Impact of a short, culturally relevant training course on cancer knowledge and confidence in Western Australia's Aboriginal Health Professionals
Dr Emma Croager, Education & Research Division, Cancer Council Western Australia, 15 Bedbrook Place, Shenton Park 6008, Western Australia, Fax: (08) 9388 4399;
Objective: To develop, deliver and evaluate a cancer education course for Indigenous Health Professionals.
Method: The cancer education course combines expert presentations, interactive sessions and visits to local cancer treatment centres. Three four-day courses have been run, in both metropolitan and regional Western Australia (WA). Cancer knowledge and confidence were measured at baseline, course completion and at follow-up (six to eight months). Data were analysed within subject.
Results: Thirty-five Aboriginal Health Professionals have completed the program, most from rural or remote WA. All confidence items significantly improved at course completion (p<0.005), but improvements for only two items, ‘I know what cancer is’ and ‘I can describe the different common cancers’, were sustained at follow-up (p<0.05). Knowledge of treatment (p<0.05), screening (p<0.05) and the most common cancers in women (p<0.005) were significantly greater after course completion, but increased knowledge was not sustained at follow-up.
Conclusion: Demand for places suggests that Aboriginal Health Professionals are interested in developing knowledge, skills and confidence in cancer control. Attendance increased understanding of cancer and improved cancer knowledge however this was not maintained.
Implications: A short, culturally relevant training course increases cancer knowledge and confidence, however, ongoing education is needed to maintain this.
Cancer is a leading cause of disease burden and death in Australia. It is estimated that 1 in 3 men and 1 in 4 women will be diagnosed with cancer in the first 75 years of life.1 The good news is that at least half of all cancers could be prevented with a healthy lifestyle – by stopping smoking, maintaining a healthy body weight, being physically active, eating a balanced diet, and avoiding alcohol and excess sun exposure.2 Self-awareness and screening are also important, as early detection improves the chance of successful treatment if cancer does develop.3 Furthermore, there is increasing evidence that a healthy diet and moderate physical activity can improve treatment outcomes and survival.4
Indigenous Australians (Aboriginal and Torres Strait Islanders) suffer a greater burden of ill health and have a shorter life expectancy than the rest of the Australian population.5 The impact of cancer on Indigenous people often attracts much less attention than it deserves, because the level of identification of Indigenous Australians in cancer notifications is known to be poor.6,7 Rates for some common cancers, such as cancer of the lung, unknown primary, lip/mouth/pharynx, liver and cervix, are higher in Indigenous people than non-Indigenous people, whereas other forms of cancer, such as breast and bowel, are moderately lower.7
Indigenous Australians are more likely to have cancers with a poor prognosis (some of which are largely preventable, for example lung and liver cancer), are diagnosed later, are less likely to receive adequate treatment and are twice as likely to die from it, than other Australians.5 Cancer has only recently been identified as a leading cause of death for Indigenous Australians and, as such, is increasingly becoming an important health issue for Indigenous Australians.6,8
Dissemination of evidence-based information and education about the biology of cancer and its prevention, early detection and treatment has done much to change the fatalistic beliefs and attitudes towards cancer within the general population.9,10 However, many Indigenous Australians still hold the belief that cancer is a death sentence.11–13 A recent study carried out among Aboriginal people in Western Australia (WA) has identified that misunderstanding, fear of death, fatalism, shame, preference for traditional healing, beliefs that cancer is contagious and other spiritual issues are common.13
There is an urgent need to increase awareness among Indigenous Australians that prevention, early detection and treatment of cancer saves lives, and to address the cultural barriers that impede access to related services for this population.14 This will only be achieved by working collaboratively with Indigenous organisations and communities to improve understanding of cancer control issues and by building capacity within the Indigenous health workforce.15 As a first step, the Cancer Council Western Australia commissioned an external review to investigate how best to meet the cancer control needs of the state's Indigenous people.16 It identified that knowledge about cancer and cancer-related services is inadequate and, among the recommendations, improving Indigenous Health Professionals’ knowledge of cancer was identified as a priority. To address this, a cancer education course was developed to provide culturally relevant training in cancer control for Indigenous Health Professionals in WA. To our knowledge, this is the first study to report on evaluation of such education with this target group.
