“The most culturally safe training I’ve ever had”: the co-design of a culturally safe Managing hepatitis B training course with and for the Aboriginal health workforce of the Northern Territory of Australia

The terms cultural competency and cultural safety are often interchanged. However, differentiation between the terms is important. Cultural competency is the achievement of measurable skills, knowledge, and attitudes, which theoretically leads one to become aware of their own culture whilst providing care to diverse populations [20]. Cultural safety was originally described by Māori nurse Dr Irihapeti Ramsden who explained that we live in a neo-colonial environment that requires a profound understanding of the social function of racism and the colonial process [21]. Cultural safety extends beyond competency, with an emphasis of dignity and respect and is only determined by the recipient of the exchange, in our context Aboriginal and Torres Strait Islander individuals, families and communities [22, 23]. An abundance of frameworks exist describing cultural safety and cultural safety training for health professionals to guide culturally safe health care (for the clinician patient relationship) [22‐28]. While it is recognised as essential that Aboriginal and Torres Strait Islander Peoples have access to meaningful training options [29], less is described with respect to creating culturally safe education for the Aboriginal health workforce. Distinct from cultural safety training for health professionals, this paper documents a process of developing a culturally safe training course for the Aboriginal health workforce.

Most of the team have worked together for many years and have built trusted relationships through shared underlying values. Although strong hierarchies can exist in health, our team has deep respect for each role, with none being more important to patient outcomes than the other. The Aboriginal and Torres Strait Islander members of the team come from diverse language and cultural groups throughout the NT and Torres Strait Islands. TDS, a Tiwi woman, has been an Aboriginal Health Practitioner (AHP) for 19 years. She had family or kinship relationships with the participants in pilot 2. PMW, AHP and artist, is a Ngangi speaker and lives in Nauiyu community, on Malak Malak land. SW, a Warnidilyakwa woman and Anindilyakwa speaker from Groote Eylandt, has worked as an AHP for over 20 years. SN, a Gurindji woman and AHP for 24 years. GG is an Aboriginal Community Worker (ACW), researcher and proud Yolŋu man. SB is a Yolŋu woman and senior AHP. CR is a proud Arrernte, Kaytete woman and has extensive family and kinship relationships across the NT. LB, an AHP for over 40 years, grew up in West Arnhem Land with Iwaidja speaking and mainland Kunwinku clans. ST is a descendent of the Dauareb Tribe, of Mer (Murray) Island in the Torres Strait with over 20 years clinical and research experience. The non-Indigenous members of the team include nurses and PhD candidates (KH, PB) and doctors (JD, JSD, CC) and hepatitis program managers (EVC, PS) with a combined experience in Aboriginal and Torres Strait Islander health of over one hundred years. As decolonisation researchers we are critically conscious of the impacts and damages inflicted by colonisation [22]. We acknowledge our position of privilege and reflect on and act to remove any potential biases [22, 30, 31]. We are grateful to live and work on Aboriginal and Torres Strait Islander land and understand that we are on a continuing learning journey.

This study is part of a larger Participatory Action Research (PAR) project, Hep B PAST, a partnership approach to sustainability eliminate CHB from the Aboriginal and Torres Strait Islander population of the NT [32]. The project aims to improve CHB-related health literacy, clinical care and the cascade of care for people living with CHB [32]. A key component to support primary health care to manage CHB is capacity building of health professionals through the delivery of CHB education for doctors, nurses, and the Aboriginal health workforce. As there was no specific CHB-related education for the Aboriginal health workforce we aimed to fill this gap, through the co-design and development of the “Managing hepatitis B” course.

Co-design is emerging as an empowering methodology for Aboriginal and Torres Strait Islander Peoples and is a culturally grounded, respectful approach that involves true partnerships [33]. Underpinning co-design methodology for health programs and research are principles of collaboration, empowerment, and capacity building. To achieve these principles, research must be flexible, undertaken with respect, enact shared decision making and have equitable accountability [33]. Achieving effective co-design takes time and researchers must allow ethical space, which is needed when peoples from disparate worlds and cultures engage in work together [34]. The process for the co-design of the course is summarised in Fig. 1.

