Friday, March 14, 2014

Aboriginal Education and Closing the Gap – Is it time to turn it inside-out?

"We may be doomed to fail – I fear – until we achieve the most basic target of all: the expectation that every child will attend school every day."

Those are the words of Tony Abbott, Prime Minister, in his speech to parliament a few weeks ago. It's difficult to disagree. He went on to propose a new target: 

"to end the gap between indigenous and non-indigenous school attendance within five years."

And he goes on to say every school should know their attendance rates, and talk about anti-truancy measures. 
In health, we have started to wonder why it is that people might not want to come to our health services, and discovered, to our surprise, that we open at inconvenient hours, people don't have transport to get there, we charge them money, make the rooms look unwelcoming and then insult people. Health providers are starting to think about making our services more welcoming.

Much of the commentary I've seen about improving school attendance rates in Aboriginal and Torres Strait Islander children talks about removing people's money and employing truancy officers. No where is it asked "Is there a reason these children might not want to come to school?"

We just assume that the way schools are run are how it has to be. Is there another way? Could schools run in a way that Aboriginal and Torres Strait Islander children and parents are clamoring to go?

I asked my friend, Andy Best, who is an experienced school principal, and Al Gore presenter. He has done a Churchill Fellowship and published on environmental education in Indigenous communities.
I'm not saying this is how we should do it. But I am saying perhaps we can be more imaginative in how we think about school that makes children want to come.

Here is what Andy wrote about what he learned in Alaska.

Everything created is around us. We are just part of it. But you teach your children behind doors, and thank your creator behind walls.
Noel Butler

