Key facts
Why is it important?
Aboriginal and Torres Strait Islander people are significantly under-represented in the health workforce (see measure 3.12 Aboriginal and Torres Strait Islander people in the health workforce). Improving and supporting the participation of Indigenous Australians in tertiary education for health-related disciplines is vital to increasing Indigenous Australian participation in the health workforce. Vocational education and training can provide essential pathways for Indigenous Australians to enter tertiary education and the health professions (Gwynne et al. 2019). Aboriginal Community Controlled Health Services (ACCHSs) provide training pathways in a range of management, administrative and health careers (Campbell et al. 2018). They are the primary setting for employment of Indigenous Australians in Aboriginal Health Worker positions and offer pathways for further training and education.
Findings
What does the data tell us?
Higher education for health-related courses
In the Higher Education Student Statistics collection for 2018, there were 1,310 commencements and 597 completions for health-related courses for Indigenous students (Table D3.20.1).
Between 2001 and 2018, enrolment rates for Indigenous students in health-related courses have significantly increased from 27 to 61 per 10,000, and completion rates have significantly increased from 5 to 11 per 10,000 population (Figure 3.20.1). Over this period, the enrolment rates for Indigenous students increased at a faster rate than the completion rates (157% compared with 134%). There was also a significant increase in enrolment and completion rates for non-Indigenous students in health-related courses, widening the enrolment gap between Indigenous and non-Indigenous students (a gap of 17 per 10,000 in 2001 and a gap of 21 per 10,000 in 2018) (Table D3.20.7). The completion rate for Indigenous students studying health-related courses in 2018 was 81% compared with 92% for non-Indigenous students (Table D3.20.6).
Figure 3.20.1: Domestic higher education students enrolled in and completing health-related courses, by Indigenous status, 2001 to 2018
Source: Table D3.20.7. AIHW analysis of Selected Higher Education Statistics (Department of Education).
In 2018, health-related course enrolments for Indigenous Australians were highest for nursing (1,801 or 67% of enrolments and 281 or 71% of completions), followed by rehabilitation therapies (278 or 10% of enrolments and 32 or 8% of completions). The third-highest course was public health, with 270 or 10% of enrolments (116 of those in Indigenous health) and 31 or 8% of completions (13 of those for Indigenous health) (Table D3.20.3, Table D3.20.5, Table 3.20-1, Table 3.20-2).
Table 3.20-1 and Table 3.20-2 also show that in 2018, the rate ratios for enrolments and completions from Indigenous to non-Indigenous was highest for nursing and lowest for pharmacy.
Table 3.20-1: Undergraduate domestic health-related course enrolments, Indigenous and non-Indigenous students, 2018
Detailed field of education |
Indigenous Number |
Indigenous Rate (per 10,000) |
Non-Indigenous Number |
Non-Indigenous Rate (per 10,000) |
---|---|---|---|---|
Nursing |
1,801 |
32.6 |
61,121 |
31.5 |
Public health |
270 |
4.9 |
9,624 |
5.0 |
Indigenous health |
116 |
2.1 |
19 |
0.0 |
Medical studies |
211 |
3.8 |
7,687 |
4.0 |
Rehabilitation therapies |
278 |
5.0 |
22,051 |
11.4 |
Dental studies |
53 |
1.0 |
2,467 |
1.3 |
Pharmacy |
36 |
0.7 |
5,375 |
2.8 |
Radiography |
40 |
0.7 |
3,686 |
1.9 |
Optical science |
<5 |
n.p. |
1,180 |
0.6 |
Total undergraduate domestic students(a) |
2,683 |
48.6 |
112,396 |
57.9 |
Total enrolments(b) |
3,349 |
. . |
187,051 |
. . |
(a) Only the major course of each student is counted, so a student studying multiple courses is only counted once.
(b) Includes undergraduate, postgraduate, domestic and international students.
Note: n.p. not published
Source: Tables D3.20.3. AIHW analysis of Selected Higher Education Statistics (Department of Education).