The review of eleven policies and frameworks around cultural safety and Aboriginal and Torres Strait Islander health and education revealed strong themes of addressing racism and the need to improve equity in healthcare and health outcomes for Aboriginal and Torres Strait Islander Peoples [10, 22‐24, 26, 44‐46]. The value of the Aboriginal health workforce was highlighted, as was the need to improve recruitment and retention and strengthen the Aboriginal health workforce, including the need for greater education and training opportunities [23‐27, 44]. There was no clear implementation plan or framework on how to deliver culturally safe training for the capacity building of the Aboriginal health workforce. We considered all key principles, with NAATSIHWP and NHMRC frameworks most closely aligned to what we believe essential to achieve culturally safe training. With the foundation principle of spirit and integrity, we integrated the principles of reciprocity; respect; cultural contextuality and continuity; equity and access; responsibility and advocacy and sustainability [24, 45] with the overarching theory of the empowering potential grounded in cultural safety and decolonisation [21, 30, 57]. Whilst not explicitly mentioned in the frameworks reviewed, a strong and consistent finding throughout the iterative process of course development was that values described in Maslow’s Hierarchy of human needs [59] are critical for participants to be empowered and safe in the learning environment and to maximise critical thinking and learning potential. This involves a holistic approach, including physiological, safety, love and belonging, and self-actualisation [59].

A conceptual process model for the co-design and development of culturally safe education for Aboriginal and Torres Strait Islander Peoples was conceived. This was further refined through the writing process with the Aboriginal and Torres Strait Islander research and teaching team, with author PMW putting the concepts into art and story, depicted in Fig. 2. We understand that this study has been co-designed as part of research and that health educators may be more time limited. The conceptual process model in Fig. 2 can be utilised considering the principles and values described in the outer and inner circles and filling in the ochre and brown sections with the steps taken to achieve each principle. Table 2 describes practical examples of how to demonstrate alignment with principles, as a guide.

A full-day course was delivered in two communities. Seven participants, all ACWs, attended pilot one, which allowed us to assess if course materials were at the appropriate level for this group. Nineteen AHP students, from across Australia attended pilot 2. Ideally education should be delivered in someone’s preferred language, however the challenges with achieving this are exemplified in our first pilot where there were four distinct first languages (Burarra, Kunwinjku, Ndjebbana, Yolŋu Matha) amongst our seven participants. The pilot courses were delivered in English (by KH) using plain language. Aboriginal and Torres Strait Islander teaching team members (LB, TDS, SN) were seated at tables with participants to clarify messages in small groups.

Two-way (also called both-way) teaching philosophy was used, which positions Aboriginal and Torres Strait Islander Peoples as knowledge holders in all educational transactions and preferences, bringing together Western academic discipline, respectfully embracing diversity in all cultural contexts [60, 61]. It involves a continuing reflection of teaching and learning [60]. The course involved a mix of slides, activities, role plays, case studies and games. Case studies were developed to reflect the roles of the Aboriginal health workforce in CHB management in a remote NT context. Parallels and examples were drawn to other chronic conditions to increase utility and transferability of skills learnt and to assist in making links to a chronic conditions model of care. The course utilised the Hep B Story app, developed by our research group to improve health literacy about CHB by providing education in a person’s first language [36], currently available in nine NT Aboriginal and Torres Strait Islander languages [32].

Reflective analysis and journaling (by KH, LB) occurred directly after the delivery of pilot one. Reflections included that overall, the participants were positive, actively engaged and were comfortable to ask questions and share stories. Observations and feedback throughout the course identified that although having training in community enabled more ACWs to attend it also led to distractions for the participants, who were not always able to fully engage due to being called out of class and having the “little faces (of local children) looking through the windows.” Group discussions with the participants confirmed these observations, with one participant saying. “There’s too much humbug [harassment] if we stay (in community), its better if we go to Darwin [to learn].”

Despite distractions, there were some clear learnings, including that hepatitis B was an ancient virus which has been present as an infection in Aboriginal and Torres Strait Islander Peoples for over 50,000 years [62]. This piece of knowledge was mentioned as important in group discussions and on butcher paper evaluation. One participant reflected. “It [HBV] is not a “white fellas” disease, it is old, from our ancestor’s time.”

All the participants expressed that the course was acceptable, and they enjoyed learning about CHB. They articulated they enjoyed the interactive and visual aspects of the course. With one participant commenting. “It had pictures, some people are visual learners, so I found this helpful.” and another, “I really liked the fun games. The game about how you get hep b was good for me.”

Reflective analysis and discussion after the course between the facilitators (KH, TDS, LB, and SN) found that there was excellent energy in the room and thorough engagement from the participants. Facilitators commented that throughout breaks the participants continued to ask questions about CHB and provided positive feedback on delivery methodologies, content and a feeling of cultural safety and respect.