On the northern headland of Ulladulla Harbour in New South Wales you can take a stroll around ‘One Track for All’ The track is punctuated with carvings depicting the history of the area. It examines the history prior to the arrival of Europeans and since their arrival. The above quote is taken from one of the carvings on display.
Currently in Australia we are grappling with ways to improve educational outcomes for our Indigenous Students. This, like all issues relating to Education, attracts a multitude of opinions. Most people have been to school and most people are quick to offer up solutions to educational challenges based upon their experiences. Sadly, the experiences of many of our Aboriginal and Torres Strait Islander people haven’t been happy ones when it comes to their time spent at school, and they can’t be blamed for having a lack of trust in our education systems, or a lack of desire to subject their children to similar experiences. Many well-intentioned and dedicated professionals have struggled in their attempts to improve educational outcomes for Indigenous students.
I was grappling with this problem in 2006, whilst working as a principal of a school in Sydney, NSW. We had a special unit at my school which served students with Emotional Disturbance and Behaviour Disorders. These students would arrive from around the district with high levels of disengagement from the learning process. A significant number of the children were Aboriginal. The school had highly developed Environmental Programs and was a pilot school for the Australian Sustainable Schools Initiative (AuSSI).  It was during this period that I noticed that the environmental education programs were having a significant impact in re-engaging these students in the learning process. I was keen to explore this idea further and over the next twelve months I developed a study proposal which I submitted to the Winston Churchill Memorial Trust at the beginning of 2008.
I was fortunate enough to be awarded a Churchill Fellowship later that year which took me to the United Kingdom and USA to study Environmental Education and Student Engagement.
The fellowship was undertaken between the 1st September and the 5th October 2008.There were three main goals for the fellowship:
1.            To equip the next generation of children with the necessary skills required to overcome the challenges that lie ahead of them.
2.            To provide innovative learning programs for Aboriginal students and enhance their performance in literacy and numeracy.
3.            To re-engage students with challenging behaviours in the learning process using authentic experiences in quality learning environments.
In New York State I was able to attend a lecture and workshop on the theme of “Saving Our Children From Nature Deficit Disorder” at Cornell University and also had the opportunity to gain ideas from practitioners in the field and meet with a Native American Professor with a wealth of experience in Indigenous Studies. I then travelled to Fairbanks Alaska to spend some time at a high school with an enrolment of more than 90% Native American students.
Environmental Education as a Key Element in Achieving Successful Learning Outcomes for Indigenous Students
I had the pleasure of meeting with Professor Jane Mt Pleasant at Cornell University in Ithaca. Jane specialises in Soil Sciences, but had been the head of the Native American Studies Program at Cornell until recently. Jane is a Native American and she provided me with some valuable insights into student engagement.
She explained that Native Americans have a spiritual connection with the land and a highly developed sense of place in much the same way as Australian Aboriginal people. This made Environmental Education an excellent vehicle for learning. She cautioned against programs that were tokenistic and tried to steer clear of programs that were just about “beads and feathers.” She graciously shared aspects of her own learning journey with me and the two hour interview that we had scheduled seemed to be over in minutes. Her advice to me was to examine what was happening in Alaska as there were some excellent programs in that state. This was very encouraging as I explained that I was heading North to Alaska the very next day.
I travelled to Fairbanks, Alaska and spent three days at Effie Kokrine Charter School. This school was a school of choice for the students. More than ninety percent of students were Native American with the vast majority being Athabascan Indian.
The schools vision, mission and goals were clearly defined and are as follows:
Students will learn through their individual learning styles and develop core values to guide their lives. When they graduate, they will leave as successful students, empowered, reflective, and grounded in tradition/culture.
Our mission is to empower students through understanding and utilizing individual learning styles, reflection through portfolios, and grounding in tradition/culture through blending western and traditional ways of knowing in forming our world view.
1.            100% of students in the junior and senior classes be involved in taking college classes in their area of interest.
2.            80% of graduates from Effie Kokrine Charter School will be students who began attending school at EKCS in the 7th grade.
3.            80 % of students taking the HSGQE at Effie Kokrine Charter School will be proficient in reading, writing and math.
4.            90% of students enrolled at Effie Kokrine Charter School will be, on any given day, present and in class on time.
5.            100% of students at Effie Kokrine Charter School will have a clearly defined and developed life plan in place.
