Cultural safety in hospitals: validating an empirical measurement tool to capture the Aboriginal patient experience

Walking together in friendship: Learning about cultural safety in mainstream mental health services through Aboriginal Participatory Action Research

OBJECTIVE

Culturally safe service provision is essential to improving social and emotional wellbeing among Aboriginal and Torres Strait Islander communities, and to eliminating health inequities. Cultural safety is about ensuring that all people have a safe and healing journey through services, regardless of their cultural background. In this project, we aim to (1) understand how Aboriginal and Torres Strait Islander peoples conceptualise cultural safety, and (2) co-design a qualitative interview for the next phase of this project, where we plan to learn about experiences of cultural safety within mental health services.

METHODS

We conducted six focus groups (in one metro and two regional areas, Western Australia). Following an Aboriginal Participatory Action Research methodology, we yarned with Aboriginal and Torres Strait Islander mental health service users, carers, community members, mental health professionals and Cultural Healers about cultural safety.

RESULTS

Participants described a culturally safe service as one where Aboriginal cultural knowledges, life experiences, issues and protocols are understood and acknowledged, and reported that mainstream mental health services are not currently culturally safe. Participants emphasised the importance of building trust, rapport, reciprocity and following appropriate relational processes when designing a qualitative interview for the next phase.

CONCLUSIONS

A lack of cultural safety in mental health services is likely to contribute to the disparity in outcomes between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians. Embedding cultural safety into research design allows for authentic community engagement and facilitates knowledge sharing around ways to improve cultural safety in mental health services.

Pathways: A guide for developing culturally safe and appropriate patient-reported outcome (PROMs) and experience measures (PREMs) with Indigenous peoples

BACKGROUND

Members of the Indigenous Health Program, BC Children's and Women's Hospitals and the University of British Columbia embarked on a joint project to describe best practices to support the creation of patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) with Indigenous peoples.

METHODS

The project involved a review of previous research on patient-reported measures (surveys) that had been specifically developed for Indigenous populations. It also involved interviews with key stakeholders-Indigenous and non-Indigenous academic researchers, and Indigenous community leaders and community members. Themes from the interviews and the literature review were combined and synthesized into pathways/a framework for survey development.

RESULTS

The pathways document consisted of 13 protocols and associated teachings for guiding processes and framing survey questions. These encompassed building relationships, community engagement and consultation, benefits to community, ceremony and storytelling, two-way learning, participatory content development, governance and accountability. Findings emphasized the criticality of Indigenous leadership in setting priorities for PROMs and PREMS and establishing relationships that honour Indigenous experiences through all phases of a study. Assessment of the framework's validity with select research participants and the Project Advisory Committee was positive.

CONCLUSION

This is the first framework to guide development of PROMs and PREMs with Indigenous peoples and communities. It addresess both process and outcome and includes concrete steps that collaborators can take when establishing a partnership that is respectful and inclusive of Indigenous ways of knowing and being.

'God is the one who give child': An abductive analysis of barriers to postnatal care using the Health Equity Implementation Framework

Background

Postnatal care is recommended as a means of preventing maternal mortality during the postpartum period, but many women in low- and middle-income countries (LMICs) do not access care during this period. We set out to examine sociocultural preferences that have been portrayed as barriers to care.

Methods

We performed an abductive analysis of 63 semi-structured interviews with women who had recently given birth in three regions of Ethiopia using the Health Equity Implementation Framework (HEIF) and an inductive-deductive codebook to understand why women in Ethiopia do not use recommended postnatal care.

Results

We found that, in many cases, health providers do not consider women's cultural safety a primary need, but rather as a barrier to care. However, women's perceived refusal to participate in postnatal visits was, for many, an expression of agency and asserting their needs for cultural safety.

Trial registration

n/a.

Conclusions

We propose adding cultural safety to HEIF as a process outcome, so that implementers consider cultural needs in a dynamic manner that does not ask patients to choose between meeting their cultural needs and receiving necessary health care during the postnatal period.

