Sharing stories: indigenous alcohol and other drug workers' well-being, stress and burnout

Examining global Indigenous community wellness worker models: a rapid review

BACKGROUND

There is a growing interest in employing community wellness worker models in Indigenous populations to address inequities in healthcare access and outcomes, concerns about shortage in health and mental health human resources, and escalating burden of chronic and complex diseases driving significant increase in health services demand and costs. A thorough review of Indigenous community wellness worker models has yet to be conducted. This rapid review sought to outline the characteristics of a community wellness worker model in Indigenous contexts across the globe, detailing factors shaping implementation challenges and success.

METHODS

A rapid review of the international peer-reviewed and grey literature of OVID Medline, Global Index Medicus, Google, and Google Scholar was conducted from January to June 2022 for Indigenous community wellness/mental health worker models and comparative models. Articles were screened and assessed for eligibility. From eligible articles, data pertaining to study design and sample; description of the program, service, or intervention; model development and implementation; terminology used to describe workers; training features; job roles; funding considerations; facilitators and barriers to success; key findings; outcomes measured; and models or frameworks utilized were extracted. Data were synthesized by descriptive and pattern coding.

RESULTS

Twenty academic and eight grey literature articles were examined. Our findings resulted in four overarching and interconnected themes: (1) worker roles and responsibilities; (2) worker training, education, and experience; (3) decolonized approaches; and (4) structural supports.

CONCLUSION

Community wellness worker models present a promising means to begin to address the disproportionately elevated demand for mental wellness support in Indigenous communities worldwide. This model of care acts as a critical link between Indigenous communities and mainstream health and social service providers and workers fulfill distinctive roles in delivering heightened mental wellness supports to community members by leveraging strong ties to community and knowledge of Indigenous culture. They employ innovative structural solutions to bolster their efficacy and cultivate positive outcomes for service delivery and mental wellness. Barriers to the success of community wellness worker models endure, including power imbalances, lack of role clarity, lack of recognition, mental wellness needs of workers and Indigenous communities, and more.

Healthcare social network research and the ECHO model™: Exploring a community of practice to support cultural brokers and transfer cultural knowledge

BACKGROUND

Project ECHO® networks at Children's Health Queensland Hospital and Health Service (CHQHHS) are communities of practice designed to mitigate services and systems fragmentation by building collaborative partnerships addressing priority child and youth health needs. Aboriginal and Torres Strait Islander people experience the negative impacts of fragmentation in addition to historical challenges of absent or culturally inappropriate health services. Access to culturally safe and responsive services can be improved by engaging Aboriginal and Torres Strait Islander Health Workers and similar roles in an online community of practice, supporting the integration of cultural and clinical knowledge and self-determination of Aboriginal and Torres Strait Islander consumers in decisions affecting their health. Analysing professional support networks and knowledge sharing patterns helps identify enablers and barriers to partnerships. Using social network research, the multilevel network inclusive of ECHO network members and their colleagues was studied to identify interdisciplinary and cross-sector advice exchange patterns, explore the position of cultural brokers and identify common relational tendencies.

METHODS

Social network theories and methods informed the collection of network data and analysis of advice-seeking relationships among ECHO network members and their nominees. Registered members from two ECHO networks were invited to complete the Qualtrics survey. Networks analysed comprised 398 professionals from mainstream health, Aboriginal and Torres Strait Islander Community Controlled Health Organisation, education, disability and child safety service settings.

RESULTS

Brokers were well represented, both those who hold knowledge brokerage positions as well as cultural brokers who incorporate clinical and cultural knowledge enabling holistic care for Aboriginal and Torres Strait Islander patients (38 individuals, 17% of network). Professionals who occupy brokerage positions outside the ECHO network tend to be more connected with co-members within the network.

CONCLUSIONS

This study is the first application of contemporary social network theories and methods to investigate an ECHO network. The findings highlight the connectivity afforded by brokers, enabling the coordination and collaboration necessary for effective care integration. Inclusion of cultural brokers in an ECHO network provides sustained peer group support while also cultivating relationships that facilitate the integration of cultural and clinical knowledge.

