What does the “third space” mean to you as a health professional? Eileen Tan Lisa Molony Kate Brazzale

Acknowledgment of country We respectfully acknowledge the past and present traditional owners of this land on which we are meeting, the Noongar people. It is a privilege to be standing on Noongar country.

Introduction Why should health professionals be aware of the "third space"? What should health professionals take into account when looking after Aboriginal and Torres Strait Islander patients? Why are cultural implications important for health professionals to take into consideration? Introduce group Introduce topic Introduce focus questions

Importance of identity What does it mean to be Aboriginal? "An Aboriginal or Torres Strait Islander is a person: of Aboriginal or Torres Strait Islander descent who identifies as an Aboriginal or Torres Strait Islander and is accepted as such by the community in which he (she) lives.“ What does your identity mean to you? This is called the 'three-part' definition of Aboriginal identity and is used by all Commonwealth departments [2]. And is a the ‘white authority’ way of identifying Aboriginal people. “The very fabric of what it means to be Aboriginal [is] that being, living and breathing the journey, walking the land as proud Aboriginal people, knowing the importance of being respectful within our community and wanting with all your heart and ability to make positive change”. —Paul Ralph, CEO KARI Aboriginal Resources Inc [38]

Culture shock Culture shock: the tension and anxiety, combined with feelings of isolation, sensations of loss, confusion and powerlessness, associated with entering a new culture. When we move to a new culture, we take with us the values, beliefs, customs and behaviours of our old culture. Depending on how similar this new culture is to our own, our beliefs, customs, values and behaviours may clash with those encountered in the new environment. A loss of familiar signs and symbols, such as words, gestures, facial expressions, customs or norms, can result in confusion, disorientation, misunderstandings, stress and anxiety. For example giving the thumbs up in Australia generally means ‘job well done’, giving the thumbs up in the middle east is the equivelant of raising the middle finger, meaning ‘sit on it and swivel’. Likewise, if you were talking to someone and they turned their head away from you, you would think they were being rather rude. However in some cultures, people turn their eyes away from you so that their ‘best ear’ is facing you…which makes more sense when you think about it. - Culture shock can be very destructive and undermines the ability of dominant culture to satisfactorily perform their professional tasks. The Aboriginal community is left to cope with the fall-out from the culture shock suffered by the dominant culture.

Aboriginal terms of reference A way to determine Indigenous viewpoints on issues within an Indigenous context. Core values include: The worth and validity of contemporary Indigenous cultures The right of expression of Indigenous realities Self-determination and self-management Positive social change Social justice The recognition and acceptance of Indigenous diversity Reconciliation of contending issues between Indigenous people The worth of the group

the third space

How third space to the health industry? “WA Health Is dedicated to working with the Australian Department of Health and Aboriginal communities in building new partnership for services provided; developing culturally appropriate Health services and providing safe, high equality and accountable Health service to the Aboriginal community” (Health Reform Implementation taskforce, 2007). Indigenous and Health professions has a variety of differences that are met and respected together as one. Cultural belief Views and Values Expectations Traditions Historical factors Family structure

Conceptual framework that includes the four dimension

How third space applies to the health industry? It is the space for the four dimensions to be met between the Aboriginal and non- aboriginal domain. Experiences Concentrates on the experience of Aboriginals in relation to the issue under discussion. Aspiration Concentrates on what the critical reference group wants to achieve in relation to the issue. Understanding Focuses on the persons understanding of the issue; as well as judging if further explanation is needed. Cultural element It draws on cultural differences and traditions which includes current culture practices.

Challenges for health professionals Communicating among the aboriginals Understanding their traditions and beliefs Traditional healing where some professions might disagree on Not being able to achieve the outcome until a certain level of trust has been created Obtaining informed consent for treatment Explaining diagnosis and treatment to patients

health professions and aboriginal may clash in a health environment Communication and language issues Poor cultural understanding Racism and prejudice Values and beliefs Mistrust of the system

Operating within the third space Advantages Disadvantages Access to higher quality services Culturally secure services that will improve health outcome for Aboriginal people Improve customer satisfaction Provide opportunity to improve the broader determinants of health

Aboriginal Health Statistics Life expectancies of Indigenous versus Non- Indigenous Males and Females. On average Indigenous Men die 11 years earlier then Non- Indigenous Males Indigenous Females die 9 years earlier then Non-Indigenous Females. Data from the Australian Bureau of Statistics 2005-2007 data surveys.