Patient-Defined Cultural Safety in Perinatal Interventions: A Qualitative Scoping Review

Problem

Cultural safety is an approach to patient care designed to facilitate respect of patients' cultural needs and address inequities in care in culturally diverse situations.

Background

Much literature considers culturally safe care during the perinatal period, yet little is known about how patients experience and understand cultural safety. This is despite patient-defined care being one of the definitions of cultural safety.

Question Hypothesis or Aim

This scoping review investigates what is known from existing qualitative literature about patients' experience of cultural safety frameworks in perinatal interventions.

Methods

A search for "cultural safety" OR "culturally safe" in PubMed, Ovid Medline, Ovid Embase, Cumulated Index to Nursing and Allied Health Literature, Scopus, Scielo, and Latin America and the Caribbean Literature on Health Sciences returned 2233 results after deduplication. Title-abstract and full-text screenings were conducted to identify qualitative studies of cultural safety from perinatal patients' perspectives. Seven studies were included in the final analysis. Data were open coded using NVivo.

Findings

Three themes were identified: (1) care that acknowledged that their lives were different from patients in the dominant culture, (2) receiving care in community, and (3) care providers who respected their choices and culturally specific knowledge.

Discussion

This research shows how cultural safety intersects with other equity-based frameworks used in midwifery and obstetrics.

Conclusion

Building on this research could lead to new protocols that address complex social and physical needs of marginalized people during the perinatal period.

Awareness and understanding of concussion among Aboriginal Australians with high health literacy

Aim

Indigenous Australians have higher rates of traumatic brain injury, with 74-90% of such injuries being concussion. This study explores concussion awareness and knowledge in Aboriginal Western Australians with high health literacy.

Materials & methods

Participants, aged 18-65 years, engaged in research topic yarning, and thematic analysis of the qualitative data then undertaken.

Results

There was awareness that direct head trauma can result in concussion, but a lack of differentiation between concussion and other head injuries. Knowledge was gained from sport, media or lived-experience. Symptom minimization and diversity of concussion symptoms prevented participants from seeking medical treatment. This was exacerbated by a mistrust of the medical system.

Conclusion

Research findings highlight knowledge and service gaps where co-designed strategies can be targeted.

Audit tools for culturally safe and responsive healthcare practices with Aboriginal and Torres Strait Islander people: a scoping review

Aboriginal and Torres Strait Islander people in Australia face disparities in accessing culturally safe and appropriate health services. While current cultural safety and responsiveness frameworks set standards for improving healthcare practices, ensuring accountability and sustainability of changes, necessitates robust mechanisms for auditing and monitoring progress. This study examined existing cultural safety audit tools, and facilitators and barriers to implementation, in the context of providing culturally safe and responsive healthcare services with Aboriginal and Torres Strait Islander people. This will assist organisations, interested in developing tools, to assess culturally responsive practice. A scoping review was undertaken using Medline, Scopus, CINAHL, Informit and PsychInfo databases. Articles were included if they described an audit tool used for healthcare practices with Aboriginal and Torres Strait Islander people. Selected tools were evaluated based on alignment with the six capabilities of the Indigenous Allied Health Australia (IAHA) Cultural Responsiveness in Action Framework. Implementation barriers and facilitators were identified. 15 papers were included. Audit tools varied in length, terminology, domains assessed and whether they had been validated or evaluated. Seven papers reported strong reliability and validity of the tools, and one reported tool evaluation. Implementation facilitators included: tool comprehensiveness and structure; effective communication; clear organisational responsibility for implementation; commitment to prioritising cultural competence; and established accountability mechanisms. Barriers included: the tool being time-consuming and inflexible; responsibility for implementation falling on a small team or single staff member; deprioritising tool use; and lack of accountability for implementation. Two of the six IAHA capabilities (respect for the centrality of cultures and inclusive engagement) were strongly reflected in the tools. The limited tool evaluation highlights the need for further research to determine implementation effectiveness and sustainability. Action-oriented tools, which comprehensively reflect all cultural responsiveness capabilities, are lacking and further research is needed to progress meaningful change within the healthcare system.

