Meaning of Health

CONCEPTIONS OF HEALTH HELD BY ABORIGINAL, TORRES STRAIT ISLANDER, AND PAPUA NEW GUINEA HEALTH SCIENCE STUDENTS

GILLIAN BOULTON-LEWIS, HITENDRA PILLAY, LYNN WILSS Queensland University of Technology

DAVID LEWIS University of Queensland

Abstract

Health is considered to be a fundamental human right. Concurrently health is assumed to be a global social goal (Bloom, 1987) yet many third-world countries and some sub-populations within developed countries do not enjoy a healthy existence. The research reported in this paper examined the conceptions of health, conceptions of illness and health practices for a group of Aboriginal, Torres Strait Islander, and Papua New Guinea university students studying health science courses. Results found three conceptions of health and three conceptions of illness that showed these students held traditional/cultural and Western beliefs about health and health practices. These findings may contribute to the development of health care courses that are more specific to how these students understand health. This may also serve to improve the educational status of Aboriginal and Torres Strait Islander people and potentially improve the health status within these communities.

Defining Health

In contemporary society health is defined in various ways which in part are determined by context and culture. No single correct or universal conception of health exists, as Dines and

Cribb (1993) contend “health may be a concept that can be defined in a number of different ways – all of which have equal validity” (p. 8). However common to current views is the notion that health constitutes more than simply avoiding illness. For example the World Health

Organisation conceptualises health as a resource for daily living and as including a positive concept that emphasises social and personal resources as well as physical capabilities (Raphael,

1998). In a broader sense Raphael considers that health incorporates community development which focuses on the provision of shelter, education, food, income, sustainable resources, social justice, and equity. Lawson (1992) advanced a perspective on health that he believes remained 1 dominant throughout the 20th Century. That is, health is compartmentalised into physical, spiritual and emotional as well as social and intellectual dimensions. The ensuing hypothesis was that one could be fit physically, for example, while at the same time deficient in other areas.

However Lawson believes there are limitations to this conception of health and suggests a more socially oriented alternative where relationships exist between personal-individual health and societal and environmental health attributes. This incorporates a holistic conception of health that recognises cultural influences, lifestyle choices, and the natural-environmental context.

While there appear to be many perspectives on health and deriving a conception in universal terms would seem to be a complex task, it is possible to draw common elements that may be cross-cultural. Levine and Sorenson (1984) believe there is consensus among varied cultural groups that health means an absence of symptoms or signs of illness, it includes a sense of well-being, and a capacity to perform. In other words there are respectively biomedical, personal and sociocultural components to health. Personal and sociocultural components are a focus for Fabrega (1997) when he conceptualises health according to modern Western societies compared to primitive or non-Western societies. For Western society health is depicted as being opposed to disease and as a concern for individuals who pursue health through specific and directed actions. However health in non-Western societies is governed by holism and integration of body and mind. Individuals influence the group and social practices in relation to health reflect a spiritual, moral, and political concern. This is particularly evident in “village-level societies” (Fabrega, p. 31) where the belief exists that victimization by another within the group can cause sickness. In such instances there is dependence on a ‘protohealer’ for relief of symptoms or resolution of the conditions associated with the sickness. For example there are areas in Papua New Guinea where traditional healers currently exist (Williams, 1998). While it is apparent that common elements regarding the meaning of health exist amongst different cultures there are also differences. As Fabrega indicates, “the parameters of health, sickness, and

2 healing differ in different societies” (p. 24). Health factors that are particular to Indigenous

Australians are presented in the following section.

Health and Indigenous Australians

In Australia Indigenous people remain the least healthy sub-population. They have a higher death rate than non-Indigenous males and females for every age-group and admission rates to hospitals are higher in every age group compared to that of non-Indigenous people (National

Aboriginal and Torres Strait Islander Health Clearinghouse, 1999). Following is a summary of the most prevalent health conditions experienced by Indigenous Australians when compared with non-Indigenous Australians:

. Cardiovascular disease, deaths are twice as high and respiratory disease, deaths are seven

times more common with hospitalisation more than three times greater;

. Diabetes, approximately four times higher and renal disease approximately 295 per 100 000

for Indigenous people and 69 per 100 000 for non-Indigenous people per annum;

. Communicable diseases such as tuberculosis and HIV are greater; and

. Death from injury is about three-and-a-half times more common and includes interpersonal

violence and injury from fire and falls.

Other common illnesses experienced by Indigenous Australians are diarrhoea, pneumonia, bronchitis, middle ear infection, skin sores, and trachoma (Mathews, 1998). In the Torres Strait

Islands many people have experienced health problems that are associated with an increased intake of Westernised foods and a reduction in the amount of exercise that was experienced previously as a part of their traditional lifestyle (Mills, Pensio, and Sailor, 1997). In recent years this has resulted in an increase in heart disease, obesity, cancer and complications during pregnancy.

