved in decisions.
- Patients may bring multiple family members to appointments.
- Do not assume lack of autonomy; respect collectivism as culturally normative.
- “Would you like to have family involved in making this decision?”
Traditional Healing
- May include bush medicine, traditional healers, ceremonies.
- Ask respectfully if using traditional treatments.
- Avoid dismissing – instead, explore how it can be integrated with biomedical care.
- Ensure no interaction with prescribed medicines.
Barriers & Building Therapeutic Relationships
| Barrier | Practical Response |
|---|---|
| Historical mistrust & intergenerational trauma | Acknowledge openly; provide trauma-informed care (safety, choice, collaboration). |
| Systemic racism / power imbalance | Reflect on clinician bias; share control (negotiated agenda, shared notes). |
| Shame & stigma (e.g. STIs, mental health) | Provide privacy, avoid public questioning, normalise sensitive topics. |
4. Communication Practices and Styles
Non-Verbal Communication
- Minimal eye contact
- Looking down/away signals respect, not disinterest.
- Follow the patient’s lead; avoid sustained, direct gaze, especially cross-gender
- Comfortable silence
- Pauses allow reflection and show respect.
- Wait quietly, watch body language; resist the urge to “fill the gap.”
- Body language is key – observe posture, gestures, facial expression.
Verbal Communication
- Person before business
- Aboriginal and Torres Strait Islander cultures often prioritise relationships over tasks.
- Start with a warm introduction and small talk (a “social yarn”).
- Ask where the person is from, share something of yourself – this builds trust.
- Avoid rushing into clinical matters.
- Aboriginal and Torres Strait Islander cultures often prioritise relationships over tasks.
- Indirect “round-about” questioning–
- Storytelling, metaphors, and analogies may be used to express key concerns.
- Use phrases like: “Some people in your situation might feel…”
- Avoid direct, complex, or compound questions.
- Storytelling (“yarning”) allows safe exploration of health issues.
- Avoid pressuring for direct answers.
- Allow time and space.
- Family-centred decision-making
- Respect the role of family and kinship in decision-making.
- Ask: “Would you like time to speak with family about this?”
- Provide privacy and space for family discussions when needed.
- Expect that decisions may take more time.
- Plain English & visual aids
- english or biomedical terms may be second language.
- Avoid jargon, use pictures, models, medicine packs;
- teach-back to confirm understanding
- https://www.jcts.org.au/category/patient-information-sheets/
- Use teach-back method:
- “Can you tell me in your own words what we just talked about?”
- Active listening & ‘yes’ bias
- Don’t assume “yes” means understanding.
- Patients may say “yes” to please you or end the visit.
- After a “yes”, ask, “Can you tell me how you’ll take these tablets?” to verify comprehension
- Reflective listening
- Repeat or paraphrase the patient’s words to show you’re listening and to clarify meaning.
- Avoid making assumptions or jumping to conclusions.
- Teach-Back Method
- After explaining something, ask:
- “Can you tell me in your own words how you’ll take this medication?”
- Yarning (Conversational Health Promotion)
- Begin with informal conversation – don’t jump into clinical talk.
- Use open-ended questions: “Tell me what’s been going on for you lately.”
- Avoid clinical questions too early.
- Let patient guide the conversation pace.
- “Ask Before Tell”
- Rather than immediately giving advice, instructions, or information (“telling”), the GP first asks questions to understand the patient’s perspective, concerns, cultural context, and level of health literacy. It prioritizes listening, understanding, and building trust.’
Examples of “Ask Before Tell” in Practice
| Scenario | “Ask” Example | Why It’s Important |
|---|---|---|
| Diabetes management | “What do you know about diabetes?” | Understand baseline knowledge and correct misinformation. |
| Medication adherence | “How do you feel about taking this medication every day?” | Identify barriers like fear, beliefs, or access issues. |
| Lifestyle advice | “What does a healthy day look like for you?” | Learn about lifestyle in a culturally relevant way before giving advice. |
Clinician checklist (“ASK before you SPEAK”)
- Acknowledge Country & introduce yourself.
