Cultural competence – transforming policy, services, programs and practice

This chapter discusses some of the complex issues surrounding the notion of cultural competence—and the critical need for practitioners to develop knowledge, skills, understandings and attributes to be responsive in diverse cultural settings. The argument for culturally competent mental health practitioners and services is situated within a human rights framework which underpins the principles, standards and practice frameworks intended to facilitate/contribute to the capacity and empowerment of mental health practitioners and clients, families and communities. The National Practice Standards for the Mental Health Workforce 2013 (the practice standards) outline core competencies (including cultural competence) regarded as essential for the mental health workforce: mental health nursing, occupational therapy, psychiatry, psychology and social work. The documented impact of these disciplines/professions on Aboriginal people requires new ways of working that are empowering, respectful and ethical. A case is made for the importance of practitioners providing more culturally inclusive and appropriate care to increase the likelihood that clients and their carers will experience a sense of cultural safety (as well as culturally appropriate services) for Aboriginal clients, their families and communities. The practice standards are complemented by professional guidelines and the National Standards for Mental Health Services 2010 (the service standards). This chapter provides a range of tools and strategies and a Critical Reflection Framework for Analysis to assist students or practitioners to adopt a critical standpoint in order to develop key competencies (knowledge, skills, attitudes and values) to be culturally respectful and effective in their practice in Aboriginal and Torres Strait Islander mental health. Equally important is the need for strategies for self-care and support such as mentoring, journaling, peer support, counselling and engaging in self-reflective, transformative practice.&nbsp

IMPROVING PHYSICAL LITERACY IN MIDDLE SCHOOL INDIGENOUS AND NON-INDIGENOUS STUDENTS

Physical activity levels in Canadian youth are decreasing. This Organizational Improvement Plan (OIP) focuses on improving physical literacy in middle school Indigenous and non-Indigenous students in a Northern Ontario urban school. The Daily Physical Activity (DPA) policy in Ontario public elementary schools has achieved about 50% fidelity in classrooms since its inception in 2005 (Allison, et al., 2016; Ontario Agency for Health Protection and Promotion, 2015, p. 60). Leading a physically active lifestyle is essential for education outcomes, public health, and general health and wellbeing. Improving physical literacy in youth increases their motivation to be physically active, and through a Quality Daily Physical Education (QDPE) program, can also increase student achievement significantly (Dudley, 2019, October 8; PHE, 2020). Students engaged in physical education programming where learning is prioritized are more motivated to learn across all subjects (Dudley, 2018). From a public health perspective, the urgency for Canadians to become more active has never been more critical. The rate of non-communicated diseases (NCDs) can be reduced significantly by meeting the Canadian Society for Exercise Physiology (CSEP) physical activity guidelines. At the current rate, 50% of non-Indigenous and 80% of Indigenous youth will develop diabetes in their lifetime (Diabetes Canada, 2018). Currently, only 35% of five to seventeen-year-olds, and under 16% of 18-79 year-olds, are meeting CSEP’s physical activity guidelines (ParticipACTION, 2018). This OIP explores how a culturally responsive framework along with community connections are essential in improving physical literacy in middle school Indigenous and non-Indigenous students. Developing physically literate youth is essential for the future of our youth, education system, and public healthcare

What was the impact of a participatory research project in Australian Indigenous primary healthcare services? Applying a comprehensive framework for assessing translational health research to Lessons for the Best

Objectives To (1) apply the Framework to Assess the Impact from Translational health research (FAIT) to Lessons from the Best to Better the Rest (LFTB), (2) report on impacts from LFTB and (3) assess the feasibility and outcomes from a retrospective application of FAIT. Setting Three Indigenous primary healthcare (PHC) centres in the Northern Territory, Australia; project coordinating centre distributed between Townsville, Darwin and Cairns and the broader LFTB learning community across Australia. Participants LFTB research team and one representative from each PHC centre. Primary and secondary outcome measures Impact reported as (1) quantitative metrics within domains of benefit using a modified Payback Framework, (2) a cost-consequence analysis given a return on investment was not appropriate and (3) a narrative incorporating qualitative evidence of impact. Data were gathered through in-depth stakeholder interviews and a review of project documentation, outputs and relevant websites. Results LFTB contributed to knowledge advancement in Indigenous PHC service delivery; enhanced existing capacity of health centre staff, researchers and health service users; enhanced supportive networks for quality improvement; and used a strengths-based approach highly valued by health centres. LFTB also leveraged between $A1.4 and$A1.6 million for the subsequent Leveraging Effective Ambulatory Practice (LEAP) Project to apply LFTB learnings to resource development and creation of a learning community to empower striving PHC centres. Conclusion Retrospective application of FAIT to LFTB, although not ideal, was feasible. Prospective application would have allowed Indigenous community perspectives to be included. Greater appreciation of the full benefit of LFTB including a measure of return on investment will be possible when LEAP is complete. Future assessments of impact need to account for the limitations of fully capturing impact when intermediate/final impacts have not yet been realised and capture

