Theory to social action: A university-based strategy targeting prejudice against Aboriginal Australians

A scoping review of frameworks utilized in the design and evaluation of courses in health professional programs to address the role of historical and ongoing colonialism in the health outcomes of Indigenous Peoples

Indigenous education curriculum has been implemented in health professional programs as a potential solution to addressing commonly held false beliefs, as well as negative social attitudes and behaviours. As such it is important to map and analyze the current literature on educational initiatives that teach about historical and ongoing colonialism as a determinant of health to identify commonly used theoretical frameworks and outcomes assessed, as well as the intended and unintended short- and long-term outcomes on health professional learner's beliefs, attitudes and behaviours. This scoping review follows the framework by (Peters et al., JBI Evidence Synthesis 18:2119-2126, 2020). Six databases (MEDLINE, CINAHL, PsychInfo, Sociological Abstracts, ERIC, and ProQuest Dissertations and Theses) were searched with grey literature included through hand-searching of Indigenous journals and citation searching for papers published up until 2022 based on an established search criterion. Two reviewers independently screened articles. In total, 2731 records were identified and screened; full text was assessed for 72 articles; 14 articles were identified as meeting all the inclusion criteria and included in the final review. Commonly- used theoretical frameworks were transformative learning and cultural safety, with a variety of evaluation tools used and post-intervention outcomes measured across the studies (e.g., knowledge, beliefs, attitudes, behaviour and general learner feedback). Indigenous education interventions require longitudinal evaluation studies to address shortcomings in the design and evaluation of outcomes associated with teaching about colonialism as a structural determinant of health. It is critical that we identify and monitor the intended and unintended consequences of such curriculum as we look to develop solutions to changing health professional learners' false beliefs and attitudes, in hopes to inform their future care practices.

Beliefs around the causes of inequities and intergroup attitudes among health professional students before and after a course related to Indigenous Peoples and colonialism

BACKGROUND

Addressing the Truth and Reconciliation Calls to Action on including anti-racism and cultural competency education is acknowledged within many health professional programs. However, little is known about the effects of a course related to Indigenous Peoples and colonialism on learners' beliefs about the causes of inequities and intergroup attitudes.

METHODS

A total of 335 learners across three course cohorts (in 2019, 2020, 2022) of health professional programs (e.g., Dentistry/Dental Hygiene, Medicine, Nursing, and Pharmacy) at a Canadian university completed a survey prior to and 3 months following an educational intervention. The survey assessed gender, age, cultural identity, political ideology, and health professional program along with learners' causal beliefs, blaming attitudes, support for social action and perceived professional responsibility to address inequities. Pre-post changes were assessed using mixed measures (Cohort x Time of measurement) analyses of variance, and demographic predictors of change were determined using multiple regression analyses. Pearson correlations were conducted to assess the relationship between the main outcome variables.

RESULTS

Only one cohort of learners reported change following the intervention, indicating greater awareness of the effects of historical aspects of colonialism on Indigenous Peoples inequities, but unexpectedly, expressed stronger blaming attitudes and less support for government social action and policy at the end of the course. When controlling for demographic variables, the strongest predictors of blaming attitudes towards Indigenous Peoples and lower support for government action were gender and health professional program. There was a negative correlation between historical factors and blaming attitudes suggesting that learners who were less willing to recognize the role of historical factors on health inequities were more likely to express blaming attitudes. Further, stronger support for government action or policies to address such inequities was associated with greater recognition of the causal effects of historical factors, and learners were less likely to express blaming attitudes.

CONCLUSION

The findings with respect to blaming attitudes and lower support for government social action and policies suggested that educational interventions can have unexpected negative effects. As such, implementation of content to address the Truth and Reconciliation Commissions Calls to Action should be accompanied by rigorous research and evaluation that explore how attitudes are transformed across the health professional education journey to monitor intended and unintended effects.