Aboriginal people recognise that ill-health is caused by a number of factors including physical, social and spiritual and that treatment encompasses all three aspects. In particular

Aboriginal aetiology encompasses four basic explanations for ill-health including loss of a vital

3 substance from the body (soul-loss) and introduction of a foreign and harmful substance into the body (spirit intrusion or possession) (Saggers and Gray, 1991). In remote areas of Australia, these beliefs currently exist and are influential in the continuation of traditional medicine for illnesses. For example in Groote Island, traditional knowledge explains the cause of some types of illness as being ‘sung’ or ‘sorcerised’ (Saggers and Gray, 1991, p. 52). There are instances in

Australia where traditional and Western medicine co-exist and Aboriginal patients seek assistance from both sources. Mobbs (1991) describes the health care facilities of an Aboriginal community in a small remote mining town as including non-Aboriginal health services as well as an elderly Aboriginal who practised traditional healing.

Recognition of ill-health is dependent to some degree on the definition of health.

According to Anderson (1999) the core elements that define Aboriginal health involve the

“physical, social, emotional, cultural, and spiritual well-being not only of the individual but of the whole community” (p. 65). Inherent in this view is a holistic conception of health, a connection between people, life, and death, and a relationship to the land.

Indigenous Health Workers

In Australia an integral component in the effort to address health problems faced by Aboriginal and Torres Strait Islander people is the Indigenous health worker. In particular they play an important role in the delivery of primary health care to Indigenous communities (Clapham,

Digregorio, Dawson, and Hughes, 1997). Their role is diverse and ranges from planning, implementing, and managing Indigenous community health programs to that of cultural translator (Clapham et al., 1997). Grootjans (1997) explains that Indigenous health workers are involved in primary health care and that their work encompasses three main activities: basic clinical practice, health promotion, and community development.

While training Indigenous health care workers is essential, it can also be a challenging and somewhat complex endeavour. This is due, in part, to the prior educational experiences of many

Indigenous people. They are the most educationally disadvantaged group in Australia

4 (Department of Education, Employment and Training, 1989). Aboriginal and Torres Strait

Islander university students comprise only 1% of higher education enrolments compared to the

National average participation rate of 4.8%. They are under-represented in several areas including health (Higher Education Division, Department of Education, Training and Youth

Affairs, 1999) and 42% of Indigenous students are enrolled in sub-degree courses compared to

11% of other students (Hester, 1994, p. 96).

Aboriginal and Torres Strait Islanders also have lower success and retention rates (Bin-

Sallick, 1999) at university than non-Indigenous students. Clapham et al. (1997) believe that the challenge for tertiary institutions is to make tertiary education accessible to Indigenous people while at the same time producing graduates who are skilled and knowledgeable in the cultural needs of their people. This requires the development of ‘culturally relevant’ programs that recognise the learning styles, cultural perspective, prior educational experiences and informal learning experiences of Indigenous students. Some universities recognize and actively cater for diversity among their students. For example support services that have been operationalised for

Indigenous students include tutorial assistance, access to academic support, personal counseling, and Indigenous study enclaves (Anderson, 1998).

Once trained, Indigenous health care workers may face difficulties when employing health care practices. They may be challenged by the disparity between Indigenous and Western models of health and illness (Clapham, et al, 1997). As noted earlier in Western models health opposes disease as the focus for individuals who pursue health through specific and directed actions. However health in non-Western societies is governed by holism and integration of the body and mind. Specifically health in traditional Aboriginal terms incorporates the connections between body, land, and spirit (Golds, et al., 1997). Difficulties may also occur as non-

Indigenous and Indigenous people sometimes hold different perceptions of the role of the

Indigenous health worker (Senior and Daniels, 2000). Senior and Daniels conducted a study of health services in a remote Aboriginal community and found that non-Aboriginal residents

5 believed that Aboriginal health workers were for Aboriginal people only and that their qualifications were limited. Other findings were that Aboriginal people often feel shy about going to a clinic, they do not like being treated by a doctor or nurse of the opposite sex to them and they worry about taking tablets, a concern that sees some turning to bush medicine as an alternative. Aboriginal people may also turn to sorcery and witchdoctors for cures (Senior and

Daniels, 2000). Other confounding factors may include difficulty in maintaining confidentiality within Aboriginal communities, poorly informed management committees, and remoteness.

