FPA Health (also known as Family Planning NSW) is a non-government organisation which specialises in providing practice-based reproductive and sexual health services to the people of New South Wales (NSW), Australia. As a priority it seeks to provide state-wide services to the rural community. Within this brief is the challenge of providing appropriate and sustainable clinical and health promotion services to the Aboriginal community.
The genesis of this article was the experience of working with Aboriginal Community Liaison Workers (ACLW) in this reproductive and sexual (mainly women's) health setting. As Coordinator of Medical Services and Manager of FPA Health's rural centre at Dubbo in western New South Wales, it was the author's role to set up and run the clinical service and health promotion programs.
The primary aim of this article is to share the learning and knowledge gained in managing two projects in which an ACLW was employed. It also aims to illustrate the role and value of utilising a community liaison worker within a mainstream health service. The beneficial outcomes include improving service provision to Aboriginal women and adding to community knowledge about reproductive and sexual health issues. As an introduction to this subject, there is a brief description of the barriers identified in the literature which make it difficult or impossible for Aboriginal women to take part in preventive health care programs, as well as potential activities to improve participation.
FPA Health projects employing Aboriginal community liaison workers
In 2002 the opportunity arose to take part in the first of the two projects, this was a collaboration with the Dubbo/Plains Division of General Practice, Macquarie Area Health Service and the Royal Australian College of General Practitioners (RACGP) Aboriginal and Torres Strait Islander Women's Project1. This project aimed to identify and reduce barriers to Aboriginal and Torres Strait Islander women's uptake of cervical and breast screening programs by improving access to GPs. It was designed to include clinical and health promotion components and the active engagement of Aboriginal Health Workers as consultants and facilitators. A primary objective was to investigate the best way to provide preventive health care for the women in each of three separate communities (rural, regional and metropolitan) and to evaluate the success of the model. The site managed by FPA Health was located in Coonamble in northwestern NSW. The other sites were in Mackay, Queensland and Adelaide, South Australia.
The second project was supported by funding from the Rio Tinto Aboriginal Foundation (RTAF) and was conceived of as a direct result of the outcomes from Coonamble. It aimed to improve reproductive and sexual health literacy for young Aboriginal women in the Macquarie region of NSW (based in Dubbo) by providing a well women's clinic and community health promotion activities, including a structured health literacy component.
Barriers to accessing mainstream health services for Aboriginal women in Australia
An extensive literature review had been conducted as part of the RACGP Women's Aboriginal & Torres Strait Islander Project to examine the research identifying barriers to the access of health care for Indigenous women. A further review was conducted by FPA Health to identify local issues. There were significant disincentives for women to access main stream services1-4. The barriers included3-8:
- culturally inappropriate services
- cost of services
- poor access to transport (in many rural areas there is no public transport)
- lack of awareness of existing services.
Furthermore, in the sensitive area of reproductive and sexual health, shame, embarrassment and a preference for a female provider, as well as a desire to have an Indigenous 'point of contact' or Indigenous service provider were issues raised as reasons not to take part in preventive health care2,3,7,8. In discussions with community women prior to commencing both the Coonamble and Dubbo projects, it also became clear that there had been a lack of appropriate health promotion activities to educate women about the importance of preventive health care.
Strategies that could improve access to main stream health services for Aboriginal women in Australia
Activities that could potentially break down the barriers to access were also identified from the literature.
Employment of Aboriginal staff: A consultative project that looked specifically at overcoming barriers to Aboriginal patients accessing general practices in central western NSW5 identified the employment of Aboriginal staff as an important strategy to improve access for Aboriginal people. This indicates that the service is 'Aboriginal friendly' and, thus, provides a culturally appropriate point of contact for Aboriginal patients.
Cross cultural training: Other strategies identified in the literature for improving Indigenous health care by mainstream services include support and cross-cultural training, the identification of an Aboriginal mentor, visits to Aboriginal community centres and language training1-4,6-8. Ideally, clinicians and medical practice staff should all undergo local cultural awareness training. However, this is only a starting point and staff should engage in an on-going two-way learning process with their Aboriginal colleagues and clients.
