Among 959 students undertaking their first placements co-ordinated by WACRH during the years 2019–2022, 453 were eligible for inclusion in the study (Fig. 1). Non-completion of surveys impacted on the sample of eligible students, with 117 of 868 otherwise eligible students (13.5%) failing to complete the commencement survey, followed by substantial further attrition due to 290 (38.6%) of the remaining 751 students failing to complete the end-of-placement survey. Non-completion was especially pronounced in the 2022 student cohort (27.9%, compared with 66.3–78.6% in the previous years, i.e., 2019–2021 [Table S1]).
[Insert Fig. 1 about here.]
Figure 1 Placement record selection procedure
WACRH Western Australian Centre for Rural Health
The students in the sample were demographically and educationally diverse (Table 1). They represented a broad range of allied health disciplines across both undergraduate (n = 308, 68.0%) and postgraduate (n = 145; 32.0%) professional degree programs, with the majority enrolled in pharmacy (n = 92; 20.3%), chiropractic and social work (each n = 59, 13.0%), and occupational therapy and physiotherapy (each n = 56; 12.4%).
Table 1
Baseline characteristics of allied health students (N = 453) and their rural placements
| Range Median | Mean | SD |
Age (years) | 18–60 23 | 25.0 | 6.1 |
| | n | % |
Gender | Female | 325 | 71.7 |
| Male | 128 | 28.3 |
| Other | 0 | 0.0 |
Rural origin | No | 343 | 75.7 |
| Yes (Australia) | 104 | 23.0 |
| Yes (Overseas) | 6 | 1.3 |
Qualification Level | Undergraduate | 308 | 68.0 |
| Postgraduate | 145 | 32.0 |
Prior Indigenous experience | No | 295 | 65.1 |
| Yes | 158 | 34.9 |
Placement model | Assisted/Supported | 256 | 56.5 |
| Comprehensive/Blended | 197 | 43.5 |
Placement year | 2019 | 121 | 26.7 |
| 2020 | 112 | 24.7 |
| 2021 | 169 | 37.3 |
| 2022 | 51 | 11.3 |
Discipline of study* | Audiology | 10 | 2.2 |
| Biomed/Med Science | < 5 | < 1.0 |
| Chiropractic | 59 | 13.0 |
| Dietetics/Nutrition | 14 | 3.1 |
| Exercise Physiology | 27 | 6.0 |
| Health Promotion | 12 | 2.7 |
| Health Science | < 5 | < 1.0 |
| Medical Imaging | 14 | 3.1 |
| Music Therapy | < 5 | < 1.0 |
| Occupational Therapy | 56 | 12.4 |
| Pharmacy | 92 | 20.3 |
| Physiotherapy | 56 | 12.4 |
| Podiatry | 22 | 4.9 |
| Public Health | 6 | 1.3 |
| Social Work | 59 | 13.0 |
| Speech Pathology | 22 | 4.9 |
*Discipline of student presented to demonstrate diversity of sample but not included as a covariate in analyses. Cell numbers < 5 obscured to protect confidentiality.
Feeling ‘Confident’ or ‘Very confident’ working with Aboriginal people at the commencement of the placement (Table 2) was independently associated with gender (adjusted relative risk [aRR] for male compared with female students 1.51; 95% confidence interval [95% CI] 1.23–1.86), with reported rural Australian origin compared with no such background (aRR 1.46; 95% CI 1.18–1.80), and with reported previous personal experience with Indigenous people compared with none (aRR 1.40; 95% CI 1.13–1.72), but not with age group, qualification level or year of placement.