The associations of dispositional mindfulness, self-compassion, and reappraisal with symptoms of depression and anxiety among a sample of Indigenous students in Canada

ObjectiveDepression and anxiety are major concerns among students. Unfortunately, there are disparities between the mental health of majority culture students (White; Judeo-Christian) and that of Indigenous students. Although mindfulness, self-compassion, and reappraisal are correlated with symptoms of psychopathology among White students, these relationships have never been examined among Indigenous students. Participants: Undergraduate Indigenous students recruited from a Canadian institution. Methods: We administered self-report measures of depression, anxiety, dispositional mindfulness, self-compassion, and emotion regulation strategies (cognitive reappraisal and emotional suppression). Results: 37.5% (n = 33) and 40.9% (n = 36) reported significant symptoms of depression or anxiety, respectively. Dispositional mindfulness and self-compassion were negatively and strongly associated with depression symptoms (r = -.58 and r = -.58, respectively). Further, both constructs were also negatively and strongly associated with anxiety symptoms (r = -.55 and r = -.53, respectively). We also found a negative correlation between reappraisal and depression and anxiety symptoms. Conclusions: Mindfulness, self-compassion, and reappraisal are associated with depression and anxiety symptoms among this sample of Indigenous students.

A critique of measures of emotion and empathy in First Peoples' cultural safety in nursing education: A systematic literature review

BACKGROUND

In Australia, undertaking cultural safety education often evokes strong emotional responses by health students. Despite the potential for emotion to drive transformative learning in this space, measures of emotion are uncommon.

AIM

To review existing tools that intend to measure emotional components of learning in relation to cultural safety education.

METHODS

Articles published in English from January 2005 to January 2020; reported studies from Australia, New Zealand, Canada and United States of America; and measured an emotional construct/s after an education intervention offered to university students enrolled in a health programme were included. Studies were assessed for quality according to the Critical Appraisals Skills Programme criteria.

RESULTS

Eight articles were reviewed; five conducted in the United States of America, and three in Australia. Intervention type, measures, methodological rigour and outcomes varied. Studies predominately measured empathy, guilt and/or fear.

CONCLUSIONS

Although students' emotional responses were measured, processes for students to reflect upon these reactions were not incorporated in the classroom. The review has implications for future research and curricula through developments in measuring and acting upon emotion in cultural safety education for nursing students in Australia.

Diversity Training Goals, Limitations, and Promise: A Review of the Multidisciplinary Literature

In this review, we utilize a narrative approach to synthesize the multidisciplinary literature on diversity training. In examining hundreds of articles on the topic, we discovered that the literature is amorphous and complex and does not allow us to reach decisive conclusions regarding best practices in diversity training. We note that scholars of diversity training, when testing the efficacy of their approaches, too often use proxy measures for success that are far removed from the types of consequential outcomes that reflect the purported goals of such trainings. We suggest that the enthusiasm for, and monetary investment in, diversity training has outpaced the available evidence that such programs are effective in achieving their goals. We recommend that researchers and practitioners work together for future investigations to propel the science of diversity training forward. We conclude with a roadmap for how to create a more rigorous and relevant science of diversity training. Expected final online publication date for the Annual Review of Psychology, Volume 73 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Examining the transformative potential of emotion in education: A new measure of nursing and midwifery students' emotional learning in first peoples' cultural safety

BACKGROUND

There is growing evidence that non-Indigenous health students engage with cultural safety content in complex emotional ways. Identifying those emotions may contribute to transformative learning.

OBJECTIVES

To develop and test a measure of student emotion using an approach that centres relevant theory and First Peoples' perspectives, values and lived realities.

DESIGN

This study used a descriptive, cohort design.

PARTICIPANTS AND SETTING

All health professional students enrolled in an undergraduate Australian First Peoples health course (n = 616) were invited to complete an online survey.

METHODS

A staged approach to tool development included: (1) item generation; (2) response selection; (3) expert review; (4) pilot testing, and (5) psychometric testing of the 20-item draft tool. Tests included item analysis, principal components analysis with varimax rotation, subscale analysis, and internal reliability.

RESULTS

One hundred and nine surveys were analysed (17.7% response rate) predominantly from nursing and midwifery students (n = 96, 88.1%). Testing resulted in the development of the two-scaled Student Emotional Learning in Cultural Safety Instrument (SELCSI). The 12-item Witnessing scale revealed three factors explaining 62.17% of variance, and the 8-item Comfort scale had two factors explaining 67.62% of the variance. Cronbach's alpha showed good internal consistency (Witnessing scale α = 0.78; Comfort scale α = 0.88). There was a correlation between mean Witnessing (M = 50.06, SD 5.66) and Comfort (M = 32.44, SD 5.01) scores (r = 0.47, p < 0.001, 95% CI [0.304-0.643]).

