innovations in Indigenous health worker education

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Journal of Higher Education Policy and Management, Vol. 19, No. 1, 1997

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The Community as Pedagogy: innovations in Indigenous health worker education

KATHLEEN CLAPHAM, KRISTIE DANIEL DIGREGORIO, ANGELA DAWSON & IAN H U G H E S , University of Sydney, Australia

Introduction The dilemma facing Indigenous1 communities intent on preserving the teachings of their own communities is that their employment opportunities and their efforts at self-determination depend on their being able to function in the Western culture, which includes being educated in Western institutions. Since the 1980s Aboriginal education units within universities, previously referred to as enclaves,2 have played an important role in facilitating the acquisition of Western academic skills by Indigenous students. The growth of these units has coincided with the numbers of Indigenous university students doubling between 1988 and 1993 (Reference Group, 1994). However, recent developments in Indigenous higher education have also seen a demand for a continuing dialogue between the community and university educators, a dialogue which recognises the validity of indigenous forms of knowledge and values the teaching of the elders. For university educators this is both crucial and extremely challenging for reasons that will be outlined below. This paper will describe the vital role that one Aboriginal education unit plays in Indigenous higher education and outlines its development from 'enclave' to innovator in Indigenous health education. Yooroang Garang, The Centre for Indigenous Health Studies at the University of Sydney (previously the Aboriginal Education Unit of Cumberland College of Health Sciences), provides professional training programs for Indigenous health workers and supports Indigenous students undertaking courses in a wide range of other health professions. The development of the Centre, itself a pioneer in Australian health worker education, will be described, as will a more recent development, community-based and independent learning packages for Indigenous health workers. Among the salient issues in the development of the packages is the need for critical appraisal of the respective roles of the university and the community as teachers of Indigenous health workers.

The Health Status of Indigenous Australians Approximately 1.6% or 283,600 of Australians are Indigenous (McLennan, 1996). The poor health of Indigenous Australians is well-documented and provides a clarion call for 1360-080X/97/010035-09 © 1997 Australasian Institute of Tertiary Education Administrators


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urgent attention to Indigenous health. The effects of the European invasion of Australia on the health and healing of Indigenous Australians continue to reverberate in their health and healing two centuries after the first European settlers arrived in 1788 (Reid & Trompf, 1991; Saggers & Gray, 1991; O'Connor & Parker, 1995). Despite the attention given to Indigenous health issues in recent years, poor health conditions persist, highlighting the complex nature of ill-health in the Indigenous population and the need for equally complex and sensitive responses. Such responses must focus not only on the prevalence of particular diseases which harm but also on the Indigenous experience of racism in Australian society as described by Mitchell (1994), which continues to impinge on the daily mental, physical and spiritual health of many Indigenous people. The 1991 Report of the Royal Commission into Aboriginal Deaths in Custody extended its view beyond the legal system to examine the myriad of factors that affect the current status of Indigenous peoples in Australia, including their health status (Australian Government Publishing Service, 1992). The Commission concluded that the health of the Indigenous Australians is worse than that of other Australians, as indicated by nearly every possible health measure, and that available health services are illequipped to deal with these overwhelming health needs. Recent findings (Bhatia, 1995, pp. 11-13) offer evidence that die health status of Indigenous Australians remains critical. • Death rates for all causes among Aboriginal and Torres Strait Islander peoples remained relatively stable between 1988 and 1993 but in the same period there was a 12% decline in death rates for all causes in the total Australian population. • In 1992 Aboriginal infant mortality rates were 22.0 and 31.5 deaths per 1000 live births in Western Australia and Northern Territory respectively, 3-4 times higher than for all Australians combined. • The mean birthweight of Aboriginal infants was 3150g, 206g less than the national average for all births. Twelve and a half per cent of babies of Aboriginal mothers had low birthweight, double the proportion noted in all infants of 6.3%. • Diabetes is much more prevalent in the Aboriginal population, possibly as high as 15-20% in some communities, compared with the proportion in die non-Indigenous population of 2—3%. • From 1979 to 1983 the death rate from cervical cancer among Northern Territory Indigenous women was more than six times the death rate among all Australian women. As common as the continual reporting of such abysmal health statistics is the emphasis on the essential role of die Indigenous healdi worker in die delivery of primary health care to Indigenous communities. Both the National Aboriginal Health Strategy Working Party (1989) and die Royal Commission into Aboriginal Deadis in Custody (Australian Government Publishing Service, 1992) recognise the training of Indigenous healdi workers as integral to improving the health status of Aboriginal and Torres Strait Islander people. Indigenous health workers' roles are expansive and include planning, implementing and managing Indigenous community healdi programs and providing direct primary health care and healdi promotion services. Health workers are often regarded as acting as 'cultural translators' bridging traditional and Western world views (Flick, 1995). As Flick asserted, Aboriginal health workers ... are an integral part of the interface between whitefella medicine and whitefella medical workers and doctors ... Aboriginal Health Workers are die backbone of primary health care services to [Indigenous] people, (p. 10)