Exploring self-determined solutions to service and system challenges to promote social and emotional wellbeing in Aboriginal and Torres Strait Islander people: a qualitative study

Introduction

Many Aboriginal and Torres Strait Islander people living on Kaurna Country in northern Adelaide experience adverse health and social circumstances. The Taingiwilta Pirku Kawantila study sought to understand challenges facing Aboriginal and Torres Strait Islander communities and identify solutions for the health and social service system to promote social and emotional wellbeing.

Methods

This qualitative study applied Indigenous methodologies undertaken with Aboriginal and Torres Strait Islander governance and leadership. A respected local Aboriginal person engaged with Aboriginal and Torres Strait Islander community members and service providers through semi-structured interviews and yarning circles that explored community needs and challenges, service gaps, access barriers, success stories, proposed strategies to address service and system challenges, and principles and values for service design. A content analysis identified the breadth of challenges in addition to describing key targets to empower and connect communities and optimize health and social services to strengthen individual and collective social and emotional wellbeing.

Results

Eighty-three participants contributed to interviews and yarning circles including 17 Aboriginal community members, 38 Aboriginal and Torres Strait Islander service providers, and 28 non-Indigenous service providers. They expressed the need for codesigned, strengths-based, accessible and flexible services delivered by Aboriginal and Torres Strait Islander workers with lived experience employed in organisations with Aboriginal and Torres Strait Islander leadership and governance. Community hubs and cultural events in addition to one-stop-shop service centres and pre-crisis mental health, drug and alcohol and homelessness services were among many strategies identified.

Conclusion

Holistic approaches to the promotion of social and emotional wellbeing are critical. Aboriginal and Torres Strait Islander people are calling for places in the community to connect and practice culture. They seek culturally safe systems that enable equitable access to and navigation of health and social services. Aboriginal and Torres Strait Islander workforce leading engagement with clients is seen to safeguard against judgement and discrimination, rebuild community trust in the service system and promote streamlined access to crucial services.

Exploring the impact of rural health system factors on physician burnout: a mixed-methods study in Northern Canada

BACKGROUND

Burnout among physicians is a consequence of chronic occupational stresses and emotionally intense work demands. However, much of the evidence exploring burnout is derived from urban settings and may not reflect the work and social contexts of physicians in Indigenous communities or in rural and resource-constrained areas. We sought to characterize health system factors that influence burnout among physicians practicing in the three northern territories of Canada.

METHODS

We conducted a mixed-methods study that included an online survey and qualitative interviews with physicians practicing in Nunavut, Northwest Territories, or Yukon in 2019. The survey adapted content from the Maslach Burnout Inventory. Results were analyzed with logistic regression to assess the association between health system factors and burnout. We conducted in-depth interviews with 14 physicians. Qualitative data was coded and analyzed for themes using the ATLAS.ti software.

RESULTS

Thirty-nine percent of survey respondents (n = 22/57) showed features associated with burnout. Factors associated with burnout included use of electronic medical records (β = - 0.7, p < .05), inadequate financial remuneration (β = - 1.0, p < .05), and cross-cultural issues (β = - 1.1, p < .05). Qualitative analysis further identified physician perceptions of lack of influence over health system policies, systemic failures in cultural safety, discontinuity of care, administrative burden, and physician turnover as important drivers of burnout.

CONCLUSIONS

Physicians practicing in northern regions in Canada experience stress and burnout related to health system factors and cross-cultural issues. The relationship between cross-cultural issues and burnout has not previously been reported. This work may have implications for physician wellbeing and workforce attrition in other resource-constrained or culturally diverse clinical settings.

Factors influencing the provision of care for Inuit in a mainstream residential addiction rehabilitation centre in Southern Canada, an instrumental case study into cultural safety

BACKGROUND

Provision of culturally safe care has been proposed to address health inequity, including in the areas of mental health and addiction. The factors that influence the provision of culturally safe care remain understudied. This paper explores the factors influencing the efforts of a mainstream residential addiction rehabilitation centre to provide culturally appropriate and quality care for Inuit.