Table 3.20-2: Undergraduate domestic health-related course completions, Indigenous and non-Indigenous students, 2018
Detailed field of education |
Indigenous Number |
Indigenous Rate (per 10,000) |
Non-Indigenous Number |
Non-Indigenous Rate (per 10,000) |
---|---|---|---|---|
Nursing |
281 |
5.1 |
12,657 |
6.5 |
Public health |
31 |
0.6 |
1,616 |
0.8 |
Indigenous health |
13 |
0.2 |
5 |
n.p. |
Medical studies |
27 |
0.5 |
1,535 |
0.8 |
Rehabilitation therapies |
32 |
0.6 |
4,216 |
2.2 |
Dental studies |
14 |
0.3 |
621 |
0.3 |
Pharmacy |
5 |
0.1 |
957 |
0.5 |
Radiography |
5 |
0.1 |
677 |
0.3 |
Optical science |
<5 |
n.p. |
138 |
0.1 |
Total undergraduate domestic students(a) |
394 |
7.1 |
22,149 |
11.4 |
Total enrolments(b) |
599 |
. . |
45,584 |
. . |
(a) Only the major course of each student is counted, so a student studying multiple courses is only counted once.
(b) Includes undergraduate, postgraduate, domestic and international students.
Note: n.p. not published
Source: Tables D3.20.3 & D3.20.5.
Enrolment rates for Indigenous Australians in health-related courses were lowest in the Northern Territory (25 per 10,000) and highest in Victoria (56 per 10,000). The course completion rate for Indigenous Australians in health-related courses was highest in Tasmania (12 per 10,000) (Table D3.20.27).
Of the total number of Indigenous Australians enrolled in health-related courses, 83% were females (Table D3.20.26). Enrolment rates for health-related courses were lower for Indigenous than non-Indigenous students in the younger age groups (15–34). For those aged 35 and over, the rate was higher for Indigenous students (Table D3.20.2, Figure 3.20.2).
Figure 3.20.2: Undergraduate domestic health-related courses enrolments, by age group and Indigenous status, 2018
Source: Table D3.20.2. AIHW analysis of Selected Higher Education Statistics (Department of Education).
Vocational Education and Training
In 2018, there were 6,195 enrolments of Indigenous students in health-related VET courses, with 1,320 course completions (Table D3.20.9, Table D3.20.11). Indigenous students were 1.8 times as likely to be enrolled in VET health-related courses as non-Indigenous students (112 and 62 per 10,000 respectively) (Table D3.20.9).
Health-related course completion rates were higher for Indigenous students compared with non-Indigenous students (24 and 16 per 10,000, respectively) (Table D3.20.11). The health-related course completion rate for Indigenous students has significantly improved between 2003 and 2018 (from 6.0 to 20.1 per 10,000); and this rate of improvement was faster than for non-Indigenous completions (from 4.2 to 9.7 per 10,000) (Table D3.20.23, Table D3.20.24, Figure 3.20.3).
Figure 3.20.3: Government-funded VET qualifications completed, by Indigenous status, aged 15 and over, 2003 to 2018
Source: Table D3.20.23, Table D3.20.24. AIHW and NCVER analysis of the National VET Provider Collection, 2018.
In 2018, the most common VET health-related courses for Indigenous students were public health (2,815 enrolments and 715 completions) and nursing (1,100 enrolments and 175 completions) (Table D3.20.9, Table D3.20.11, Table D3.20-3, Table 3.20-4).
Table 3.20-3: Total Vocational Education and Training (TVA) health-related course enrolments, by Indigenous status and course, 2018
Detailed field of education |
Indigenous Number |
Indigenous Rate (per 10,000) |
Non-Indigenous Number |
Non-Indigenous Rate (per 10,000) |
---|---|---|---|---|
Medical studies |
— |
0.0 |
500 |
0.3 |
Nursing |
1,100 |
19.9 |
28,120 |
14.2 |
Pharmacy |
10 |
0.2 |
1,200 |
0.6 |
Dental studies |
255 |
4.6 |
6,180 |
3.1 |
Optical science |
10 |
0.2 |
410 |
0.2 |
Public health |
2,815 |
51.0 |
21,955 |
11.1 |
Rehabilitation therapies |
30 |
0.5 |
245 |
0.1 |
Complementary therapies |
235 |
4.3 |
10,620 |
5.4 |
Other health |
1,735 |
31.4 |
53,075 |
26.9 |
Total students |
6,195 |
112.2 |
122,310 |
62.0 |
Note: Students may enrol in more than one course.
Source: Tables D3.20.9 & D3.20.11.