- Share something of yourself; start with a social yarn.
- Keep questions indirect, allow silence.
- Be mindful of eye contact, body language, personal space.
- Explain why you need information or contact; ask permission.
- Find out who needs to be in the room for decisions.
- Offer interpreters, visual aids, plain language.
- Reflect on your own assumptions and power in the room.
- End with teach-back: “Can you show me how you’ll use the spacer?”
5. Respecting Family and Community Structures
Elders
- Cultural leaders and decision-makers.
- Show respect, ask how they wish to be addressed.
- Include them when appropriate: “Would you like an Elder or family member involved in our discussion today?”
Family Involvement
- Family may attend appointments or speak on behalf of the patient.
- Do not assume lack of capacity – this is often cultural preference.
- Respect intergenerational support.
Avoiding Shame
- “Shame” is a profound concept—akin to humiliation, not guilt.
- May cause disengagement, silence, or withdrawal.
- Sensitive issues (e.g. STIs, mental health, substance use) require discretion.
- Avoid public questioning, maintain privacy.
6. Trauma-Informed and Culturally Safe Care
Acknowledge Historical Trauma
- Be aware of past discrimination, marginalisation, and Stolen Generations.
- → These may affect trust in healthcare. Show empathy, not assumptions.
Historical and Intergenerational Trauma
- High rates of complex trauma due to colonisation, displacement, and forced child removal.
- May lead to mistrust of authority or healthcare systems.
Trauma-Informed Care Principles
- Safety: Physical, cultural, emotional.
- Trustworthiness: Consistency, transparency.
- Choice: Informed decisions.
- Collaboration: Respect shared power.
- Empowerment: Patient as expert in their own story.
7. Clinical Practice Strategies
Allow Time
- Avoid rushing, especially on first contact.
- Build rapport slowly—clinical matters come after trust.
- Offer longer or multiple appointments.
Flexible Scheduling
- Cultural obligations (e.g. funerals, ceremonies) may take precedence.
- Offer alternative times without judgement.
Continuity of Care
- Use staged care plans.
- Reassess regularly – health beliefs and context may evolve.
Remote & Rural Communication
- Platforms: phone, secure messaging, video; confirm patient’s preferred tech.
- Follow-up: schedule recall visits; enlist local outreach/AHWs for face-to-face checks.
- Handovers: concise summaries to RFDS, visiting specialists, or local hospitals; ensure culturally safe discharge instructions.
- Advocacy: identify service gaps (e.g. dialysis, rehab) and escalate via regional networks.
8. Team-Based and Organisational Practices
Employ Aboriginal Health Workers
- Provide liaison between patient and doctor.
- Offer to include them: “Would you like support from our Aboriginal Health Worker today?”
Culturally Competent Staff
- Reception and clinical staff must be trained in:
- Cultural protocols.
- Communication styles.
- Avoiding assumptions or stereotypes.
Ask about Identity Respectfully
- “We ask about Aboriginal or Torres Strait Islander identity to help provide culturally specific services that might benefit you.”
Culturally Welcoming Environment
- Acknowledge Traditional Custodians.
- Display Aboriginal artwork, flags, posters.
- Use culturally relevant patient resources (language, symbols).
Interpreter Services
- Especially for remote communities (e.g., Yolŋu Matha, Pitjantjatjara).
- Use AIS or TIS National.
- Train reception staff to offer interpreter discreetly.
Visual Aids
- Use anatomical models, culturally familiar images.
- Reinforce concepts via demonstration.
9. Holistic Health Approach
| Dimension | Key Consideration |
|---|---|
| Biological | Respect integration of traditional and Western medicine |
| Psychological | Provide trauma-informed mental health care; explore cultural identity |
| Social | Assess family, housing, kinship, social support |
| Cultural | Acknowledge and respect traditional healing, ceremonies, Elders, connection to land |
10. System Navigation and Social Support
- Aboriginal-specific health services: Refer to Aboriginal Community Controlled Health Services (ACCHS) when appropriate.