Going against the flow: a sociotechnical network analysis of endemic acute rheumatic fever and rheumatic heart disease in remote indigenous communities of Australia

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are autoimmune conditions caused by Group A Streptococcus (Group A Strep) infections. ARF/RHD are mostly eradicated from the Global North yet are endemic in many remote Aboriginal and Torres Strait Islander communities of Australia. The risk factors for ARF/RHD are similar to the material conditions of poverty, including overcrowded housing and poor access to health services. Despite extensive interventions, surveillance, and evaluation of these conditions over many years, an entrenched experience of illness persists due to a complex array of social, material, political, cultural, and economic factors. Using actor network theory (ANT) as a primary analytical lens I will examine processes leading to the current socio-technical network conformation of ongoing ARF/RHD. I focus on three nodes, each centring on a different element of this network: firstly, benzylpenicillin G (BPG) antibiotics used for prevention, secondly, echocardiograms (ECGs) used for diagnosis and screening, and finally, Group A Strep vaccines that are yet to be developed into a useable product. For each node I analyse the scientific, policy, and sociological literature by mapping and tracing associated human and non-human elements and considering how their configurations have changed over time. Further, I explore the contingent ways in which these nodes have become important elements in temporarily stabilised network conformations. Despite the persistent and embedded presence of ARF/RHD in remote Indigenous communities for many decades, the dynamic nature of the network reveals that this is not an inevitable inequality. Rather, there is vast potential for socially just change through local Indigenous-led approaches to holistic healthcare

Common Insights, Differing Methodologies: Towards a Fusion of Indigenous Methodologies, Participatory Action Research, and White Studies in an Urban Aboriginal Research Agenda

In this paper we discuss three broad research approaches: Indigenous Methodologies, Participatory Action Research, and White Studies. We suggest that a fusion of these three approaches can be useful, especially in terms of collaborative work with Indigenous communities. More specifically, we argue that using Indigenous Methodologies and Participatory Action Research, but refocusing the object of inquiry directly and specifically on the institutions and structures that Indigenous peoples face, can be a particularly effective way of transforming Indigenous peoples from the objects of inquiry to its authors. A case study focused on the development of appropriate research methods for a collaborative project with the Urban Aboriginal communities of the Okanagan Valley in BC, Canada, provides an illustration of the methodological fusion we propose

Aboriginal women's visions of breast cancer survivorship : intersections of race(ism)/class/gender and "...diversity as we define it"

This dissertation combines the empowering methodology of photovoice with focus groups and in-depth interviews, to develop a contextual understanding of the meaning of breast cancer for Aboriginal women. Photovoice is a participatory action research method, as well as a process towards health promotion. The participants in this study took pictures to document their realities and engaged in critical reflection individually and in a group process, using images and stories to advocate community and policy changes. A combination of epidemiological, sociological, and anti-oppressive theoretical lenses were used to analyze the women’s stories and data, which served to acknowledge heterogeneity, while integrating multiple social contexts. The emerging framework revealed multi-faceted identities, commonalities of situation, and prominent social forces that affect identity and cancer experience. Interpretation of the women’s stories and pictures resulted in four general themes: 1) adjusting to physical and psychological changes; 2) the need for culturally relevant sources of support; 3) shifting identities; and 4) personal and political advocacy/policy directions. Prominent social forces include: culturally derived meanings of identity and sexuality, cultural and historical experiences/traditions of Aboriginal peoples, racism and racial stigmas, and socio-economic inequalities. Breast cancer experiences are shown to be significantly linked to history and the impact of colonization and neo-colonialism. Findings also point to the importance of recognizing heterogeneity, which does not minimize the impact of colonial histories and oppression, but points to the importance of employing an anti-oppressive theoretical lens and research framework, able to handle complex intersecting social forces and multiple agencies. These findings provide support for using the photovoice methodology with Aboriginal women, especially for its ability to shift power from researchers to insiders, privilege Indigenous knowledges, and for providing opportunities for critical and multiple tellings. The dissertation concludes by introducing a governmentality lens, which questions whether photovoice methods can address the social and historical problems at the level of policy. This study directs our attention to the need for further research on: 1) the link between breast cancer experiences to historical, political, and social contexts of lives of Aboriginal peoples; and 2) the potential of photovoice methods to affect policy and social justice