Table 3.20-4: Total Vocational Education and Training (TVA) health-related course completions, by Indigenous status and course, 2018
Detailed field of education |
Indigenous Number |
Indigenous Rate (per 10,000) |
Non-Indigenous Number |
Non-Indigenous Rate (per 10,000) |
---|---|---|---|---|
Medical studies |
— |
0.0 |
180 |
0.1 |
Nursing |
175 |
3.2 |
7,345 |
3.7 |
Pharmacy |
5 |
0.1 |
790 |
0.4 |
Dental studies |
60 |
1.1 |
1,985 |
1.0 |
Optical science |
5 |
0.1 |
160 |
0.1 |
Public health |
715 |
12.9 |
9,690 |
4.9 |
Rehabilitation therapies |
15 |
0.3 |
60 |
0.0 |
Complementary therapies |
60 |
1.1 |
4245 |
2.2 |
Other health |
290 |
5.3 |
7,785 |
3.9 |
Total students |
1,320 |
23.9 |
32,240 |
16.3 |
Note: Students may enrol in more than one course.
Source: Tables D3.20.9 & D3.20.11.
There were 390 VET course completions for Aboriginal and Torres Strait Islander health worker occupations. Indigenous females accounted for 73% of the completions for Indigenous students in these courses (Table D3.20.20).
The VET load pass rate for Indigenous students studying health-related courses was 76% compared with 82% for non-Indigenous students (Table D3.20.16). Of Indigenous enrolments for VET health-related courses, 77% were females (Table D3.20.40). The total number of student enrolments for VET health-related courses was higher for Indigenous than non-Indigenous Australians in all age groups (Table D3.20.39, Figure 3.20.4).
Figure 3.20.4: Total Vocational Education and Training (TVA) health-related course enrolments, by Indigenous status and age, 2018
Source: Table D3.20.39. AIHW and NCVER analysis of the National VET Provider Collection, 2018.
What do research and evaluations tell us?
Interviews conducted with Indigenous students and their parents/carers living in East Gippsland found that the barriers to health careers faced by the students included:
- poor school retention rates;
- negative school experiences including low teacher expectations and culturally insensitive teaching styles;
- lack of information and exposure to role models in the early years of secondary school;
- inappropriate subject choice (low take up of mathematics and science in Years 11 and 12);
- lack of self-belief and confidence;
- a tendency to prefer study in Technical and Further Education (TAFE) rather than in a university;
- family commitments/obligations; and
- the time and financial costs associated with academic study (Paton et al. 2017).
Completion rates for Indigenous Australian students enrolled in health related higher education courses are relatively low compared with non-Indigenous students (Anderson 2011). A study of higher education outcomes of Indigenous students enrolled at regional universities in Queensland and the Northern Territory found that 20% of Indigenous students were studying nursing or other health areas (Shalley et al. 2019). A cohort analysis of the total student group found that more Indigenous women than Indigenous men were participating and that their completion rates were much higher. However, completion rates for Indigenous students studying at these Queensland and Northern Territory universities were lower than the completion rates for Indigenous students enrolled at all Australian universities. Full-time study intensity was associated with higher award completion success, and 6% of students were still engaged with their study and working towards award completion 10 years after enrolment. Interviews of students and staff identified barriers related to communication, technology and financial support, especially for students in remote locations.
Many factors affect the rate of Indigenous Australian student completions (Anderson 2011). A cohort study of Indigenous students commencing bachelor degrees in 2005 showed a completion rate of 46.7% after nine years, while for non-Indigenous students, the completion rate was 73.9% (Edwards & McMillan 2015). One in five Indigenous students did not return after their first year, one-quarter dropped out after their first year, and 8% were still enrolled after nine years. The 2013 University Experience Survey results showed that 23.9% of Indigenous students had seriously considered leaving university early, compared with 17.6% of non-Indigenous students. Almost half (44%) of the Indigenous students who considered leaving early said that the reason for this was financial difficulties, compared with 29% of non-Indigenous students. Indigenous students were also more likely to indicate that financial circumstances affected their study. In the health sciences, there is a high attrition rate during the early years of higher education, especially in the first year (Anderson 2011). A 2017 study of Indigenous students at the University of Adelaide found that 10% of respondents agreed or strongly agreed that they would be likely to withdraw from their studies and that there was a positive association between caring responsibilities for parents, children and extended family and likelihood of withdrawal (Hearn et al. 2019).
A 2019 systematic review identified 26 studies focused on retention issues for Indigenous students covering fields of study, including nursing and midwifery, medicine, psychology, and public health (Taylor et al. 2019). Student characteristics such as family and peer support networks were associated with staying in university, and having competing obligations was the most frequently reported barrier, followed by financial hardship. Academic preparation and prior educational experiences were also factors. School and faculty characteristics, including access to the Indigenous Student Support Centre, were reported as providing support, while racism and discrimination were reported as major barriers across multiple studies.