CONCLUSIONS

The two scales of students' emotional learning were found to have preliminary validity and reliability. Use of the tool has important theoretical, pedagogical and methodological considerations for cultural safety in nursing and midwifery education. This tool may contribute to understanding how nursing and midwifery students learn to practice in culturally safe ways.

Understanding Australian policies on public health using social and political science theories: reflections from an Academy of the Social Sciences in Australia Workshop

There is strong, and growing, evidence documenting health inequities across the world. However, most governments do not prioritize policies to encourage action on the social determinants of health and health equity. Furthermore, despite evidence concerning the benefits of joined-up, intersectoral policy to promote health and health equity, it is rare for such policy approaches to be applied systematically. To examine the usefulness of political and social science theory in understanding the reasons for this disjuncture between evidence and practice, researchers and public servants gathered in Adelaide for an Academy of the Social Sciences in Australia (ASSA) Workshop. This paper draws together the learnings that emerged from the Workshop, including key messages about the usefulness of various theories as well as insights drawn from policy practice. Discussions during the Workshop highlighted that applying multiple theories is particularly helpful in directing attention to, and understanding, the influence of all stages of the policy process; from the construction and framing of policy problems, to the implementation of policy and evaluation of outcomes, including those outcomes that may be unintended. In addition, the Workshop emphasized the value of collaborations among public health researchers, political and social scientists and public servants to open up critical discussion about the intersections between theory, research evidence and practice. Such critique is vital to render visible the processes through which particular sources of knowledge may be privileged over others and to examine how political and bureaucratic environments shape policy proposals and implementation action.

Critical Reflexivity in Indigenous and Cross-cultural Psychology: A Decolonial Approach to Curriculum?

Critical reflexivity is a mechanism for working toward decoloniality in higher education, with the potential to prompt students' to critique the contexts in which they are embedded, and facilitate transformative learning. We present a critical examination of the tensions surrounding decoloniality and critical reflexivity in an undergraduate unit on Indigenous and cross-cultural psychology at a large Australian university. We invited students in the unit to participate in a written reflexive exercise at the beginning (N = 44) and end of semester (N = 23) and analyzed these reflections qualitatively for level (four-category scheme for coding) and content (causal layered analysis) of reflection. Findings suggest that, while students' primarily demonstrate reflective engagement at levels preordinate to critical reflexivity, they are also engaged in active and nuanced processes of negotiating discomfort and uncertainty in this space. We pose critical commentary on the notion of safety in teaching practice, and consider the role of the academic institution in parametrizing the decolonial stance. This research holds application and transferability to higher education settings, and for the enduring project of engaging a decolonial approach to the curriculum within psychology.

Experiences and outcomes of health professional students undertaking education on Indigenous health: A systematic integrative literature review

OBJECTIVES

To explore the experiences and outcomes of health professional students when undertaking education on Indigenous health.

DESIGN

An integrative systematic literature review.

DATA SOURCES

The search was undertaken from September 2017-November 2017. Six databases were searched: CINAHL, Scopus, Informit Health Collection, Informit Indigenous Collection, Proquest - Nursing and Allied Health Collection; and Proquest - Health and Medical Collection. Reference lists of all articles were scanned for further relevant articles.

REVIEW METHODS

The search strategy was limited to English articles published in the previous decade. Articles were included if they focused on Indigenous health content provided to health professional university students, with a focus on Indigenous populations of Australia, New Zealand, Canada and the United States of America. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guided the review. Studies were evaluated for methodological rigour using the CASP rating checklist. Both qualitative and quantitative data were coded using thematic qualitative analysis methods and presented as a meta-aggregation.

RESULTS

Twelve articles were included. Synthesis found significant variability in the ways Indigenous health issues were taught and integrated into health programs, particularly with regards to quality, methodological rigour of evaluation, pedagogical approaches and student experiences. Four themes were developed to describe student experiences and learning outcomes. These included: increasing knowledge of Indigenous health; emotional responses to content and teaching processes; perceived value of Indigenous health education; and cultural competence and critical thinking.