The Community as Pedagogy

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Training Indigenous Health Workers While a great deal of emphasis has been placed on training Indigenous people for health work, there are multiple challenges to providing this training. In general, studies continue to echo the finding that Indigenous people are the most educationally disadvantaged group in Australia (Department of Education, Employment and Training, 1989). Access and participation by Indigenous adult students has been estimated at three to five times lower than for the Australian community as a whole (Department of Education, Employment and Training, 1989; Castles, 1993). The participation of Indigenous students in higher education has increased in recent years, with the number of Indigenous university students nearly doubling. However, the gap between educational attainment by Indigenous students and the attainment of otiier Australians has remained consistent and the percentage of Indigenous people with university degrees is still a fraction of the percentage of the rest of Australians: 0.6% of Indigenous Australians have university degrees, compared to 7.6% of other Australians. The greatest increase in Indigenous post secondary participation rates has been in Technical and Further Education, where 40% of the students are enrolled in basic education and preparatory courses. The challenge for tertiary institutions is not only in making tertiary education accessible to Indigenous people and producing Indigenous graduates skilled in a broad range of areas, but also ensuring that the knowledge imparted by those institutions is relevant and appropriate to the particular cultural needs and aspirations of Indigenous people. As illustrated below, the issue of relevance is multi-dimensional. Stephen Harris (1988) summarises the task for Indigenous Australians, from his conversations with Indigenous educators in Northern Australia, as 'coming up level' without 'losing themselves'. Harris explains: To 'come up level' I believe is a serious hope of Aboriginal people: to have some of their people level on every rung of the white education ladder. That's why Aboriginal people often say, 'We want our own doctors, lawyers, teachers, pilots, mechanics' and so on. Yet beside this hope of 'coming up level' is a fear: a fear that to get white education means that Aborigines take the risk of losing themselves ... Some did not trust adult training away from their community because all the young people they had sent away 'lost themselves': they either did not come back to their people or they did not fit in if they did come back, (p. 169) Research undertaken by Veronica Arbon and Maria Nugent at the University of Sydney (Arbon & Nugent, 1994) adds a further dimension to the issue of relevance. Criticising tertiary access programs which focus on the preconceived notions of what Indigenous students lack (referred to as a deficiency model), their research shows that successful tertiary access programs should focus on the processes, attitudes and structures found within the university which are exclusionary to Indigenous students. In contrast to traditional Western approaches to tertiary education a 'culturally relevant' education recognises the uniqueness of the learning styles, cultural perspective and life experience that Indigenous students bring to the educational experience. Contrasts between Western and Indigenous models have been recently documented by theorists who suggest that Indigenous students are accustomed to learning tiirough observation, active imitation, and trial and error, but find themselves in classrooms which focus on passive learning; Indigenous culture values spontaneity and independence and


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Indigenous students struggle to adapt to structured classrooms, dependent upon enforcement by authority figures; Indigenous culture emphasises the unity and harmony of Aboriginal life, yet Indigenous students find themselves in educational systems that emphasise individual assertiveness and achievement; Indigenous culture emphasises holism and synthesis, the interrelated nature of experiences, yet traditionally Western educational systems emphasise analysis, without acknowledging the interconnectedness of different components (Christie et at, 1985; Christie, 1988; Sayers, 1988; Hughes, 1991; Williams, 1996). A relevant education is also one diat recognises that, just as education has been a vehicle for the colonisation of Australia, it is also an important vehicle for the self-determination of Indigenous Australians. In a recent study of the factors leading to student success in vocational education and training, the key finding was that student success is dependent upon an institution's ability to acknowledge Indigenous students' cultures (Mclntyre et al, 1996). There is not one Indigenous culture, but many Indigenous cultures and it is essential for student success that institutions are responsive to students' cultural differences, for example, by having flexible time schedules and negotiable assessments because of the competing personal and course demands being made on students and by involving the larger Indigenous community in course development and evaluation. Indigenous health workers face specific challenges in obtaining effective training, challenges related to issues of culture, health models, and community. Like other Indigenous students, health workers often struggle to maintain their Indigenous identity when they leave their communities to undertake training. Mitchell (1994, p. 15) observes: [Of] major concern is whether, by passing through mainstream educational institutions [Indigenous health workers] will become assimilated and somehow 'less Aboriginal' or 'White Aboriginal'.3 Indigenous health workers are also challenged by dissonance between Indigenous and Western models of health and illness. Health workers must balance Western concepts based on disease within the individual body and Indigenous understandings of health which are more holistic and rely on social, historical and cultural explanations for ill health (Clapham et al., forthcoming). Finally, health workers are challenged by the nature of the communities in which they live. They struggle to maintain confidentiality within strongly networked Aboriginal communities; they struggle with bureaucracies, employers and management committees who are poorly informed about Indigenous health issues and, for those living in rural areas, they struggle with the isolation of being in remote communities. In summary, research findings on Australian health are unequivocal: Indigenous Australians' health is the worst in the nation. Researchers also offer that die best hope for improving this condition is empowering Indigenous health workers to provide health care for their communities. However, educational access and attainment rates among Indigenous Australians echo the dismal health rates: Indigenous Australians are the most educationally disadvantaged group in Australia. A solution for the educational status of Indigenous Australians must acknowledge die need not only for access but also for relevance of the education provided. As discussed, relevant education for health worker trainees must address challenges that these students face related to culture, health models, and community. It has been die goal of Yooroang Garang, The Centre for Indigenous Health Studies and the innovations of the Centre to contribute to both of these pressing issues by providing relevant education to empower health workers to


