Pedagogical Principles & Approach

There are ten key pedagogical principles that are most likely to contribute to successful curriculum design and delivery in the area of Indigenous health. The principles are listed here, along with strategies, examples and cautions for teaching and implementation approaches.

  • Principle 1 - Educating medical students about the health of Aboriginal and Torres Strait Islanders is unique among teachings about the health of other Australians, and we can teach medicine in a way that enhances students’ understanding of Indigenous experiences and world-views.
  • Principle 2 - Indigenous health is an integral part of medical education.
  • Principle 3 - Teaching from a positive strengths-based model, rather than a deficit model, is more likely to encourage effective learning environments and attitudes.
  • Principle 4 - Planning vertical and horizontal integration is important.
  • Principle 5 - Indigenous staff are key curriculum developers and enhancers.
  • Principle 6 - The attitudes of all teaching, clinical and administrative staff counts towards effective learning.
  • Principle 7 - In order to facilitate the most effective learning possible, partnerships with local Indigenous individuals, organisations, and communities will need to bedeveloped.
  • Principle 8 - It is important to teach Indigenous cultural safety/awareness separately from multicultural awareness.
  • Principle 9 - Students can be important curriculum enhancers if effectively supported and encouraged, but they should not be expected or relied upon to perform this function.
  • Principle 10 - Multi-disciplinary collaboration is likely to enhance learning outcomes.
Principle 1
Educating medical students about the health of Aboriginal and Torres Strait Islanders is unique among teachings about the health of other Australians, and we can teach medicine in a way that enhances students’ understanding of Indigenous experiences and world-views.
Rationale

Indigenous Australians are the original Australians, with unique experiences and beliefs around wellness and illness. Further, Indigenous Australians are marginalised on most social, economic and political indicators. Broader society and, therefore, many medical students are exposed to, and conditioned by, a range of particular views, stereotypes and values regarding Indigenous Australians and their health. Thus, effective learning in this area requires us to enable students to engage critically with the realities faced by Indigenous Australians, and challenge any stereotypes that may exist.

Strategies

Both our experience and recent research shows the best strategies in this area are ones that facilitate positive learning experiences and interactions with Aboriginal Torres Strait Islander Australians based on real-world contexts, including:

  • teaching that enables experiential processes and interactions;
  • strategies that address the emotional reactions of students in a respectful and culturally safe manner; and
  • allowing the student to move beyond awareness to a more critical analysis andunderstanding of their role in facilitating change.
Examples
  • Cultural based camps or community visits where students can be immersed in the realities of everyday life for Indigenous Australians, particularly in relation to their health care.
  • Talking circles or lectures/tutorials where Indigenous Elders or community representatives are empowered to share their experience with students, and the students are supported to ask questions in respectful ways.
Cautions
  • The ‘real Aborigines’ do not all live in remote northern (in fact, 60 per cent of Indigenous Australians live in large towns and cities). It is important to  wary not of reinforcing a stereotype by only teaching this component in Rural Health week, for example. 
  • Approach teaching from a strengths-base perspective, rather than potentially reinforcing negative stereotypes by approaching all teaching from a deficit model. 
  • Given that Indigenous Australians are not a homogenous group, it is important to offer a range of views and examples of Indigenous experience both in terms of geographical location (e.g., urban, rural, remote) and historical and cultural experience (e.g., extended family, stolen generation, strong cultural ties, lost language).
Principle 2

Indigenous health is an integral part of medical education

Rationale

Aboriginal and Torres Strait Islanders are Australian citizens and, therefore, are entitled to equality in health outcomes. Indigenous Australian concepts of wellness and illness have enriched medical practice and health care. For example, concepts of community control, holistic health and whole-of-government approaches have influenced the development of primary health care in Australia more broadly.

Further, in this context, the term ‘Indigenous health’ refers both to discrete topics concerning Indigenous issues, and to Indigenous peoples’ experiences in other areas of medicine and while interacting with the health system. Finally, Indigenous health presents some complex medical issues that may inform teaching in other areas of the curriculum—Indigenous staff may be key in helping to identify and contextualise such cases.

Strategies

In our experience, it is important to provide a foundation for Indigenous health by teaching discrete, compulsory subjects/lectures/PBLs about Indigenous history, cultures, societies, experiences and interactions with health systems and policies. This can be effectively complemented with Indigenous examples and content appropriately placed throughout the curriculum.