Evaluating the impact of 'Ask the Specialist Plus': a training program for improving cultural safety and communication in hospital-based healthcare

BACKGROUND

First Nations peoples in colonised countries often feel culturally unsafe in hospitals, leading to high self-discharge rates, psychological distress and premature death. To address racism in healthcare, institutions have promised to deliver cultural safety training but there is limited evidence on how to teach cultural safety. To that end, we created Ask the Specialist Plus: a training program that focuses on improving healthcare providers intercultural communication skills to improve cultural safety. Our aim is to describe training implementation and to evaluate the training according to participants.

METHODS

Inspired by cultural safety, Critical Race Theory and Freirean pedagogy, Ask the Specialist Plus was piloted at Royal Darwin Hospital in Australia's Northern Territory in 2021. The format combined listening to an episode of a podcast called Ask the Specialist with weekly, one-hour face-to-face discussions with First Nations Specialists outside the clinical environment over 7 to 8 weeks. Weekly surveys evaluated teaching domains using five-point Likert scales and via free text comments. Quantitative data were collated in Excel and comments were collated in NVivo12. Results were presented following Kirkpatrick's evaluation model.

RESULTS

Fifteen sessions of Ask the Specialist Plus training were delivered. 90% of participants found the training valuable. Attendees enjoyed the unique format including use of the podcast as a catalyst for discussions. Delivery over two months allowed for flexibility to accommodate clinical demands and shift work. Students through to senior staff learnt new skills, discussed institutionally racist systems and committed to behaviour change. Considering racism is commonly denied in healthcare, the receptiveness of staff to discussing racism was noteworthy. The pilot also contributed to evidence that cultural safety should be co-taught by educators who represent racial and gender differences.

CONCLUSION

The Ask the Specialist Plus training program provides an effective model for cultural safety training with high potential to achieve behaviour change among diverse healthcare providers. The training provided practical information on how to improve communication and fostered critical consciousness among healthcare providers. The program demonstrated that training delivered weekly over two months to clinical departments can lead to positive changes through cycles of learning, action, and reflection.

Healthcare professionals' cultural safety practices for indigenous peoples in the acute care setting - a scoping review

BACKGROUND

For Indigenous Peoples the disparities in health status are largely associated with the direct social determinants of invasion and colonisation, marginalisation, intergenerational traumas, and lack of conscious government policy to address these ongoing effects. There is currently limited evidence in the literature on what Cultural Safety practices mean in acute care settings.

OBJECTIVE

We aimed to understand the extent and type of evidence in relation to current knowledge and evidence regarding Cultural Safety practices for Indigenous Peoples in acute care settings.

DESIGN

This is a scoping review.

METHODS

We searched six databases in consultation with a librarian experienced in health research.

RESULTS

A total of 16 papers were included in the scoping review. Four main barriers to Cultural Safety in practice were identified; Among the included studies, only one quality improvement study reported an intervention, which improved culturally safe care.

CONCLUSION

The four barriers identified each have a variable impact on Indigenous Peoples' health outcomes and are dependent upon the circumstances and experiences of both Indigenous Peoples and healthcare professionals.

Identifying the key characteristics of a culturally safe mental health service for Aboriginal and Torres Strait Islander peoples: A qualitative systematic review protocol

BACKGROUND

Mental health inequities between Indigenous and non-Indigenous populations are well documented. There is growing recognition of the role that culturally safety plays in achieving equitable outcomes. However, a clear understanding of the key characteristics of culturally safe mental health care is currently lacking. This protocol outlines a qualitative systematic review that aims to identify the key characteristics of culturally safe mental health care for Aboriginal and Torres Strait Islander peoples, at the individual, service, and systems level. This knowledge will improve the cultural safety of mental health care provided to Indigenous peoples, with a focus on Aboriginal and Torres Strait Islander peoples in Australia.

METHODS AND EXPECTED OUTPUTS

Through a review of academic, grey, and cultural literature, we will identify the key characteristics of culturally safe mental health care for Aboriginal and Torres Strait Islander peoples in Australia. We will consider the characteristics of culturally safe care at the individual practitioner, service, and systems levels.