The most successful strategies used by nursing, health and medical science faculties to improve retention of Indigenous students included:
- culturally appropriate recruitment and selection processes
- comprehensive orientation and pre-entry programs
- building a supportive and enabling school culture
- appointing Indigenous academics
- embedding Indigenous content throughout the curriculum
- developing mentoring and tutoring programs
- flexible delivery of content
- partnerships with the Indigenous Student Support Centre
- providing social and financial support
- ‘leaving the door open’ for students to return (Taylor et al. 2019).
While there has been growth in the number of Indigenous students undertaking tertiary nursing courses, there are concerns that the completion rates have not kept pace and the attrition rates remain an issue (Cramer et al. 2018; Kelly & Henschke 2019). A review of growth in the Indigenous nursing workforce in New South Wales and across Australia from 2008 to 2015 recognised the commitment of government policy and funding initiatives but concluded there had been limited effect on growth (Deravin et al. 2017). Interviews conducted with eight final year Queensland Indigenous tertiary nursing students about enablers for successful course completion found a narrative of student experience covering making a difference, valuing Indigeneity, healing strength of connections, resisting racism, embracing support, and persevering towards completion (West et al. 2016). The Indigenous nursing students in this study reported experiences of racism and stereotypes from academics and other students, and institutional racism including the policies and practices of the universities and health-care institutions (West 2012; West et al. 2013). This study also conducted interviews with 13 academics from Queensland universities, where it was reported there was sometimes a tendency for Indigenous nursing students to restrict their use of support services to the Indigenous Education Support Unit and Indigenous academics, or for university support services to go unused, and there was a need to raise the profile of the available support services among students. Another study interviewing four Indigenous nursing students found that while they were aware of support services available at the university, they were reluctant to access them, as they did not want to be identified as Indigenous (Kelly & Henschke 2019). Usher and others (2005) did in-depth interviews with 22 Indigenous students enrolled in undergraduate nursing degrees across Australia and found the students faced a number of challenges, including financial hardship; staff insensitivity to cultural issues; discrimination; and a lack of Indigenous mentors (Usher et al. 2005). A more recent study conducted in-depth interviews and a focus group with five Indigenous Health Workers enrolled in a Bachelor of Nursing at an Australian university (Stuart & Gorman 2015). All participants said that they had often encountered racist remarks during their course, including from other students and hospital staff while on clinical practice. This study also noted the importance of prior Indigenous Health Worker experience being recognised for course exemptions. Participants reported experiencing difficulty in having this recognised, possibly due to a lack of understanding of the Indigenous Health Worker role.
A review of research into enrolled nursing education found that studies focus on higher education, and VET for enrolled nurses is overlooked (Cramer et al. 2018). In Western Australia, 16 Indigenous students in a Diploma of Nursing course found that academic skill assessments and tailored educational support at entry (if needed) can resource students to navigate increasingly complex course content (Slatyer et al. 2016). Course flexibility to help students negotiate study in combination with ongoing family and financial obligations was important, as were strategies to develop resilience and connect with support networks.
Qualitative research conducted in rural and remote New South Wales community mental health services has learnings for the Bachelor of Health Sciences (Mental Health) and traineeship pathway undertaken by Aboriginal mental health workers (AMHW) (Cosgrave et al. 2018). AMHWs working in these services experienced low levels of job satisfaction, especially while undertaking the embedded training program. They had concerns that this qualification was not recognised in the New South Wales Health system, which had negative effects on remuneration and career opportunities. The authors recommended that changes be made to the education component of the AMHW training program and, in particular that the degree qualification be changed to one of the recognised eligible professions for clinical roles.
Over the period 2012 to 2015, Wontulp-Bi-Buya College in Queensland ran the Certificate III in Addictions Management and Community Development and the Certificate IV in Indigenous Mental Health: Suicide Prevention (Stephens & Monro 2019). Two evaluations into the effectiveness of the delivery and the outcomes of these courses found successful course delivery, satisfaction and completion rates above the national average. The Certificate IV course had 60 students, with a 78% completion rate. The evaluation found that graduates of the course developed personal empowerment and a sense of control over their life and had emerged with a set of oral and practical skills to work effectively with service providers in health and community services. The Certificate III course had 140 students, and 57% graduated between 2012 and 2014. A further 15% completed the course but were unable to receive accreditation because they had not paid the entire student contribution fee. The evaluation found the course to be responsive and relevant for the training and applied learning of Indigenous community leaders (Stephens 2014).