METHODS

An instrumental case study was conducted, informed by ethnographic and creative research methods. Over 700 h of participant observation were carried out between March 2018 and January 2020, in addition to qualitative semi-structured interviews (34 participants) and/or member-checking activities (17 participants) conducted with a total of 42 individuals: 20 Inuit residents, 18 clinical/specialized staff, and 4 clinical/administrative managers. An interpretive thematic analysis was performed to examine the factors that may influence the provision of culturally safe care for Inuit residents.

RESULTS

Ten categories of interrelated factors were identified and classified according to whether they relate to individual, programmatic, organizational, or systemic levels. These categories covered: (1) residents' and staff's life experiences; (2) personal and relational qualities and skills; (3) the model of care; (4) model flexibility; (5) ways in which relational aspects were considered; (6) sensitivity of the organization towards the population served; (7) human resources and professional development issues; (8) social climate; (9) political, relational, and funding climate; and (10) legislative, regulatory, and professional environment. While system-level factors generally had a negative effect on experiences of cultural safety, most factors at other levels had both favourable and unfavourable effects, depending on the context and dimensions examined.

CONCLUSIONS

The results offer insight into the interplay between the challenges and barriers that mainstream organizations face when working with Inuit, and the opportunities and enablers that organizations can build on to improve their services. This paper contributes to a better understanding of the challenges and opportunities to providing culturally safe addiction programs to Inuit within a complex intervention setting. It concludes by highlighting some areas for improvement to advance cultural safety in this context.

Social and emotional wellbeing among Indigenous Australian correctional officers

The workplace challenges of correctional officers have been well documented. Yet little is known about how such stressors impact the wellbeing of correctional officers from minority cultural-subgroups. This study explored Indigenous Australian correctional officers' social and emotional wellbeing (SEWB) when managing workplace adversity. Specifically, the study sought to identify culturally-specific stressors, protective factors and associated response tendencies to gain a more robust understanding of the factors that impact Indigenous officers' wellbeing in the workplace. In total, 15 Indigenous Australian correctional officers from the Northern Territory participated in the study through focus groups or semi-structured interviews. Thematic analysis of participant data revealed that Indigenous correctional officers' SEWB is influenced by four broad categories: cultural connection, morale, social functioning and somatic health. Results are discussed in terms of common themes, future research and implications for assisting the SEWB of Indigenous officers.

"My work? Well, I live it and breathe it": The seamless connect between the professional and personal/community self in the Aboriginal and Torres Strait Islander health sector

BACKGROUND

Australian Aboriginal and Torres Strait Islander health professionals often juggle the challenges of working and living in the same community in ways that are positive for both themselves and their clients. This study specifically examines the strategies Aboriginal and Torres Strait Islander health professionals have developed to enable them to feel empowered by the sense of being always visible or perceived as being always available. Findings provide examples of how participants (Team Members) established a seamless working self, including how they often held different perspectives to many work colleagues, how Team Members were always visible to community and how Team Members were comfortable to be seen as working when not at work.

METHODS

This qualitative study engages an Indigenous research methodology and uses an Indigenous method, PhotoYarning, to explore lived experiences of a group (n = 15) of Aboriginal and Torres Strait Islander health workers as they worked in the Australian health sector.

RESULTS

The analysis presented here comes from data generated through PhotoYarning sessions. Team Members in this study all work in health care settings in the communities in which they also live, they manage an extremely complex network of interactions and relationships in their daily working lives. They occupy an ambivalent, and sometimes ambiguous, position as representing both their health profession and their community. This article explores examples of what working with seamlessness involved, with findings citing four main themes: (1) Being fellow members of their cultural community, (2) the feeling of always being visible to community as a health worker, (3) the feeling of always being available as a health worker to community even when not at work and (4) the need to set an example.

CONCLUSIONS

While creating the seamlessness of working and living in the same community was not easy, Team Members considered it an important feature of the work they did and vital if they were to be able to provide quality health service to their community. However, they reported that the seamless working self was at odds with the way many of their non-Indigenous Australian colleagues worked and it was not well understood.

