Making a difference: the early impact of an Aboriginal health undergraduate medical curriculum

Health care workers’ attitudes to and understanding of Aboriginal people do not occur in isolation and often reflect the same narrow ethnocentric views commonly held by other non-Aboriginal Australians.1 Since the 1970s, many attempts have been made to introduce issues relevant to Aboriginal and Torres Strait Islander peoples’ health into medical curricula.2-6 All of these have focused on single events or activities in a single year of the medical course.6

Despite the presence of Indigenous health units within at least two medical schools in Australia in the late 1990s (at the University of Western Australia [UWA] and the University of Newcastle), there was increasing concern about the relative paucity of teaching of Aboriginal health to all health students.7

Both the Royal Commission into Aboriginal Deaths in Custody and the National Aboriginal Health Strategy made recommendations on improving the education of health care practitioners in relation to Aboriginal health issues.8,9 The recommendations included guidance on the content and manner in which Aboriginal health curricula should be developed and delivered, with a particular emphasis on involvement of Aboriginal people. Countering assumptions and stereotypes requires moving beyond knowing about cultural appropriateness towards adopting culturally secure practice.10 In a health context, “cultural security” means that health services are delivered in such a manner and setting that no person is “afforded a less favourable outcome simply because they hold a different cultural outlook”.11 Central to achieving effective change in this area is recognising that Aboriginal health is an important area of study that requires allocation of adequate time in the curriculum and sufficient teaching resources.7 This was a key recommendation of the Committee of Deans of Australian Medical Schools Indigenous health curriculum framework project.12

Here we describe how UWA has recently embarked on such a program within its medical course. We document early findings on final-year students’ perceptions of their preparedness, ability and future commitment in relation to Aboriginal health.

Beginning in 1984, final-year (Year 6) medical students at UWA were given a 2-hour seminar on Aboriginal health before starting their rural general practice placement.3 In 1996, a guest lecture and a tutorial were added, bringing to 6 hours the maximum formal teaching allocation in Aboriginal health over the 6-year course (David Atkinson, former Director, Centre for Aboriginal Medical and Dental Health [CAMDH], UWA, personal communication).

The CAMDH was established in 1996. Its specific roles were to improve the recruitment and retention of Indigenous students; to develop Aboriginal health teaching within the Faculty of Medicine, Dentistry and Health Science; and to provide health-related support and resources for Aboriginal communities and organisations.

In 1999, as a part of the Faculty’s submission to the Australian Medical Council for a new curriculum, CAMDH staff proposed the introduction of a comprehensive, course-long curriculum in Aboriginal health. The Australian Medical Council approved the new curriculum, which began to be progressively introduced in 2000 with the new intake of Year 1 students. The first cohort of students to experience the full core curriculum in Aboriginal health completed their final year in 2005, having had a minimum of 37 hours of direct teaching in the area. Some had had well over 150 hours, depending on how many Aboriginal health options they chose. Coexistent with the introduction of these curriculum changes was the establishment, in 2002, of the Rural Clinical School (RCS) within the Faculty. The RCS provides rurally based education for 25% of Year 5 students, who spend the whole of that year in one of eight sites across Western Australia.

Central to developing and implementing the integrated Aboriginal health curriculum has been the articulation, for each year level, of learning outcomes aimed at developing knowledge, skills and attitudes (Box 1).

The first (baseline) cohort (Year 6, 2003) had a maximum of 3 hours’ teaching in Aboriginal health in Years 1 to 3; three problem-based-learning tutorials with some Aboriginal health content in Years 4, 5 and 6; and an Aboriginal health orientation seminar before their rural general practice placement in Year 6. This added up to a total of 7 hours of formal teaching and learning in Aboriginal health. Eight students in this cohort participated in the RCS program in their fifth year.

The second cohort (Year 6, 2004) had, in addition to the experiences of the 2003 cohort, a structured, small-group reflective program in Year 5, involving two 1.5-hour tutorials and a self-directed, self-chosen task. This resulted in a total of 11 hours of formal teaching and learning in Aboriginal health throughout their course. Twenty-one students in this cohort participated in the RCS program in their fifth year.

Eighty-four of 110 Year 6 students (76%) responded to the IAHUC survey in the first cohort and 97/114 (85%) in the second cohort. The Cronbach α value for the IAHUC questionnaire was 0.84, indicating the scale was internally consistent. Between 35% and 75% of students and graduates responded to the “Preparedness to practise” survey (Box 3).