Rationale for the Study

Phenomenographic methodology was used to determine Indigenous University students’ conceptions of health. The focus of phenomenographic inquiry is to investigate the qualitatively different ways that people experience phenomena (Marton, 1988) and to delineate the subsequent ways of understanding, or conceptions, as categories of description. Morgan and Beaty (1997) explain that an experience has structural and referential aspects. Structural aspects concern the constituent parts of the experience and their relationship to each other as well as contextual factors.

Integrated with structural are referential, or in other words meaning, aspects.

As stated, conceptions emerge from experiences and understandings of phenomena, therefore other aspects related to health were also ascertained. These included students’ understandings of illness, their awareness of cultural aspects to health, and health practices. An assumption was that these students may hold conceptions of health that are different from those held in Western society and these conceptions may not be addressed in health care courses. It is also important to know more about conceptions of health for these groups as there are increasing numbers of Indigenous students undertaking primary health care courses. As far as we can determine, there are no other studies that have ascertained conceptions of health for Indigenous students.

6 Methodology

Sample

The sample comprised 21 students undertaking health studies in two universities in Queensland,

Australia. Three students studying at Queensland University of Technology (QUT), were from

Papua New Guinea; the others were studying Indigenous Primary Health Care at the University of Queensland. Three of these students were also from Papua New Guinea, 6 were Aboriginal, and 9 were Torres Strait Islanders. Eight of the students lived in Torres Strait and studied on a part-time basis at the University of Queensland campus on Thursday Island. The other students were all studying full-time. Ages ranged from 20 to 47 years with a mean age of approximately

33.8 years. Seven students had completed Year 12, the others had completed Year 10 and most then undertook courses through Technical and Further Education; four had previously undertaken university studies in teaching or nursing. The students came from varied work experiences and diverse backgrounds, living conditions, and cultural experiences.

Interviews

Individual, semi-structured, audiotaped interviews, each lasting approximately an hour, were conducted by a Torres Strait Islander research assistant1 and the third author. These occurred in

Brisbane and the Torres Strait Islands. Predetermined questions, used to stimulate dialogue, covered the following topics: cultural experiences incorporating health issues and practices, meaning of health, meaning of illness, experiences of health care and illness, and health problems faced by Indigenous people. Following phenomenographic methodology (Svensson,

1997) interviews were framed so that questions related to each other and were contextualised.

For example students were asked about their health in general and how they stay healthy or, if they were ill, what action they would take. They were then asked what ‘health means’ followed by what ‘illness means’. The interviewers probed responses, relevant to health, as they arose.

1 Our thanks go to Muriel Bin Dol for her help in conducting the interviews. 7 Consultation with Indigenous people is essential when conducting research involving their communities (AIATSIS, 2000). It is also essential to obtain ethical clearance to conduct research involving Aboriginal and Torres Strait Islanders. This was sought and gained from QUT Human

Research Ethics Committee after the chief investigator (the first author) consulted with a senior member of the Indigenous Unit at QUT. The objectives and procedures of the study were discussed and assurance was given that the Indigenous participants were not in a dependent relationship with those conducting the research. Other members of the research team met with a

Papua New Guinea post-graduate student representative to discuss the project prior to conducting interviews with Papua New Guinea students and permission to interview students on

Thursday Island was gained after the Chairperson of the Torres Strait Island Health Council was informed of the objectives and procedures of the research. Additionally prior to the interview each student was given an information sheet explaining these details. The interviewer discussed this with them and asked if they understood it or if they had any questions. To ensure that a shared understanding of information was achieved, an Indigenous interviewer along with the third author, conducted each interview. Participants were also told that they could withdraw at any point if they wished. Each participant acknowledged their understanding of the process and their willingness to participate by signing a consent form. After the interview they were paid a fee for their time and contribution to the research. Once each interview was transcribed it was sent to the participant so they could check it for accuracy.

Analysis

The analysis was conducted to determine students’ conceptions of health, their conceptions of illness and their health practices. Conceptions are explained as being relational because intentions and the context in which phenomena occur (Johansson, Marton, and Svensson, 1985) influence people’s experiences. Firstly, interviews were transcribed from the audiotapes. Then in a departure from previous phenomenographic studies, interview transcripts were summarised as a series of case studies that focused on culture and health, health practices, health problems, the meaning of health

8 and illness, and earlier generations and health. The summaries ensured rigor and decreased the memory load for the researchers as there were approximately 150 single spaced pages of interview transcripts to consider. They also served as concise indicators of important points and proved to be a useful means by which all the data could be considered and managed at the same time.

