Health care in the Forensic Health care in the Forensic arena:arena:

Considerations for the Considerations for the Indigenous patientIndigenous patient

Jennifer DelimaJennifer DelimaMBBS, MHAMBBS, MHA

FACRRM, FRACGP, FACRRM, FRACGP, M Forensic Med, M Forensic Med,

FAChAMFAChAM

Indigenous Australians : Wikipedia 2011

Who am I to speak?Who am I to speak?• ‘Mainstream’ Australia from another culture• Experiencing the cultural competence or not of

‘mainstream’ Australian service providers• Residing in a remote Aboriginal community,

& being ‘adopted’ within & participating in some of the culture

• Working within varied environments of the NT, with its high Aboriginal population compared to the remainder of Australia – Regional, and remote from an Eastcoast urban health provision context

• Providing Forensic medical services through the varied environments of Sexual assault, Custodial medicine, some Watch-house work and Addiction medicine

• ….so my reflections on these, I share…

1. Everyone has a right to access high quality and safe health care

2. A partnership of care between families, carers, patients, consumers, and services

3. Recognises International Human rights agreements -to provide the highest possible standard of physical and mental health care

4. Respects and acknowledges different cultures and ‘ways of life’ that make up our society

Our usual health care Our usual health care environment:environment:

• For the patient’s benefit -> improve wellbeing

• Aim to reduce the power differential between clinician and patient by being patient centric

• Maintain patient autonomy• Personal information only divulged

with patient permission• Non punitive

Forensic health care tasks:Forensic health care tasks:

• Assess fitness to examine, detain, police interview, charge, release

• Assess for substance intoxication / withdrawal, mental disorder / illness

• Examine complaints of assault –victim / alleged assailants

• Document and interpret injuries• Collect forensic samples• Interpret findings• Provide expert opinion in Court / Tribunals• Provide initial medical management • Recommend ongoing treatment plan if

appropriate

Forensic health care environment:Forensic health care environment:

• Service across both forensic and health care• To assist assessment of crime-

Justice centric • Not always for the patient’s benefit • Cannot reduce the power differential between

clinician and patient • Cannot maintain patient autonomy• Personal information may be divulged • May have a punitive outcome

Clinical medicine interacts with the law, judiciary, police and

the living person

Context of the Indigenous Context of the Indigenous patientpatient

Northern Territory

Population: 239,500Indigenous: 31.6%

Incarceration:821/100,000

Indigenous: 86% 706 /100,000

Australia

Population: 23,130,900Indigenous: 3%

Incarceration: 0.2%130 /100,000

Indigenous : 1868/100,000(x14 that of Non- I)

3238.0.55.001 Estimates of ATSI Australians June 2011 , ABS

4713.7.55.001 Population characteristics ATSI, NT June 2006, ABS

ABS 4517.0 Prisoners in Australia 2011; Population studies Brief 2009 CDU

ABS 4517.0 Prisoners in Australia 2013

General health delivery General health delivery recommendations:recommendations:

• Avoid eye contact …?• Same gender provider as the patient..?• Speak softly, don’t shout..?• Don’t rush the patient, give time..?• Careful about asking about sexual history

and follow through examination –taboo areas..?

• Different culture = different needs..?

Concepts in Indigenous Concepts in Indigenous healthhealth

• What does “Indigenous Health” mean?• The social determinants of health:

- economic and social conditions influencing health - education, employment, access to basic needs- access to health, discrimination experience,- Maslows hierarchy of needs,

• Concepts of identity• Concepts of culture• Concepts of ‘what is health?’

WHO WHO ‘‘Social Determinants of Health Social Determinants of Health Conceptual FrameworkConceptual Framework

Social Determinants of health CDC and Prevention

What do we know of What do we know of Indigenous cultureIndigenous culture

• Many different culturally distinct groups identified by land areas, language, ‘dreamtime’ stories and lore.

• The Land and relationship to it is fundamental to the person’s spirituality

• Kinship system of ‘Family’ provides an extended network with roles different to that of mainstream Australia

Considerations when Considerations when providing health careproviding health care……..

