In Australia, there has been increasing recognition that improving cultural safety for Aboriginal and Torres Strait Islander health care users can improve their access to health care and the quality of the health care they receive (AHMAC 2016). This in turn is likely to improve health outcomes and help to address gaps in health and wellbeing between Indigenous and non-Indigenous Australians. See Indigenous health and wellbeing.

The National Aboriginal and Torres Strait Islander Health Plan 2013–23 describes a vision for the Australian health system that is culturally safe, free of racism and inequality and one where all Aboriginal and Torres Strait Islander people have access to health services that are effective, high-quality, appropriate and affordable (Department of Health 2013).

Defining cultural safety

In Australian research there are various definitions of cultural safety and what it means in relation to the provision of health care.

The Cultural Respect Framework 2016–26 defines cultural safety as: ‘not [being] defined by the health professional, but is defined by the health consumer’s experience—the individual’s experience of care they are given, ability to access services and to raise concerns’.

The framework outlines the essential features of cultural safety, including:

  • an understanding of one’s culture
  • an acknowledgement of difference, and a requirement that caregivers are actively mindful and respectful of difference(s)
  • it is informed by a theory of power relations
  • an appreciation of the historical context of colonisation, the practices of racism at individual and institutional levels, and their impact on First Nations people’s living and wellbeing, both in the present and past (AHMAC 2016).

How is cultural safety measured?

The AIHW developed the Cultural Safety in Health Care for Indigenous Australians: Monitoring Framework to bring together available data to assess progress in achieving cultural safety in health care for Aboriginal and Torres Strait Islander people (AIHW 2019a).

The framework has 3 reporting modules which each include measures focusing on culturally respectful health care services, patient experience of health care among Indigenous people, and access to health care as an indirect measure of cultural safety. It presents measures from national, state and regional data sources where possible.

Module 1
Culturally respectful health care services

Module 2
Patient experience of health care

Module 3
Access to health care services

How health care is delivered and whether systems and providers are aware and responsive to Indigenous Australians’ cultural perspectives.

Informed by the Cultural Respect Framework for Aboriginal and Torres Strait Islander Health.

Indigenous Australians’ experiences of health care, and is not defined by the caregiver.

Based on a literature review and research on Indigenous Australians’ views on cultural safety.

Access to health care services as a way of indirectly assessing cultural safety, though disparities may be due to a range of factors, such as availability or affordability.

Relates to different levels of the health system—preventative health services; primary health care; hospital and specialist services.

Health care services

The cultural safety of Aboriginal and Torres Strait Islander health care users cannot be improved in isolation from the provision of health care, and the extent to which health care systems and providers are aware of and responsive to Indigenous Australians’ perspectives. The structures, policies and processes across the health system all play a role in delivering culturally respectful health care. Aspects of the provision of culturally safe health care include organisational commitments to provide culturally safe care, appropriate communication and services, Indigenous workforce development and training, client and community feedback and collaboration with Indigenous organisations.

Most of the available data for this module relate to Aboriginal and Torres Strait Islander-specific primary health care services. Monitoring cultural safety and cultural respect directly in the health system are limited by a lack of measures in national and state level data (AIHW 2017 unpublished; DHHS 2016). This is particularly the case in relation to reporting on the policies and practices of mainstream health services, such as primary health care services and hospitals.

Selected results from the available data show that:

  • 95% of Indigenous primary health care providers had a formal commitment to provide culturally safe health care in 2017–18 (AIHW analysis of Online Services Reports data 2012-13 to 2017-18).
  • 363 Indigenous medical practitioners (0.4% of all employed medical practitioners) were employed in Australia in 2017—an increase from 234 in 2013 (AIHW 2019b).
  • 3,540 Indigenous nurses and midwives (1.1% of all employed nurses and midwives) were employed in Australia in 2017—an increase from 2,434 in 2013 (AIHW 2019b).
  • 4 in 10 (40%) Indigenous primary health care providers provided interpreter services to Indigenous Australians in 2017–18 (AIHW analysis of Online Services Reports data 2012-13 to 2017-18).