In response to “the best thing about the course is,” one participant commented that it was, “Culturally appropriate and safe”. This sentiment was confirmed in group discussions, the feedback was overwhelmingly positive about course acceptability, with one participant reflecting. “This was the most culturally safe training I’ve ever had.”. The delivery and style of the course was described as “fun”, “interesting” and “understandable,”. The facilitators received positive reviews, with three mentions that “The course was very well presented” and “the facilitators were deadly [awesome].”

The acceptance of course delivery was supported through feedback in small group discussions, with participants again using terms “understandable” and “fun.” One participant commented, “I love how it was so interactive.”. To the question “If I could change the course, I would prefer….” The responses included three mentions of “nothing,” “more games and videos” and “longer course.” Through group discussions several people agreed that the course could be longer (than one full day) to consolidate learnings and further explore hepatitis B serological interpretation, which people found challenging.

The processes of course design was reviewed against culturally safe principles, adapted from NAATSIHWP and NHMRC [24, 45], used as process indicators. We measured evidence from the co-design process and the delivery of the pilot courses, describing practical examples. The research team reflected on whether each domain was achieved. We found that that course design closely aligned with culturally safe principles, see Table 2.

The process of co-designing the “Managing hepatitis B” course began in 2018, with a 6-month evaluation to be ready for piloting. Two pilot courses were run, in remote communities in the NT, in 2019, with a total of twenty-six participants attending. The final product is a 1.5-day course which has been delivered eight times to over 150 participants, throughout the NT, between 2019 and 2023 [63]. Course materials and guidelines for use are available on request to corresponding author.

Studies have shown that Aboriginal and Torres Strait Islander Peoples want and benefit from having an Aboriginal and Torres Strait Islander person involved in their health care [65‐68]. Research in the NT has shown the AHP profession has seen a decline in numbers in the past decade [4]. Cultural safety, teamwork, collaboration, recognition, and professional development have been identified as crucial to the retention of Aboriginal health staff [4]. Our education was designed to increase capacity of the broader Aboriginal health workforce. Education should seek to build upon the skills and knowledge of the whole workforce and encourage the development of non-clinical skills, such as leadership or research [69], providing safe workplace environments, supervision, mentoring and offering opportunities for ongoing collaboration [48, 70]. This was embedded within our training, with our model encouraging past participants to become future facilitators, leading to numerous occasions where they were invited to share their knowledge in national and international settings [71‐73]. Education should be guided by the principles of cultural safety and PAR in its program design and interactions. Participatory action research engenders change through both research outcomes and through the research process itself [74]. As well as contributing to course content and delivery, the Aboriginal and Torres Strait Islander research and teaching team developed Hep B games as a low-cost vehicle for education and helped shape the role plays and case studies to be relevant for various regions and cultural contexts in the NT. Being involved in the research process provided ongoing opportunities for two-way learning within the team and empowered participants to have an impact on how CHB care was delivered in their communities. Culturally respectful communication is another key component to delivering culturally safe health care [21, 55, 65]. This should extend to health education and include a focus of strengthening interprofessional relations and involve meaningful co-creation of knowledge, as outlined in NHMRC’s principles, specifically reciprocity [45]. The collaborative, two-way learning approach intrinsic to our education model, benefited both researchers and participants and led to an enriching, respectful and enjoyable learning experience which extended beyond the training. Our findings demonstrated alignment with the NAATSIHWP framework being informed by academic, clinical expertise and Aboriginal and Torres Strait Islander cultural knowledge [24]. We were acutely aware of the importance and applicability of both verbal and non-verbal Aboriginal and Torres Strait Islander communication styles and recognition and respect for cultural obligations and cultural validation. We acknowledged and respected cultural protocols, kinship, and gender specific issues. This is particularly important when teaching HBV transmission, which includes maternal to child transmission, sexual transmission, and blood-related transmission through ceremony. At the beginning of the course, we highlighted that we would need to discuss issues related to “men’s” and “women’s” business and gave people opportunities to voice concerns with facilitators. Aligned with the social ecological model our participants and facilitators described a sense of ownership over the course developing practical strategies for learning opportunities and behavioural change [41].

Like culturally safe health care for patients, culturally safe education should be developed through reflective practice based on experience and knowledge; reflection on one’s own cultural identity and recognition of the impact culture has on one’s own behaviour and practice. Culturally safe education should flatten the hierarchy between participants and educators to facilitate two-way principles of cross-cultural learning and empowerment. Cultural safety can only be defined by those people who receive services [24]. In our study we did not ask the question “is our training culturally safe?” this was independently determined and expressed by participants. Achievement of cultural safety was further defined by the Aboriginal and Torres Strait Islander research and teaching team through reflective practice, reviewing evidence from practical examples of our model, which demonstrated alignment to cultural safety principles [75].

