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Theory that explains an Aboriginal perspective of learning to understand and manage diabetes

Theory that explains an Aboriginal perspective of learning to understand and manage diabetes with diabetes, the treating team and Dthe health system all grapple with Objective: To use grounded theory and participatory research methodology to explain how Aboriginal people learn to understand and manage type 2 diabetes. the intricacies of diabetes care. Integrated care, which is coordinated and encompasses Methods: Aboriginal people with diabetes were invited to participate in one of five focus health and social needs of those receiving groups (n=25, male=12, female=13). Focus groups and education sessions were conducted by 1,2 care, is widely regarded as the solution. Aboriginal members of the research team. Focus groups were audio recorded and transcribed, with coding and first level analysis undertaken by all members of the research team. Almost 5,000 Aboriginal people live in Dubbo, Results: Participants described colonisation and dislocation from Country and family members’ a regional city of 40,000 in New South Wales experiences with diabetes as significant historical influences which, in conjunction with the (NSW). Considering the prevalence of type model of care experienced and the type of interaction with health services, shaped how they 2 diabetes in adults in NSW is 8% and that came to understand and manage their diabetes. in remote Aboriginal settlements around 30%, we would expect between 200 and Conclusions: Patient experience of a model of care alone is not what influences understanding 750 Aboriginal people in Dubbo to have and management of diabetes in Aboriginal people. diabetes. Local services estimate between Implications for Public Health: Health service improvements should focus on understanding 41 and 174 Aboriginal people with type 2 past experiences of Aboriginal patients, improving interactions with health services and diabetes. These estimates demonstrate the supporting holistic family centred models of care. Focusing on just the model of care in likelihood that many Aboriginal people have absence of other improvements is unlikely to deliver health benefits to Aboriginal people. undiagnosed diabetes or are not supported Key words: Aboriginal health, diabetes models of care, participatory research methods, by health services to manage their diabetes. integrated care This data provided the rationale for a whole- of-locality approach to improve diabetes demonstrated that Aboriginal Health Worker Learning to understand and manage diabetes care, which assumed that the model of care led care increased the likelihood of a general consists of the acquisition of knowledge experienced by patients determined how practice management plan being in place and skills through being taught, studying or Aboriginal people understood and managed and improved clinical indicators, including a from experience. This study aimed to identify their diabetes. 1% improvement in glycaemic control. the model of care currently experienced by Aboriginal patients as it was assumed that The best care for people with diabetes is care Existing literature on care for Aboriginal improvement to the model of care was the key led by a health professional in conjunction people highlights the importance of to Aboriginal people learning to understand with the client. In NSW, the preferred model primary care, integrated care and care that 4 and manage their type 2 diabetes. The reader is general practitioner coordinated care, provides a culturally safe environment for 10-12 will see the error in our assumption, and learn which entails general practitioners and management of chronic disease. Yet while of the various factors that have influenced how their practice nurses carrying out health health assessments on Aboriginal people Aboriginal people come to understand and assessments and monitoring, and the have increased in primary care settings, manage their diabetes. engagement of a multi-disciplinary team follow-up treatment for identified problems to work with the patient to set mutually is poor and unacceptably large gaps exist 6 12 acceptable and achievable health goals. between evidence and practice. Stigma, Method Aboriginal Health Workers have long been discrimination and racism are experienced seen as part of best practice in improving by Aboriginal people in health service This project was a collaborative effort 7,8 10,14 diabetes care in Aboriginal communities. A contexts and power imbalances between between four organisations. An important recent pragmatic randomised control trial in Aboriginal patients and health services aspect to the study was the intentional 14-16 remote Australian Indigenous communities continue to limit cultural safety. privileging of Aboriginal knowledge 1. School of Rural Health, University of Sydney, New South Wales 2. Western NSW Local Health District, New South Wales 3. Dubbo Regional Aboriginal Health Service, New South Wales 4. Marathon Health, New South Wales Correspondence to: Dr Emma Webster, School of Rural Health, University of Sydney, PO Box 1043, Dubbo, NSW 2830; e-mail: Emma.Webster@sydney.edu.au Submitted: February 2016; Revision requested: May 2016; Accepted: July 2016 The authors have stated they have no conflict of interest. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. Aust NZ J Public Health. 2017; 41:27-31; doi: 10.1111/1753-6405.12605 2017 vol . 41 no . 1 Australian and New Zealand Journal of Public Health 27 © 2016 The Authors Webster et al. Article alongside research knowledge. This had the diagnosed diabetes was sought to ensure health, including reduced access to bush their perspectives were included. Two effect of equalising the relationship between medicines and traditional foods. Participants supplementary interviews were sought; all researchers and meant each of the team outlined that modern day policies limited however, no interviews resulted. led the research at different times through desired hunting and fishing practices. the process. The research team consisted of Twenty-five Aboriginal people who lived in “The government bloke was there trying to two male Aboriginal Health Workers who Dubbo, had been diagnosed with and were tell us that if we wanted to go out and shoot a roo and eat it, we had to apply to Canberra are qualified diabetes educators, two female receiving treatment for diabetes, participted first, and one old fella (said) … “My kids want in the study. Men (n=12) and women (n=13) Aboriginal Health Workers and two non- it tonight not next week or the week after.” mean age 67 (range 27-88) with diagnosis of Aboriginal women, one experienced and the Travis FG1 920-929 diabetes (range ‘pre-diabetic’ to 46 years since other inexperienced with regard to research. diagnosis) were included. Almost all (n=22) “Well I walked around here on the riverbank Grounded theory is inductive in nature reported a family history of diabetes. Tablets and I can’t find the tree I was looking for. Yeah, and assumes that substantive theory can were the most common form of diabetes I’d drink it and I’d bathe in it and I used to bathe be derived from data to explain social management (n=17) followed by diet (n=14) my kids in it in the winter time, they never got 17,18 processes. This qualitative study drew a cold. It was good stuff ... None growing down and insulin (n=12). Five participants used all on both grounded theory and participatory here ‘cause I looked and looked and looked three methods to control their diabetes. research methods and was informed by and I couldn’t find any.” Pete FG1 1271-1275 Grounded theory involves commencing constructivist epistemology. analysis from the first data collection event At a population level, participants attributed Community groups popular with Aboriginal and uses open coding to identify in vivo codes prevalence of diabetes in Aboriginal people were approached with prior that can be compiled into categories and communities to the introduction of European 17,18 permission and the research was explained. concepts. Coding was done by hand and food and sedentary lifestyles. Names of interested participants were noted open coding on