In this paper, Indigenous is used to refer to first-nation Australians, however as Aboriginal is the term preferred by most Indigenous people in WA this will be used to refer to course participants and Indigenous people in WA.13
A four-day workshop, modelled on a similar program from the Cancer Council Queensland, was developed with the help of the Cancer Council Western Australia's Aboriginal Advisory team. The workshop aims to increase cancer knowledge, and awareness of the resources and services available to help Aboriginal people with cancer and their families. A set of comprehensive learning objectives was developed covering the continuum of cancer control from prevention through to palliation. Content was designed and developed to be culturally relevant by ensuring course content and materials were developed and delivered respectfully acknowledging cultural issues including death and dying, shame, traditional bush medicine, and men's and women's business. Experiential learning and yarning sessions were also important aspects of the program. Two Aboriginal members of the Cancer Council's Aboriginal Advisory group attended the pilot program to provide feedback and advice on the course's cultural relevance
A pilot workshop was delivered in June 2008. Since then, two more courses have been run; in metropolitan and regional WA. Content was delivered by experts through a combination of classroom presentations, interactive sessions and visits to local cancer treatment centres. Wherever possible and appropriate, content was presented or co-presented by Aboriginal people. Care was taken to ensure non-Aboriginal presenters had high levels of cultural awareness. Many of the non-Aboriginal presenters had worked with Aboriginal people in regional WA. Participants from Aboriginal Medical Services and Hospitals across Western Australia were invited to participate through professional networks including the WA Aboriginal Health Workers Association and the WA Country Health Service. There was no cost to participants.
At the end of each day of the course, process evaluation was carried out. Impact evaluation was conducted at baseline and course completion by self-report questionnaire and at follow-up (mean eight months, range 6–10 months) by self report or telephone interview. Five confidence items (I know what cancer is, I can describe the different common cancers, I can discuss the impact of a cancer diagnosis with the patient, I can describe the treatment and management practices in cancer, I can describe what someone can do to decrease their chances of developing cancer) were assessed on a four-point Likert-type scale (very unsure, a bit unsure, confident, very confident). Five knowledge items (List the three major treatments for cancer. What are three population cancer screening programs in WA. What are the three most common cancers in Aboriginal men. What are the three most common cancers in Aboriginal women. What are the six lifestyle factors that influence the chances of developing cancer) were also assessed. Changes in confidence and knowledge were analysed within subjects, by paired-sample t-tests.
Ethics approval for the evaluation was obtained from the Curtin University of Technology, Human Research Ethics Committee (PH–033–2009).
Three four-day courses were run in both metropolitan and regional WA. Thirty-five Aboriginal Health Professionals participated in the program, with thirty-two of these from rural or remote WA. In 2006, there were 143 Aboriginal Health Workers in Western Australia.17 Of the 29 participants (83% response rate) that completed evaluation at course completion, there were 19 Aboriginal Health (Promotion) Workers, three Aboriginal Liaison Officers, two Registered Nurses, an Indigenous Project Officer and an Aged Care Worker (plus four non-responders). Most participants (92%) were female. Nearly two-thirds of participants had more than three years experience as a health worker (More than five years: 44%; 3–5 years: 20%; 1–3 years: 32%; less than one year: 4%). Nine participants completed follow-up.
Treatment centre visits were extremely well received and participants reported that experiencing first-hand where treatment was carried out, meeting key people involved in treatment delivery and coordination, and observing how treatment was given were of considerable benefit.
Attendance at the workshop led to statistically significant improvements in all of the confidence items at course completion (Table 1). At follow-up, increased confidence was only sustained for two items: ‘I know what cancer is’ (p<0.05) and ‘I can describe the different common cancers’ (p<0.05). Attendance at the workshop significantly improved cancer knowledge at course completion in three of the five knowledge items, which were ‘List the three major treatments for cancer’ (p<0.05), ‘What are three population cancer screening programs in WA’ (p<0.05), ‘What are the three most common cancers in Aboriginal women’ (p<0.005). However, this increased level of knowledge was not sustained at follow-up (Table 2).