Table 2
Predictors of a student reporting feeling either ‘Confident’ or ‘Very confident’ at placement commencement
| Crude | | Adjusted | |
| Relative risk (95% CI) | p | Relative risk (95% CI) | p |
Age group at registration |
< 23 years | Reference | | Reference | |
≥ 23 years | 1.13 (0.91–1.40) | 0.283 | 1.11 (0.90–1.38) | 0.316 |
Gender* |
Male | Reference | | Reference | |
Female | 0.72 (0.58–0.89) | 0.002 | 0.66 (0.54–0.82) | < 0.001 |
Rural Australian origin | | | | |
No | Reference | | Reference | |
Yes | 1.49 (1.20–1.85) | < 0.001 | 1.46 (1.18–1.80) | < 0.001 |
Qualification level | | | | |
Undergraduate | Reference | | Reference | |
Postgraduate | 0.92 (0.73–1.17) | 0.487 | 1.01 (0.85–1.20) | 0.931 |
Previous Indigenous experience |
No | Reference | | Reference | |
Yes | 1.42 (1.15–1.75) | 0.001 | 1.40 (1.13–1.72) | 0.002 |
Placement year | | | | |
2019 | Reference | | Reference | |
2020 | 0.96 (0.72–1.29) | 0.786 | 0.97 (0.73–1.29) | 0.843 |
2021 | 0.88 (0.67–1.15) | 0.340 | 0.83 (0.64–1.09) | 0.181 |
2022 | 1.05 (0.74–1.50) | 0.768 | 1.01 (0.73–1.40) | 0.937 |
* No student identified their gender as 'Other'. CI confidence interval |
The proportion of students who reported feeling Confident’ or ‘Very confident’ working with Aboriginal people increased from 42.4–82.6% between the commencement and end of placement in the overall sample, and increased substantially across most subgroups of students that were investigated, except among those who reported that their placement included no interaction with Indigenous people (Fig. 2).
[Insert Fig. 2 about here.]
Figure 2 Students who reported feeling 'Confident'/'Very confident' working with Aboriginal people: commencement versus end of placements
The baseline characteristics of 747 students who completed the commencement and the subgroup of 453 whose records comprised the principal analysis were similar in all regards except that attrition in survey completion between commencement and end of placement was notably more marked in 2022 compared with the other three years of the study (Table S1).
In the principal robust Poisson regression model (N = 453 placements; Table 3), increased confidence working with Indigenous people between the commencement and end of placement was independently associated with several baseline characteristics of the students as well as with certain attributes of their placements. Students identifying as female compared with males were more likely to report increased confidence (adjusted relative risk [aRR] 1.23; 95% confidence interval [95% CI] 1.02–1.49), but no association with students’ age was evident. Students from a background in rural Australia were less likely than other students to report increased confidence (aRR 0.80; 95% CI 0.65–0.97); those who reported having experience with Indigenous people prior to the placement had a lower likelihood of reporting increased confidence than those without previous experience (aRR 0.82; 95% CI 0.69–0.97). The placement attribute associated most strongly with increased confidence was interaction with Indigenous people within the placement setting (aRR 2.15; 95% CI 1.17–3.98). Students whose placement model was categorised as Blended/ Comprehensive had a higher likelihood of increased confidence than those who placement was categorised as Assisted/Supported (aRR 1.22, 95% CI 1.04–1.43). Placement length was also independently associated with increased confidence in a linear fashion (aRR for each additional day: 1.002; 95% CI 1.001–1.004). Compared with the pre-COVID pandemic year of 2019, increased confidence did not change significantly in any of the three subsequent years of the study period.
Table 3
Determinants of increased confidence dealing with Indigenous people during placements
| Crude | | Adjusted | |
| Relative risk (95% CI) | p | Relative risk (95% CI) | p |
Age group at registration |
< 23 years | Reference | | Reference | |
≥ 23 years | 0.93 (0.80–1.09) | 0.369 | 0.97 (0.83–1.14) | 0.739 |
Gender* |
Male | Reference | | Reference | |
Female | 1.26 (1.04–1.54) | 0.019 | 1.23 (1.02–1.49) | 0.033 |
Rural Australian origin | | | | |
No | Reference | | Reference | |
Yes | 0.84 (0.68–1.03) | 0.096 | 0.80 (0.65–0.97) | 0.025 |
Qualification level | | | | |
Undergraduate | Reference | | Reference | |
Postgraduate | 0.95 (0.80–1.13) | 0.569 | 1.01 (0.85–1.20) | 0.931 |
Previous Indigenous experience |
No | Reference | | Reference | |
Yes | 0.85 (0.72–1.01) | 0.069 | 0.82 (0.69–0.97) | 0.024 |
Placement model* | | | | |
Assisted/Supported | Reference | | Reference | |
Blended/Comprehensive | 1.29 (1.11–1.50) | 0.001 | 1.22 (1.04–1.43) | 0.015 |
Indigenous interaction within placement |
No | Reference | | Reference | |
Yes | 2.15 (1.14–4.06) | 0.018 | 2.15 (1.17–3.98) | 0.014 |
Indigenous interaction (external) during placement |
No | Reference | | Reference | |
Yes | 1.01 (0.85–1.19) | 0.934 | 1.02 (0.86–1.20) | 0.818 |
Placement length (days)** |
10-day minimum | Reference | | Reference | |
Per additional day | 1.003 (1.001–1.005) | < 0.001 | 1.002 (1.001–1.004) | 0.005 |
Placement year | | | | |
2019 | Reference | | Reference | |
2020 | 0.95 (0.75–1.20) | 0.688 | 0.86 (0.69–1.08) | 0.207 |
2021 | 1.17 (0.96–1.42) | 0.111 | 1.13 (0.94–1.37) | 0.194 |
2022 | 0.91 (0.66–1.24) | 0.541 | 0.90 (0.68–1.20) | 0.486 |
*No student identified their gender as 'Other'. ** Modelled as a continuous variable; CI to third decimal place displayed for clarity. CI confidence interval.