Examples
  • The University of Newcastle teaches compulsory foundation Indigenous health content with the aid of a CD-ROM package called Healing… Our Way, and then supplements that learning with Indigenous and non-Indigenous examples of medical conditions such as, gastroenteritis.
  • The University of Queensland teaches both Indigenous and non-Indigenous end-stage renal dialysis PBL cases as a way of contextualising Indigenous health, rather than seeing it as a discrete or stigmatised entity separate from medicine. Indigenous academic staff could be offered teaching and research places in other areas of the curriculum/medical school to reduce stereotyping and any misunderstanding that Indigenous health is separate from medical education in general.
  • Complex examples from Indigenous health may be used to inform other areas of the curriculum—for example, an Indigenous diabetes patient in a remote setting presenting with a cardiac arrest brings issues of isolation, culture and service delivery into focus—and potentially could also inform rural health and chronic disease (diabetes and cardio-vascular) teaching.
Cautions
  • Indigenous people should be included in the design, delivery and evaluation of curriculum content. If non-Indigenous people teach Indigenous health, they should collaborate with Indigenous people and organisations to effectively supplement their teaching.
  • Content should be locally accurate, as well as broadly translatable to a national context where appropriate. Local Indigenous people can help advise on this, and there are large numbers of Indigenous people in Sydney, Brisbane and Perth, for example, to assist in this process.
  • It is important to develop content and cases that are typical, but not stereotypical. For example, if only one Indigenous-specific case study is used, it need not necessarily be the alcohol and drug case. If such cases are used, it is important to contextualise and balance such examples with both non-Indigenous examples of alcohol and drugs and atypical disease in Indigenous communities.
Principle 3

Teaching from a positive strengths-based model, rather than a deficit model, is more likely to encourage effective learning environments and attitudes

Rationale

Indigenous Australian identities, while changed irreparably as a result of colonisation, are not forged by the process of colonisation alone. That is, Indigenous Australians existed before colonisation in healthy, functional societies, and continue to exert many strengths, unique talents and survival skills.

Identifying and focusing on solutions is more likely to engender a sense within students that the situation is not entirely hopeless, and that there are some strengths to be built upon, even if the health issues are complex.

Strategies

It is important to encourage conceptualisation of Indigenous Australians as living in functional, healthy societies before colonisation occurred, as well as to focus on successful health interventions thus far. Doing so contributes to a debunking of the myth that Indigenous societies were ‘primitive’ or ‘less developed’ in any way, and contributes to a sense that practitioners—with the right knowledge, skills, supports and attitudes—can contribute to better Indigenous health outcomes in partnership with Indigenous peoples.

Examples

  • Always look for the positive example of successful programs in Indigenous Australia. These include: Indigenous health promotion campaigns such as ‘condom-man’, which were ground-breaking for the whole of Australia; Indigenous acknowledgment of post-traumatic stress syndrome in stolen generation survivors that has helped prompt non-Indigenous peoples taken away from their English parents to come forward and tell their story; Indigenous youth comic ‘Deadly Vibe’ that has helped redefine the way health departments sell their messages to young people Australia-wide. 
  • Not all success stories will be written up in academic journals or government reports, but may present in more community-focused ways. This could actually help challenge students to redefine what is meant by success, and on whose terms.
  • Working with community Elders and representatives will enable students to get a dynamic, real, living account of the survival, talents and solutions Indigenous people regularly draw upon.

Cautions 

  • Make sure there is some Indigenous assessment of what is successful before using it as an example; even programs deemed successful in peer-reviewed evaluation articles in journals might not be considered useful by Indigenous community members. Looking for articles, resources or examples which have also been assessed by Indigenous people will be key. For example, if unsure about some teaching materials, ask Indigenous health staff or community representatives for their views on its suitability. 
  • If working with Indigenous Elders/community representatives, do so in ways that are culturally safe and respectful; do not expect endless repetition of their personal stories, but do follow protocols for mutual benefit. That is, work with Elders and community to see what is appropriate on a case-by case basis, rather than ‘slotting them into’ formulaic or repetitive teaching and lecture plans.
Principle 4

Planning vertical and horizontal integration is important

Rationale

As with any other area of medicine, overall co-ordination and planning will be necessary to ensure the most optimal learning outcomes.

Strategies

We suggest that to include Indigenous health most effectively in core/compulsory medical curricula, a range of measures can be taken to ensure that design, coordinationand the quality of teaching is optimised.

