An Aboriginal and Torres Strait Islander adolescent model of primary health care

Aboriginal and Torres Strait Islander adolescents aged 10–24 years represent 30% of the Aboriginal and Torres Strait Islander population.1 As a population group, these adolescents are a strong and resilient cohort. However, the health and wellbeing of Aboriginal and Torres Strait Islander adolescents needs improvement and is generally poorer compared with non‐Indigenous adolescents.2,3 It is during this life stage that the gap in morbidity and mortality widens between Aboriginal and Torres Strait Islander adolescents and non‐Indigenous adolescents, and when a difference in mortality between genders also occurs.2,3 Injury and mental health‐related conditions are the leading cause of the increased burden of disease among Aboriginal and Torres Strait Islander adolescents.2,4 Both injury and mental health‐related conditions contribute to higher rates of health system engagement, hospitalisations, mortality and the increased health gap between Aboriginal and Torres Strait Islander adolescents and non‐Indigenous adolescents.2,4 Similarly, pregnancy‐related needs among Aboriginal and Torres Strait Islander adolescent females increase health system engagement, which requires different health system functions. Sexually transmitted infections contribute to health system engagement and excess disease burden experienced by Aboriginal and Torres Strait Islander adolescents. Additionally, as does their engagement in health risk behaviours, such as smoking, alcohol and other drug consumption, and poor diet.2,3

Eighty per cent of excess mortality among Aboriginal and Torres Strait Islander adolescents is preventable within the current health system.3 These deaths are “preventable or treatable within the current health system given timely and effective health care”.3 This suggests that within the current health care system, there are many opportunities to intervene and for health gain, and to optimise future health and intergenerational health.

Aboriginal and Torres Strait Islander adolescents access health care services across a range of settings, including community and primary health care, both mainstream and the community‐controlled sector, and hospitals and emergency departments. Yet, evidence suggests the health and wellbeing needs of Aboriginal and Torres Strait Islander adolescents are unmet by current health care services.2,3 Aboriginal and Torres Strait Islander adolescents are less likely to access health care than other groups within the Aboriginal and Torres Strait Islander population.5,6 Additionally, Aboriginal and Torres Strait Islander adolescents encounter several barriers when accessing health care services, including a lack of culturally appropriate services, financial barriers, geographic isolation, privacy and confidentiality, and stigma associated with seeking health care.7

Furthermore, the health and wellbeing of Aboriginal and Torres Strait Islander adolescents is affected by the ongoing effects of colonisation, exclusion, intergenerational trauma and discrimination, and compounded by the social determinants of health.2,8 The social determinants of health, the conditions in which people are born, grow, live, work and age, are shaped by the social, political, economic, environmental and cultural factors of society.9 It is the distribution of these factors that drives inequality. Action on the social determinants of health requires government and society involvement and must be addressed if we are to improve the health and wellbeing of Aboriginal and Torres Strait Islander adolescents.9

In this perspective article, we propose an Aboriginal and Torres Strait Islander adolescent model of primary health care that centres the health and wellbeing needs of Aboriginal and Torres Strait Islander adolescents, their families and communities. This proposal builds on previous calls for investments in Aboriginal and Torres Strait Islander adolescent health and wellbeing.8,10

Aboriginal and Torres Strait Islander adolescent model of primary health care

Aboriginal and Torres Strait Islander adolescents require high quality health care that meets their health and wellbeing needs. This can be realised through designing and implementing an Aboriginal and Torres Strait Islander adolescent model of primary health care. The model of care should fulfil the following aims:

• involve adolescents, their families, and communities in primary health care design and delivery;
• provide health care that is free from discrimination;
• build an Aboriginal and Torres Strait Islander health workforce to provide care to Aboriginal and Torres Strait Islander adolescents;
• improve the competencies of the health care workforce to acknowledge and address the unique health and wellbeing needs of Aboriginal and Torres Strait Islander adolescents; and
• strengthen primary health care services, particularly Aboriginal and Torres Strait Islander community‐controlled health services, to deliver care to Aboriginal and Torres Strait Islander adolescents.

Involving Aboriginal and Torres Strait Islander adolescents in primary health care services is essential. Aboriginal and Torres Strait Islander adolescents have a fundamental right to be involved in the planning and delivery of services and in the decisions regarding their own health care.11 Aboriginal and Torres Strait Islander adolescents have a unique perspective on their lives and environment, and their engagement is key to ensuring the design and delivery of health care services meet their needs. There are several examples of approaches that have engaged Aboriginal and Torres Strait Islander adolescents in co‐designing health care services. In Perth, Western Australia,12,13 and Yarrabah in Far North Queensland,14 adolescents, Elders and health care providers co‐designed wellbeing and mental health services for Aboriginal and Torres Strait Islander adolescents. Meaningful engagement was central to both. Key principles in co‐designing health services with Aboriginal and Torres Strait Islander peoples include Indigenous leadership, a culturally grounded approach, respect, benefit to community, inclusive partnerships, and transparency and evaluation.15 When health care services involve Aboriginal and Torres Strait Islander adolescents and their communities, they can be more effective.7,8,16,17

Primary health care can be a place where Aboriginal and Torres Strait Islander adolescents do not experience discrimination.18,19,20 For example, primary health care can be free from discrimination and racism and be a culturally safe place for Aboriginal and Torres Strait Islander adolescents to flourish. Aboriginal and Torres Strait Islander community‐controlled health services are examples of this.16 The national safety and quality health service standards and the World Health Organization (WHO) Global standards for quality health‐care services for adolescents identify actions that governments and services can implement to eliminate discrimination and provide culturally safe health care services.18,19 For example, implementation of policies and procedures that acknowledge the vulnerabilities of adolescents and provision of services that are friendly, non‐judgemental and respectful of adolescents.19 Also, both standards provide actions related to providing health care free from discrimination; improving the competencies of the health care workforce; and implementing models of care appropriate to adolescents.