Understanding the Cultural Utility of Mainstream Addiction Recovery Mutual Support Groups for Indigenous Peoples’: A Case Study of SMART Recovery through an Indigenous Australian Lens

Background: Mutual support groups are one of the world’s most commonly used forms of addiction recovery support. Participation has been associated with reduced substance use and abstinence. There is, however, limited empirical understanding of how suitable or beneficial group participation is for Indigenous peoples in similarly colonised countries (Australia, New Zealand, Canada, United States of America, Hawaii). This thesis aims to improve our understanding of the cultural utility of mainstream addiction recovery mutual support group programmes for Indigenous peoples. The SMART Recovery programme will be used as a case study with Indigenous Australia as a cultural milieu. Methods: This thesis presents findings from three published empirical studies. In Study 1: a PRISMA-informed systematic literature review was performed to determine the number, nature, and scope of internationally available evidence on Indigenous people’s experiences of and outcomes associated with attending mutual support groups. Study 2: used an Indigenous-lensed multi-methods research design to explore: 1) How Indigenous Australian facilitators (n=10) and group members (n=11) experience SMART Recovery and utilise it as a recovery resource; and 2) If the SMART Recovery programme components and operational process are culturally suitable and helpful. In Study 3: a three-round Delphi synthesised with Indigenous research methods was conducted to: 1) Obtain expert opinion on the cultural utility of the Indigenous SMART Recovery handbook; 2) Gain consensus on areas in the SMART Recovery programme that require cultural modification; and 3) Seek advice on how modifications could be implemented in future programme design and delivery. Results: Study 1 revealed a paucity of empirical knowledge on the acceptability and outcomes of addiction recovery mutual support groups for Indigenous peoples of Australia, New Zealand, Canada, United States of America and Hawaii. Study 2 offers first insights into how Indigenous peoples in Australia perceive and use SMART Recovery. Based on their experiences, a range of culturally informed programme modifications were suggested to enhance its cultural utility. Study 3 confirmed that cultural modifications are needed to enhance the cultural utility of SMART Recovery for Indigenous Australian contexts. An expert panel reached consensus on five key programme modifications and developed a set of strategies to help SMART Recovery integrate these into future programme planning and design. Study 2 and 3 also demonstrated the promise of two innovative research methodologies that could be used to involve Indigenous peoples in the design and evaluation of mainstream mutual support group programmes without added burden to personal, community and/or professional obligations. Conclusions: This thesis presents the first series of studies to investigate the cultural utility of mainstream mutual support groups for Indigenous peoples. Findings suggest that culturally appropriate language, culture-based programme activities and less rigid group delivery formats would enhance suitability and helpfulness of existing programmes as a recovery resource for Indigenous peoples. Thesis findings have implications for future planning and development of SMART Recovery and other mutual support groups like 12-steps programmes. There is an urgent need to extend this research to Indigenous peoples of New Zealand, Canada, United States of America, and Hawaii – whose perspectives are not yet documented in the peer-reviewed mutual support group literature

Transformative Learning and Cultural Capabilities: Understanding Factors Associated with Student Preparedness to Work with Indigenous People in Health Settings

Indigenous Studies health curriculum has the potential to transform attitudes, behaviours and beliefs of non-Indigenous Australian students. This mixed methods research comprising five publications, and framed by Mezirow’s transformative learning theory, explored the pedagogical, personal and contextual factors of this complex learning environment. Findings support transformative learning experiences as a mechanism for changing attitudes and increasing preparedness to work in Indigenous health settings, with implications for future Indigenous Studies curriculum and educator development