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improve the health of Indigenous Australians. The Centre and its innovations are discussed below.


Yooroang Garang: a 'strong place' for Indigenous health worker education Yooroang Garang means strong place in the local Aboriginal language of die Dharug region where die Centre is located. Yooroang Garang, The Centre for Indigenous Healdi Studies at the University of Sydney has been a strong place in the development of Indigenous health worker education. Yooroang Garang was the first tertiary institution to offer an Associate Diploma in Aboriginal Healdi and Community Development in 1984 and in 1993 was the first institution to offer a degree level course in Indigenous Health with the introduction of the Bachelor in Aboriginal Healdi. Yooroang Garang strives to make tertiary education accessible and relevant for Indigenous health workers by using the newest technology while simultaneously valuing, reinforcing and strengthening the culture and identity of Indigenous people. This approach is reflected in the curricula for the Diploma and Bachelor programs which balance traditionally Western scientific knowledge in areas such as primary health care, epidemiology, biological and behavioural sciences with Indigenous experiences, knowledge and perspectives, which is also offered through subjects such as Aboriginal Studies and Perspectives in Indigenous Healdi. Additionally, through class assignments in subjects such as Community Development and in Field Education, students engage in active learning through interaction with their communities. The delivery of instruction used by Yooroang Garang is tailored to the challenges faced by Indigenous health workers. For the past twelve years Yooroang Garang courses have been offered in block-release mode, where students alternate between a total of four, two-week intensive sessions on the University of Sydney campus and six-week release times when they study at home in their communities. Block mode was developed to accommodate: • students currently employed in their communities, many as health workers; • students from rural or isolated areas; and • students with family and kin obligations. Block mode prevents students' community membership from being jeopardised during long absences at university, it maximises community involvement in the courses of study undertaken by Indigenous students, and it makes the relevance of that study to the community apparent to students.

A Recent Innovation at Yooroang Garang: community-based and independent learning packages A recent innovation developed at Yooroang Garang is the community-based and independent learning packages. These packages consist of materials designed to support independent learning by Indigenous students and groups of students during the offcampus periods of release of die Bachelor and Diploma programs. The packages emphasise students' learning in, with, and from their local communities. Although block mode programs seem to have had considerable success in allowing Indigenous students to develop their health skills while remaining in their communities,

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Yooroang Garang student evaluations indicate that students' progress (Dawson, 1994) has been hindered by factors such as:


• limitations on the ability of the institution to provide academic and tutorial support for students in rural and remote areas during block release periods; • difficulties students encounter in accessing learning and resource materials in rural and remote areas; • perceived disconnectedness of university-based health knowledge to community health issues by students and communities; • under utilised potential for synergy between academic work and the professional activities of students already employed as health workers; and • limited information and computer technology available to students. The community-based and independent learning packages have been developed to build on the strengths of existing subject-based programs but address direcdy the limitations of block mode course, by encouraging students to discover interconnections between (a) subjects taught within die course and (b) the course and their communities. Community-based and independent learning packages consist of a collection of learning materials that include print-based and audio-visual materials which add another, more practical and experiential dimension to die learning which takes place on campus. Students are invited to develop their learning within the context of dieir community; the community becomes the teacher. The packages carefully encourage the development of more advanced practical and critical thinking skills as diey progress through the course. For example, first year Diploma and Bachelor students are required to study eight individually assessed subjects taught on campus by Indigenous and non-Indigenous lecturers. Through the packages all of these subjects integrate content and skills acquisition: students are asked to compile a community resource file as a combined assignment for Community Development and Primary Health Care; continuing the same theme, to explore local sources of cultural knowledge in consultation with community leaders and professionals; and practice interviewing and listening skills acquired on campus in Communications Studies and Counselling. These exercises provide a knowledge base which is used across all subjects including Biological and Behavioural Sciences. The goals of the packages are multi-dimensional. They: • develop students' appreciation of the interconnectedness of issues facing Indigenous communities and develop a holistic understanding of health through interdisciplinary study; • facilitate the acquisition of knowledge and skill through theory and practice; • encourage experiential and participatory learning; • avoid artificial boundaries between academic disciplines; • support students working in teams on problem-posing projects in Aboriginal health and community development, for example, alcohol and other drug use, domestic violence, diabetes, family planning, and sexually transmitted diseases; • provide for students to design projects, in collaboration with Yooroang Garang staff and their communities, so that the projects are relevant to their communities; • support students' learning from, and sharing their learning with, their communities; and • draw students, community members, and Yooroang Garang staff into interdisciplinary and collaborative problem-solving for real-life issues.