Building an Aboriginal and Torres Strait Islander health workforce is critical to ensuring Aboriginal and Torres Strait Islander adolescents receive culturally appropriate care.7 This includes increasing the number of Aboriginal and Torres Strait Islander health care professionals in all roles and sectors of primary health care. Evidence indicates that health care delivered by Aboriginal and Torres Strait Islander health care professionals is more culturally appropriate and better meets the needs of Aboriginal and Torres Strait Islander people than non‐Indigenous health care professionals.7,16 We must learn from the Aboriginal and Torres Strait Islander community‐controlled sector about what works in fostering an Aboriginal and Torres Strait Islander health workforce.

Improving the competencies of the health care workforce is at the core of providing high quality, effective and culturally safe health care for Aboriginal and Torres Strait Islander adolescents.7,18 Competency is defined as “the knowledge, skills, attitudes and values necessary to perform particular tasks to an identified standard”.21 Increasingly, health care professions have included competencies specific to Aboriginal and Torres Strait Islander peoples and integrated Aboriginal and Torres Strait Islander health and wellbeing into curricula.22 However, what is required is specific competencies related to the unique health and wellbeing needs of adolescents, including Aboriginal and Torres Strait Islander adolescents. This is particularly important, as most health care professionals were trained at a time when the focus was paediatrics and when communicable diseases were more common in childhood than the non‐communicable diseases adolescents experience today.23 Therefore, there is a need to upskill the health workforce. The WHO developed the Core competencies in adolescent health and development for primary care providers to aid countries in developing competency‐based educational programs in adolescent health.24 These competencies need to be adapted to the specific health and wellbeing needs of Aboriginal and Torres Strait Islander adolescents. Mental health and sexual and reproductive health are significant concerns of Aboriginal and Torres Strait Islander adolescents, yet can be difficult topics to address.2 The National Aboriginal Community Controlled Health Organisation and the Royal Australian College of General Practitioners National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people25 recommends all young people aged 12–24 years have a social emotional wellbeing assessment, and all sexually active Aboriginal and Torres Strait Islander people aged 30 years or younger are screened for chlamydia and gonorrhoea. Despite these guidelines, less than a quarter of health assessments included a test for a sexually transmitted infection.26 Challenges related to time, skill level, comfort with the topics, and being unsure how to respond may be reasons for a lack of implementation.

Strengthening primary health care services, particularly Aboriginal and Torres Strait Islander community‐controlled health services, is crucial. Aboriginal and Torres Strait Islander adolescents should be able to access any primary health care service, and feel safe as a young person and culturally. This requires primary health care services to acknowledge the unique health and wellbeing needs of Aboriginal and Torres Strait Islander adolescents and their families. It will need services to alter their models of care and ensure that Aboriginal and Torres Strait Islander adolescents are able to freely access services without discrimination. Aboriginal and Torres Strait Islander community‐controlled health services are a great example of providing culturally safe, holistic and comprehensive primary health care,16,27 while minimising or eliminating social determinants that prevent access to primary health care.28 However, all primary health care services must deliberately have a focus on Aboriginal and Torres Strait Islander adolescents, and implement a model of care that facilitates accessible care and is based on what we know works.7

Summary

Designing and implementing an Aboriginal and Torres Strait Islander adolescent model of primary health care is essential for improving their health and wellbeing. The co‐design of accessible and responsive primary health care must involve Aboriginal and Torres Strait Islander adolescents and their communities, be free from discrimination and be culturally safe, involve an Aboriginal and Torres Strait Islander health workforce, use an appropriately skilled workforce, be grounded in culture, foster partnerships and collaboration between services and organisations, be sustainable and evaluated, and meet the priorities and needs of Aboriginal and Torres Strait Islander adolescents.15,29 This approach will require the involvement of the primary health care sector, including Aboriginal and Torres Strait Islander community‐controlled and mainstream primary health care, the Australian health care system, and state, territory and federal governments. This will ensure that primary health care is able to meaningfully redress the inequality that Aboriginal and Torres Strait Islander adolescents experience when accessing primary health care services. It is through these actions and investment in Aboriginal and Torres Strait Islander adolescents that we will be able to address the current disease burden, and intervene and alter the future risks of communicable and non‐communicable diseases. It is an investment in future health gains for current and future generations of Aboriginal and Torres Strait Islander people.11,30 Importantly, their health and wellbeing is critical for Australia and for ensuring the preservation and continuation of Aboriginal and Torres Strait peoples and culture.