the first focus group was “Well you’ve only got to think about it, the and contacted when the next suitable focus undertaken by all researchers; combinations amount of food we have now, nearly every group was planned. Extensive discussions of the research team coded the remaining processed foods that we’ve got is sugar, sugar, about approach to potential participants transcripts and participated in discussion, and sugar… the only sugar we used to have was concluded that it is desirable for prospective constant comparison of codes and incidents. the wild sugar you found while you were participants (either individuals or groups) Grounded theory uses memos as an walking around” . Travis FG1 1074-1077 to have an existing relationship with a analytic tool. This study used three types of co-researcher (which may or may not memos. Memos were produced with each Family members’ diabetes experiences be a therapeutic relationship) as trust is data collection event (based on research Most participants had a family history of considered an important element of giving team debrief ), occasional ‘top line’ memos diabetes, and realised that family history free and informed consent (that is, potential described progress and concept memos was important in terms of their own health. participants would feel more able to say defined, described and attempted to All were acutely aware of symptoms and ‘no’ to joining the research when they trust understand each concept and compare and complications of diabetes as a result of seeing members of the research team). relate these to other concepts. Memos were numerous family members get sick, suffer discussed among the research team and Five gender-specific focus groups (n=2 and die from the disease. diagrammatic models prepared to facilitate female and n=3 male) were conducted in “… my mother died from it. She went blind transition from codes and concepts to an English (language spoken at home) and 17 and everything … And my two brothers explanatory scheme. audio-recorded (85 to 108 minutes) with both had it. One died of a heart attack, and written consent of all members. Demographic Ethics approval was received from the NSW my other brother he has diabetes and they details were recorded before the focus Aboriginal Health and Medical Research had him on insulin ...” Kurt FG3 120-123 group began. Conversational transcripts Council and the Greater Western Human “… I saw my mother go through hell … were produced and pseudonyms allocated Research Ethics Committee. My mother died and my grandmother, her to ensure anonymity. Three to five members mother. She was totally blind by the time of the research team were present during Results she was 60 and now it’s all reflecting on me each focus group and rotated the roles of …” Bianca FG4 88-92 Our theory explains that there are four facilitator, organiser and note taker. Focus group questions and roles were piloted with influences that shape how Aboriginal people The high prevalence of diabetes in Aboriginal learn to understand and manage diabetes: Aboriginal Health Workers employed by a families increases exposure to experiential local health service. The focus group used a continuing effects of colonisation, seeing learning and the cultural practice of 20,21 family members suffer from diabetes, ‘conversation map’ aided by conversation intergenerational learning as a result of being cards to stimulate discussion and ensure each interaction with health services, and the party to these experiences shapes learning model of health care received. Each of these participant had a turn to answer first. The about treatment regimens and management ‘understanding your diabetes’ conversation four exerts a greater or lesser influence on practices. how an individual learns about and comes to map is a diabetes education tool and was familiar to some participants. manage diabetes (see Figure 1). Interaction with health services The sample size of five groups was pre- Colonisation Participants felt that only Aboriginal people determined. While focus group data were Participant stories demonstrated colonisation could truly understand Aboriginal culture extensive (320 transcript pages for analysis), and dislocation of Aboriginal people from and disadvantage and expressed distrust in theoretical sampling for people with newly Country continues to have a direct effect on a system that tells Aboriginal people how 28 Australian and New Zealand Journal of Public Health 2017 vol . 41 no . 1 © 2016 The Authors Indigenous Health An Aboriginal perspective of diabetes Figure 1: Theory that explains an Aboriginal perspective of learning to understand and manage diabetes. to live their lives, but has limited Aboriginal Figure 1: Theory that explains an Aboriginal perspective of learning to understand and manage diabetes. leaders or cultural voices within that system. “… they’re (white people) the ones who run the diabetic programs, they’re the ones who Continuing  effects of  come up with all these ‘you beaut’ things to do colonisation for black people with diabetes … The trouble with that philosophy is ‘cause a white fella, he’ll do that and then he’ll blame you.” Bob FG1 1165-1175 Participants described feeling stereotyped Learning to understand  by non-Indigenous health professionals and and manage diabetes. At  the level of the individual  negative reports of care focused on not feeling Seeing family  Model of care  each outer circle may have  members with  heard and a lack of cultural understanding experienced more or less influence on  diabetes offered by health professionals, resulting in the way the individual  comes to understand and  resistance to seek further help. manage their diabetes “One of the worst things I come across is because I’m dark skinned, they think I drink and smoke. I never drank or smoked in my life. And the first thing they say is, they don’t even ask the question of me ‘You will have to give Interations  up the grog and smokes’ , and I said, ‘Mate I’ve with health  never tried it in my life.’” Ross FG1 1064-1067 services “They have to understand our culture. That’s the thing, that’s what they’ve got to understand, how we’re used to live like. ” Jason “… she (doctor) came in to talk to me and Participants often adopted self-care measures FG1 1111-1113 when she opened her mouth, I thought, oh as a consequence of a communication my God she’s got to be black … I couldn’t help “… I don’t like going up to some specialist(s) breakdown with health professionals. myself. Where are your people from?” Bianca and stuff because I feel like it’s all scare tactics Participants indicated feeling let down by FG4 1422-1433 and they’re just trying to shame me and I feel the health system, expressed confusion over real bad about myself … I prefer not to go “The only thing that makes it hard, because I treatment plans and also developed their because I don’t want to feel that way.” Kaye can’t read or write, see. (My Aboriginal Health own, sometimes questionable strategies for FG2 2481-2484 Worker) understands that, and that’s why managing diabetes. he explains it to me.” Curtis FG5 1843-1844 Some participants described positive “I’ve been to a lot of dieticians and they tell you experiences with their doctor, emphasising different things and I just work things out for these stemmed from professionals Model of care experienced myself.” Vicky FG2 1247-1248 who expressed a level of caring and There was little consistency in terms of a “Doctors – sorry, not doctors, nobody understanding. The (hospital-based) renal model of care experienced by participants. educates you about your diabetes. All they physicians provided good support with some Some participants reported having their do is tell you you’ve got it, wear it and good participants reporting superior glycaemic diabetes identified opportunistically when luck to you.” Bob FG1 184-186 control under their care. they felt well, such as during a screening While participants identified a range of allied event. Others reported being hospitalised “No, I feel they’re very good. (The GP) is never health and specialist services they attended in a hurry and neither are the nurses. I can be before a diagnosis was made. Those who after their diabetes diagnosis, there was a up there, well last time I went for my check described receiving a general practitioner general lack of overall knowledge about up … I thought, ‘Oh my God, people must be led model of care found it highly acceptable. support services relevant to diabetes. This waiting.’ But he was never in a hurry.” Felicity Others reported having to continually remind included podiatry services, exercise classes, FG4 1526-1530 their doctor for routine diabetes care. chronic disease clinics, yarning groups (social Participants identified easier communication “Really, really nice … I go every three months groups where people get together regularly and I have a long appointment because first with Aboriginal staff as they perceived these to talk) or transport support to appointments. of all I go to the nurse then I go to (the GP) professionals understood Aboriginal lifestyles. Many participants felt they had figured and the nurse weighs you and does all your A level of dialogue was more accessible diabetes out themselves with assistance from sugars tells you everything and that and then between patients and Aboriginal health Aboriginal Health Workers and pharmacists. from there I go to (GP)” . Felicity FG4 223-226 professionals, ensuring a more effective Participants made a number of “There’s a lot of doctors and I’ve changed transmission of health information to recommendations to improve diabetes altogether now … Yes, but I got fully strict I can Aboriginal patients. care. A yarning approach (discussing with get him to write it out (request for tests of her “Aboriginal people they know how – what the patient) using diagrams and manikins blood sugar level) and I think I passed most they have to say to them and then they feel to explain diabetes, supplemented with of it (had ‘good’ numbers on her blood tests). comfortable if there was an Aboriginal person collaborative goal setting and a holistic So I’ve been nagging (continually reminding) sitting the other side of the table to ask them him to do that. I’ve got to go and see him family-centred approach to diabetes care was questions, they feel comfortable… ” Page FG2 Monday”. Susan FG4 927-930 recommended. Improving access to services 2243-2245 2017 vol . 41 no . 1 Australian and New Zealand Journal of Public Health 29 © 2016 The Authors Webster et al. Article by ensuring they are free, that medications and contemporary components (models of makes visible alternate ways health systems care and interactions with health services) might attend to improving diabetes care for are free or subsidised and that free transport that led to the acquisition of knowledge and Aboriginal people. is available was also recommended. skill. Each component varied in importance “Can I just say if you wanted to do something Previous studies have identified transmission for each person, and all factors continued to help blacks with diabetes ... you’ve got to of health knowledge from one generation to exert an influence on management of look at developing a holistic approach to to another as an important cultural practice diabetes over time. In hindsight it is obvious it … that holistic approach has to include emphasising the importance of family, – a model of care is about teaching and the family, and … even extended family. peers and social networks in education and So you have to include them in so that they providing clinical support, yet learning is a 10,15 support in chronic disease management. know how to look after people that have result of teaching, studying or experience. This, and the high prevalence of diabetes in problems … If we don’t have that holistic There were several issues in common between Aboriginal families, increases exposure to approach, we’re not going to last long.” Bob our participants and other population groups experiential learning about diabetes. These FG1 1543-1550 22,23 such as experiences with fragmented care, factors explain both the power of a holistic different understandings of disease between family-centred approach to diabetes care and Learning to understand and manage 22-24 the patient and the health professional provide an explanation as to why ‘modern’ diabetes and experiences of poor communication. diabetes management messages from health Participants felt they had mastered dealing The health system response to these issues professionals can lack traction with Aboriginal 4,26 with hypoglycaemic episodes but found has been to develop models of care on the people, as they can conflict with teachings of the lifestyle change challenging, including premise that optimal diabetes management the previous generation. managing medications, regularly measuring results from regular monitoring, setting and Identification of racism in health care 6 10,14 blood sugar levels and having routine achieving clinical targets supported by in Australia is not new and negative 11,27 service-wide clinical audits. Normative experiences with health care have an check-ups and tests. Many had experience models of diabetes care primarily describe ongoing effect on health seeking behaviours, of complications. All had goals relating to which health professionals should be seen even across generations. Where culturally diabetes and many were extremely motivated and what their role is in teaching the patient safe environments are provided they exert to deal with aspects of the disease. about diabetes. Modification to improve a positive influence on chronic disease “In the supermarkets I’m forever reading the 8,10,11 cultural appropriateness of these models has management. Our participants preferred packets, what do they call it? Carbohydrates built in identification of Aboriginality and interacting with Aboriginal staff of all ‘cause carbohydrates is sugar as well and then establishing trust. professions as they felt understood and underneath you can see sugar, and I always that their culture was acknowledged. Non- look at that to see how low it is before I buy Where participants described receiving the 4 Aboriginal staff could work with Aboriginal it ... I’m still doing things wrong, and I’m still general practitioner led model of care, they employees to drive health service change and learning …” Daniel FG3 217 – 222 found this an extremely positive experience, to identify how best to work with Aboriginal appreciating the time that was spent with Despite having difficulty finding support and people and pitch health messages. At a them in clinical consultations on a regular sticking with programs, many made lifestyle system level, ensuring health services are basis. We also found pharmacists and adjustments after their diagnosis. There were sufficiently staffed with Aboriginal employees Aboriginal Health Workers were key agents various levels of control and understanding, in all professions would provide good support in helping participants understand diabetes. ranging from very basic understandings to to both the community and non-Aboriginal Neither profession is recognised in the mastery of aspects of the disease such as 4,26 staff. This support needs to be extended to normative models, despite evidence of the monitoring blood sugar levels. Aboriginal workers by health services in order effectiveness of Aboriginal Health Workers “So if you know how food affects your body, 7-9 for them to be effective in their work roles. as care coordinators. This would indicate you can adjust your insulin, like if we’re going that both an adjustment to the normative Colonisation is largely regarded as ‘history’ in to have take-away … So I give myself an extra model and an improvement in the consistent Australia, with little regard for contemporary six units of insulin from when I took my sugar application of the model is required. Other effects on health. Our participants drew a last night before I went to bed, it was five. So I barriers to accessing primary care include link between the prevalence of diabetes and know what foods will send my sugar up and cost, lack of transport and expensive colonisation with its ongoing modification to what will drop it … Salads drop my sugar.” 