Patient experience

The experiences of Indigenous Australian health care users, including having their cultural identity respected, is critical for assessing cultural safety. Aspects of cultural safety include clear and respectful communication, respectful treatment, the inclusion of family members and empowerment in decision making. ‘Take own leave’, where Indigenous patients left against medical advice or were discharged at their own risk, is also measured as it may be linked to feelings of cultural safety.

Most jurisdictions undertake surveys about patients’ experiences in public hospitals, but there is little available data on Indigenous Australians’ patient experience. A high proportion of Indigenous Australians use mainstream health services, so further data developments in this area are required to allow for more comprehensive reporting across the health sector. Selected results from the latest available data show that:

  • an estimated 89% of Indigenous adults in non-remote areas who consulted a doctor in the previous 12 months said that their doctor always/usually listened (in 2018–19) (AIHW analysis of NATSIHS 2018–19)
  • an estimated 91% of Indigenous adults in non-remote areas who consulted a doctor in the previous 12 months reported their doctor always/usually showed respect for what was said (in 2018–19) (AIHW analysis of NATSIHS 2018–19).
  • the rate of Indigenous patients who left against medical advice or were discharged at their own risk ranged from less than 1% of Indigenous patients hospitalised in Tasmania to 9% in the Northern Territory (in 2015–17) (AIHW 2020, forthcoming).

See Patient experience of health care.

Access

Indigenous Australians experience poorer health than non-Indigenous Australians, but they do not always have the same level of access to health services. Disparities in access may be due to factors such as remoteness, affordability and a lack of cultural safety.

Selected measures of access to health care services for Indigenous and non-Indigenous Australians are used to monitor disparities in access. These include: immunisation rates, breast cancer screening, Indigenous health checks, access to antenatal care, potentially preventable hospitalisations, access to hospital procedures, elective surgery and emergency department waiting times, claims for MBS specialist services, treatment of end-stage kidney disease, and potentially avoidable deaths. The data provide overall measures of access, but do not include information on all the factors that can affect access. Selected results from available data show that:

  • BreastScreen participation rates for the 2-year period 2017–2018 for Indigenous women aged 40 and over were 25% compared with 34% for non-Indigenous women (AIHW 2020, forthcoming)
  • Indigenous Australians waited longer to be admitted for elective surgery in 2017–18 than non-Indigenous Australians (median waiting time of 48 days and 40 days, respectively) (AIHW 2018)
  • in 2016–17, the rate of potentially preventable hospitalisations (PPH) for Indigenous Australians was nearly 3 times the rate for non-Indigenous Australians (70 and 26 per 1,000, respectively) (AIHW 2020, forthcoming).

See Indigenous Australians’ use of health services and ‘Potentially preventable hospitalisations: an opportunity for greater exploration of health inequity‘ in Australia’s health 2020: data insights.

Where do I go for more information?

For more information on culturally safe health care for Indigenous Australians, see:

Visit Indigenous Australians for more on this topic.

References

AHMAC (Australian Health Ministers’ Advisory Council) 2016. Cultural Respect Framework 2016–26 for Aboriginal and Torres Strait Islander health: a national approach to building a culturally respectful health system. Canberra: AHMAC.

AIHW (Australian Institute of Health and Welfare) 2017, unpublished. Development of cultural safety measures. Report to the Department of Health, October 2017.

AIHW 2018. Elective surgery waiting times 2017–18: Australian hospital statistics. Health services series no. 88. Cat. no. HSE 215. Canberra: AIHW.

AIHW 2019a. Cultural Safety in Health Care for Indigenous Australians: Monitoring Framework. Cat. no. IHW 222. Canberra: AIHW. 

AIHW 2019b. National Health Workforce Data Set. Findings based on unit record data. Canberra: AIHW.

AIHW 2020, forthcoming. Aboriginal and Torres Strait Islander Health Performance Framework report 2020. Canberra: AIHW.

Department of Health 2013. National Aboriginal and Torres Strait Islander Health Plan 2013–2023. Australian Government.

DHHS (Department of Health and Human Services Victoria) 2016. Improving cultural responsiveness of Victorian hospitals: final report.  Victoria: DHHS.