The data were pooled and the researchers adopted an iterative approach to ascertain relations, similarities and differences in the students’ responses. This was conducted by moving between full transcripts and the summaries. An initial set of categories of description for health was developed by all the researchers. Following this the categories were discussed further to determine the “logical structure of the categories and the relations between them” (Bruce and Gerber, 1995, p. 446). The categories were then refined to comprise a final set that reflected the varying experiences within the group and illustrated the conceptions of health. This procedure was repeated to determine conceptions of illness. Health practices that students reported undertaking were also categorized.

Results

Conceptions of Health

The analysis indicated that there are three main conceptions of health. These are shown in Table

1 along with extracts from students’ interviews that delineate each conception. The conceptions were that health 1. means well-being; 2. is determined by the individual in terms of (a) their lifestyle and (b) by their relationship with others and the community; and 3. involves a balance with regard to holistic dimensions. In explaining phenomenographic research Marton (1994) maintains that categories of description that become apparent form a hierarchical system. We believe that the conceptions of health are hierarchical in that each builds on and adds greater depth to the meaning inherent in the prior conception. It also means that each conception is subsumed by the subsequent higher conception. The conceptions are described below according to referential, or meaning, aspects and structural aspects which delimit the conception from the context or background, as well as its component parts and the relations between them (Marton et al., 1993). In determining the referential aspects of each conception we found that they emerged

9 from three distinct perspectives. These varied according to whether a student held predominantly traditional/cultural beliefs, traditional and Western beliefs, or predominantly

Western beliefs. These are also detailed in Table 1.

1. Health means well-being. This is a simple and general conception of health that was characterized by short and limited descriptions. One student described well-being in terms of an

‘absence from disease’ however some simply described this conception without reference to other aspects of health. We believe that the students who held this conception were speaking from a Western perspective as there were no indicators to define it from a traditional viewpoint.

2. Health is determined by the individual in terms of:

(a) Lifestyle factors. The focus was on the individual in this conception with descriptions signifying the lifestyle factors that could be considered to sustain health. Some students spoke of health by comparing how they live, or their lifestyle, from traditional and Western perspectives.

From a traditional stance students spoke of how people live and of having the basics for survival which was contrasted with the “biomedical model of illness” and going to hospital as occurs in the Western culture. Those who spoke from a wholly Western perspective stated that health meant doing things like eating the right foods, exercising, and keeping weight down. The underlying tone is that health or well-being would be maintained by an individual eating and exercising carefully or seeking hospital treatment when necessary. Therefore the first conception of health is subsumed and built upon. However the individual was not spoken of in terms of their relationship with others as is evident in the following conception.

(b) Relationships with others. This conception was described in terms of traditional/cultural influences and traditional and Western influences. In the former, good relationships were reported as being essential to one’s good health because if these were not maintained then someone may do ‘puri puri’ which would result in illness. Specific steps that could reestablish relationships if they broke down, such as giving food and pigs, were described. Responses from the traditional and Western perspective emphasized relationships as the individual living in

10 harmony with people in the village (traditional) or in the house (Western). Other relationships such as living within economic and social means were spoken of as well as a connectedness with land and one’s culture. Students who expressed this conception stated that as long as these factors were maintained then well-being or health would follow. Thus this conception builds on the first conception by elaborating how well-being can be established. It also extends part (a) lifestyle factors in that the focus, while still the individual, was on relationships that need to be established as well as healthy lifestyle factors. While this conception entails a complex view of health it does not include a global perspective on health as is evident in the next conception.

3. Health involves balanced holistic dimensions. This conception was evident in each of the three perspectives. The common thread was that health constituted physical, mental, spiritual and in some cases social and environmental aspects. In the traditional/cultural responses there was the added dimension of evil spirits that can influence health. This was different from traditional and Western responses in which health included clearing the head in a spiritual and traditional sense. Responses that entailed Western influences included the importance of balancing these dimensions so that health would ensue. Students spoke in terms that portrayed the individual in a balanced relationship that constituted not only physical, mental and spiritual dimensions but also relationships with the environment and economy. As such this conception denotes a more global perspective on heath that builds on each prior conception.

11 Table 1. Conceptions of health and students’ statements that illustrate traditional/cultural, traditional and Western, and Western perspectives