8,22,23 medications and treatments and this was hunting, fishing and bush medicine practices. Bob FG1 178-184 also raised in our study. In this way, diabetes is symbolic of the dispossession, loss and grief associated with While refinements to the model of care are Discussion colonisation. Understanding this symbolic still warranted, they are unlikely to deliver link provides the basis of a more empathetic anticipated health benefits to Aboriginal While our study aimed to identify the model relationship and at a practical level health people. Furthermore, focusing health system of care experienced by Aboriginal patients, professionals should be aware that Aboriginal or service redesign on just the model of care participants answered our questions in people could be taking bush medicines that has the potential to reinforce stereotypes of a way that we had not expected. We had may interact with prescribed medications. both Aboriginal patients and non-Aboriginal assumed that learning about diabetes and health workers, as patients feel blamed when A recent systematic review of primary its management was a result of receiving programs designed by well-intentioned health care service or system level attributes a model of care from a team of health non-Aboriginal staff fail to meet their needs. identified that the patterns consistently professionals. However, participants told us Our theory makes visible the other influences associated with improved glycaemic index of historical components (colonisation and on learning about diabetes and therefore control for Indigenous patients were all family members’ experience of diabetes) 30 Australian and New Zealand Journal of Public Health 2017 vol . 41 no . 1 © 2016 The Authors Indigenous Health An Aboriginal perspective of diabetes 9. McDermott RA, Schmidt B, Preece C, Owens V, Taylor S, multifactorial in their approach. While the Historical factors such as colonisation and Li M, et al. Community health workers improve diabetes inadequacy of the evidence base was noted witnessing family members suffering from care in remote Australian Indigenous communities: by the authors, our explanatory theory would Results of a pragmatic cluster randomized controlled diabetes are also critical influences, along trial. BMC Health Serv Res. 2015;15:68. suggest the reason for multifactorial success with interaction with the health service. 10. Aspin C, Brown N, Jowsey T, Yen L, Leeder S. Strategic is that this is a complex problem influenced approaches to enhanced health service delivery for While general practitioner led care for Aboriginal and Torres Strait Islander people with by both contemporary and historical factors. diabetes management was highly acceptable chronic illness: A qualitative study. BMC Health Serv Res. 2012;12:143. to Aboriginal people in Dubbo, few had 11. Harch S, Reeve D, Reeve C. Management of type 2 Limitations experienced it and many pointed to diabetes: A community partnership approach. Aust Our sample was not representative of all Fam Physician. 2012;41(1/2):4. pharmacists and Aboriginal Health Workers 12. O’Dea K, Rowley K, Brown A. Diabetes in Indigenous Aboriginal people in Dubbo with diabetes. as those professionals who had helped them Australians: Possible ways forward. Med J Aust. It is possible our 25 participants represented 2007;186(10):2. figure out diabetes. This would indicate that 13. Bailie J, Schierhout G, Kelaher M, Laycock A, Percival N, people who were more interested in their both adjustment to the normative model and O’Donoghue L, et al. Follow-up of Indigenous-specific health and already engaged with health health assessments-a socioecological analysis. Med J an improvement in the consistent application Aust. 2014;200:5. services. It is possible their perspectives of the model is required. Continued emphasis 14. Larson A, Gillies M, Howard PJ, Coffin J. It’s enough represented best case scenarios. to make you sick: The impact of racism on the health on health system and service improvements of Aboriginal Australians. Aust N Z J Public Health. We were not able to adhere strictly to a should focus on supporting holistic patient 2007;31(4):322-9. grounded theory methodology. We had 15. Rix E, Barclay L, Wilson S, Stirling J, Tong A. Service centred and family centred models of care providers’ perspectives, attitudes and beliefs on health intended for the concurrent collection to build on to the cultural acceptability services delivery for Aboriginal people receiving and analysis of data, but due to excellent haemodialysis in rural Australia: A qualitative study. of intergenerational learning. Improving BMJ Open. 2013;3(10):e003581. momentum in our data collection and the cultural knowledge of non-Aboriginal health 16. Durey A. Reducing racism in Aboriginal health care in slow progress of group coding of our first Australia: Where does cultural education fit? Aust N Z J professionals and ensuring Aboriginal voices transcript we ran our fifth focus group prior Public Health. 2010;34 Suppl 1:87-92. can be heard in priority settings at a service 17. Birks M, Mills J. Grounded Theory: A Practical Guide. 2nd to completing coding on the first transcript. ed. London (UK): Sage; 2015. level will improve service credibility with While each transcript was coded in order 18. Sbaraini A, Carter SM, Evans RW, Blinkhorn A. How to do the Aboriginal community. Employing more a grounded theory study: A worked example of a study and compared and contrasted to the of dental practices. BMC Med Res Methodol. 2011;11:128. Aboriginal people in professional roles and developing theory, we were unable to vary 19. Higginbottom G, Liamputtong P. Par ticipator y more Aboriginal Health Workers who are Qualitative Research Methodologies in Health. London questioning in the focus groups in line with (UK): Sage; 2015. qualified diabetes educators helps Aboriginal the emerging theory and consistent with 20. Reaney M, Eichorst B, Gorman P. From Acorns to Oak constant comparison. Second, while constant patients feel they are understood. Trees: The development and theoretical underpinnings of diabetes conversation map education tools. Diabetes comparison drove theoretical sampling of Future research utilising participatory Spectr. 2012;25(2):6. newly diagnosed cases we were not able to 21. Reaney M, Gil Zorzo E, Golay A, Hermanns N, Cleall methods to drive service and system change S, Petzinger U, et al. Impact of conversation map pursue these as establishment of a sound based on this theory has potential to improve education tools versus regular care on diabetes- therapeutic relationship was prioritised over related knowledge of people with type 2 diabetes: diabetes care for Aboriginal people. A randomized, controlled study. Diabetes Spectr. recruitment. We were able to test the theory 2013;26(4):10. with data from the five participants who had 22. Maneze D, Dennis S, Chen HY, Taggart J, Vagholkar References S, Bunker J, et al. Multidisciplinary care: Experience been diagnosed with diabetes up to three of patients with complex needs. Aust J Prim Health. years previously and while the theory holds 1. New South Wales Department of Health. NSW 2014;20(1):20-6. Integrated Care Strategy [Internet]. Sydney (AUST): State with these cases we cannot defend saturation 23. Cuesta-Briand B, Saggers S, McManus A. ‘It still leaves Government of NSW; 2015 [cited 2016 Jan 19]. Available me sixty dollars out of pocket’: Experiences of diabetes of this element. from: http://www.health.nsw.gov.au/integratedcare/ medical care among low-income earners in Perth. Aust Pages/Integrated-Care-Strategy.aspx J Prim Health. 