Aboriginal health workers and diabetes care in remote community health centres: a mixed method analysis

Aboriginal health workers (AHWs) developed as a professional group in Australia from the employment of Aboriginal people, mainly women, as leprosarium workers in the 1950s and as medical assistants in the Northern Territory in the 1960s.1 They were recognised as cultural brokers and were trained on the job in basic clinical skills to deliver health care to community members. The role of AHWs was further developed with the adoption of primary health care as a policy model for improving the health of Aboriginal people.2 This led to AHW involvement in a range of health promotion activities and immunisation services and in environmental and mental health.1 However, the role of AHWs in the Australian health workforce remains poorly documented and inadequately understood.3 Of all the Australian states and territories, only the Northern Territory has enacted laws to provide professional registration for AHWs.4 This limited recognition may in part be due to the dearth of evidence on the impact of AHWs on the quality of health care.

The Coordinated Care Trials (CCTs) in the Northern Territory (1997–2002) embraced two main objectives of health system reform: to achieve community control of health services through establishing health boards with purchasing authority, and to implement best practice clinical guidelines in the form of disease- and age-specific care plans maintained on purpose-built electronic information systems.5

The CCTs were evaluated by examining changes in the organisation of health services, in clinical practice and in intermediate indicators of health outcomes.6,7 The impact of the trials on diabetes care has been reported previously.8 The aim of this article is to report on the relationship between employment of AHWs and delivery of diabetes care, and on barriers to AHWs’ involvement in diabetes and other chronic illness care.

At the baseline audit, all seven health centres had fewer than 10 AHWs/1000 residents, and four centres employed AHWs of both sexes (Box 2). Over the study period, AHW profile variables changed due to recruitment, resignation or turnover of AHWs at participating health centres.

Overall adherence to delivery of diabetes services rose progressively with increasing numbers of AHWs/1000 residents (Box 3). People in health centres with 10 or more AHWs/1000 residents received more guideline-scheduled services than those in health centres with fewer than five AHWs/1000 residents (adjusted mean difference, 17%; 95% CI, 8%–26%). The employment of male AHWs was associated with delivery of more diabetes guideline-specified services (adjusted mean difference, 6%; 95% CI, 1%–10%).

With regard to covariates, greater adherence to delivery of services was significantly and independently associated with participants having more comorbidities, the centre being served by a visiting (as opposed to a resident) doctor, having more nurses per head of population, the presence of a men’s clinic, higher levels of uptake of the computerised information system, and medium-sized (as opposed to smaller or larger) communities (Box 3).

The adherence to delivery of individual categories of services was influenced by the numbers and types of health care professionals present (Box 3). Participants attending health centres with more nurses and AHWs per head of population tended to receive more clinical examinations and laboratory investigations. Participants in health centres served by a resident doctor had less laboratory investigation services delivered than those in health centres served by a visiting doctor (adjusted mean difference, –12%; 95% CI, –20% to –5%). The adherence to delivery of basic measurements and vaccinations was linked weakly to the number of AHWs, but was not related to type of doctor or number of nurses. Greater adherence to delivery of counselling services was associated with health centres being served by a visiting doctor, but not with the number of nurses or AHWs.

There was no independent association between employment of AHWs and HbA1c levels and blood pressure control (full data are available from the authors on request). With respect to covariates, being ≥ 65 years of age and having a resident doctor were associated with better HbA1c control, and women were more likely to have better blood pressure control than men.

Interviews with community health centre staff revealed four major barriers to AHWs’ involvement in diabetes and other chronic illness care:

• Insufficient and discontinuous training of AHWs on use of clinical guidelines and computerised information systems;

• Lack of a clear division of roles among health care professionals in the area of chronic illness care;

• Lack of stable relationships with non-Aboriginal nursing staff, which influenced retention and performance of AHWs; and

• High demand for acute care, which limited opportunities for AHWs to be involved in chronic illness care.

Our findings highlight the importance of AHWs in the health workforce and are consistent with reports of the perceived importance of AHWs in the Indigenous primary care setting.1,3 Adherence to best practice guidelines for delivery of diabetes care was independently associated with employment of more AHWs per head of population and with employment of male AHWs in addition to female AHWs. The apparent significant role of male AHWs is consistent with the common distinction in Indigenous cultures between the accepted roles of men and women in society and the preference for treatment by health staff of the same sex.11

While we included a number of participant and health centre covariates in the statistical model, the associations we found may be subject to unidentified confounders not measured in the original evaluation, including the general process of capacity-building within the CCTs, characteristics of health centre organisations and individual practitioners, inputs of health board management and other community conditions.

During the course of the CCTs, there was wide variation among community health centres in the degree to which AHWs were involved in chronic illness care.5 There was a view that improved management practices could enhance the role and contribution of AHWs, in part by strengthening local delineation of roles and responsibilities for acute and chronic illness care. Other studies have supported this view.12-15

The effect of the quality of AHW–nurse relationships on AHW attendance and on the number of AHWs working in health centres has been highlighted by work in Central Australia.3 In remote health centres, high turnover among nurses reduces the likelihood of their forming significant relationships with AHWs. Jackson and colleagues, in a qualitative study of the relationship between AHWs and nurses, suggested that enhancing understanding of workplace equity and skill sharing could improve AHW–nurse relationships.16 A World Health Organization report recommends a teamwork approach to improve the attitude of health personnel towards community health workers.17

The inherent logic relationships between delivery of diabetes services and patient intermediate outcomes can be summarised in the following steps: (A) improvement in regular testing and monitoring increases (B) the likelihood of proper use of medications, and consequently increases (C) the likelihood of good intermediate outcomes. AHWs and RNs are involved in step A, and doctors are involved in both steps A and B. Step C is a product of teamwork.

As our study showed, employment of AHWs (and RNs) was associated with a higher level of delivery of services, but was not independently (and necessarily) associated with improvement in intermediate outcomes. The association between higher adherence to guidelines and having visiting doctors may arise from visiting doctors’ greater exposure to guideline implementation processes (as they are based primarily in Darwin, where much of the CCT guideline-related work occurred). On the other hand, health centres with resident doctors were associated with better control of HbA1c levels. A possible explanation is that a resident doctor may provide more timely medication adjustment for patients, which directly contributes to better glycaemic control.

Our findings should provide an incentive to further develop the role of AHWs in community health care systems — for example, in areas of counselling and health promotion and in some areas of basic measurement — at least as a precursor to referral to other practitioners. Potential roles of AHWs in relation to components of the community health care system18,19 are summarised in Box 4. It is important for health service managers to clarify and prioritise AHWs’ roles in managing chronic illness, and also to define the roles of doctors and nurses.

The importance of AHWs in primary health care is recognised in high-level policy statements such as the Aboriginal and Torres Strait Islander Health Workforce National Strategic Framework.20 The Aboriginal and Torres Strait Islander health performance indicators include information on the numbers of AHWs working in primary health care centres by state and territory.21 The NT government’s “rule of thumb” is that there should be one full-time AHW position for every 100 Aboriginal people.3 None of the participating health centres reached this standard at baseline audit, and during the study period only one centre ever achieved this goal. Our study underlines the need for strategies to increase the numbers of AHWs employed and to clarify and support their roles in the multidisciplinary primary health care setting.