Conception Traditional/Cultural Traditional and Western Western Influences Influences Influences Health means Absence from disease. well-being Just well-being basically. Yeah, that’s how I would put it’s just well-being. Health is Health with the traditional way All the good things like determined means how people live. . . . look exercise and eat the right food by the at all the basics that are needed to to fight the diseases, good foods individual survive. The Western culture like to help your immune system. in terms of the biomedical model of illness, if Keep your weight down (a) lifestyle someone is sick then go to the otherwise you will be getting factors hospital and the health services diseases, hypertension. established by the government. (b) relationships At home people might be Health means healthy living with others jealous and they might do economically, socially, be puri puri . . . it will affect involved with people, get along you to be sick so you have to with people, cooperation between live in good relationship different people in the village and with others. It can start from mentally. Health is to have a good an argument or somebody education, live in good condition, stealing a girl from a clan. a good house they can afford. If They have to go and settle it you have food then they can keep like go and pay the right the well-being going. price. Like give food and . . . connectedness towards your pigs. If you don’t solve it land, towards your people, the you will get sick. That is to relationship you build with the do with relationships. people, your family, your land, your culture, you’ve got to uphold that. The end result is health. Health involves Free of disease physically, I’ve always thought that health is For a person to be healthy, balanced holistic mentally, spiritually. In our all physical, mental and mainly health is like body, mind, place, dimensions culture spiritual dimensions spiritual as well. With health like spirituality. All those things are important. When you’re physical well everyone knows have to be balanced to have washing, the evil spirits that when you are down you need to health. live there [in the creek], well have yourself right but also with It’s a big thing health. I used to if the spirits are not happy spiritual because I’ve had a lot of think of it as the one thing like that makes you cautious. problems with it myself that I not getting sick. Now I look at know like when I have my head other things around it like cleared or something to turn to I environmental factors, housing feel better. and finance . . . unemployment, having income, enough to support your family. Mentally it helps you to think of physical, mental, and social health care. You got to balance those.

Conceptions of Illness

The analysis of responses relating to illness revealed three main conceptions. These are shown

in Table 2 along with extracts from student’s interviews that illustrate each conception. They are

12 that illness means 1. being really sick; 2. needing to take action by means of (a) seeking treatment and (b) undertaking preventative measures; and 3. an imbalance involving holistic dimensions including physical, spiritual, social, and environmental. The conceptions are hierarchical and are described below according to referential and structural aspects and traditional/cultural influences, traditional and Western influences, and Western influences.

1. Illness means being really sick. This is the most basic conception of illness which students spoke of from each of the three perspectives. There were two aspects to this conception. One involved illness as simply not being well or having a disease. The other related to illness as having a debilitating affect on a person. From a traditional/cultural perspective students explained illness as involving both of these aspects. For example one student stated that sickness is ‘when you lie down’ and also that is means being really sick. The traditional and Western perspective included contrasting a non-Indigenous view of planning for a funeral with

Indigenous people not thinking about death. Illness was also explained as sickness or not being well. Responses from the Western perspective of illness were expressed in terms of specific diseases as well as the debilitating affect. Overall this conception focuses on illness as being sick, inactive or lying down, and that sometimes someone must look after you. This is different from the next conception which refers to the action one can take to deal with or prevent illness.

2. The conception of illness as needing to take action has two aspects, as follows:

(a) Seeking treatment. This conception was expressed by students in terms of traditional and

Western influences and from Western influences alone. While illness is explained as

sickness, like the first conception, there is an added dimension in that treatment can be

sought. Students who spoke in terms of traditional and Western influences stated that

treatment could be sought from either modern medicine or a traditional practitioner or by

using home remedies. Some students held the traditional belief that illness was caused by

problems at home or in the village and that these must be addressed before treatment

would be effective. From a Western viewpoint treatment concerned going straight to the

13 doctor or slowing down for a while. While students who expressed this conception held a

proactive conception of illness they stopped short of stating that preventative measures

can be taken to avoid illness. Prevention constituted the following conception of illness.

(b) Undertaking preventive measures. Illness as taking action in terms of preventative

measures was expressed from a traditional and Western perspective and a Western

perspective. Spanning both was the underlying contention that illness can give you a

greater awareness that you can take action to prevent it. This conception is similar to the

first conception in that both share the notion that illness can be debilitating or that it

constitutes disease. It is also similar to part (a) taking action, as prevention could be

regarded as a higher form of treatment. Prevention from the traditional and Western

perspective for one student meant, on a spiritual level, the possibility of losing ones

identity. This was contrasted with not possessing an awareness of Western ways that

may result in illness, for example not eating the right food. Consequently doing the right

thing spiritually and in physical terms can be regarded as prevention. Prevention from a

purely Western influence focuses on the possibility of becoming sick if one does not take

preventative measures. This conception of illness is complex as it recognizes that illness

can be disease and that treatment is possible. However doing the right thing to avoid

illness is recognized as the course of action to take. The next conception presupposes all

prior conceptions and sees illness in a holistic and relational way.

3. Illness means an imbalance involving holistic dimensions including physical, spiritual, social, and environmental. This conception was evident in each of the three perspectives and responses in each were similar in that they explained illness as constituting physical as well as other dimensions. There was also a relational aspect to this conception which involved the necessity for the dimensions to be in balance to avoid illness.