2014;20(2):143-50. Strengths of the study include the inductive 2. Australian Medicare Local Alliance. Improving 24. Hornsten A, Sandstrom H, Lundman B. Personal nature of grounded theory and the Integration of Care. Manuka (AUST): AML Alliance; 2012. understandings of illness among people with type 2 3. Australian Bureau of Statistics. Aboriginal and Torres diabetes. J Adv Nurs. 2004;47(2):9. participatory design and the continued Strait Islander People - Selected Characteristics. In: 25. Hornsten A, Lundman B, Selstam E, Sandstrom H. involvement of the research team through to Census QuickStats 2011 [Internet]. Canberra (AUST): ABS; Patient satisfaction with diabetes care. J Adv Nurs. the analysis, interpretation and presentation 2011 [cited 2014 May 19]. Available from: http://www. 2005;51(6):9. censusdata.abs.gov.au/census_services/getproduct/ 26. New South Wales Department of Health. Clinical of study findings. This has provided a level of Services Redesign Program: Chronic Care for Aboriginal census/2011/quickstat/LGA12600?opendocument& methodological and particularly interpretive People Model of Care. Sydney (AUST): State Government navpos=220 of New South Wales; 2010. rigour not often found. The study also 4. Endocrine Network. NSW Model of Care for People 27. Chung F, Herceg A, Bookallil M. Diabetes clinic with Diabetes Mellitus. Chatswood (AUST): Agency for provided the opportunity for all members attendance improves diabetes management in an Clinical Innovation; 2013. urban Aboriginal and Torres Strait Islander population. of the team to develop research skills, 5. Western NSW Local Health District. Dubbo Aboriginal Aust Fam Physician. 2014;43(11):6. Health Integration-Diabetes Project - Meeting Notes. understanding of research techniques and 28. Schmidt B, Campbell S, McDermott R. Community (AUST ): State Government of New South Wales Health; improve cultural understanding. health workers as chronic care coordinators: Evaluation of an Australian Indigenous primary health care 6. Royal Australian College of General Practitioners. program. Aust N Z J Public Health. 2016;40 Suppl 1: General Practice Management of Type 2 Diabetes 107-14. [Internet]. Melbourne (AUST ): RACGP; 2014 [cited 2016 Conclusion 29. Sherwood J. Colonisation- It’s bad for your health: Apr 14]. Available from: http://www.racgp.org.au/your- The context of Aboriginal health. Contemp Nurse. practice/guidelines/diabetes/ 2013;46(1):13. Our study provides an explanation for 7. Si D, Bailie R, Togni S, d’Abbs P, Robinson G. Aboriginal 30. Gibson OR, Segal L. Limited evidence to assess the health practitioners, services and systems health workers and diabetes care in remote community impact of primary health care system or service level health centres: A mixed method analysis. Med J Aust. attributes on health outcomes of Indigenous people to understand how Aboriginal people learn 2006;185(1):6. with type 2 diabetes: A systematic review. BMC Health about and manage diabetes. A model of 8. Burrow S, Ride K. Review of Diabetes Among Aboriginal Serv Res. 2015;15:154. and Torres Strait Islander People. Mt Lawley (AUST): Edith care is a small part of learning to understand Cowan University Australian Indigenous HealthInfoNet; and manage diabetes for Aboriginal people. 2017 vol . 41 no . 1 Australian and New Zealand Journal of Public Health 31 © 2016 The Authors http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Theory that explains an Aboriginal perspective of learning to understand and manage diabetes

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Wiley
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© 2017 Public Health Association of Australia
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1326-0200
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1753-6405
DOI
10.1111/1753-6405.12605
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27868348
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Abstract

with diabetes, the treating team and Dthe health system all grapple with Objective: To use grounded theory and participatory research methodology to explain how Aboriginal people learn to understand and manage type 2 diabetes. the intricacies of diabetes care. Integrated care, which is coordinated and encompasses Methods: Aboriginal people with diabetes were invited to participate in one of five focus health and social needs of those receiving groups (n=25, male=12, female=13). Focus groups and education sessions were conducted by 1,2 care, is widely regarded as the solution. Aboriginal members of the research team. Focus groups were audio recorded and transcribed, with coding and first level analysis undertaken by all members of the research team. Almost 5,000 Aboriginal people live in Dubbo, Results: Participants described colonisation and dislocation from Country and family members’ a regional city of 40,000 in New South Wales experiences with diabetes as significant historical influences which, in conjunction with the (NSW). Considering the prevalence of type model of care experienced and the type of interaction with health services, shaped how they 2 diabetes in adults in NSW is 8% and that came to understand and manage their diabetes. in remote Aboriginal settlements around 30%, we would expect between 200 and Conclusions: Patient experience of a model of care alone is not what influences understanding 750 Aboriginal people in Dubbo to have and management of diabetes in Aboriginal people. diabetes. Local services estimate between Implications for Public Health: Health service improvements should focus on understanding 41 and 174 Aboriginal people with type 2 past experiences of Aboriginal patients, improving interactions with health services and diabetes. These estimates demonstrate the supporting holistic family centred models of care. Focusing on just the model of care in likelihood that many Aboriginal people have absence of other improvements is unlikely to deliver health benefits to Aboriginal people. undiagnosed diabetes or are not supported Key words: Aboriginal health, diabetes models of care, participatory research methods, by health services to manage their diabetes. integrated care This data provided the rationale for a whole- of-locality approach to improve diabetes demonstrated that Aboriginal Health Worker Learning to understand and manage diabetes care, which assumed that the model of care led care increased the likelihood of a general consists of the acquisition of knowledge experienced by patients determined how practice management plan being in place and skills through being taught, studying or Aboriginal people understood and managed and improved clinical indicators, including a from experience. This study aimed to identify their diabetes. 1% improvement in glycaemic control. the model of care currently experienced by Aboriginal patients as it was assumed that The best care for people with diabetes is care Existing literature on care for Aboriginal improvement to the model of care was the key led by a health professional in conjunction people highlights the importance of to Aboriginal people learning to understand with the client. In NSW, the preferred model primary care, integrated care and care that 4 and manage their type 2 diabetes. The reader is general practitioner coordinated care, provides a culturally safe environment for 10-12 will see the error in our assumption, and learn which entails general practitioners and management of chronic disease. Yet while of the various factors that have influenced how their practice nurses carrying out health health assessments on Aboriginal people Aboriginal people come to understand and assessments and monitoring, and the have increased in primary care settings, manage their diabetes. engagement of a multi-disciplinary team follow-up treatment for identified problems to work with the patient to set mutually is poor and unacceptably large gaps exist 6 12 acceptable and achievable health goals. between evidence and practice. Stigma, Method Aboriginal Health Workers have long been discrimination and racism are experienced seen as part of best practice in improving by Aboriginal people in health service This project was a collaborative effort 7,8 10,14 diabetes care in Aboriginal communities. A contexts and power imbalances between between four organisations. An important recent pragmatic randomised control trial in Aboriginal patients and health services aspect to the study was the intentional 14-16 remote Australian Indigenous communities continue to limit cultural safety. privileging of Aboriginal knowledge 1. School of Rural Health, University of Sydney, New South Wales 2. Western NSW Local Health District, New South Wales 3. Dubbo Regional Aboriginal Health Service, New South Wales 4. Marathon Health, New South Wales Correspondence to: Dr Emma Webster, School of Rural Health, University of Sydney, PO Box 1043, Dubbo, NSW 2830; e-mail: Emma.Webster@sydney.edu.au Submitted: February 2016; Revision requested: May 2016; Accepted: July 2016 The authors have stated they have no conflict of interest. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. Aust NZ J Public Health. 2017; 41:27-31; doi: 10.1111/1753-6405.12605 2017 vol . 41 no . 1 Australian and New Zealand Journal of Public Health 27 © 2016 The Authors Webster et al. Article alongside research knowledge. This had the diagnosed diabetes was sought to ensure health, including reduced access to bush their perspectives were included. Two effect of equalising the relationship between medicines and traditional foods. Participants supplementary interviews were sought; all researchers and meant each of the team outlined that modern day policies limited however, no interviews resulted. led the research at different times through desired hunting and fishing practices. the process. The research team consisted of Twenty-five Aboriginal people who lived in “The government bloke was there trying to two male Aboriginal Health Workers who Dubbo, had been diagnosed with and were tell us that if we wanted to go out and shoot a roo and eat it, we had to apply to Canberra are qualified diabetes educators, two female receiving treatment for diabetes, participted first, and one old fella (said) … “My kids want in the study. Men (n=12) and women (n=13) Aboriginal Health Workers and two non- it tonight not next week or the week after.” mean age 67 (range 27-88) with diagnosis of Aboriginal women, one experienced and the Travis FG1 920-929 diabetes (range ‘pre-diabetic’ to 46 years since other inexperienced with regard to research. diagnosis) were included. Almost all (n=22) “Well I walked around here on the riverbank Grounded theory is inductive in nature reported a family history of diabetes. Tablets and I can’t find the tree I was looking for. Yeah, and assumes that substantive theory can were the most common form of diabetes I’d drink it and I’d bathe in it and I used to bathe be derived from data to explain social management (n=17) followed by diet (n=14) my kids in it in the winter time, they never got 17,18 processes. This qualitative study drew a cold. It was good stuff ... None growing down and insulin (n=12). Five participants used all on both grounded theory and participatory here ‘cause I looked and looked and looked three methods to control their diabetes. research methods and was informed by and I couldn’t find any.” Pete FG1 1271-1275 Grounded theory involves commencing constructivist epistemology. analysis from the first data collection event At a population level, participants attributed Community groups popular with Aboriginal and uses open coding to identify in vivo codes prevalence of diabetes in Aboriginal people were approached with prior that can be compiled into categories and communities to the introduction of European 17,18 permission and the research was explained. concepts. Coding was done by hand and food and sedentary lifestyles. Names of interested participants were noted open coding on the first focus group was “Well you’ve only got to think about it, the and contacted when the next suitable focus undertaken by all researchers; combinations amount of food we have now, nearly every group was planned. Extensive discussions of the research team coded the remaining processed foods that we’ve got is sugar, sugar, about approach to potential participants transcripts and participated in discussion, and sugar… the only sugar we used to have was concluded that it is desirable for prospective constant comparison of codes and incidents. the wild sugar you found while you were participants (either individuals or groups) Grounded theory uses memos as an walking around” . Travis FG1 1074-1077 to have an existing relationship with a analytic tool. This study used three types of co-researcher (which may or may not memos. Memos were produced with each Family members’ diabetes experiences be a therapeutic relationship) as trust is data collection event (based on research Most participants had a family history of considered an important element of giving team debrief ), occasional ‘top line’ memos diabetes, and realised that family history free and informed consent (that is, potential described progress and concept memos was important in terms of their own health. participants would feel more able to say defined, described and attempted to All were acutely aware of symptoms and ‘no’ to joining the research when they trust understand each concept and compare and complications of diabetes as a result of seeing members of the research team). relate these to other concepts. Memos were numerous family members get sick, suffer discussed among the research team and Five gender-specific focus groups (n=2 and die from the disease. diagrammatic models prepared to facilitate female and n=3 male) were conducted in “… my mother died from it. She went blind transition from codes and concepts to an English (language spoken at home) and 17 and everything … And my two brothers explanatory scheme. audio-recorded (85 to 108 minutes) with both had it. One died of a heart attack, and written consent of all members. Demographic Ethics approval was received from the NSW my other brother he has diabetes and they details were recorded before the focus Aboriginal Health and Medical Research had him on insulin ...” Kurt FG3 120-123 group began. Conversational transcripts Council and the Greater Western Human “… I saw my mother go through hell … were produced and pseudonyms allocated Research Ethics Committee. My mother died and my grandmother, her to ensure anonymity. Three to five members mother. She was totally blind by the time of the research team were present during Results she was 60 and now it’s all reflecting on me each focus group and rotated the roles of …” Bianca FG4 88-92 Our theory explains that there are four facilitator, organiser and note taker. Focus group questions and roles were piloted with influences that shape how Aboriginal people The high prevalence of diabetes in Aboriginal learn to understand and manage diabetes: Aboriginal Health Workers employed by a families increases exposure to experiential local health service. The focus group used a continuing effects of colonisation, seeing learning and the cultural practice of 20,21 family members suffer from diabetes, ‘conversation map’ aided by conversation intergenerational learning as a result of being cards to stimulate discussion and ensure each interaction with health services, and the party to these experiences shapes learning model of health care received. Each of these participant had a turn to answer first. The about treatment regimens and management ‘understanding your diabetes’ conversation four exerts a greater or lesser influence on practices. how an individual learns about and comes to map is a diabetes education tool and was familiar to some participants. manage diabetes (see Figure 1). Interaction with health services The sample size of five groups was pre- Colonisation Participants felt that only Aboriginal people determined. While focus group data were Participant stories demonstrated colonisation could truly understand Aboriginal culture extensive (320 transcript pages for analysis), and dislocation of Aboriginal people from and disadvantage and expressed distrust in theoretical sampling for people with newly Country continues to have a direct effect on a system that tells Aboriginal people how 28 Australian and New Zealand Journal of Public Health 2017 vol . 41 no . 