Examples

  • Statements of intent regarding Indigenous health in overall school strategic plans, in curriculum map objectives and in student attributes and outcomes are critical. These may assist in co-ordination, give schools self-set milestones to assess development, and signal commitment.
  • Indigenous health content can be vertically integrated such that a ‘staircase’ approach is taken, in which foundation or basic learning in the earlier years is built upon to produce more advanced skills like communication, putting community partnerships into operation, and managing diabetes in Indigenous peoples, for example.
  • Where possible, Indigenous health content can be most successfully delivered by horizontally integrating such content into broader curriculum teaching at any given point. For example, schools might teach Indigenous epidemiological profiles around the same time that population health basics are taught more generally. 
  • Horizontal integration might be supplemented with approaches taken by GP, nursing and Aboriginal health worker training, which have developed units that can be adapted to the needs of a medical curriculum.
  • Quality of delivery can be maximised by involving Indigenous staff and communities in curriculum design and on-going evaluation, using Indigenous staff and communities in delivery, encouraging non-Indigenous staff to undertake professional development activities, and looking nationally and internationally to share examples both of good practice and of teaching and learning resources.

Cautions

  • Collapsing as much Indigenous health content into one day of rural week, for example, does not allow a ‘stair-cased’, gradual learning approach. Spreading out Indigenous health content over the curriculum contributes to more stable, sustained learning, and avoids the potential stigmatisation of Indigenous health as only a rural issue.
  • Teaching Indigenous health only as part of rural health can also potentially marginalise urban Indigenous experience. A significant proportion of Indigenous people live in urban areas. While the two separate disciplines may at times be appropriately taught together, it is important to balance rural teaching with urban Aboriginal Medical Service (AMS) placements, for example.
Principle 5

Indigenous staff are key curriculum developers and enhancers

Rationale

Indigenous staff members are not only professionals in their own right, but also carry a wealth of historical, social, cultural and community expertise. Utilising this expertise will enhance students’ overall learning experience.

Strategies

It will be important to ensure Indigenous academic and general staff have key input into decision making around Indigenous health curriculum design, delivery and evaluation. In addition, Indigenous non-academic staff and communities may still have input into the curriculum based on their broader expertise. Indigenous academic and general staff will require recognition, adequate support and professional development opportunities, given that they will often carry multiple obligations beyond a regular staff role.

Examples

  • Indigenous people (ideally academic staff) should have some senior decisionmaking capacity about the design, delivery and evaluation of Indigenous health content.
  • Input of this nature should be supplemented by specific Indigenous curriculum committees and/or community partnership groups.
  • Indigenous people (academic and general staff and community members) could be encouraged to teach in other areas of the curriculum based on their professional interests and capabilities.
  • Indigenous community input can be encouraged through campus-wide Indigenous education centres, or by establishing and utilising community partnership groups.
  • The medical school could run a seminar for Indigenous non-academic staff and community members to share ideas about medical education and curriculum development in general. Such a basic information-sharing exercise could build their capacity to contribute in meaningful ways.
  • Where non-Indigenous staff have no or limited expertise in Indigenous health, they should invite Indigenous staff to co-teach, thus ensuring cultural dimensions are covered, along with the specific medical case in question (e.g., teaching a PBL/case on burns for an Indigenous patient).

Cautions

  • Indigenous people can be empowered to facilitate or lead this process, but they should not carry the whole weight of implementation; curriculum committees and the whole school will need to demonstrate support and commitment to the process.
  • While it is acknowledged that Indigenous academic staff are currently few in number, other Indigenous staff or community members can contribute cultural, sociological or community development expertise.
  • Indigenous non-academic staff should not be expected to go beyond their area of expertise or be ‘thrown in at the deep end’, but rather be invited to contribute where comfortable.
  • Curriculum development and Indigenous student support are two separate roles, and one Indigenous staff member should not be unrealistically burdened or expected to perform both roles. It will be important to build the capacity of the school to deliver both separate, but related, functions.
  • Student support for non-Indigenous students experiencing Indigenous health for the first time is a whole other area, and Indigenous staff alone should not be expected to perform this function. It may be necessary to ensure that non-Indigenous student support staff are trained in Indigenous health so that they are able provide support to non-Indigenous students.
Principle 6

The attitudes of all teaching, clinical and administrative staff counts towards effective learning

Rationale

Role-modelling of positive attitudes and well-informed teaching in any learning environment is a powerful dynamic, particularly when student doctors place so much emphasis on teacher–clinicians as mentors.

Strategies

Medical schools should ensure that staff who design, deliver, evaluate and administer curriculum are both confident and aware of some of the basic information they are dealing with, and passionate about improving Indigenous health outcomes. This may be planned as a school-wide endeavour, which will helpto create a positive and respectful culture.