PROSPERO REGISTRATION NUMBER

CRD42021258724.

VOICE-Validating Outcomes by Including Consumer Experience: A Study Protocol to Develop a Patient Reported Experience Measure for Aboriginal and Torres Strait Islander Peoples Accessing Primary Health Care

Aboriginal and Torres Strait Islander peoples' (hereafter respectfully referred to as Indigenous Australians) experiences of health care are shaped by historical, social and cultural factors, with cultural security critical to effective care provision and engagement between services and community. Positive patient experiences are associated with better health outcomes. Consequently, it is an accreditation requirement that primary health care (PHC) services must formally gather and respond to patient feedback. However, currently available patient feedback tools were not developed with Indigenous Australians, and do not reflect their values and world views. Existing tools do not capture important experiences of care of Indigenous Australians in PHC settings, nor return information that assists services to improve care. Consistent with the principles of Indigenous Data Sovereignty, we will co-design and validate an Indigenous-specific Patient Reported Experience Measure (PREM) that produces data by and for community, suitable for use in quality improvement in comprehensive PHC services. This paper presents the protocol of the study, outlining the rationale, methodologies and associated activities that are being applied in developing the PREM. Briefly, guided by an Aboriginal and Torres Strait Islander Advisory Group, our team of Indigenous and non-Indigenous researchers, service providers and policy makers will use a combination of Indigenous methodologies, participatory, and traditional western techniques for scale development. We will engage PHC service staff and communities in eight selected sites across remote, regional, and metropolitan communities in Australia for iterative cycles of data collection and feedback throughout the research process. Yarning Circles with community members will identify core concepts to develop an "Experience of Care Framework", which will be used to develop items for the PREM. Staff members will be interviewed regarding desirable characteristics and feasibility considerations for the PREM. The PREM will undergo cognitive and psychometric testing.

Co-designing research with Aboriginal and Torres Strait Islander consumers of mental health services, mental health workers, elders and cultural healers

INTRODUCTION

The disparity in mental health outcomes compared with non-Indigenous Australians means that there is an urgent need to develop an evidence base around how services can better support Aboriginal and Torres Strait Islander communities. A critical first step is to embed cultural safety into research methodologies.

OBJECTIVE

Here, we aim to establish the foundation of a research project through co-designing a qualitative interview with Aboriginal and Torres Strait Islander consumers and community members about experiences of cultural safety with mainstream mental health services.

DESIGN

Voices of Aboriginal and Torres Strait Islander peoples must be empowered across all stages of research. An Aboriginal-led research team conducted focus groups to understand clear, sensitive, and culturally appropriate ways of asking about experiences in mental health care, to co-design an interview on this topic. Participants were Aboriginal and Torres Strait Islander consumers of mental health services, carers, mental health workers, Elders and Cultural Healers, living in Metropolitan and Regional Western Australia.

FINDINGS

Results suggest that Indigenous governance, together with investing in ongoing, and meaningful cultural awareness and cultural safety training (cultural awareness being a first step towards safety) for non-Indigenous researchers, together with taking the time to build respectful partnerships with communities through ongoing consultation, were appropriate and comprehensive methods of co-designing an interview.

DISCUSSION

The process of working with Aboriginal and Torres Strait Islander peoples in research is as important as the outcome. Aboriginal and Torres Strait Islander leadership, self-determination, and relationship building with communities are essential.

CONCLUSION

Empowering co-design methodologies are flexible, iterative, and ensure that the experiences and views of participants are valued, leading to more meaningful results.