Cultural liaison: When working with Aboriginal women it is important to gain an understanding of family and family commitments, the important role of the local elders, the subtleties of women relating to women and the concept of 'women's business'2,3,7. It is virtually impossible to negotiate this complex matrix without a mentor or cultural broker.
Working with key community members
The literature also refers to the importance of key members of the Indigenous community1,4,7,9,. These include elders, AHWs, aunts and grandmothers5,8,9. In the report, Aboriginal and Torres Strait Islander Sexual Health Promotion Initiatives in NSW9, the importance of engaging key community members, especially elders was identified as vital to the success or failure of program initiatives. The extended family is also a crucial influence for Indigenous women's uptake of preventive health care. In an article examining why Western Australian Aboriginal women participated in cervical screening, it was stated that their participation may be quite unrelated to having made an informed choice to have a Pap test: 'These [reasons] included the woman's liking and respect for the practitioner offering the smear and encouragement by kin (sister, grandmother, aunt) to do so'11.
Why an Aboriginal Community Liaison Worker?
Consultation with Aboriginal healthcare providers and the community
In both projects the planned activities were designed to break down the barriers identified in the literature. Interestingly, we found that these were the same barriers identified by the communities themselves. In both cases, the community identified the critical importance of the employment of an Aboriginal worker who could be an effective advocate and cultural broker as part of the primary-care team. The active engagement of these workers in the projects became the principal strategy for the successful participation of the communities. A vital part of both the development and implementation of the proposed activities and the recruitment of the Aboriginal worker was on-going consultation and collaboration with the local Aboriginal healthcare providers and the community.
Coonamble: A key strategy of the national RACGP-designed project was collaboration with the local Aboriginal Medical Service (AMS) and the utilisation of their Aboriginal Health Workers (AHWs). The AHW is trained to provide health information and services to the Aboriginal community and is a vital member of the primary healthcare team in Aboriginal Community Controlled Health Services (ACCHS) such as AMS, as well as in mainstream health-service provision. AHWs, apart from their health provider skills, are also recognised 'cultural brokers' and act as mediators between the Aboriginal community and mainstream services 2,6,9,10,. Unfortunately, trained AHWs are not always available; there was an AMS Committee in Coonamble but an AMS had not been established and there was no AHW available for the project.
An alternative solution to this problem was resolved by the AMS Committee and key members of the local community. The solution proposed by this group to provide the all important link between the mainstream service (FPA Health) and the women of the local Aboriginal community was to identify a woman in the community who would fulfil the role of liaison worker.
This problem solving attitude is a testament to the persistence of the AMS Committee in Coonamble, who recognised the importance of cervical and breast cancer screening for the women in their community. They were determined to take the opportunity to see if the project would result in improvement in both women's uptake of preventive care and access to services. Their proposal to employ an Aboriginal Community Liaison Worker (ACLW) was accepted and a position description written according to the needs of the role.
Dubbo: In the second project, in the absence of an easily accessible women's consultative group, an Aboriginal Women's Advisory Group was formed by FPA Health with a broad membership across the Dubbo Aboriginal community. This group included the Chief Executive Officer of the local AMS, the AHW for the sexual health service and key community women. As a result of consultation with this group a recruitment process for an ACLW was developed. Because Dubbo is a much larger and more diverse community than Coonamble, it was important to find a worker who would be acceptable to a number of different local Aboriginal groups and have the necessary skill base. The skills that were identified as vital by the Aboriginal Women's Advisory Group included:
- a close knowledge of the local Aboriginal community
- good oral communication skills
- a commitment to confidentiality
- enjoyment of working in a team
- a desire to learn new skills.
It was interesting to hear a number of women comment during the consultative process, that AHWs were less visible in the community than in the past and were, at times, difficult to access as a result. They favoured the idea of engaging an appropriate community member who would be visible and easy to access in the community and who could undertake training later if required.