Examples

  • It may be opportune to require all teaching staff in the first instance, and then all general staff, to attend a one-day seminar on Indigenous issues (preceded by preparatory reading and followed by a series of professional seminars and/or value-adding exercises). The program will be most successful if designed, delivered and evaluated in conjunction with Indigenous staff and community members.
  • Any professional development activities taken in this area, such as that listed above, may be rewarded with Continuing Medical Education points, for example.
  • Staff could be acknowledged for any particular expertise they develop in Indigenous health in conjunction with Indigenous communities.
  • Senior clinical teaching staff could be co-opted to such professional development by negotiating with hospital management on time and resources to allow their participation. Schools may consider offering teaching hospitals inkind incentives in other areas.
  • Specific partnerships between medical schools, Aboriginal Medical Services and teaching hospitals may allow a powerful avenue/forum for support, advocacy and improved service delivery.

Cautions

  • While it may be strategic to engage Indigenous staff to teach Indigenous health, this should not take precedence over the fostering of positive attitudes and learning for all staff about Indigenous health.
  • It cannot be presumed that one day, or even a semester, of seminars will equip staff with all the necessary knowledge, tools and confidence to deliver curriculum as effectively as possible. The focus, therefore, should be on opening up dialogue, facilitating on-going professional development and partnerships and encouraging peoples’ commitment and passion to improving Indigenous health outcomes.
  • Schools may wish to set up processes which can adequately deal with any grievances or issues that adversely impact on the teaching of Indigenous health; for example, a process where particular grievances are heard by a committee of Indigenous and non-Indigenous staff and community representatives. If committee members feel the situation warrants particular attention or has broader implications for teaching in the school, they can be empowered to make recommendations to the Dean for resolution.

Principle 7

In order to facilitate the most effective learning possible, partnerships with local Indigenous individuals, organisations, and communities will need to be developed

Rationale

Grounding Indigenous health in local contexts will enable the school to improve the quality of learning, facilitate specific strategies like community placements, and demonstrate its commitment to Indigenous health in real-world settings. Well managed partnerships of this nature are likely to enrich learning.

Strategies

Indigenous academic and support staff within the medical school (or university, in their absence) will be best placed to start making links with community groups. Such partnerships should be co-ordinated by one staff member charged with the responsibility to liaise and manage the relationship. Be mindful that partnerships of this nature will require time and resources to establish and maintain, and that staff and/or community representatives should be resourced adequately to undertake these functions.

Examples

  • Establish links and develop a partnership with the local AMS or other organisation to facilitate collaboration, e.g., community placements.
  • Invite community representatives to be partners in forming an Indigenous reference committee, which may inform and assist in making decisions about curriculum design, delivery and evaluation.
  • Establish links with local traditional owners and formally recognise them in medical school functions, literature and lectures.
  • At the University of Melbourne, a lecture is given to medical students by an Elder/senior community representative, while several Indigenous community members from the Koorie Heritage Trust lead tutorial discussions in conjunction with regular university tutors. The lecturers and tutors all meet beforehand to discuss their strategies and to ensure cultural safety.

Cautions

  • Many Aboriginal Medical Services are happy to accommodate requests for partnership and community placements, yet schools should remain mindful that they need to compensate AMSs for the time and resources such placements require, as they would any general practice, for example.
  • It is critical that Indigenous Australians are both empowered and have some ownership and cultural safety in this process.
  • Partnerships of this nature may take more time than expected to develop. Trust and honesty of approach are important here, and Indigenous staff may be best to help initiate, broker and develop such relationships.
  • Given the nature of Indigenous community relations, it is imperative that the school be guided by Indigenous staff in cases where there are disagreements between community factions.
Principle 8

It is important to teach Indigenous cultural safety/awareness separately from multicultural awareness

Rationale

Indigenous Australians are the First Australians, have unique experiences and cultures, and poor health outcomes. The Indigenous experience is quite distinct from the migrant experience, with different implications for health and well-being. Merging education about the health of Indigenous Australians with that of new Australians disrespects the former’s place in Australia.

Strategies

Awareness about Indigenous cultures and experiences can be taught most successfully by ensuring that:

  • culture is taught in a reflexive way, in which all students get to identify and question their own cultural values and beliefs;
  • Indigenous cultural safety/awareness is taught separately to multicultural awareness (given the specific issues Indigenous Australian health disparities encompass and the place of Aboriginal and Torres Strait Islanders as the First Australians); and
  • International Indigenous experiences/examples are given, so that international students can reflect on Indigenous experiences in their own countries.
Examples
  • Teaching personnel should be encouraged to start with cultural reflexivity and reflectiveness before moving into learning about ‘the other’.
  • Schools may wish to deliver specific Indigenous cultural safety/awareness on an on-going basis, while also including Indigenous components in any general units regarding culture and health in general.
  • Local Indigenous staff and communities can be invited to have input into this part of the curriculum as guest lecturers, adjunct lecturers or cultural advisors on a casual or on-going basis.
Cautions
  • It is important to allow Indigenous staff/communities/peoples to design and deliver this part of the curriculum with school support and in conjunction with school capacities and realities.
  • Care should be taken to invite a range of Indigenous experiences to be portrayed, rather than concentrating on potentially romantic or stereotypical views of Indigenous cultures.
  • Content in this area is always most effectively delivered if there are reflexive and non-voyeuristic techniques used (i.e., ‘learning about self through the medium of the other’ as opposed to ‘learning about the other and not one’s self’).
Principle 9