The curriculum of the school was planned thematically for the year around Numeracy, Language, Culture and Literacy and every grade in the school covered the same topic but at different levels through a spiralling content. All subjects were built on an Athabascan Values Framework (in italics)
SUBSISTENCE/HEALTH/WELLNESS Sharing/Providing for Family/Compassion/Love/Dignity
FAMILY/TRIBE/COMMUNITY Respect for Elders/Love for Children/Responsibility/Unity
LANGUAGE/CULTURAL EXPRESSION Knowledge of Language/Wisdom/Spirituality
ENERGY/ECOLOGY/TECHNOLOGY Respect for Nature/Hard Work/Self Sufficiency
LIVING IN PLACE/ SURVIVAL Honoring Our Ancestors/Honesty/Humility/Humour
EXPLORING HORIZONS Caring/Cooperation/Endurance
On my first day at the school I sat in on a class where students were presenting assessment tasks as a culmination activity for their unit on Subsistence. A young girl was reading a procedure to the class that she had written on “How to Disembowel a Moose.” She had detailed knowledge and when I questioned the students, many class members had killed their first moose. They explained the traditional laws that must be followed and it was obvious that they had developed the values of sharing, providing for family, compassion and love and dignity that underpinned this unit of work. Later in the day the students went out to the snow covered vegetable garden to weed. They had harvested the crop the week before as part of the unit and had used some of the food at a community “Potluck” in the school gymnasium. Environmental Education has a strong connection with subsistence lifestyle and this was evident in the assessment tasks presented by the other students on topics such as fishing and caribou hunting. The children were very much aware of the balance in nature and the need to preserve it.
Lessons were based upon authentic learning experiences. I learnt how to split spruce roots for basket weaving and canoe making. Year 11 students had subjects such as Boat/Snow Machine Maintenance and Arctic Biology, and Year 10 students studied Climate Change in the Sub-Arctic, and Traditional Shelter and Clothing. Year 9 were engaged in studies of Survival in the Boreal Forest and Migration and Sense of Place.
Elders were welcome in the school and parents came and went at will as a result of the school’s open door policy. I interviewed a parent of a girl who told me that her daughter would have been lost in the local high school and that Effie Kokrine was a safe haven for her. She said that the parents valued the school because they believed that the school valued them.
I interviewed a student who had only recently enrolled in the school from interstate, or the “Lower 48” as the other states are referred to in Alaska. He told me that he really valued this school as it was good to study Indigenous Culture and Values and that it made the learning more relevant to him.
The school principal, Mrs Linda Evans, who is Athabascan, felt that the school was managing the thematic approach to the curriculum really well in the Junior High School as the class structure leant itself to a thematic approach to learning. She believed that this was more difficult in the Senior High School where teachers had been trained with traditional secondary pedagogy. This observation was similar in British Schools and indeed in Australia. Senior High teachers are very much driven by external testing agendas and this tends to limit their ability to integrate learning across several subject areas. I was interested to hear from a Native American Math teacher in the Senior High School who said that he was keen to develop a more integrated approach which incorporated Learning Styles as set out in the school’s mission. I interviewed an English teacher, who felt that this was too difficult, yet when I observed his lesson he had integrated traditional culture and environmental education brilliantly. 
All of the teachers in the Junior High School were Native American and half of the Senior High School teachers were also. They were highly qualified with several of the teachers having qualifications in Learning Styles and several teachers undertaking studies in an Advanced Learning Styles course. The intellectual quality of the work was rich and students were highly engaged. It is interesting to note that many of the students came from challenging family backgrounds, but rose above these challenges in the school environment. Children had to sit state exams even though their curriculum was different. The school had set grade level equivalences into their curriculum to ensure that state expectations and standards could be maintained.
The principal had only been appointed a few weeks before my visit. She is committed to the school’s mission and is planning to strengthen the school’s ability to fulfil it through well planned professional learning for the staff. She has a very demanding role as she is the only administrative staff member on the teaching staff and doesn’t have any other members of staff in school leadership positions. She is working hard to strengthen the collective vision of the staff.
I left the school with a firm belief that Environmental Education can provide authentic learning experiences for all students, and is a particularly engaging vehicle for Indigenous Students. I can also see great value in connecting students from Australia with students from different cultural backgrounds using the internet to enhance their understanding of the world as a whole.
I believe that Noel Butler was right in his criticism. Let’s empower our First Australians by building their learning around their cultural values, and taking them outside to reconnect with Mother Earth and authentic learning. Maybe just maybe it’s not too late to regain their trust as learners and really close the gap.