Community Engagement and Psychometric Methods in Aboriginal and Torres Strait Islander Patient-Reported Outcome Measures and Surveys-A Scoping Review and Critical Analysis

(1) Background: In healthcare settings, patient-reported outcome measures (PROMs) and surveys are accepted, patient-centered measures that provide qualitative information on dimensions of health and wellbeing. The level of psychometric assessment and engagement with end users for their design can vary significantly. This scoping review describes the psychometric and community engagement processes for PROMs and surveys developed for Aboriginal and Torres Strait Islander communities. (2) Methods: The PRISMA ScR guidelines for scoping reviews were followed, aimed at those PROMs and surveys that underwent psychometric assessment. The Aboriginal and Torres Strait Islander Quality Appraisal Tool and a narrative synthesis approach were used. (3) Results: Of 1080 articles, 14 were eligible for review. Most articles focused on a validity assessment of PROMs and surveys, with reliability being less common. Face validity with Aboriginal and Torres Strait Islander communities was reported in most studies, with construct validity through exploratory factor analyses. Methodological design risks were identified in the majority of studies, notably the absence of explicit Indigenous knowledges. Variability existed in the development of PROMs and surveys for Aboriginal and Torres Strait Islander communities. (4) Conclusions: Improvement in inclusion of Indigenous knowledges and research approaches is needed to ensure relevance and appropriate PROM structures. We provide suggestions for research teams to assist in future design.

Study protocol: Clinical yarning, a communication training program for clinicians supporting aboriginal and Torres Strait Islander patients with persistent pain: A multicentre intervention feasibility study using mixed methods

Objectives

Ineffective communication between healthcare clinicians and Aboriginal and Torres Strait Islander patients with persistent pain is a significant barrier to optimal pain management. This manuscript is a study protocol and describes the development and evaluation methods of a tailored, culturally-informed training program, to improve clinicians’ communication with patients.

Study design

This is a single-arm, multicentre (2 metropolitan and 1 regional persistent pain service) intervention feasibility study that will be evaluated using mixed methods.

Methods

A communication training program will be developed informed by qualitative interviews with key stakeholders, and adapt the patient-centred ‘clinical yarning’ framework for the Queensland context. Evaluation of the effectiveness of the training will involve the analysis of quantitative data collected at three study sites over a 12-month period. At the patient level, communication experience will be rated at differing times of the training rollout to reflect participants' experience of communication either prior to or following the treating clinician attending the communication training. At the clinician level, evaluation of the training program will be based on changes of ratings in the importance of training, knowledge, ability and confidence to communicate with Aboriginal and Torres Strait Islander patients; satisfaction, acceptance and relevance to their clinical practice. This study will be grounded in the needs and preferences of communication of Aboriginal and Torres Strait Islander people living with pain.

Conclusion

It is hypothesized that the patient-centred intervention will have immediate benefits for patients, improving patient experience of care. This research will focus on an area of unmet need in addressing persistent pain.

Evaluation of a First Peoples-led, emotion-based pedagogical intervention to promote cultural safety in undergraduate non-Indigenous health professional students

BACKGROUND

Undergraduate health students learn cultural safety in complex and emotional ways. Pedagogies that account for these complexities must be developed and evaluated.

OBJECTIVES

To evaluate a First Peoples-led emotion-based pedagogical intervention on non-Indigenous health professional students' development towards cultural safety.

DESIGN

A pre-post mixed-methods intervention design.

SETTING AND PARTICIPANTS

All undergraduate health students undertaking a semester-long First Peoples cultural safety course (n = 395) were invited to participate.

METHODS

The intervention involved students' written reflections and comfort (1 = very uncomfortable to 5 = very comfortable) with workshop content, using a gawugaa-gii-mara (head, heart, hands) form. The educator analysed student responses collected on the form, to prompt discussion in a series of four workshops. Students also completed the online 20-item Student Emotional Learning in Cultural Safety Education Instrument (SELCSI) which has two scales, Witnessing and Comfort. gawugaa-gii-mara responses were thematically coded. Paired sample t-tests examined differences over time. Eta squared determined effect size.

RESULTS

There were 102 matched pre-post-intervention surveys. Both SELCSI scales had excellent internal consistency (Witnessing α = 0.80, Comfort α = 0.92). A statistically significant difference was observed between students' mean scores on the Witnessing scale prior to the course (M = 47.10, SD = 6.51) compared to post-course (53.04, SD = 4.80), t(95) = 8.70, p < 0.001 (two-tailed) with a large effect size (d = 0.88). Most Comfort scale items increased but were not statistically significant. Data from the gawugaa-gii-mara intervention (n = 162 written responses) revealed students were challenged by self-reflexivity. There was a disconnect between what students had learnt (gawugaa), what they had felt (gii) and how this would be applied in professional practice (mara).