"Got to build that trust": the perspectives and experiences of Aboriginal health staff on maternal oral health

BACKGROUND

In Australia, models of care have been developed to train antenatal care providers to promote oral health among pregnant women. However, these models are underpinned by Western values of maternity care that do not consider the cultural needs of Aboriginal and Torres Strait Islander women. This study aimed to explore the perceptions and experiences of Aboriginal health staff towards oral health care during pregnancy. It is part of a larger program of research to develop a new, culturally safe model of oral health care for Aboriginal women during pregnancy.

METHODS

A descriptive qualitative methodology informed the study. Focus groups were convened to yarn with Aboriginal Health Workers, Family Partnership Workers and Aboriginal management staff at two antenatal health services in Sydney, Australia.

RESULTS

A total of 14 people participated in the focus groups. There were four themes that were constructed. These focused on Aboriginal Health Workers and Family Partnership Workers identifying their role in promoting maternal oral health, where adequate training is provided and where trust has been developed with clients. Yet, because the Aboriginal health staff work in a system fundamentally driven by the legacy of colonisation, it has significantly contributed to the systemic barriers Aboriginal pregnant women continue to face in accessing health services, including dental care. The participants recommended that a priority dental referral pathway, that supported continuity of care, could provide increased accessibility to dental care.

CONCLUSIONS

The Aboriginal health staff identified the potential role of Aboriginal Health Workers and Family Partnership Workers promoting oral health among Aboriginal pregnant women. To develop an effective oral health model of care among Aboriginal women during pregnancy, there is the need for training of Aboriginal Health Workers and Family Partnership Workers in oral health. Including Aboriginal staff at every stage of a dental referral pathway could reduce the fear of accessing mainstream health institutions and also promote continuity of care. Although broader oral health policies still need to be changed, this model could mitigate some of the barriers between Aboriginal women and both dental care providers and healthcare systems.

"We're very much part of the team here": A culture of respect for Indigenous health workforce transforms Indigenous health care

BACKGROUND

Improving health outcomes for Indigenous people by strengthening the cultural safety of care is a vital challenge for the health sector, both in Australia and internationally. Although Indigenous people have long requested to have Indigenous practitioners involved in their health care, many health services report difficulties with recruiting and retaining Indigenous staff. This article describes Indigenous workforce policies and strategies from two Australian health services, as well as cancer-service specific strategies.

METHODS

Services were identified as part of a national study designed to identify and assess innovative services for Indigenous cancer patients and their families. In-depth interviews were conducted in a small number of identified services. The interviews from two services, which stood out as particularly high performing, were analysed through the lens of Indigenous health workforce.

RESULTS

Twenty-four hospital staff (Indigenous and non-Indigenous), five Indigenous people with cancer and three family members shared their views and experiences. Eight themes were identified from the way that the two services supported their Indigenous workforce: strong executive leadership, a proactive employment strategy, the Indigenous Health Unit, the Indigenous Liaison Officer, multidisciplinary team inclusion, professional development, work environment and a culture of respect. Participants reported two positive outcomes resulting from the active implementation of the eight workforce themes: 'Improved Indigenous patient outcomes' and 'Improved staff outcomes'.

CONCLUSIONS

These two cancer services and their affiliated hospitals show how positive patient outcomes and a strong Indigenous health workforce can be achieved when a health service has strong leadership, commits to an inclusive and enabling culture, facilitates two-way learning and develops specific support structures appropriate for Indigenous staff. It is hoped that the strategies captured in this study will be used by health services and cancer services to inform their own policies and programs to support building their Indigenous workforce.

Factors supporting retention of aboriginal health and wellbeing staff in Aboriginal health services: a comprehensive review of the literature

INTRODUCTION

Aboriginal Health and Wellbeing staff are crucial for successful primary health care for Aboriginal communities. However, they are often affected by high rates of stress, burnout, and staff turn-over, which can impact primary health care delivery to Aboriginal peoples. The aim of this review was to identify organisational factors that help support the retention of Aboriginal Health and Wellbeing staff in Aboriginal Health services.