14 Table 2. Conceptions of Illness and students’ statements that illustrate traditional/cultural, traditional and Western, and Western perspectives.

Conception Traditional/Cultural Traditional and Western Western Influences Influences Influences Illness means Sickness, when you are Not being well. Probably just being Disease. (What sort?). Depends really, really sick. Sick as sick, cancer or whatever illness. Most like if you have a mental illness being really in you need someone to of my family we don’t think about or some physical illness. sick look after you. When you illness. I mean I think non-Indigenous Illness means like debilitating, lie down. you plan where you are going to have you can’t function. your plot for your funeral and stuff like that but Indigenous people they don’t think about death and that, they don’t really think about illness. Illness means Illness I would look at in the sense of If I’m really, really sick I go physical. If I am sick then I need to be straight to the doctor. If I’m needing to treated whether I go to a traditional feeling sick I just take it slowly take action practitioner or modern medicine or I for a while. could use home remedy. by means Illness in a medical point of view is of: disease or virus gets into your body and (a) seeking makes you sick and that is true I believe that but there are some other treatment things that can make you ill. If you are ill go to the hospital, doctors prescribe medicine, but you are not really well . . . they explain to the doctor let me go home. In PNG we say that’s ‘straitem tok’. Got to sort out your problems, come back get medicines and for me I’ve seen a lot of patients get well.

Illness, on a spiritual level, could be Some sickness can be very not doing the right thing. . . . loss of scary if you don’t understand (b) prevention identity. Illness could be because you the sickness and how to prevent are not aware in the Western way, in them, stop them happening. It is the Western world. You are not aware not good getting them and of what’s out there. Like diabetes and trying to deal with them there stuff people can prevent. Illness in the but preventing them. Sickness Western way, you are not eating the is something that if you don’t right food. Eating KFC. prevent it from happening, it is something that you can be sorry later on in life. Illness means an . . . for Indigenous people, Illness of health you mean? Well I reckon if all of those imbalance you can be sick in body or illness of health could be described as (spiritual, emotional, physical) involving holistic you can be sick in spirit physical illness, emotional illness, the are balanced then you are right. dimensions and sometimes those two opposite of, like you get ill when you Otherwise you can’t be healthy including things can overlap. If you don’t have these things. physically but if you are physical, are sick in your spirit you mentally healthy then that is it spiritual, social, can be sick in your body you get out of problems. environmental and if you feel happy or If you don’t have a safe house, really good in spirit then a secure home, then it will that can relate the same affect your physical health, you way to the health of your will get sickness. If you don’t body. look after your mental health well you can’t think.

15 From the traditional/cultural perspective illness was viewed as being sick in either spirit or body or both with one affecting the other. Similarly in the traditional and Western perspective illness was explained as a part of health when a student asked “Illness of health you mean?” It was also described as resulting from a lack of physical and emotional well-being. Responses from a totally Western perspective explained that there must be a balance in each dimension to be healthy. This was extended by some students to include safe and secure housing and environmental factors. Thus while responses were specific to the beliefs held by each student there were common elements to each perspective. This conception is more complex than the previous conceptions as it involves many dimensions that constitute illness, and conversely health, and it also takes into account the influence one dimension can have on another.

Health Practices

Students were asked what they do to maintain health and also what they do if they become ill.

We have categorized their responses according to the three perspectives, traditional/cultural influences, traditional and Western influences and Western influences.

Health practices. Health practices that were traditionally influenced related to eating vegetables and also abiding by the rules of the community. Some responses indicated that some students routinely integrated traditional and Western health measures. For example while one student stated that she ate “traditional leaves that grow in the forest”, she also stated that she exercised, ate raw vegetables, and ate lots of greens which can be construed as Western behaviours. Another stated that he played sport and went to the gym while at the same time he considered “going out West to fish and hunt to be in touch with the land and the spiritual side” equally important which denotes a mix of traditional and Western behaviours. Most students reported Western influences to their health practices such as eating the right foods and exercising. However some spoke of specific Western practices such as having a flu vaccination, meditating, and ensuring that stress levels were low. Others felt that people need to be educated

16 so that they can become more aware of preventative health measures such as personal hygiene, good sanitation, and immunization.

Practices related to illness. While most traditional practices related to illness involved seeing the village healer, students were aware of other traditional means of treating illness. For example one student stated “there are some plants good for flu, coconut drink for diarrhea”.

Consulting the village healer sometimes followed initial treatments such as home remedies or sleeping. As one student stated when asked if they would go to the Doctor, “No. I wouldn’t because I have to do what I can do first. I if have a headache I drink a lot of water then I sleep.”