1 © 2016 The Authors Indigenous Health An Aboriginal perspective of diabetes Figure 1: Theory that explains an Aboriginal perspective of learning to understand and manage diabetes. to live their lives, but has limited Aboriginal Figure 1: Theory that explains an Aboriginal perspective of learning to understand and manage diabetes. leaders or cultural voices within that system. “… they’re (white people) the ones who run the diabetic programs, they’re the ones who Continuing  effects of  come up with all these ‘you beaut’ things to do colonisation for black people with diabetes … The trouble with that philosophy is ‘cause a white fella, he’ll do that and then he’ll blame you.” Bob FG1 1165-1175 Participants described feeling stereotyped Learning to understand  by non-Indigenous health professionals and and manage diabetes. At  the level of the individual  negative reports of care focused on not feeling Seeing family  Model of care  each outer circle may have  members with  heard and a lack of cultural understanding experienced more or less influence on  diabetes offered by health professionals, resulting in the way the individual  comes to understand and  resistance to seek further help. manage their diabetes “One of the worst things I come across is because I’m dark skinned, they think I drink and smoke. I never drank or smoked in my life. And the first thing they say is, they don’t even ask the question of me ‘You will have to give Interations  up the grog and smokes’ , and I said, ‘Mate I’ve with health  never tried it in my life.’” Ross FG1 1064-1067 services “They have to understand our culture. That’s the thing, that’s what they’ve got to understand, how we’re used to live like. ” Jason “… she (doctor) came in to talk to me and Participants often adopted self-care measures FG1 1111-1113 when she opened her mouth, I thought, oh as a consequence of a communication my God she’s got to be black … I couldn’t help “… I don’t like going up to some specialist(s) breakdown with health professionals. myself. Where are your people from?” Bianca and stuff because I feel like it’s all scare tactics Participants indicated feeling let down by FG4 1422-1433 and they’re just trying to shame me and I feel the health system, expressed confusion over real bad about myself … I prefer not to go “The only thing that makes it hard, because I treatment plans and also developed their because I don’t want to feel that way.” Kaye can’t read or write, see. (My Aboriginal Health own, sometimes questionable strategies for FG2 2481-2484 Worker) understands that, and that’s why managing diabetes. he explains it to me.” Curtis FG5 1843-1844 Some participants described positive “I’ve been to a lot of dieticians and they tell you experiences with their doctor, emphasising different things and I just work things out for these stemmed from professionals Model of care experienced myself.” Vicky FG2 1247-1248 who expressed a level of caring and There was little consistency in terms of a “Doctors – sorry, not doctors, nobody understanding. The (hospital-based) renal model of care experienced by participants. educates you about your diabetes. All they physicians provided good support with some Some participants reported having their do is tell you you’ve got it, wear it and good participants reporting superior glycaemic diabetes identified opportunistically when luck to you.” Bob FG1 184-186 control under their care. they felt well, such as during a screening While participants identified a range of allied event. Others reported being hospitalised “No, I feel they’re very good. (The GP) is never health and specialist services they attended in a hurry and neither are the nurses. I can be before a diagnosis was made. Those who after their diabetes diagnosis, there was a up there, well last time I went for my check described receiving a general practitioner general lack of overall knowledge about up … I thought, ‘Oh my God, people must be led model of care found it highly acceptable. support services relevant to diabetes. This waiting.’ But he was never in a hurry.” Felicity Others reported having to continually remind included podiatry services, exercise classes, FG4 1526-1530 their doctor for routine diabetes care. chronic disease clinics, yarning groups (social Participants identified easier communication “Really, really nice … I go every three months groups where people get together regularly and I have a long appointment because first with Aboriginal staff as they perceived these to talk) or transport support to appointments. of all I go to the nurse then I go to (the GP) professionals understood Aboriginal lifestyles. Many participants felt they had figured and the nurse weighs you and does all your A level of dialogue was more accessible diabetes out themselves with assistance from sugars tells you everything and that and then between patients and Aboriginal health Aboriginal Health Workers and pharmacists. from there I go to (GP)” . Felicity FG4 223-226 professionals, ensuring a more effective Participants made a number of “There’s a lot of doctors and I’ve changed transmission of health information to recommendations to improve diabetes altogether now … Yes, but I got fully strict I can Aboriginal patients. care. A yarning approach (discussing with get him to write it out (request for tests of her “Aboriginal people they know how – what the patient) using diagrams and manikins blood sugar level) and I think I passed most they have to say to them and then they feel to explain diabetes, supplemented with of it (had ‘good’ numbers on her blood tests). comfortable if there was an Aboriginal person collaborative goal setting and a holistic So I’ve been nagging (continually reminding) sitting the other side of the table to ask them him to do that. I’ve got to go and see him family-centred approach to diabetes care was questions, they feel comfortable… ” Page FG2 Monday”. Susan FG4 927-930 recommended. Improving access to services 2243-2245 2017 vol . 41 no . 1 Australian and New Zealand Journal of Public Health 29 © 2016 The Authors Webster et al. Article by ensuring they are free, that medications and contemporary components (models of makes visible alternate ways health systems care and interactions with health services) might attend to improving diabetes care for are free or subsidised and that free transport that led to the acquisition of knowledge and Aboriginal people. is available was also recommended. skill. Each component varied in importance “Can I just say if you wanted to do something Previous studies have identified transmission for each person, and all factors continued to help blacks with diabetes ... you’ve got to of health knowledge from one generation to exert an influence on management of look at developing a holistic approach to to another as an important cultural practice diabetes over time. In hindsight it is obvious it … that holistic approach has to include emphasising the importance of family, – a model of care is about teaching and the family, and … even extended family. peers and social networks in education and So you have to include them in so that they providing clinical support, yet learning is a 10,15 support in chronic disease management. know how to look after people that have result of teaching, studying or experience. This, and the high prevalence of diabetes in problems … If we don’t have that holistic There were several issues in common between Aboriginal families, increases exposure to approach, we’re not going to last long.” Bob our participants and other population groups experiential learning about diabetes. These FG1 1543-1550 22,23 such as experiences with fragmented care, factors explain both the power of a holistic different understandings of disease between family-centred approach to diabetes care and Learning to understand and manage 22-24 the patient and the health professional provide an explanation as to why ‘modern’ diabetes and experiences of poor communication. diabetes management messages from health Participants felt they had mastered dealing The health system response to these issues professionals can lack traction with Aboriginal 4,26 with hypoglycaemic episodes but found has been to develop models of care on the people, as they can conflict with teachings of the lifestyle change challenging, including premise that optimal diabetes management the previous generation. managing medications, regularly measuring results from regular monitoring, setting and Identification of racism in health care 6 10,14 blood sugar levels and having routine achieving clinical targets supported by in Australia is not new and negative 11,27 service-wide clinical audits. Normative experiences with health care have an check-ups and tests. Many had experience models of diabetes care primarily describe ongoing effect on health seeking behaviours, of complications. All had goals relating to which health professionals should be seen even across generations. Where culturally diabetes and many were extremely motivated and what their role is in teaching the patient safe environments are provided they exert to deal