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TABLE 1. Schedule for implementing CBL pilot Form of instruction

Title

Sample topics

Location

CBL: pre-package

Preparing for study

Educational goal-setting, time management, motivation, self-esteem

Students' communities

Block one

Orientation

CBL: package one

Studying in Aboriginal Health and Community Development

Yooroang Garang Learning resources in community, skills needed for working in Indigenous health and community development

Block two CBL: package two

Yooroang Garang Information gathering

Reading and interpreting data, conducting interviews, gather media resources

Block three CBL: package three



Yooroang Garang Writing and presenting .

Academic writing skills, presentations in the workplace, participation in Koori meetings

Block four


Yooroang Garang

The packages draw on the experiences and priorities of Indigenous people and their communities and potential outcomes include empowering students to become agents of change in their local communities as well as reciprocal learning for members of Aboriginal communities that are involved in student projects.

Development and Implementation of the Program The packages were developed by Yooroang Garang during 1996 and will be piloted with the first year Diploma and Bachelor students during 1997. The following table outlines how the packages complement the blocks of instruction during students' first year of the two-year Diploma and four-year Bachelor programs. In February, during orientation, students will receive a preliminary package entided, 'Preparing for Study'. This package introduces diem to community-based and independent learning and encourages them to reflect on issues of academic readiness. The three main CBL packages that follow are entitled 'Studying in Aboriginal Health and Community Development', 'Information Gathering', and 'Writing and Presenting'. As the tides and the activities listed below suggest, the packages are designed to guide students in their progress at university from observation and studying, to planning, implementation and action.

The Role of Consultation The development of the packages to this point and their continued development relies heavily on negotiation and consultation with Indigenous communities, ensuring their

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continued relevance to Indigenous cultures and communities. Before the packages were developed Yooroang Garang and their companion program at the University of Sydney, the Koori Centre, surveyed students and practicing health workers to identify salient educational issues for developing learning modules. As the packages have been developed, current students have been asked to participate, for example, by reflecting on their own learning experiences and offering incoming students strategies for success at university. These students have also been invited to evaluate the packages and to make suggestions for improvement before the packages are finalised for the 1997 pilot. After the packages have been disseminated the first-year students, as well as practicing health workers and health worker educators, will be involved in continuing evaluation of the pilot. It is only through this process of consultation that the program can be assured of continued relevance for Indigenous health workers.

Conclusions The salient issues in the development of the packages have been: how to ensure that the packages were distinct from distance learning where the tertiary institution is the central focus of student learning rather than seeing the Indigenous community as central to instruction; how to develop a collective vision for community based learning packages across multiple subjects taught by individual content experts; how and when to involve the community at the earliest possible stages of development of a project while at the same time having made sufficient progress with the development of the project for the community to be able to offer a critical assessment; the need to focus on implementation but also on assessment; the tension of involving the community in students' learning but not overtaxing already overworked community members; the tension of encouraging a more continuous learning process (off-block as well as on-block) without overwhelming students who are busy with health work and family responsibilities; the challenge of providing off-campus tutorial support for students as they work through the package. Throughout the process of conceptualisation, planning and development of the packages, the attempt has been to continue the dialogue with the Indigenous community so that the community is truly central in the education of Indigenous health workers. The goal, not only for the packages but also for Yooroang Garang, is to empower Indigenous students and their communities by using community as pedagogy.

Correspondence: Dr Kathleen Clapham, Yooroang Garang: The Centre for Indigenous Health Studies, Faculty of Health Sciences, University of Sydney, PO box 170, Lidcombe, NSW 2141, Australia. Tel:+ 61 (0)2 9351 9238; Fax:+ 61 (0)2 9351 9112; E-mail: [email protected].

NOTES 1. 2.

3.

The inclusive term 'Indigenous' has been used throughout the paper to refer to Australian Aboriginal and Torres Strait Islander people. This word reflects the 'inward' focus of Aboriginal Education Units which operated within Australian universities to provide students with the skills they needed to succeed in their courses (Arbon & Nugent, 1994). A published version of this paper is forthcoming in TAJA (The Australian Journal of Anthropology) December 1996.


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