Wednesday, February 5, 2014

Should we be doing health assessments?

I was recently interviewed for an Australian Doctor item on health assessments, after I’d been involved in a Twitter discussion. I thought I’d set out my thinking and links to the evidence I’m using. I do need to point out that these are my personal views, and don’t represent the policy of any of the organisations I work for.
In Australia, GPs are paid by Medicare for doing health assessments. Health Assessments in Aboriginal and Torres Strait Islander people are particularly encouraged, being used as a KPI for many services, and essentially as a proxy measure for activity in Aboriginal and Torres Strait Islander Health.(See for example, p10 of this PDF, the main evaluation report of the government's program) With this pressure and expenditure, of course you’d expect it to work. 
The evidence is not as strong as you might think. First up was this study which caused some ripples in the UK, though not really in Australia. It’s a systematic review done by the Cochrane Collaboration, so is pretty much gold standard in the expertise of performing this sort of research. And this sort of research – that is, a systematic review - is the most reliable in giving trustworthy answers. They hunted down all the studies ever done to answer this question, and discovered that doing health checks didn’t help people live longer, and didn’t reduce people’s diseases. In fact, they were diagnosed earlier, and so lived more of their life with a diagnosis, without getting benefit from this. It also looked like people had just as many admissions to hospital, disabilities, as much worry, the same number of visits to the physician, and no fewer absences from work, though these findings were less clear.
Shortly after this, another study from Australia came along. They wondered if the outcomes of health checks were better for those performed in General Practice. They used the same systematic review methodology, where they tried to find all the research that had been done on this. They found that there were improvements in total cholesterol, body mass index and systolic and diastolic (that is the top and bottom) blood pressure figures. However, these improvements were very small – the authors say that they were statistically significant, which means that these results are probably not a chance finding. However, it is likely that a change of 0.13mmol/L in cholesterol, and 0.45kg.m2 does not make a difference in real life. This result has been reported asreassuring us GPs that it is worth us doing health assessments after all. I’m not so sure. There is no evidence of making people live longer in these studies, and there is even a suggestion that doing a health assessment increases your likelihood of dying of cardiovascular disease – another statistically significant result.
At face value, the evidence would indicate that we are certainly not saving any lives by doing health assessments, we may be labelling people with pathology for more of their lives, without any attendant benefits, and this may even be an intervention that gives people heart attacks or strokes earlier!
There is an argument to be made that in a population that have a higher risk of cardiovascular disease, such as Aboriginal and Torres Strait Islander people (though not only that group), there will be more benefit from doing health assessments. That may well be true, but there is no evidence at all either way at the moment – the best we have is what I have described above. This means by making this argument, we are entering a completely evidence-free zone. We may well be doing harm without realising it. Usually in medicine we are cautious about using an intervention widely if there is no evidence that it is beneficial. This would not be the first time that a combination of optimism and “common sense” that something ought to work has trumped the lack of evidence.

I’m not a complete nihilist, though, and I do think there is a way forward.
First, let’s note that health checks don’t appeal to everybody. This systematic review shows that those who are least likely to attend health checks are men, people without much money, people who aren’t white, and less well educated. In other words, those who most need them. It may be that in the field of Aboriginal and Torres Strait Islander Health we have come up with a mechanism that intuitively appeals to those developing the system but not to those using it.

What would those using it want? We know from this research that the way to break down cultural barriers for Aboriginal and Torres Strait Islander people using health services is to have a relationship with someone in the service. Unless used in a very nuanced way, a health assessment is a very transactional approach, making a consultation a data gathering exercise, not a relationship developing exercise. It’s quite possible that this effort is alienating to people. Certainly, examples where health checks have been well received have been when they are promoted as part of service activities that promote relationships.

The alternative approach is to build on the strengths of General Practice and Primary Care. 85% of people in Australia have seen their GP in the previous year, and the average number of visits is 5 or 6 each year. Julian Tudor Hart described anticipatory care, where the relationship developed and the series of visits over time meant that preventative activities could be performed in this context. He was the first GP in the world to know the blood pressure of every one of his patients. The two approaches, health checks and anticipatory care, were compared in Scotland. This is not an outcomes study, but we do know the outcomes for general health checks (see above) and we also know the outcomes for many of the individual preventive activities. The ones recommended are documented in the RACGP Red Book, and for Aboriginal and Torres Strait Islander people in the National Guide to a Preventive Health Assessment by RACGP and NACCHO. (Declaration – I was on the editorial panel of this guideline and wrote the mental health chapter). 
The solution, I think, is to promote the completion of individual evidence based preventive activities in the context of a long term therapeutic relationship. The Kanyini Vascular collaboration audit showed that this is already happening - cardiovascular disease preventive activity was occurring at the same level as in non-Indigenous people, but the number of health assessments billed was very low. Behaviour changes and referrals are more likely to be performed, as the GP and Primary Care team can keep on following up. Ideally, Medicare would pay at the completion of the recommended activities, whether this was in a single consultation or over many. (The Diabetes PIP Cycle of care is already paid in this way (PDF)). Granted, the evidence for this approach is limited. But the best evidence we have for the alternative shows that it might be harmful. Clinicians are being asked to perform money-raising interventions, which services are measured on, and potentially doing harm in the process.