with aspects of the disease. about diabetes. Modification to improve a positive influence on chronic disease “In the supermarkets I’m forever reading the 8,10,11 cultural appropriateness of these models has management. Our participants preferred packets, what do they call it? Carbohydrates built in identification of Aboriginality and interacting with Aboriginal staff of all ‘cause carbohydrates is sugar as well and then establishing trust. professions as they felt understood and underneath you can see sugar, and I always that their culture was acknowledged. Non- look at that to see how low it is before I buy Where participants described receiving the 4 Aboriginal staff could work with Aboriginal it ... I’m still doing things wrong, and I’m still general practitioner led model of care, they employees to drive health service change and learning …” Daniel FG3 217 – 222 found this an extremely positive experience, to identify how best to work with Aboriginal appreciating the time that was spent with Despite having difficulty finding support and people and pitch health messages. At a them in clinical consultations on a regular sticking with programs, many made lifestyle system level, ensuring health services are basis. We also found pharmacists and adjustments after their diagnosis. There were sufficiently staffed with Aboriginal employees Aboriginal Health Workers were key agents various levels of control and understanding, in all professions would provide good support in helping participants understand diabetes. ranging from very basic understandings to to both the community and non-Aboriginal Neither profession is recognised in the mastery of aspects of the disease such as 4,26 staff. This support needs to be extended to normative models, despite evidence of the monitoring blood sugar levels. Aboriginal workers by health services in order effectiveness of Aboriginal Health Workers “So if you know how food affects your body, 7-9 for them to be effective in their work roles. as care coordinators. This would indicate you can adjust your insulin, like if we’re going that both an adjustment to the normative Colonisation is largely regarded as ‘history’ in to have take-away … So I give myself an extra model and an improvement in the consistent Australia, with little regard for contemporary six units of insulin from when I took my sugar application of the model is required. Other effects on health. Our participants drew a last night before I went to bed, it was five. So I barriers to accessing primary care include link between the prevalence of diabetes and know what foods will send my sugar up and cost, lack of transport and expensive colonisation with its ongoing modification to what will drop it … Salads drop my sugar.” 8,22,23 medications and treatments and this was hunting, fishing and bush medicine practices. Bob FG1 178-184 also raised in our study. In this way, diabetes is symbolic of the dispossession, loss and grief associated with While refinements to the model of care are Discussion colonisation. Understanding this symbolic still warranted, they are unlikely to deliver link provides the basis of a more empathetic anticipated health benefits to Aboriginal While our study aimed to identify the model relationship and at a practical level health people. Furthermore, focusing health system of care experienced by Aboriginal patients, professionals should be aware that Aboriginal or service redesign on just the model of care participants answered our questions in people could be taking bush medicines that has the potential to reinforce stereotypes of a way that we had not expected. We had may interact with prescribed medications. both Aboriginal patients and non-Aboriginal assumed that learning about diabetes and health workers, as patients feel blamed when A recent systematic review of primary its management was a result of receiving programs designed by well-intentioned health care service or system level attributes a model of care from a team of health non-Aboriginal staff fail to meet their needs. identified that the patterns consistently professionals. However, participants told us Our theory makes visible the other influences associated with improved glycaemic index of historical components (colonisation and on learning about diabetes and therefore control for Indigenous patients were all family members’ experience of diabetes) 30 Australian and New Zealand Journal of Public Health 2017 vol . 41 no . 1 © 2016 The Authors Indigenous Health An Aboriginal perspective of diabetes 9. McDermott RA, Schmidt B, Preece C, Owens V, Taylor S, multifactorial in their approach. While the Historical factors such as colonisation and Li M, et al. Community health workers improve diabetes inadequacy of the evidence base was noted witnessing family members suffering from care in remote Australian Indigenous communities: by the authors, our explanatory theory would Results of a pragmatic cluster randomized controlled diabetes are also critical influences, along trial. BMC Health Serv Res. 2015;15:68. suggest the reason for multifactorial success with interaction with the health service. 10. Aspin C, Brown N, Jowsey T, Yen L, Leeder S. Strategic is that this is a complex problem influenced approaches to enhanced health service delivery for While general practitioner led care for Aboriginal and Torres Strait Islander people with by both contemporary and historical factors. diabetes management was highly acceptable chronic illness: A qualitative study. 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It is possible their perspectives of the model is required. Continued emphasis 14. Larson A, Gillies M, Howard PJ, Coffin J. It’s enough represented best case scenarios. to make you sick: The impact of racism on the health on health system and service improvements of Aboriginal Australians. Aust N Z J Public Health. We were not able to adhere strictly to a should focus on supporting holistic patient 2007;31(4):322-9. grounded theory methodology. We had 15. Rix E, Barclay L, Wilson S, Stirling J, Tong A. Service centred and family centred models of care providers’ perspectives, attitudes and beliefs on health intended for the concurrent collection to build on to the cultural acceptability services delivery for Aboriginal people receiving and analysis of data, but due to excellent haemodialysis in rural Australia: A qualitative study. of intergenerational learning. Improving BMJ Open. 2013;3(10):e003581. momentum in our data collection and the cultural knowledge of non-Aboriginal health 16. Durey A. Reducing racism in Aboriginal health care in slow progress of group coding of our first Australia: Where does cultural education fit? Aust N Z J professionals and ensuring Aboriginal voices transcript we ran our fifth focus group prior Public Health. 2010;34 Suppl 1:87-92. can be heard in priority settings at a service 17. Birks M, Mills J. Grounded Theory: A Practical Guide. 2nd to completing coding on the first transcript. ed. London (UK): Sage; 2015. level will improve service credibility with While each transcript was coded in order 18. Sbaraini A, Carter SM, Evans RW, Blinkhorn A. How to do the Aboriginal community. Employing more a grounded theory study: A worked example of a study and compared and contrasted to the of dental practices. BMC Med Res Methodol. 2011;11:128. 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Limited evidence to assess the health practitioners, services and systems health workers and diabetes care in remote community impact of primary health care system or service level health centres: A mixed method analysis. Med J Aust. attributes on health outcomes of Indigenous people to understand how Aboriginal people learn 2006;185(1):6. with type 2 diabetes: A systematic review. BMC Health about and manage diabetes. A model of 8. Burrow S, Ride K. Review of Diabetes Among Aboriginal Serv Res. 2015;15:154. and Torres Strait Islander People. Mt Lawley (AUST): Edith care is a small part of learning to understand Cowan University Australian Indigenous HealthInfoNet; and manage diabetes for Aboriginal people. 2017 vol . 41 no . 1 Australian and New Zealand Journal of Public Health 31 © 2016 The Authors

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