Aboriginal Health Statistics Health complication Comparative incidence rate Comment Circulatory system 2 to 10-fold 5 to 10-fold increase in rheumatic heart disease and hypertensive disease, 2-fold increase in other heart disease, 3-fold increase in death from circulatory system disorders. Circulatory system diseases account for 24% deaths. Renal failure 2 to 3-fold 2 to 3-fold increase in listing on the dialysis and transplant registry, up to 30-fold increase in end stage renal disease, 8-fold increase in death rates from renal failure, 2.5% of total deaths. Communicable 10 to 70-fold 10-fold increase in tuberculosis, Hepatitis B and Hepatitis C virus, 20-fold increase in Chlamydia, 40-fold increase in Shigellosis and Syphilis, 70-fold increase in Gonococcal infections. Diabetes 3 to 4-fold 11% incidence of Type 2 Diabetes in Indigenous Australians, 3% in non-Indigenous population. 18% of total deaths. Cot death Over the period 1999–2003, in Queensland, Western Australia, South Australia and the Northern Territory, the national cot death rate for infants was three times the rate of Non-Indigenous. Mental health 2 to 5-fold 5-fold increase in drug-induced mental disorders, 2-fold increase in diseases such as schizophrenia, 2 to 3-fold increase in suicide. Optometry/ Ophthalmology 2-fold A 2-fold increase in cataracts. Neoplasms (Tumour) 60% increase in death rate 60% increased death rate from neoplasms. In 1999–2003, neoplasms accounted for 17% of all deaths. Respiratory 3 to 4-fold increased death rate from respiratory disease accounting for 8% of total deaths.

Aboriginal Health Statistics

Aboriginal Health Statistics Selected Chronic Conditions: Ratio of Indigenous Australian’s to Non-Indigenous Australians — 2004–05

Aboriginal Health Statistics Diabetes Comparison between Indigenous and Non Indigenous 2005 Cardiovascular Comparison between Indigenous and Non Indigenous 2005

Aboriginal Health Statistics

Implications for Health Professionals Third Space “A place where Indigenous and Non-Indigenous people can come and work together without fear of prejudice from ‘baggage’.” An area of mutual respect between Indigenous and Non-Indigenous people where they can work collaboratively. Health Professionals need Knowledge. Of where the other comes from; their “space” Understanding Of roles and responsibilities Empathy Towards both sides Willingness to be open Accepting of differences Avoid stereotyping

Implications for Health Professionals Aboriginal and Torres Strait Islanders are not the same. Discontinue use of out-dated, derogatory terminology. Half-caste, full-blood, quadroon, etc. Always use the terms Aboriginal Man/Woman/People or Torres Strait Islander Man/Woman/People. Aboriginal people mistrust people who offer services related to “protection” and “intervention. European colonisation. Government Policies post colonisation. The “Stolen Generation”. Government policy til 1969. “Keep your word.” Changes made. e.g. Kevin Rudd’s “Apology”. NSW Department of Community Services 2009 & National Disability Services WA 2009

Implications for Health Professionals Sensitive issues due to past Government policies have contributed to: Dispossession of land Family fragmentation Mental health issues Social and emotional wellbeing issues Grief and loss issues Self-harm and intentional injury Over-representation of Suicide rates Family and domestic violence issues Loss of country Loss of identity Poverty Racism Unemployment Poor health outcomes Poor education outcomes Below standard literacy and numeracy rates Alcohol and substance abuse/misuse Over-representation in the juvenile and criminal justice system NSW Department of Community Services 2009 & National Disability Services WA 2009

Implications for Health Professionals Respect Elders, The Land, Animals, Ancestors. “Sorry Business” Kinship Defines roles and responsibilities within the family. Ensure that extended family is included in important meetings or when making decisions. Gender responsibilities. Men’s Business – issues which have a male perspective within aboriginal culture. Women’s Business – issues which have a female perspective within aboriginal culture. NSW Department of Community Services 2009 & National Disability Services WA 2009

Implications for Health Professionals Language Originally 300 nations speaking 250 languages with up to 600 dialects. Nonverbal cues Eye contact. Hand and facial gestures. Silence Progression of Conversation. Semantic Ambiguity Swearing Communication Techniques Use uncomplicated language, Not “jargon”. Be wary of comprehension NSW Department of Community Services 2009 & National Disability Services WA 2009

Close the Gap Campaign Australia’s largest Campaign to improve Indigenous Health. Aimed at reduced the Life Expectancy Gap between Indigenous and Non Indigenous Australians to 0 years by 2031. OXFAM is campaigning to: Increase Aboriginal and Torres Strait Islanders’ access to health services Address critical social issues such as poor housing, nutrition, employment and education Build Indigenous control and participation in the delivery of health and other services Get governments at state and national level to work in partnership with Indigenous communities, health organisations and experts to develop and monitor a plan to tackle the Indigenous health crisis Promote real and meaningful partnerships between Indigenous COAG, 2011 and OXFAM 2006

Need for Education To understand the needs of our Aboriginal or Torres Strait Islander Patients The majority of Aboriginal people access health care from Non-Aboriginal services. Downing and Kowal 2011 Majority of Nurses interviewed felt that didn’t receive enough cultural training to look after Aboriginal and Torres Strait Islander patients They felt that they weren't giving them the level of care the needed and deserved. Canada’s Approach Kilpatrick, 2004 Looked at the need for Aboriginal Education.

Focus Question.

References