Table 1. Change in participants’ confidence after completing the Cancer Education Course for Aboriginal Health Professionals.
|I know what cancer is||2.59||1.64||0.955||6.199||21||0.000a||2.80||2.80||0.700||2.689||9||0.025b|
|I can describe the different common cancers||2.59||1.64||0.955||4.983||21||0.000a||2.80||2.20||0.600||2.714||9||0.024b|
|I can discuss the impact of a cancer diagnosis with the patient||1.81||2.90||1.048||5.552||20||0.000a||2.40||1.75||0.500||1.861||9||0.096|
|I can describe the treatment and management practices in cancer||2.73||1.73||1.000||4.806||21||0.000a||3.00||2.44||0.556||1.474||8||0.179|
|I can describe what someone can do to decrease their chances of developing cancer||2.45||1.64||0.818||3.645||21||0.002a||2.70||2.10||0.600||1.964||9||0.081|
Table 2. Change in participants’ cancer knowledge after completing the Cancer Education Course for Aboriginal Health Professionals.
|List the three major treatments for cancer||2.48||2.81||-0.333||-2.092||20||0.049a||2.70||2.60||0.100||0.361||9||0.726|
|What are three population cancer screening programs in WA||2.05||2.38||-0.333||-2.320||20||0.031a||2.30||2.40||-1.000||-1.000||9||0.343|
|What are the three most common cancers in Aboriginal men||2.10||2.35||-0.250||-1.422||19||0.171||2.10||2.40||-0.300||-1.406||9||0.193|
|What are the three most common cancers in Aboriginal women||2.00||2.48||-0.476||-3.211||20||0.004b||2.22||2.56||-0.333||-0.894||8||0.397|
|What are the six lifestyle factors that influence the chances of developing cancer||3.79||4.00||-0.211||-0.455||18||0.654||4.00||4.33||-0.333||-1.414||8||0.195|
It is well recognised that health professionals can enable and empower people to increase control over and improve their health and wellbeing.18 Indigenous Health Professionals have an important role to play in demystifying cancer within the Indigenous community; therefore it is important to provide them with knowledge and confidence about cancer control issues. Appropriately targeted education for Indigenous Health Professionals about the prevention, risks, symptoms, treatment and palliation of cancer is urgently needed and the Cancer Education Course has begun to address this.
Demand for places in the Cancer Education Course suggests that Aboriginal Health Professionals are interested in developing knowledge, skills and confidence in cancer control. To date, approximately 20% of all Aboriginal Health Workers in Western Australia have attended the course.17 Impact evaluation indicates that the culturally-relevant program successfully increased participant knowledge and confidence in cancer control issues; however the increased knowledge and confidence was not sustained after completion of the course. Ongoing education and support of participants is needed to maintain confidence and to ensure cancer knowledge is passed on to the community in a culturally appropriate way. Education and support strategies used to support other health professionals; such as regular phone or email contact, newsletters, facilitator visits and tailored refresher programs; could be used to provide ongoing support for participants.
One culturally relevant strategy to consider is establishing partnership or mentoring opportunities, as Indigenous people benefit from two-way learning through relationships (knowledge sharing), self-determination and control.19 One approach might be for the Aboriginal Health Professional to partner with a local expert in cancer prevention, detection or treatment who can assist them to deliver community education on cancer-related issues.20 Such approaches have not been well evaluated in the literature, however, the concept is in accordance with recommendations for supporting Indigenous learners.21,22 In some regions, course participants are being well-supported by the established networks of cancer professionals that already exist across WA, However, it is acknowledged that in some regional and remote areas of Western Australia more innovative approaches will be needed.
The Cancer Education Course itself provided a two-way learning opportunity, as participants improved confidence and knowledge in cancer prevention, early detection, treatment and palliation, and Cancer Council staff and course contributors learnt from the Aboriginal Health Professionals’ personal and community experiences of cancer. Participants had the opportunity to meet key people involved in cancer prevention and treatment and, through the various visits, experience first-hand what it would be like for an Aboriginal patient to have treatment. Concomitantly, course contributors made contact with Aboriginal Health Professionals across the state and developed important community contacts. A major challenge in WA is co-ordinating cancer care for people living in regional and remote areas. The course presented a unique opportunity to begin to improve advice on and co-ordination of cancer care for Aboriginal cancer patients living in these areas.
An intervention of this kind is not the sole panacea to the many challenges in tackling Indigenous cancer issues. However, the evidence presented here demonstrates the Cancer Education Course is a promising contribution to improving cancer knowledge and confidence in Aboriginal Health Professionals.
Funding for the program was received from the WA Cancer and Palliative Care Network, Department of Health Western Australia.
Cancer Council WA would like to thank our Aboriginal Advisory Team and the Cancer Council Queensland for their invaluable advice and support. We thank all of the participants, as well as the health professionals and services that gave their time to help deliver the program.