For some, consulting the village healer was preferable to seeking modern medicine as evidenced in the statement “. . . they know that the person in the village, the village healer, can heal better than modern medicine then they go to that person, give pig to them and that person heals them”.

Some students spoke about practices related to illness that involved traditional and Western influences. For example, “I had a bit of asthma. I went on to puffers and couldn’t get rid of it.

[So] I used this bush medicine . . . it got rid of it”, and “I would go straight to the hospital. If I have problems with my family or the council, anything that I think are related to my illness I’ve got to solve that too”. The notion that traditional healers are important but not the only source of help was evident when one student stated, “People still think that the traditional practitioners help. We need to strengthen this by integrating it with our health care system in our country.

Traditional and modern medicine need to complement each other”. Practices influenced by

Western behaviour included going to the doctor, taking aspirin, or looking after oneself.

Discussion

The research reported in this paper concerns aspects of health for Indigenous Australian and

Papua New Guinea university students studying in health science courses. Most of these students were also working in health related fields. The results indicate that these students hold varying conceptions of health and illness and they also practice a range of health related behaviours. This points to the notion that health is conceived of as a complex and diverse

17 phenomenon. It also adds validity to the contention put forward by Dines and Cribb (1993) that there in no one universal conception of health. It is important to know how Indigenous

Australians think about health as they remain the least healthy sub-population in Australia

(National Aboriginal and Torres Strait Islander Health Clearinghouse, 1999). Implications with regard to teaching in health care courses are presented below.

The students reported conceptions of health that ranged from a simple explanation of health as well-being to a more complex and holistic view of health as the consequence of physical, mental, and spiritual equilibrium in the context of social or community well-being.

Between these was the conception of health as determined by the individual in regard to lifestyle factors and their relationships with others, the land and one’s culture. The conception of health as well-being is similar to that proposed by Levine and Sorenson (1984) who drew from the ideas of several cultural groups to explain health as an absence of symptoms or signs of illness, as including well-being, and a capacity to perform. While the students in this study did not state that health included a capacity to perform they did address this notion in the first conception of illness when one student stated, ‘illness means debilitating, you can’t function’. Therefore conversely it could be argued the health would mean a capacity to function or perform. This adds to the complexity that is inherent in the meaning of health as explained by these students.

Health as determined by the individual and health as involving holistic dimensions are similar to Fabrega’s (1997) findings about health when he compared Western and non-Western societies and the beliefs they held. Fabrega found that health as a concern for individuals was a characteristic of Western societies. This was apparent in the findings of this study in the conception of health as involving the individual and lifestyle factors which was influenced by predominantly Western ideals. Lawson (1992) advanced a more complex conception of health that is like the individual and relationships with others conception found in this study. Lawson explained that relationships exist between personal-individual health and societal and environmental attributes. The Australian Indigenous and Papua New Guinea students spoke of

18 health in this way from a traditional and traditional and Western perspectives. It is interesting that there is no totally Western perspective of health involving the individual and their relationships. Perhaps this is because relationships with others, the land and culture are more specific to those living in village-like societies. It also confirms the individual outlook towards health in Western societies as reported by Fabrega.

Health as involving balanced, holistic dimensions is a sophisticated and advanced conception. This is the only conception of health that students spoke of from each perspective which adds to its complexity. While others contend that Aboriginal health involves physical, social, emotional, cultural and spiritual dimensions (Anderson, 1999) we could not find any reports that define Indigenous beliefs about health according to the different perspectives. This holistic conception might be expected, particularly in the traditional view, as Fabrega (1997) noted health in non-Western societies is governed by holism and integration of body and mind.

Lawson (1992) explains this multidimensional view of health as being dominant throughout the

20th Century. We argue that while it is an advanced conception of health the findings of this study attest to other advanced conceptions that should also be noted as valid for Indigenous people. The holistic view on health was also supported by the health practices reported by the students. Many stated that they undertook various measures to remain healthy such as eating correctly, exercising and ensuring spiritual harmony which indicates a holistic perspective with

Western influences on health practices.

Similarly for illness there were mixed conceptions. For several at least, minor illnesses and discomforts could be largely ignored as illnesses at all while more serious illnesses and accidents could sometimes be considered retribution for secret immorality, or indeed as revenge through magical means such as ‘puri puri’. Others saw illness as the consequence of poor socio- economic circumstances, low income, poor housing, poor diet, poor hygiene, or mere chance.

However many students expressed an integrated view and accounted for illness in ‘holistic’ terms as the possible consequence of immoral or anti-social behaviour that might lead to guilt,

19 stress, and mental disorders as much as the result of unwise physical behaviour, poor diet, bad hygiene, disease or an accident.