CONCLUSIONS

Methodologically sound longitudinal studies are required to test if early changes in student knowledge and attitudes may be sustained. How students' 'increase in knowledge' translates to cultural capability is unclear, and there is a need for validated tools to measure this construct. A more sophisticated critique of how students emotionally engage with Indigenous health content, including understanding the relationships between 'discomfort' and transformative experiences is required.

Applying a Midwifery Lens to Indigenous Health Care Delivery: The Contribution of Campus Learning and Rural Placements to Effecting Systemic Change

STUDY BACKGROUND

Increasing cultural safety in health settings is essential to address stark health disparities between Indigenous and non-Indigenous Australians. Respect for cultural knowledge, better communication, and recognition of racism as a determinant of health are required for improved service delivery. How this knowledge is acquired in health professional training and translated to clinical settings is poorly understood.

PURPOSE

Impacts of an innovative Indigenous health unit and remote clinical placements on knowledge acquisition and attitude change were explored among midwifery students to inform cultural competency initiatives in health professional training.

METHODS

A multiphased, mixed methods research design used surveys, observations, and interviews. Qualitative analysis was strengthened through triangulation with quantitative data.

RESULTS

A unit conceived with substantial Indigenous Australian input and which privileged these voices enhanced knowledge and shifted attitudes in a positive direction; however, immediate gains diminished over time. Remote placements had a profound effect on student learning. Exposure to Indigenous Australians in classrooms and communities, and the self-reflection generated, helped dispel stereotypes and challenge assumptions based on limited cultural knowledge and contact.

CONCLUSION

Optimization of receptivity to Indigenous Australian content and opportunities for remote placements contributed to students' developing cultural capabilities with implications for all health professional training. Whether this heightened awareness is enough to address institutional racism identified in health service delivery remains unanswered. The focus must include those established health practitioners and administrators who influence organizational culture if real systemic change is to occur. Given appropriate on-going support, graduates can play a vital role in expediting this process.

Validation of the first peoples cultural capability measurement tool with undergraduate health students: A descriptive cohort study

BACKGROUND

Health professional graduates require the capacity to work safely, both clinically and culturally, when delivering care to Indigenous peoples worldwide. In the Australian context, the Aboriginal and Torres Strait Islander Health Curriculum Framework (The Framework) provides guidance for health professional programs to integrate, teach and assess Aboriginal and Torres Strait Islander peoples' (First Peoples) health content. There is, however, a lack of validated tools that measure the development of students' cultural capabilities.

OBJECTIVES

To validate the Cultural Capability Measurement Tool with a cohort of health professional students.

DESIGN

A descriptive cohort design was used.

SETTING AND PARTICIPANTS

All students (N = 753) enrolled in a discrete First Peoples Health course at an Australian university were invited to complete the Cultural Capability Measurement Tool.

METHODS

The tool was tested for reliability, content and construct validity using confirmatory factor analysis; and concurrent validity using and the Cultural Understanding Self-Assessment Tool.

RESULTS

A sample of 418 (73% response rate) was recruited. Most participants were enrolled in the Bachelor of Nursing program (n = 369, 82%). The Cultural Capability Measurement Tool had a Cronbach's alpha coefficient of 0.86. A five-factor solution was confirmed which reflected the cultural capability domains and accounted for 51% of the variance. Scores correlated with students' cultural understanding (r = 0.28, p < 0.001).

CONCLUSIONS

Successful implementation of The Framework requires instruments to measure changes in students' cultural capabilities. Measuring nursing students' cultural capabilities can inform their development, identify areas of strengths and deficits for educators, and will ultimately contribute to the development of a culturally safe nursing workforce.

Development of a First Peoples-led cultural capability measurement tool: A pilot study with midwifery students

BACKGROUND

Midwives have a central role in closing the gap in health inequalities between Australias' First Peoples and other childbearing women. The Aboriginal and Torres Strait Islander Health Curriculum Framework (The Framework) identifies five core cultural capabilities (respect, communication, safety and quality, reflection and advocacy) to foster culturally safe health care.

AIM

To use a decolonising, First Peoples-led approach to develop and validate a tool to measure the development students' cultural capabilities.