A New South Wales vocational education scholarship program was designed for Indigenous students in Certificates III and IV Dental Assisting and Certificate IV in Allied Health Assistance using enablers of success previously identified for Indigenous tertiary nursing students (Gwynne et al. 2019). The enablers were teachers’ understanding and awareness; relationships, connections and partnerships; institutional structures, processes and systems; and family and community knowledge, awareness and understanding. An evaluation of the program assessed whether these enablers contributed to a very high completion rate for a group of 31 Indigenous Australians enrolled in the program. Twenty students and eight teaching and support staff consented to participate in the evaluation and were interviewed. The evaluation found that the students and staff perceived these enablers as contributing to student success, and identified additional enablers, including employer support and ‘listening and improving’—referring to continuous improvement and students feeling heard when they raised issues. The evaluation concluded that it might be possible to improve the completion rates if VET programs are better designed to meet the cultural, family and learning needs of Indigenous students while recommending a larger study be conducted to inform future design and delivery.
Implications
Trends to 2018 show an increase in the completion rates for Government-funded health-related courses in the VET sector. There has also been a significant improvement in higher education enrolment and completion rates; however, the gap has widened due to increases in non-Indigenous student enrolment and completion rates. Improving retention and completion rates for Indigenous Australians training for health-related disciplines remains an area of focus.
Strategies are required to increase enrolment in courses for the health disciplines in which Indigenous students are under-represented. There is a need to strengthen VET to higher education pathways, and dual-sector institutions may play a role in this (Frawley et al. 2017). ‘Creative synergies’ may also help. For example, a partnership agreement was developed between a New South Wales university and TAFE for school-based traineeships to be undertaken concurrently with the Higher School Certificate (HSC) for students aspiring to enter nursing programs but who may not achieve the required Australian Tertiary Admission Rank (ATAR) (Kinnane et al. 2014).
Indigenous students are under-represented in undergraduate and VET pharmacy course enrolments and completions. Improving access to and the effectiveness of pharmacy scholarships can help increase Indigenous student participation in pharmacy courses, through mechanisms such as the Seventh Community Pharmacy Agreement which funds the Aboriginal and Torres Strait Islander Pharmacy Scholarship and the Aboriginal and Torres Strait Islander Pharmacy Assistant Traineeship schemes.
Improvements in secondary school educational retention and attainment are also necessary (see measure 2.05 Education outcomes for young people). In order to design effective initiatives to support Indigenous students in higher education, more attention needs to be directed towards primary students, in addition to secondary students and students already at university (Gore et al. 2017).
Some medical schools have been significantly more successful in attracting and retaining Indigenous medical students. These schools have adopted comprehensive approaches, including locally based strategies involving personal contact and community engagement, building relationships with potential students and their families and communities, and Indigenous medical or health support units. Indigenous Australian medical students reported the presence of a support unit as their main reason for choosing a university (57%). The presence of Indigenous staff within the school was also important, along with mentoring, curriculum and cultural safety (Minniecon & Kong 2005). Similarly for nursing, appointing Indigenous nursing academics, building partnerships between nursing schools and Indigenous Education Support Units, and implementing tailored cross-cultural awareness programs for nurse academics have been proposed to enable successful course completions by Indigenous nursing students (West et al. 2014).
The National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework (2016–2023) provides a guide to assist planning, prioritising, target setting, monitoring and reporting of progress in Aboriginal and Torres Strait Islander health workforce capacity building. A key aim of the Framework is to improve recruitment and retention of Indigenous health professionals in clinical and non-clinical roles across all health disciplines, including through ensuring workplace environments are culturally safe for Indigenous health workers. The Framework also suggests strategies for increasing the number of Indigenous Australians studying and completing qualifications in health. The National Aboriginal and Torres Strait Islander Health Workforce Plan 2021–2031, was informed by an extensive national consultation process. Consultations identified that improved recruitment and retention of Indigenous Australians requires a culturally safe health and education sector, and in order to successfully grow the Indigenous health workforce, barriers to education, employment and career progression need to be addressed consistently at both the national and jurisdictional level.
The policy context is at Policies and strategies.
References
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