In the National Review of Aboriginal and Torres Strait Islander Health Worker Training12, it was interesting to note the following comment on AHWs and formal certification:
Employers also appear to be recruiting Aboriginal Health Workers with more formal qualifications from educational institutions and are placing less emphasis on the Aboriginal Health Workers' status within the community or their experience and/or age13.
Many individuals consider that the current recruitment trends are removing the processes from the community context and community authority, giving greater management of Aboriginal Health Workers to external controls by other professional and registration bodies14.
What are the characteristics of an Aboriginal community liaison worker?
Skills and background
To work effectively with the local Aboriginal community, the person providing the liaison must be acceptable to the members of the Indigenous community: the elders, the Aboriginal services and other prominent social figures. The liaison person may or may not be a member of the traditional people of the area, but must be an accepted by the traditional people as a community member, and must also be able to work with other people in the community.
Training and formal qualifications
Discussion with the advisory group in Dubbo about the desirability of formal qualifications for the worker indicated that this was not a prerequisite, and that communication skills and the ability to work across disparate groups was more important. There was discussion that the opportunity to undertake training was important, but that the worker should decide on that and do so at her own pace. A general grasp of the concept of a preventive service was considered useful but, again, not vital.
The first ACLW employed by FPA Health stated categorically that she did not want to learn about health issues, because she felt that both the employer and clients would burden her with unwanted responsibility, and that in a small town she would know too much of other people's 'business'. The background to this request was that in the past she had been approached by a general medical service to act as a liaison worker and had been asked to take on far more responsibility for health care than she considered safe or ethical.
In the role that she undertook for us as community liaison worker, she said that she was very happy with the level of responsibility required. Over time the worker found that, in spite of her intention not to become involved in training, she developed an interest in and knowledge about reproductive and sexual health issues that she felt to be empowering.
ACLW position description
The responsibilities of the employee at FPA Health included:
- making appointments, supporting and transporting Aboriginal women to the FPA Health clinic
- assisting with reminder and recall for the follow up of clients
- helping to organise suitable community activities, which may include group sessions, one-on-one education and recreational activities
- advising other members of the team on cross-cultural issues
- driving clients to and from health education sessions
- maintaining a list of contacts
- assisting in reviewing appropriate resources for use by clients and community.
In utilising an untrained community based worker in the projects conducted by FPA Health, we have moved outside the evidence base on the benefits of working with Indigenous health workers. On reviewing the literature the benefits from employing Indigenous health workers include:
- Improving the community's utilisation of health services and increasing the provision of both direct clinical and health promotion services to the community by increasing the health service's capacity to address the community's needs5,9,10,11.
- Apart from the implicit and instinctual belief many health workers have that working alongside the community is 'the way to go', there is ample evidence for the usefulness of working with the community of interest to improve health outcomes5,8,9,11,14.
- There may also be less identifiable gains. Utilising members of a community in work that may impact on that community in a significant way, may also build on 'personal and societal characteristics that can be mobilised into action for the good of the community'15, or increase community capacity.
While the literature provides us with important information about the capacity building benefits of working with Indigenous health workers and the community, can this be extrapolated to the utilisation of untrained liaison workers in the FPA Health managed projects in Coonamble and Dubbo?
What were the outcomes?
Has the employment of an ACLW contributed any quantifiable gains for the Aboriginal women of Coonamble and Dubbo and has there been any evidence of a building of community capacity in a sustainable way?
Coonamble: The project in Coonamble would not have had any meaningful health outcomes had it not been for the community involvement, and specifically the employment of the ACLW. The community had identified a need for a specific Aboriginal Well Women's Clinic and health information in the area of cervical screening, contraception and the transmission and prevention of sexually transmissible infections (STI).
There was a strongly pro-breast screen Aboriginal worker employed by the health service who had done a great job in improving the women's utilisation of Breastscreen. However, women were not accessing the local GPs, who were all male, nor the Women's Health Nurse for cervical screening for reasons such lack of transport, feeling embarrassed, shame and the lack of Aboriginal liaison in making an appointment. The area health service identified that fewer than 10 women had had a cervical screen in the previous year.