METHOD

A pre- post intervention design was used. Development of the Cultural Capability Measurement Tool followed a staged process which centred on First Peoples' knowledges. This process included: item generation, expert review; a pilot, test-retest; and psychometric testing (reliability, factor analysis and construct validity). All third year midwifery students (n=49) enrolled in a discrete First Peoples health course were invited to complete the survey pre and post course.

FINDINGS

A response rate of 77.5% (n=38/49) pre-course and 30.6% (15/49) at post-course was achieved. The tool demonstrated good internal reliability (Cronbach alpha=.89-.91). Principal component analysis with varimax rotation produced a five-factor solution. A paired samples t-test revealed a significant increase from pre-course (mean 93.13, SD 11.84) to post-course scores (mean=100.53, SD 7.54) (t (14)=-2.79, p=.014).

CONCLUSION

A First Peoples approach was critical to tool development and conceptual validity. The 22 item Cultural Capability measurement Tool reflected the core cultural capabilities of The Framework. The draft tool appears suitable for use with midwifery students.

Asylum Seekers and Resettled Refugees in Australia: Predicting Social Policy Attitude From Prejudice Versus Emotion

While most of the world's refugees reside in developing countries, their arrival to western countries is highly politicised, giving rise to questions about the types of entitlements and rights that should, or should not, be granted. In this study, using a mixed-methods community questionnaire (N = 185), we examined attitudes towards social policies aimed at providing assistance to two categories of new arrivals to Australia: resettled refugees (who arrive via its official refugee resettlement program) and asylum seekers (who arrive via boat and then seek refugee status). Social policy attitude was examined as a consequence of feelings of anger, fear, and threat, as well as levels of prejudice. Participants felt significantly higher levels of anger, fear, threat, and prejudice towards asylum seekers compared to resettled refugees. For both resettled refugees and asylum seekers, prejudice was an independent predictor of more restrictive social policy attitudes. For resettled refugees, fear and perceived threat were independent predictors for more restrictive social policy whereas for asylum seekers anger was an independent predictor of restrictive social policy. The qualitative data reinforced the quantitative findings and extended understanding on the appraisals that underpin negative attitudes and emotional responses. Practical implications relating to challenging community attitudes are discussed.

Exploring undergraduate midwifery students' readiness to deliver culturally secure care for pregnant and birthing Aboriginal women

BACKGROUND

Culturally secure health care settings enhance accessibility by Aboriginal Australians and improve their satisfaction with service delivery. A culturally secure health service recognises and responds to the legitimate cultural rights of the recipients of care. Focus is upon the health care system as well as the practice and behaviours of the individuals within it. In an attempt to produce culturally secure practitioners, the inclusion of Aboriginal content in health professional programs at Australian universities is now widespread. Studies of medical students have identified the positive impact of this content on knowledge and attitudes towards Aboriginal people but relatively little is known about the responses of students in other health professional education programs. This study explored undergraduate midwifery students' knowledge and attitudes towards Aboriginal people, and the impact of Aboriginal content in their program.

METHODS

The study surveyed 44 students who were in their first, second and third years of a direct entry, undergraduate midwifery program at a Western Australian (WA) university. The first year students were surveyed before and after completion of a compulsory Aboriginal health unit. Second and third year students who had already completed the unit were surveyed at the end of their academic year.

RESULTS

Pre- and post-unit responses revealed a positive shift in first year students' knowledge and attitudes towards Aboriginal people and evidence that teaching in the unit was largely responsible for this shift. A comparison of post-unit responses with those from students in subsequent years of their program revealed a significant decline in knowledge about Aboriginal issues, attitudes towards Aboriginal people and the influence of the unit on their views. Despite this, all students indicated a strong interest in more clinical exposure to Aboriginal settings.

CONCLUSIONS

The inclusion of a unit on Aboriginal health in an undergraduate midwifery program has been shown to enhance knowledge and shift attitudes towards Aboriginal people in a positive direction. These gains may not be sustained, however, without vertical integration of content and reinforcement throughout the program. Additional midwifery-specific Aboriginal content related to pregnancy and birthing, and recognition of strong student interest in clinical placements in Aboriginal settings provide opportunities for future curriculum development.