- Logistical barriers: Support transport or telehealth options.
- Social work: Link with services for education, housing, Centrelink, NDIS, or legal aid.
11. Key Program Knowledge for GPs
- MBS 715 Aboriginal Health Checks
- Closing the Gap prescriptions (PBS co-payment relief)
- Aboriginal-specific mental health, maternal health, and chronic disease programs
Consultation Flow Cheat-Sheet
- Pre-Visit Prep:
- Check CTG registration
- interpreter booking
- family attendance
- AHW availability.
- Greeting & Social Yarn (5 min):
- Acknowledge Country ➔ share self ➔ ask about family/“Where’s home for you?”
- Validate connection to Country, culture, and spirituality
- Information Yarn (Narrative history):
- Indirect questions
- silence
- visual aids
- explore Country
- kinship
- Allow time – don’t rush
- traditional healing.
- Clinical Examination:
- Explain each step
- obtain permission before touch.
- Management Yarn (Shared planning):
- Present options visually
- allow private family talk.
- Address trauma and intergenerational loss
- Respect gender-specific cultural practices
- Teach-Back & Wrap-Up:
- “In your own words, how will you take this medicine?” ➔ book review ➔ document preferred contact method.
- Post-Visit Coordination:
- Email/SMS summary in plain English; liaise with AHW; schedule recalls.
ATSI-Specific Preventive & Chronic Disease Management
(Use alongside MBS 715 health check and local PHN/ACCHO protocols)
Screening & Prevention
| Condition / test | Start age (ATSI) | Frequency | Practical notes |
|---|---|---|---|
| CVD absolute risk | 30 y (earlier if strong FHx, metabolic syndrome, CKD, etc.) | Annual | Use First Nations CVD risk algorithm; treat if ≥5 % 5-y risk. heartfoundation.org.au |
| Blood pressure | Any age with risk; otherwise from 18 y | Opportunistic / every visit | Use ABPM/HBPM if borderline. |
| Type 2 diabetes (HbA1c ± FBG) | 18 y | 3-yearly (annual if BMI ≥25, GDM hx, steroid use, CVD, etc.) | HbA1c ≥5.7 % → OGTT or repeat. |
| CKD (eGFR + ACR) | 18 y with any risk (DM, HTN, smoking, Prem LBW, ATSI) | Annual | Simultaneous BP and lipid check. |
| Lipids | 25 y (earlier if risk) | 5 y if low risk; 1-2 y if CVD risk ≥5 % | Non-fasting panel acceptable. |
| STI screen (CT, NG, syphilis, HIV) | 15–29 y (≤35 y in remote) | Annual if not in long-term monogamous relationship | Urine/vaginal PCR + serology. sti.guidelines.org.au |
| Cervical screening (HPV self-collect OK) | 25–74 y | 5-yearly | Prioritise self-collection to lift participation. |
| Breast cancer (mammography) | 40–49 y opportunistic; 50–74 y organised | 2-yearly | Encourage mobile van screening. |
| Bowel cancer (iFOBT) | 40 y | 2-yearly | Offer clinic kits if poor postal return. www1.racgp.org.au |
| RHD (high-prev regions) | 5–15 y | Opportunistic echo | Integrate with school health programs. |
| Ear & hearing (children) | Birth onward | Each child-health check | Tympanometry/Audiology if OM risk. |
| Oral health | All ages | Yearly | Leverage AHW/dental therapist programs. |
Immunisation – key ATSI vs non-Indigenous differences (NIP-funded)
| Vaccine | First Nations schedule | General schedule |
|---|---|---|
| Pneumococcal | PCV13 at 50 y → 23vPPV 8 wk later, repeat 23vPPV ≥5 y later | Single 23vPPV at 70 y if no other risk |
| Influenza | Annual from 6 mo | Funded ≥65 y, pregnancy, 6 mo–<5 y or chronic disease |
| Hepatitis B | Universal infant + funded catch-up at any age if non-immune | Catch-up only in risk groups |
| Meningococcal B | Funded for all infants <2 y (2 + 1 schedule); boosters per risk | Not routine; privately funded unless medical risk |