CONCLUSIONS

The First Peoples-led, emotions-based pedagogical intervention was brief, meaningful and effective. As students grappled with their emotional connection to self-reflexivity as well as their ability to translate new knowledge into culturally safe practice, these offer important avenues for future research.

There is no health without cultural safety: Why cultural safety matters

The authors would like to pay respect to Aboriginal and Torres Strait Islander Peoples by acknowledging the traditional owners of the lands on which this paper was written, the Wadjuk people of the Nyungar Nation and the Darkinjung people. One author (XX) would like to acknowledge her Wiradjuri ancestry and express respect to her Elders past and present and to Culture and Country.

Chronic disease health literacy in First Nations people: A mixed methods study

AIM

To explore chronic disease education, self-management and health literacy abilities from First Nations Australian adults with chronic disease through the integration of qualitative and quantitative findings.

BACKGROUND

Chronic disease management requires good health literacy abilities to manage long-term health needs. First Nations people have a higher burden of chronic disease although little is known regarding chronic disease health literacy of First Nations people.

DESIGN

A concurrent embedded mixed methods study reported using the Consolidated Criteria for Reporting Qualitative Research guidelines.

METHODS

Data were collected from First Nations people with one or more chronic diseases living in remote Australia between February-November 2017. Quantitative data (n = 200) were collected using the Health Literacy Questionnaire along with demographic and health data. Qualitative data (n = 20) were collected via face-to-face interviews to examine chronic disease education and self-management experiences. Data were analysed separately then integrated to develop meta-inferences.

RESULTS

Poor communication from healthcare providers coupled with low health literacy abilities is a major barrier to both active and successful management of chronic disease. Communicating in medical jargon resulted in individuals being placed in a power differential causing lack of trust and relationship breakdowns with healthcare providers affecting active chronic disease self-management. The perception of inevitability and ambivalence towards chronic disease and the notion of futility towards self-management were concurred with the low level of active engagement in health care.

CONCLUSIONS

Yarning is an important strategy used by First Nations people for communication. For nurses, understanding and developing skills in yarning will facilitate cultural safety, communication and understanding about chronic disease self-management in contexts where health literacy abilities are challenged.

RELEVANCE TO CLINICAL PRACTICE

Using yarning, and plain language visual aids, and teach-back will readdress the power differential experienced by First Nations people and may also improve understanding of chronic disease self-management.

"The support has been brilliant": experiences of Aboriginal and Torres Strait Islander patients attending two high performing cancer services

BACKGROUND

Improving health outcomes for Indigenous people by providing person-centred, culturally safe care is a crucial challenge for the health sector, both in Australia and internationally. Many cancer providers and support services are committed to providing high quality care, yet struggle with providing accessible, culturally safe cancer care to Indigenous Australians. Two Australian cancer services, one urban and one regional, were identified as particularly focused on providing culturally safe cancer care for Indigenous cancer patients and their families. The article explores the experiences of Indigenous cancer patients and their families within the cancer services and ascertains how their experiences of care matches with the cancer services' strategies to improve care.

METHODS

Services were identified as part of a national study designed to identify and assess innovative services for Indigenous cancer patients and their families. Case studies were conducted with a small number of identified services. In-depth interviews were conducted with Indigenous people affected by cancer and hospital staff. The interviews from two services, which stood out as particularly high performing, were analysed through the lens of the patient experience.

RESULTS

Eight Indigenous people affected by cancer and 23 hospital staff (Indigenous and non-Indigenous) were interviewed. Three experiences were shared by the majority of Indigenous cancer patients and family members interviewed in this study: a positive experience while receiving treatment at the cancer service; a challenging time between receiving diagnosis and reaching the cancer centre; and the importance of family support, while acknowledging the burden on family and carers.