Do indigenous health curricula in health science education reduce disparities in health care outcomes?

OBJECTIVE

To undertake a systematic literature review to determine the scope, rationales, and evaluation foci of indigenous health curricula included in university-based professional training of health care service providers.

STUDY DESIGN

Systematic review.

DATA SOURCES

We searched the Australasian Medical Index, ATSIhealth (Aboriginal and Torres Strait Islander Health Bibliography), CINAHL PLUS, MEDLINE, SCOPUS version 4, and Web of Science databases using relevant keywords. Our initial search identified 1247 articles and our refined search identified 57 articles. Thirty-six articles published between 1999 and 2011 that referred to indigenous health-related curricula within university health science courses were selected for review.

DATA SYNTHESIS

While almost all the articles were explicit that improving indigenous health was an aim of their curriculum, none evaluated the impact of curricula on patient outcomes.

CONCLUSION

There appears to be a widespread assumption in the literature that improving practitioner skills, knowledge and attitudes will lead to improvements in indigenous health outcomes. The literature showed evidence of efforts towards evaluating learner (student) outcomes, but no evidence of evaluation of patient outcomes. We need to begin to design methods that focus on evaluating the impacts of indigenous health curricula on patient outcomes, while continuing to investigate the impact of curricula on learner outcomes.

Feeling their stories: contemplating empathy, insider/outsider positionings, and enriching qualitative research

Empathy is a very familiar term in the helping and caring literature. What appears to link empathy in the helping literature to the aims and goals of qualitative research and, in particular, to the argument underpinning insider/outsider debates, is a discernible common quest. That quest is to be able to hear, feel, understand, and value the stories of others and to convey that felt empathy and understanding back to the client/storyteller/participant. When relevant, the quest also includes conveying that felt understanding to a broader audience. In this article, I highlight commonalities between empathy in professional practice and empathy in qualitative research processes, including the shared experiences and understanding informing research relationships that are discussed as "insider/outsider" status. I review, discuss, and critique relevant literature, and I conclude by suggesting that cultivating empathy in qualitative research training could contribute to facilitating more enriched, insightful research encounters.

Effects of Non-Indigenous Australian Human Resource Managers' Gender and Attitudes and Applicants' Ethnicity and Gender on Resumé Evaluations

In this web-based survey, 60 non-Indigenous Australian human resource (HR) professionals reviewed four fictitious job resumés for an Indigenous male, Indigenous female, non-Indigenous male and non-Indigenous female. Participants rated the resumés against five key selection criteria and then ranked them in terms of suitability for a HR position, team fit (TF) with participants' current HR team, and suitability for a customer service (CS) position. Finally, participants completed a modified Attitude toward Indigenous Australians scale. Although participants' gender and attitudes and applicants' gender and ethnicity did not have an effect on resumé ratings, rank differences for the HR position and TF for the whole sample were significantly different, with the non-Indigenous male applicant being preferred to the Indigenous male and female applicants. Participants holding a negative attitude toward Indigenous people consistently ranked the non-Indigenous male applicant more favourably than the Indigenous male and female applicants and the non-Indigenous female applicant more favourably than the Indigenous male applicant. Female participants ranked the non-Indigenous male applicant more favourably than the Indigenous male and female applicants for the HR position and TF. Implications for Indigenous Australian employment disadvantage are examined with reference to social identity and contemporary racism theories.

Bystander Antiprejudice: Cross-Cultural Education, Links With Positivity Towards Cultural ‘Outgroups’ and Preparedness to Speak Out

This article describes a 12-week intervention targeting positivity towards asylum seekers, Indigenous Australians and Muslim Australians. The study also assessed change in the intention to engage in bystander activism in four different scenarios: two Indigenous (old-fashioned and modern prejudice), one Muslim and one asylum seeker. There was a significant increase in positivity towards asylum seekers, Indigenous Australians and Muslim Australians. There was also a significant increase in ‘speaking out intention’, a form of bystander anti-prejudice, in three of the scenarios, but not in response to the Indigenous old-fashioned prejudice scenario. The study indicates that structured education on cross-cultural issues can improve attitudes to perceived ‘outgroups’ and, for the most part, increase participants' intention to speak out against prejudice.