The first conception of illness, being really sick, is effectively the converse of the first conception of health, that is well-being. Students spoke of this from each perspective. It is interesting to note that from the traditional/cultural perspective, illness was explained as ‘lying down’ and needing ‘someone to look after’ you while the Western view explains that illness can be debilitating with no mention of the need for someone to look after you. These are similar views. However they are culturally influenced in that non-Western cultures hold a more shared view of health where individuals influence the group or you may need someone to look after you while in Western societies individuals pursue health by their own means (Fabrega, 1997).

Those who did not mention the need for someone to look after you seem to be influenced by predominantly Western views on health.

Illness as needing treatment or taking preventative measures was evident in the traditional and Western and Western perspectives. There were no traditional/cultural perspectives in these categories. Some students spoke of health practices that included seeking a traditional healer or following preventative health measures by eating traditional foods. However it would seem that these students also undertook Western health practices as might be expected from students studying health courses. While some traditional beliefs were very strong they were not the only ones held be these students.

The highest conception of illness complements the highest conception of health. Both involve a holistic view that is complex and encompasses several facets such as physical, spiritual, and environmental. Saggers and Gray (1991) contend that Aboriginal ill-health is complex and additionally that it influences the continuation of traditional medicine for illness.

The traditional/cultural influence of sickness in the spirit and body may also help to explain the continued health practice of seeking traditional healers as explained by some students in their health practices. The Western perspective evidenced the need to have balanced dimensions and

20 some students spoke about environmental and economic influences on health which was also noted by Lawson (1992). This is interesting as it is an advanced and socially oriented conception. While the Western perspective on health may be characterized by individualism there would also seem to be communal traits.

Similarly, with regard to health practices there was a spread of behaviours described.

While students recognised that there were benefits in Western biomedical intervention in many illnesses there was also the view that there was efficacy in the practices of traditional healers and the use of traditional remedies. Indeed in some regions these means of treatment may be all that are ready at hand and biomedical resources may be scarce and far away. Several students however were firm in their preference for the services of doctors and hospitals however uncertain they were of the outcome of treatment.

Conclusion

The findings of this study indicate that these Indigenous and Papua New Guinea health students hold varied and in some cases complex conceptions on health and illness and they undertake many measures to maintain good health. It was also evident that while these students were all

Indigenous they held both traditional/cultural and Western views on health. Others have noted that Indigenous beliefs about health are complex (Lawson, 1992) but we could not find any other reports that defined health according to the different perspectives held by Indigenous and

Papua New Guinea students in this study. While many students held Western beliefs about health and illness, the traditional influences were strong. This finding denotes the importance of the traditional/cultural beliefs that were held by these students. This holds implications for the teaching of health courses.

Generally these Indigenous university students have conceptions of health and illness that accommodate biomedical science within an integrated scheme of mental, physical and spiritual well-being, both personal and social. Further studies may determine whether the conceptions of health, illness and the health practices revealed in this study are as different as they may at first

21 appear from the outlook of most non-Indigenous university students. Conceptions of health in

‘holistic’ terms – as more than the absence of disease – are now widely held in society at large.

At the same time the survival of a belief in ‘non-scientifically verifiable’ causation and as yet unproven cures – among other acknowledged material factors – may also exist in many forms outside the Indigenous communities. Such beliefs clearly may survive a science based education or at least co-exist with it. But while clearly accepting the biomedical model of health as efficacious, some Indigenous students at one extreme expect more: that, among other conceptions of health, positive respect will also be shown conceptions of health and illness that incorporate traditional/cultural as well as traditional and Western beliefs. University teachers need to be aware of this expectation and mediate alternative views with care. Confining consideration of health and illness issues within a narrow medical model of health will not accommodate the beliefs of these Indigenous and Papua New Guinea students. Therefore we believe that health science courses for Indigenous students should be culturally relevant and acknowledge the traditional/cultural beliefs of Indigenous students.

The sample in this study was small and the findings cannot be generalized. However it would be feasible to suggest that other Indigenous students who are studying health courses in universities may also hold traditional/cultural and Western views. For these students to integrate their views into their health care practices they must be allowed to integrate them in their health courses. Those teaching in health courses should become aware of the experiences and beliefs of their Indigenous students so that they can accommodate these within their teaching and courses.

Further studies should be undertaken to explore in greater detail the findings of this study and other areas related to health such as health problems for Indigenous people and changing views on health for Indigenous health students.

Note: The inclusive term Indigenous is used in Australia to refer to Australian Aboriginal and Torres Strait Islander people. Papua New Guinean (PNG) people are referred to separately.

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