| Meningococcal ACWY | As per national childhood/adolescent program, plus risk indications | Same |
| Shingles (Shingrix) | ≥50 y (2 doses, 2–6 mo apart) | ≥65 y |
| Pertussis (dTpa) in pregnancy | All pregnant women each pregnancy (20–32 wk) | Same (no difference) |
GP MANAGEMENT CONSIDERATIONS
| Condition | ATSI-Specific Considerations |
|---|---|
| Mental Health | Use trauma-informed care; assess for grief, cultural disconnection, incarceration trauma |
| Smoking | High prevalence – offer NRT + Quitline + culturally tailored programs at every visit |
| Nutrition | Consider food insecurity, traditional diet, access to healthy food; refer to dietitian if available |
| RHD | Early treatment of GAS pharyngitis, monthly benzathine penicillin if diagnosed |
| Skin Infections | Early treatment of scabies, impetigo – community level burden is high |
| Child Health | Monitor growth, development, hearing, oral health, immunisation catch-up |
CLINIC TOOLS & STRATEGIES
- Use 715 Health Check template (Best Practice/Medical Director or MBS-provided)
- Collaborate with Aboriginal Health Workers (AHWs) or local ACCHO
- Provide visual aids, flip charts, or language-specific resources
- Use interpreter service if English not first language
- Document cultural needs, preferred name, family involvement in file
Colloquial terms related to health and their respective health contexts:
| Term | Meaning | Health Context |
|---|---|---|
| Deadly | Colloquial term meaning excellent or great | “Deadly health programs” or “deadly doctors” refer to excellent health services or professionals. |
| Djukurrpa (Dreaming) | Spiritual belief system, explaining the creation and cultural laws | Holistic health is tied to spiritual and cultural beliefs, encompassing mind, body, and spirit. |
| Yarning | Informal conversation or storytelling | Used in healthcare to build trust and understanding; “yarning circles” in mental health or counselling settings. |
| Liyan (Kimberley Region Term) | Inner sense of well-being or gut feeling | Refers to emotional and spiritual wellbeing. A “good” liyan means feeling balanced and healthy. |
| Marngrook | Traditional Aboriginal football game or physical play | Physical activity is essential for maintaining physical health and wellbeing, especially for youth. |
| Koori, Murri, Nunga, Yolngu, Palawa | Regional names for Aboriginal groups (e.g., Koori in NSW/VIC, Murri in QLD) | Used in health services to provide culturally safe care (e.g., “Koori Health Services”). |
| Mob | Family, group, or community | Health programs often focus on supporting the “mob” or community’s collective health and wellbeing. |
| Ngurra | Home or country | Connection to country is essential for mental, emotional, and spiritual wellbeing. |
| Birthing on Country | Culturally safe birthing practices on ancestral land | Programs integrate cultural values into maternal and infant healthcare for better health outcomes. |
| Strong Spirit, Strong Mind, Strong Body | Holistic view of health (balance of physical, mental, emotional, spiritual) | Concept used in health programs to promote overall wellbeing. |
| Dadirri (Deep Listening) | Deep listening or inner quiet | Promotes mental and emotional healing, often used in therapeutic settings to support mental health. |
| Sorry Cuts | Self-inflicted cuts during mourning (part of “Sorry Business”) | Culturally significant but requires sensitive medical care to prevent infection and promote healing. |
| Bush Medicine | Traditional plant-based medicine used for healing | Often integrated with or used as an alternative to Western medicine in ATSI communities. |