CONCLUSIONS

This article is significant because it demonstrates that with a culturally appropriate and person-centred approach, involving patients, family members, Indigenous and non-Indigenous staff, it is possible for Indigenous people to have positive experiences of cancer care in mainstream, tertiary health services. If we are to improve health outcomes for Indigenous people it is vital more cancer services and hospitals follow the lead of these two services and make a sustained and ongoing commitment to strengthening the cultural safety of their service.

Measuring health care experiences that matter to Indigenous people in Australia with cancer: identifying critical gaps in existing tools

BACKGROUND

Measurement of patients' healthcare experiences is increasingly used as an indicator of quality of care, but there are concerns that existing measures omit information that is meaningful to patients and that results may not be used systematically to inform service improvement. Further, current approaches may be inadequate for some population groups, such as Indigenous people in Australia, whose healthcare experience is impacted by the context of colonisation and discordance between Indigenous understandings of health and the Western biomedical health system. This study aimed to assess the extent to which existing patient experience measures used in Australia collect information about critical aspects of cancer care, as previously identified by Indigenous people affected by cancer and their health care providers.

METHODS

A two-stage process was used to examine the adequacy of existing patient experience measures for Indigenous people in Australia: (1) relevant tools and measures were identified and assessed, and four measures selected as suitable comparators; (2) comparators were examined in detail and mapped against topics identified in earlier research as important to Indigenous people with cancer. Gaps in topic coverage in comparators were identified.

RESULTS

No comparators completely captured the critical aspects of cancer care identified by Indigenous people affected by cancer and their health care providers. The number of topics 'partially' captured by the four comparators ranged from 4 to 7 out of 9. While most topics were partially covered, the lack of questions around culture and cultural safety was notable.

CONCLUSIONS

Existing tools are likely to miss key aspects of Indigenous peoples' experiences of cancer care in Australia. Failure to adequately assess care experiences related to cultural safety may compromise efforts to improve health outcomes. Addressing gaps requires development of experience measures that are strengths-based, reflect an Indigenous worldview and measure aspects of experience relevant to Indigenous people.

Occurrence and timely management of problems requiring prompt intervention among Indigenous compared with non-Indigenous Australian palliative care patients: a multijurisdictional cohort study

OBJECTIVES

Anticipation and prompt relief of symptoms among patients with a life-limiting illness is a core element of palliative care. Indigenous Australians commonly encounter cultural barriers in healthcare that may impair outcomes. The Palliative Care Outcomes Collaboration collects patient care data for the purposes of continuous quality improvement and benchmarking, with each recorded care episode divided into phases that reflect a patient's condition. We aimed to investigate differences between Indigenous and non-Indigenous patients in the occurrence and duration of 'unstable' phases (which indicate unanticipated deterioration in a patient's condition or circumstances), and determine attainment of the relevant benchmark (resolution of unstable phases in ≤3 days in 90% of cases) for both groups.

DESIGN

Cohort study.

SETTING

Australia-wide hospital-based and community-based specialist palliative care (1 January 2010 to 30 June 2015).

PARTICIPANTS

139 556 (1502 Indigenous and 138 054 non-Indigenous) adult patients.

OUTCOME MEASURES

Indigenous and non-Indigenous patients were compared on (1) the risk of a phase being categorised as unstable, (2) the duration of unstable phases, and (3) the risk of unstable phases being prolonged (>3 days). Crude and adjusted estimates were produced from three-level robust Poisson regression and complementary log-log discrete time survival models.

RESULTS

Unstable phases occurred with similar frequency overall among Indigenous and non-Indigenous patients (adjusted relative risks 1.06; 95% CI 1.00 to 1.11; not significant after correction for multiple comparisons). The duration and risk of prolongation of unstable phases were similar in both patient groups, with no significant differences evident among subgroups. The benchmark was not met for either Indigenous or non-Indigenous patients (unstable phase duration >3 days in 24.3% vs 25.5%; p=0.398).

CONCLUSIONS

Despite well-documented shortcomings of healthcare for Indigenous Australians, there is no clear evidence of greater occurrence or prolongation of unanticipated problems among Indigenous patients accessing specialist palliative care services in hospital or the community.