FPA Health provided a Well Women's Clinic staffed by a doctor and nurse once a month during the course of the project. All the appointments were made by the ACLW, who also transported women who had no access to transport, and followed up clients who needed referral or a further consultation.
FPA Health has a database for all clinic attendees and a recall system for abnormal Pap test results. All clinic visits and services provided are recorded. De-identified reports of attendance and trends for various services are reviewed quarterly. Demographic details are also collected, including clients' self-identify as being of Aboriginal or Torres Strait Islander origin.
During the course of the project (May to December 2002) the Well Women's Clinic saw 47 women in consultation and screened 33. In the screened women, four had never had a Pap test and eight had not had a Pap test for over 4 years. There were four abnormal Pap test results and two women had colposcopy and treatment. In addition contraception, STI and menopausal issues were discussed and managed.
The clinic service and health promotion messages were presented to women in meetings organised by the ACLW at the Land Council, Community Development Employment Project (CDEP), high school and other community settings. The meetings were conducted as an informal 'yarning' session. The first meeting at the Land Council was conducted prior to the first clinic session and introduced the doctor to the community. Appointments for the clinic were often made as a result of attending one of these sessions, but there were also referrals from the community midwives, the AHW and Aboriginal Health Education Officer employed by Macquarie Area Health Service and by 'word of mouth'.
A detailed evaluation of the RACGP Women's Aboriginal and Torres Strait Islander Project, Coonamble can be found in The RACGP Aboriginal and Torres Strait Islander Women's Project Evaluation Report1.
Although the ACLW was employed for a relatively short time, the local area health service became very interested in the model used and ultimately obtained funding to employ an ACLW. The Women's Health Service provided by the area health service has now employed their own worker, and the worker who was employed by FPA Health is still very active in a voluntary capacity in working to improve women's health. Indeed, in a recent community consultation about another project, which would potentially involve FPA Health and the Women's Health Service, both women were actively involved in determining the best interests of the women of the town.
Perhaps one of the most powerful effects this small project had was that of increasing the awareness of clinical staff at FPA Health about Aboriginal culture and 'women's business'. A new and growing interest in working to improve the provision of health services in the reproductive and sexual health services to Aboriginal women developed across the organisation, and led directly to the application to the RTAF for funding to apply the model in another area of western NSW.
Dubbo: The RTAF provided supportive funding to FPA Health for a more extensive project aimed at improving reproductive and sexual health outcomes for Aboriginal women in western NSW.
The RTAF funding enabled FPA Health, Dubbo, to develop a specific Aboriginal women's project which included a Well Women's Clinic, health promotion program and liaison with other services. A primary aim of this project was to provide a program to improve health literacy in the area of reproductive and sexual health for young women. The project planning commenced in April 2003 and the ACLW was recruited in September 2003.
The Women's Advisory Group provided local cultural awareness training for the staff at the commencement of the project, and helped to develop the process for recruiting the ACLW. The Advisory Group was very supportive to the project and acted as a sounding board for planned activities, provided problem solving skills and assisted the ACLW in accessing hard to reach groups of women.
The FPA Health clinical service in Dubbo was established in 2001 and is provided by doctors on a roster who fly in for 2 days a week and work alongside a nurse. In the clinic setting, the doctors and nurses utilised the skills of the ACLW in dealing with consultations where the client was very anxious or unable to explain her problem. At the client's request, the ACLW could attend the consultation and support her in making follow-up appointments either at FPA Health or with other services as required.
A particular intervention of the RTAF project was the development of a structured Health Literacy Program conducted at South Dubbo Campus for young Aboriginal women in years 8 and 9. The ACLW had a primary role in assisting in the presentation of this program and liaising with the (mainly) Aboriginal presenters. The program enrolled 12 students, of whom eight received certificates of completion. It was conducted during school hours over 7 weeks and had a focus on preventive health care, including contraceptive choices, learning about the body, STI, and included sessions on how to access services. The program was evaluated with a pre- and post-test questionnaire, the results of which indicated improved knowledge about reproductive and sexual health issues, and increased confidence in accessing services.