METHODS

A comprehensive literature review was undertaken. Eleven electronic databases were searched for papers published between 2002 and 2017 and supplemented by hand searching. Papers were included if they were in English, full text, peer-reviewed, and had a focus on retention of Aboriginal Health and Wellbeing staff, or health staff in comparable roles working in Aboriginal health services. Twenty-six papers were included in the final review.

RESULTS

Five key themes were identified as being important to the retention of Aboriginal Health and Wellbeing staff in Aboriginal Health Services: feeling culturally safe and secure within the workplace; teamwork and collaboration; supervision and strong managerial leadership and support from peers (to debrief, reflect, receive emotional support and strengthen coping mechanisms); professional development (the opportunity for skill development and role progression); and recognition (of work load, quality of work performed, being trusted to work autonomously, and financial remuneration that reflected the high pressure of the role).

CONCLUSION

Aboriginal Health and Wellbeing staff are fundamental to successful primary health care for Aboriginal peoples. State and Federal Governments should consider formalising recognition of the significant cultural knowledge that Aboriginal Health and Wellbeing staff bring to their roles. Formal recognition could also pave the way to revise remuneration as well as ensure adequate support mechanisms are put in place to improve retention and reduce stress and burnout affecting Aboriginal Health and Wellbeing staff.

Community Health Worker Programs to Improve Healthcare Access and Equity: Are They Only Relevant to Low- and Middle-Income Countries?

Background: Community Health Workers (CHWs) are proven to be highly effective in low- and middle-income countries with many examples of successful large-scale programs. There is growing interest in deploying CHW programs in high-income countries to address inequity in healthcare access and outcomes amongst population groups facing disadvantage. This study is the first that examines the scope and potential value of CHW programs in Australia and the challenges involved in integrating CHWs into the health system. The potential for CHWs to improve health equity is explored.

Methods: Academic and grey literature was searched to examine existing CHW roles in the Australian primary healthcare system. Semi-structured telephone interviews were conducted with a purposive sample of 11 people including policymakers, program managers and practitioners, to develop an understanding of policy and practice.

Results: Literature on CHWs in Australia is sparse, yet combined with interview data indicates CHWs conduct a broad range of roles, including education, advocacy and basic clinical services, and work with a variety of communities experiencing disadvantage. Many, and to some extent inconsistent, terms are used for CHWs, reflecting the various strategies employed by CHWs, the characteristics of the communities they serve, and the health issues they address. The role of aboriginal health workers (AHWs) is comparatively well recognised, understood and documented in Australia with evidence on their contribution to overcoming cultural barriers and improving access to health services. Ethnic health workers assist with language barriers and increase the cultural appropriateness of services. CHWs are widely seen to be well accepted and valuable, facilitating access to health services as a trusted ‘bridge’ to communities. They work best where ‘health’ is conceived to include action on social determinants and service models are less hierarchical. Short term funding models and the lack of professional qualifications and recognition are challenges CHWs encounter.

Conclusion: CHWs serve a range of functions in various contexts in Australian primary healthcare (PHC) with a common, valued purpose of facilitating access to services and information for marginalised communities. CHWs offer a promising opportunity to enhance equity of access to PHC for communities facing disadvantage, especially in the face of rising chronic disease.

Factors Affecting the Retention of Indigenous Australians in the Health Workforce: A Systematic Review