Students can be important curriculum enhancers if effectively supported and encouraged, but they should not be expected or relied upon to perform this function

Rationale

Peer learning, support and role-modelling will take on extra value in this context given the back-log of inappropriate information generally in the public domain regarding Aboriginal and Torres Strait Islander peoples and their health.

Strategies

While many students will initially question the relevance of Indigenous health to ‘real medicine’, schools may continue to encourage their support for Indigenous health, as it can be an enhancing phenomenon for the design and delivery of Indigenous health content.

Examples
  • Where possible, two Indigenous students should be co-scheduled to take the same PBLs/cases at the same times. This is more likely to facilitate effective learning for them by virtue of enhancing their cultural safety, and increasing their potential ability to contribute to peer education and curriculum enhancement.
  • Encouraging students to research and design effective new interventions and treatments may decrease the negative sense that ‘there’s nothing we can do about the bad situation’. It is vital, however, that they have first understood and demonstrated respect for, and use, of protocols and consultations.
  • Monash University rural health student club organises a prestigious and successful annual lecture in memory of a deceased non-Indigenous student who was a passionate advocate for Indigenous health care improvement.
  • Where racism or discrimination may exist in the student body, or indeed the staff, it is important to name and identify it, encourage discussion, and make sure it is dealt with in a respectful and safe environment. This can be done in ways that empower victims, educate perpetrators and contribute to a sense of shared co-operation, resolution and learning.
Cautions
  • Encouraging student initiative and creativity will require experienced staff guidance and supervision to ensure cultural safety and respect.
  • Indigenous students should not be expected to be experts on everything Indigenous, and are not likely to co-operate if publicly asked to produce sensitive information. More successful strategies might be to encourage their participation if they feel comfortable, but not to expect it.
  • In instances of racism and discrimination, it is our experience that if such instances are ‘swept under the carpet’, or alternatively ‘blown out of proportion’, then learning environments can be seriously compromised. A recognised strategy of dealing with such instances may assist in the process of shared learning and growth.
Principle 10

Multi-disciplinary collaboration is likely to enhance learning outcomes

Rationale

There are regular audits and curriculum development initiatives in Indigenous health across a range of health sciences. It may be timely to link these developments and share with other disciplines, thereby saving resources and enhancing student understandings of the topics and cases at hand. Multidisciplinary learning also obviously contributes to a more rounded practitioner and, in the case of Indigenous health, may contribute to the development of more holistic thinking and practice.

Strategies

Literature reviews and curriculum development should take into account developments in other disciplines as a way of utilising the best available resources, thereby saving on the resources required to ‘reinvent the wheel’ every time

Examples
  • Case studies/PBLs/scenarios may draw upon and assess students’ ability to communicate and collaborate with Aboriginal Health Workers and/or community representatives.
  • Indigenous week, or rural week, activities may see students go on rounds with community mental health nurses or social workers to gain a clearer understanding of psychosocial and psychosomatic health issues.
  • Students might be required to discreetly observe Indigenous patient–health professional interaction (perhaps with the hospital’s Aboriginal Liaison Officer) in an accident and emergency ward, and note any differences or similarities in communication approaches to non-Indigenous patients.
  • The University of Newcastle teaches a core Aboriginal health subject to all health sciences students (covering societies, cultures, history), followed up by advanced discipline-specific cases/modules/subjects.
Cautions
  • Obviously, developments and resources in other areas will need to be tailored or adapted to suit the specific requirements of teaching medicine.
  • Always encourage inter-disciplinary collaboration, rather than competition, especially given the often scant resources in contexts delivering health services to Indigenous patients.
  • Working with Indigenous health professionals and community members will require a whole period of relationship development, trust building and ownership in the process of specific module or broad curriculum design. Indigenous staff should be asked to assist in introductions and the following of protocols and cultural safety requirements.
  • Make sure teaching and learning resources are locally appropriate.
  • Be realistic about the time and resource constraints of guest tutors and lecturers and be prepared to compensate them for their contributions.