The environment - proximity to tradition and‘country’,

- socioeconomic state- family connectedness

• The Urban • The Regional urban• The ‘Town camp’• The ‘Remote’• The ‘Destitute and exiled’

Urban Aboriginal Urban Aboriginal

• Long embraced ‘mainstream’ Australian Culture• Lifestyle, family relationships, life goals,

comprehension of law is no different to ‘mainstream’

• Awareness of ‘Country’ and Kin but not closely adhered to

• Influence of ‘Country’ and Kin is by choice not imperative

APPROACH: usual ‘mainstream’ care acknowledgement of culture need as advised by the patient , typically minimal modification required

’

Regional Urban Regional Urban AboriginalAboriginal

• Embraced ‘mainstream’ Australian Culture BUTstill toggles their Traditional Aboriginal culture

• Life goals, comprehension of law may be similar to ‘mainstream’, BUT lifestyle and family relationships are traditionally strong

• Aware and sensitive to needs of ‘Country’ and Kin

• Influence of ‘Country’ and Kin is sometimes little by choice

APPROACH: ‘mainstream’ care with cognisance of possible different cultural need. Often with a shyness and reticence to advise of their cultural need.

‘‘Town campTown camp’’ AboriginalAboriginal• Reside on the outskirts of ‘mainstream’ Australian

Culture and maintain an almost complete Traditional Aboriginal culture and beliefs

• English language competency is typically limited • Lifestyle and family relationships are traditionally

strong • Life goals, comprehension of Australian law may

be confused especially as it may be contrary to ‘traditional’ requirements

• Influence of ‘Country’ and Kin is imperative

APPROACH: ‘mainstream’ care comprehension of cultural need. proactively modify approach to facilitate the mainstream processes

Interpreter* services Cultural broker

‘‘RemoteRemote’’ AboriginalAboriginal• Reside on Traditional lands, where the culture is

Traditional and the minority population is ‘mainstream Australian

• English language is not practised. Service providers speak ‘pidgen’

• Lifestyle and family relationships are traditionally strong

• Life goals, comprehension of Australian law is distant and confusing and often contrary to ‘traditional’requirements

• Influence of ‘Country’ and Kin is imperativeAPPROACH: ‘mainstream’ care

‘active’ comprehension of cultural need. proactively modify approach to facilitate engagement of mainstream processes. Interpreter* services Cultural broker assistance

The destitute and exiledThe destitute and exiled……..• Typically the ‘Town Camp’ or Remote Aboriginal• Living in the ‘river-bed’, ‘long grass’, ‘under the

bridge’ etc• English language is typically idiomatic and limited• Itinerant lifestyle and lost family relationship • Absent life goals, comprehension of Australian law

is confusing • Maslows hierarchy of needs – basic food, shelter

and sleep, warmth, sex• Influence of ‘Country’ and Kin has resulted in

exclusionAPPROACH: ‘mainstream’ care

comprehension of cultural need. proactively modify approach to facilitate the mainstream processes. Interpreter* services Cultural broker assistance

So in Clinical Forensic MedicineSo in Clinical Forensic Medicine……....• Practice is synonymous with knowledge,

fairness, independence, impartiality, upholding basic human rights

• We remain health providers as distinct from the police and judiciary

• Our patient may no longer have the privilege of autonomy and self direction

• And when our patient is Aboriginal and not fully versed with ‘mainstream’ Australia….

1. Seek information about the link to traditional culture

2. Allow for a longer and slower progress in consultation time

3. Use pictorial communication despite overt english language fluency

4. Preparedness to extend your own role5. Consider need to have appropriate kin presence

(not necessarily our mainstream kin role)6. Permit a graduated number of consults to

facilitate confidence, trust, engagement7. Consider gender issues** 8. Maintain professionalism – maintain an

unbiased and caring ‘health’ presence

Specific Considerations:

So forensic health care to the So forensic health care to the Indigenous patientIndigenous patientCulturally safe practice

- Cultural awareness :aware that there are differences between people.

– Cultural sensitivity :Recognising that difference is okay and that an individual’s difference might impact on others.Take steps to provide care that is supportive

– Cultural competence : that we meet the patient’s cultural needs

– Cultural safety :accepts that the care provided is meeting their cultural needs.

Thank you !

References:References:

• Health care and Indigenous Australians; Cultural safety in practice. K. Taylor and P. Guerin. Palgrave Macmillan, 2010.

• Inequity and Health: A Call to Action. RACP Policy Statement 2005.

• Cultural safety - what does it mean for our work practice? Robyn Williams, Lecturer in Indigenous Health, FATSIS, NTU

• http://www.creativespirits.info/aboriginalculture/health/hospitals-doctors-health-aboriginal-people