In their recent comprehensive review of co-design approaches with First Nations Peoples, Butler et al. found themes which would lead to success and which we applied to our co-design, including Aboriginal and Torres Strait Islander leadership, a culturally grounded approach, inclusive partnerships and evidence-based decision making [33]. We found the process of co-design is just as important as the product but to do it properly takes time and space to develop relationships and partnerships.

Flexible approaches to health education accommodate the various commitments, learning styles and skills specific for the Aboriginal health workforce and increase visual representations and interactive approach [51, 52]. These approaches allow the focus to be on the development of skills rather than traditional assessment focused, repetition-based training [76]. Literature suggests that Aboriginal and Torres Strait Islander Peoples learn more effectively when teaching includes kinaesthetic, contextual, role plays, practical session, observing and sharing strategies [48, 53, 77, 78]. Visual and interactive materials, games and stories telling, and case studies were all an integral part of the course. Aboriginal and Torres Strait Islander cultures have a strong oral history and allowing time for storytelling contributed positively to our course [78, 79]. Participants were given the opportunity to apply knowledge in contexts relevant to their everyday lives and given space to safely discuss community issues, sharing stories and challenges and discussing solutions with peers, fostering a collaborative, strengths-based approach to learning [80]. To improve sustainability of education and to encourage self-sufficiency post course, appropriate resources, key messages and ongoing mentoring and support was provided to participants. This is crucial is maintaining and building knowledge [48, 81, 82]. Similar to findings in other studies our participants requested refresher training and access to resources [81] which were provided.

Applying adult learning principles [38], clear objectives, relevant topics, a strong connection to learner’s real-life knowledge and experience, and maximising opportunities for interactivity were applied [83]. Whilst there were core learning objectives within the syllabus that needed to be met in order to provide evidence-based care and management for people living with CHB, there was also flexibility for our Aboriginal and Torres Strait Islander researchers and participants to shape course content. Consideration of various levels of English-language, literacy, health literacy and past formal learning experiences were all considered [51, 52]. Where language or written text was used, it was in plain language and avoided intangible concepts and idiom [78, 84]. The teach-back method was also employed. This involves clinicians clarifying with patients the information given to assess whether intended messages were appropriately being conveyed, to identify misunderstanding and initiate clarifications [58]. It has been shown to be effective in increasing understanding and retention of health information in a cross-cultural setting [58, 85] and in improving knowledge for people living with CHB [58]. We used this tool to assess our teaching and to introduce the concept and explain its utility, so participants could then also consider using the teach-back method in their professional roles with patients.

Creating culturally welcoming spaces has been identified as an enabler to cultural safety in Aboriginal and Torres Strait Islander health and education settings [86]. Choosing an appropriate venue, offering food and drink, and allowing appropriate time for breaks have also been influential factors in training success [79]. We consulted with local staff about food preferences as food provides comfort and a sense of emotional as well as nutritional sustenance [21].

Although we are supportive of providing training opportunities in community, with 76 remote communities in the NT [87], it is not financially viable, environmentally sustainable nor an effective way to deliver our program. Another consideration is the large emotional demands the Aboriginal heath workforce experience in their roles [88], their commitment to their communities often extends beyond standard working hours, with no marked separation between their ‘personal life’ and ‘professional life’ [1]. This responsibility risks exhaustion if not adequately supported and recognised [89]. Our findings indicated a preference for training out of community to allow space to learn without being disturbed by the pressures inherent to their roles. Our endorsed courses are being delivered in regional centres to allow greater access and equity to training opportunities, and in recognition of the risks associated with Aboriginal heath workforce’s responsibilities in community, and may be a strategy to reduce burnout, enhancing sustainability and retention of the workforce [88]. We describe the evaluation of the endorsed courses elsewhere [63].

Throughout our study we have strengthened and developed strong, trusted, and respectful relationships with participants and communities. We were able to harness these trusted networks at the beginning of the COVID-19 pandemic to provide information and used this model of education to engage, co-design, deliver and evaluate COVID-19 education for the Aboriginal health workforce, confirming the adaptability of the course co-design. This “Managing hepatitis B” course has received positive national attention and the syllabus has been shared with Aboriginal Community Controlled organisations in other states of Australia. Work is underway to extend its application and accessibility for greater reach. The authors encourage wide use and adaptation to local Aboriginal and Torres Strait Islander culture and context, ensuring Aboriginal and Torres Strait Islander colleagues participate in review and delivery of content.