A further significant outcome in which the ACLW provided advocacy and cultural advice was a referral partnership with the Aboriginal Maternal Infant Health Strategy to improve ante- and post-natal care for young Aboriginal women.
Published research indicates that within the area of improved communication of health information (or health literacy), there is evidence in that the use of simple language and visual material which incorporates Indigenous Australian design and culture is important in the provision of health promotion in a realistic and appropriate format9. The ACLW has regularly advised us on the user friendliness of resources for health promotion in the community, including written and audiovisual material, and also sources new items she feels will be useful.
Estimating the capacity-building nature of the ACLW in our Dubbo service provision is perhaps best captured by the fact that the number of new Aboriginal clients to our clinical service increased:
- In the 6 months prior to the employment of the ACLW (May to September 2003), 27 Aboriginal clients attended (from a total of 437 clients) and had 39 consultations.
- In the 6 months following the employment of the ACLW (October 2003 to April 2004), 35 Aboriginal clients attended (from a total of 493 clients) and had 48 consultations.
Following the employment of the ACLW we were better able to access a hard to reach group of women, some of whom had never had a Pap test or had not had a test for more than 4 years. Over the period October 2003 to April 2004, 11 new Aboriginal clients accessed the clinic and 5 of these attended for cervical screening.
As a result of the RTAF project activities, which include the work of the ACLW in the community, FPA Health now has close links and ongoing relationships with other organisations. These include the Aboriginal Maternal Infant Health Strategy, the Circle Sentencing Program, the West Dubbo Women's Group, at least two local high schools, the Aboriginal Early Childhood Centre and local Aboriginal community groups, including Elders and mothers' groups.
FPA Health also works closely with the local ACCHS, the Thubbo Aboriginal Medical Cooperative in Dubbo, to ensure that we do not duplicate services but act in a complementary manner. The AHW from both the AMS and the sexual health service have referred clients and have advised, supported and worked alongside the ACLW in our service.
In terms of the capacity building of FPA Health, the presence of the ACLW who has attended conferences and organisational training programs with other members of staff in Sydney and Dubbo is inestimable. Clinicians and administrative staff have all become more involved in working to improve health outcomes for Aboriginal women, and are very interested in learning about the culture and experiences of Aboriginal families and the best way to provide services.
What have we learned?
- Employing an ACLW enabled our clinical service to improve access and follow up for Aboriginal clients.
- The recruitment and employment process for the ACLW needs to be conducted with the support and collaboration of key community members.
- The responsibilities of the ACLW need to be clearly defined so that areas of responsibility are clear.
- An ACLW contributes advocacy and cultural brokerage skills in organising health promotion activities that target Aboriginal women.
- An ACLW assists with identifying culturally appropriate material for health education purposes.
- The inclusion of an ACLW in a healthcare team provides an advocate and teacher who can increase the capacity of the other team members to work with Aboriginal people.
The projects conducted in Coonamble and Dubbo have been valuable learning experiences for FPA Health and have contributed enormously to our practical knowledge in providing services to Aboriginal women. The employment of community liaison workers was critical to this service provision. Working with ACLWs has been an enriching experience and by sharing this knowledge, it is hoped that other services may benefit.
At the close of the RTAF funded project, FPA Health committed to continue the concept of community liaison in its delivery of services to Aboriginal clients. The Women's Advisory Group will continue to meet quarterly to provide guidance and ideas. The ACLW resigned in April 2005 to work full time with the Circle Sentencing Program; she will, however, continue to be a member of the Women's Advisory Group and continue to provide input into community projects. As a direct result of the success of the RTAF funded project, a full time Aboriginal Health Promotion Officer position has now been created at FPA Health Dubbo to facilitate health promotion and project work.
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