Indigenous Australians are under-represented in the health workforce. The shortfall in the Indigenous health workforce compounds the health disparities experienced by Indigenous Australians and places pressure on Indigenous health professionals. This systematic review aims to identify enablers and barriers to the retention of Indigenous Australians within the health workforce and to describe strategies to assist with development and retention of Indigenous health professionals after qualification. Four electronic databases were systematically searched in August 2017. Supplementary searches of relevant websites were also undertaken. Articles were screened for inclusion using pre-defined criteria and assessed for quality using the Mixed Methods Assessment Tool. Fifteen articles met the criteria for inclusion. Important factors affecting the retention of Indigenous health professionals included work environment, heavy workloads, poorly documented/understood roles and responsibilities, low salary and a perception of salary disparity, and the influence of community as both a strong personal motivator and source of stress when work/life boundaries could not be maintained. Evidence suggests that retention of Indigenous health professionals will be improved through building supportive and culturally safe workplaces; clearly documenting and communicating roles, scope of practice and responsibilities; and ensuring that employees are appropriately supported and remunerated. The absence of intervention studies highlights the need for deliberative interventions that rigorously evaluate all aspects of implementation of relevant workforce, health service policy, and practice change.

Diversity in eMental Health Practice: An Exploratory Qualitative Study of Aboriginal and Torres Strait Islander Service Providers

BACKGROUND

In Australia, mental health services are undergoing major systemic reform with eMental Health (eMH) embedded in proposed service models for all but those with severe mental illness. Aboriginal and Torres Strait Islander service providers have been targeted as a national priority for training and implementation of eMH into service delivery. Implementation studies on technology uptake in health workforces identify complex and interconnected variables that influence how individual practitioners integrate new technologies into their practice. To date there are only two implementation studies that focus on eMH and Aboriginal and Torres Strait Islander service providers. They suggest that the implementation of eMH in the context of Aboriginal and Torres Strait Islander populations may be different from the implementation of eMH with allied health professionals and mainstream health services.

OBJECTIVE

The objective of this study is to investigate how Aboriginal and Torres Strait Islander service providers in one regional area of Australia used eMH resources in their practice following an eMH training program and to determine what types of eMH resources they used.

METHODS

Individual semistructured qualitative interviews were conducted with a purposive sample of 16 Aboriginal and Torres Strait Islander service providers. Interviews were co-conducted by one indigenous and one non-indigenous interviewer. A sample of transcripts were coded and thematically analyzed by each interviewer and then peer reviewed. Consensus codes were then applied to all transcripts and themes identified.

RESULTS

It was found that 9 of the 16 service providers were implementing eMH resources into their routine practice. The findings demonstrate that participants used eMH resources for supporting social inclusion, informing and educating, assessment, case planning and management, referral, responding to crises, and self and family care. They chose a variety of types of eMH resources to use with their clients, both culturally specific and mainstream. While they referred clients to online treatment programs, they used only eMH resources designed for mobile devices in their face-to-face contact with clients.

CONCLUSIONS

This paper provides Aboriginal and Torres Strait islander service providers and the eMH field with findings that may inform and guide the implementation of eMH resources. It may help policy developers locate this workforce within broader service provision planning for eMH. The findings could, with adaptation, have wider application to other workforces who work with Aboriginal and Torres Strait Islander clients. The findings highlight the importance of identifying and addressing the particular needs of minority groups for eMH services and resources.

Addressing inequities in alcohol consumption and related harms

Social determinants, or the conditions in which individuals are born, grow, live, work and age, can result in inequities in health and well-being. However, to-date little research has examined alcohol use and alcohol-related problems from an inequities and social determinants perspective. This study reviewed the evidence base regarding inequities in alcohol consumption and alcohol-related health outcomes in Australia and identified promising approaches for promoting health equity. Fair Foundations: the VicHealth framework for health equity was used as an organizing schema. The review found that social determinants can strongly influence inequities in alcohol consumption and related harms. In general, lower socioeconomic groups experience more harm than wealthier groups with the same level of alcohol consumption. While Australia has implemented numerous alcohol-related interventions and policies, most do not explicitly aim to reduce inequities, and some may inadvertently exacerbate existing inequities. Interventions with the greatest potential to decrease inequities in alcohol consumption and alcohol-related harms include town planning, zoning and licensing to prevent disproportionate clustering of outlets in disadvantaged areas; interventions targeting licensed venues; and interventions targeting vulnerable populations. Interventions that may worsen inequities include national guidelines, technological interventions and public drinking bans. There is a need for further research into the best methods for reducing inequities in alcohol consumption and related harms.