Median scores for IAHUC questionnaire items and the proportion of respondents agreeing with each statement are shown in Box 2. The highest level of agreement (≥ 70%) in both cohorts was recorded for items related to Aboriginal health being a social priority, trust being a key issue for culturally secure health care, and feeling intimidated being a barrier to culturally secure health care.

Over 60% of respondents in both cohorts agreed that preventive health care in Aboriginal health was more important than curing sick Aboriginal people, that spiritual beliefs influence the health of Aboriginal people and that doctors need to think beyond the individual when considering Aboriginal health issues.

Items with the lowest level of agreement (< 30%) among respondents related to Aboriginal health care and service provision. Fewer students in the second cohort agreed that the health care issues for Aboriginal people were the same across Australia, but more agreed that their only role in improving Aboriginal health was in treating sick Aboriginal people in a hospital or clinic.

There was a significantly higher level of agreement among respondents in the second cohort on items relating to students’ preparedness and ability to work with and care for Aboriginal and Torres Strait Islander people (Box 2). For example, students in the second cohort reported a higher ability to communicate with Aboriginal people and provide culturally secure health care. They also rated their preparedness to advocate and improve the health of Aboriginal people as higher. Sixty-five per cent of respondents in the second cohort agreed they had a social responsibility to work for change in Aboriginal health, and 48% agreed they would work for change in Aboriginal health as a personal priority. The significant difference in student self-rated preparedness within the second cohort continued through to the commencement of their internship (Box 3).

Thirty-seven students in the first Year 6 cohort and 28 in the second cohort responded to the five open-ended statements (Box 4).

Data on IAHUC questionnaire responses of the RCS students in the 2003 and 2004 cohorts were not separately identified. However, 15/21 RCS students responded to the “Preparedness to practise” survey at the beginning of their internship in 2005. The RCS interns had a significantly higher perception of their ability to communicate with Aboriginal people and apply knowledge to provide culturally secure care than the urban-based UWA graduates.

We have shown that with a relatively small amount of targeted and structured teaching and learning in Aboriginal health, significant shifts in self-perceived levels of knowledge, skills and attitudes are possible. However, there is still room for improvement.

While students’ self-rating of preparedness was a potential limitation, the results demonstrate positive effects of the additional learning experience offered to the students who completed Year 6 in 2004. There were significant improvements in students’ preparedness to recognise Aboriginal health as a social priority and in their perceived ability, and future commitment, to work for changes in Aboriginal health.

Students’ responses to the open-ended statements seem to demonstrate a shift from an individual focus towards a more meaningful understanding of culturally secure care at a community level. However, as only a third of students from each group provided open-ended feedback, this conclusion can only be very tentative.

The results reported here represent the beginning of a long-term evaluation to guide the refinement and expansion of the Aboriginal health curriculum in the medical course at UWA. We have already started to draw on our experience to develop further curriculum initiatives within the dental course at UWA. The development of reliable and valid assessment tools in the area of Aboriginal health is also a priority.

The Committee of Deans of Australian Medical Schools report offers a framework to guide the style, content and delivery of Aboriginal health curricula in medical programs.12 We believe that, based on our experience, the keys to success in achieving learning outcomes are integrating the material presented, involving Aboriginal people in planning and provision of teaching and learning, and drawing on the skill and experience of the teachers.

It has been argued that “getting students out of urban hospitals and into places where Aboriginal people live is crucial to creating shifts in awareness and knowledge in relation to Aboriginal health”.6 We have shown that providing students with information and experiences that allow them to become better informed and challenge stereotypical attitudes and understandings does not require rural immersion. While experience in rural and remote areas can be challenging and effective, the majority of Aboriginal people live in urban areas, and the skills and abilities that practitioners need to work effectively with Aboriginal people apply equally in urban or rural settings.

The aim of the initiatives at UWA has been to ensure that our graduates in medicine will not only be more likely to provide culturally secure health care services, but will also be more likely to have an interest in and commitment to improving Aboriginal people’s health. By educating medical students to be better informed, more experienced, and aware of the underlying issues, it is hoped that some of the barriers to access to health care services will be significantly reduced. Creating a more culturally secure health workforce is challenging, rewarding and achievable. Pursuing this path is essential, not only because of the important role medical education can make in improving Aboriginal health outcomes, but also because of its contribution to the larger issue of promoting better understanding and reconciliation.