In the sensitivity analysis that excluded 2022 placements (Table 4), the adjusted estimates were equivalent or only marginally closer to the null compared with those evident in the principal analysis model, although the statistically significance of these associations was not maintained across all covariates in the 2019–2021 placement data (N = 402). In this smaller sample, increased confidence was not significantly associated with either student sex or previous Indigenous experience. Both placement model and indigenous interaction within the placement, although not placement length, were significantly associated with increased confidence. In the other sensitivity analysis that incorporated additional students who identified as Indigenous (n = 4) or as non-citizens / non-permanent residents (n = 32) (N = 489 students; Table 5), results resembled those from the principal analysis in relation to associations between student and placement characteristics and increased confidence.
Table 4
Sensitivity analysis: Determinants of increased confidence dealing with Indigenous people during placements (2019–2021 only)*
| Crude | | Adjusted | |
| Relative risk (95% CI) | p | Relative risk (95% CI) | p |
Age group at registration |
< 23 years | Reference | | Reference | |
≥ 23 years | 0.92 (0.78–1.08) | 0.285 | 0.96 (0.82–1.13) | 0.643 |
Gender** |
Male | Reference | | Reference | |
Female | 1.24 (1.01–1.51) | 0.040 | 1.21 (0.99–1.47) | 0.058 |
Rural Australian origin | | | | |
No | Reference | | Reference | |
Yes | 0.83 (0.67–1.03) | 0.095 | 0.80 (0.65–0.98) | 0.035 |
Qualification level | | | | |
Undergraduate | Reference | | Reference | |
Postgraduate | 0.93 (0.77–1.11) | 0.403 | 0.98 (0.81–1.17) | 0.793 |
Previous Indigenous experience |
No | Reference | | Reference | |
Yes | 0.86 (0.72–1.04) | 0.112 | 0.84 (0.70–1.01) | 0.062 |
Placement model** | | | | |
Assisted/Supported | Reference | | Reference | |
Blended/Comprehensive | 1.26 (1.07–1.48) | 0.005 | 1.21 (1.03–1.44) | 0.022 |
Indigenous interaction within placement |
No | Reference | | Reference | |
Yes | 1.93 (0.99–3.76) | 0.054 | 1.97 (1.05–3.68) | 0.033 |
Indigenous interaction (external) during placement |
No | Reference | | Reference | |
Yes | 0.95 (0.80–1.12) | 0.522 | 0.96 (0.82–1.14) | 0.673 |
Placement length (days)*** |
10-day minimum | Reference | | Reference | |
Per additional day | 1.002 (1.001–1.004) | 0.013 | 1.000 (1.000–1.004) | 0.084 |
Placement year | | | | |
2019 | Reference | | Reference | |
2020 | 0.95 (0.75–1.20) | 0.688 | 0.88 (0.70–1.10) | 0.259 |
2021 | 1.17 (0.96–1.42) | 0.111 | 1.14 (0.94–1.37) | 0.187 |
* 2022 data removed to investigate potential bias due to high proportion of end-of-placement questionnaire non-completion during that year (N = 402). ** No student identified their gender as 'Other'. *** Modelled as a continuous variable; Confidence interval displayed with third decimal place for clarity. CI confidence interval.
Table 5
Sensitivity analysis: Determinants of increased confidence dealing with Indigenous people during placements (including Indigenous/foreign students)*
| Crude | | Adjusted | |
| Relative risk (95% CI) | p | Relative risk (95% CI) | p |
Age group at registration | | | | |
< 23 years | Reference | | Reference | |
≥ 23 years | 0.96 (0.83–1.11) | 0.564 | 0.99 (0.85–1.15) | 0.884 |
Gender** | | | | |
Male | Reference | | Reference | |
Female | 1.30 (1.07–1.57) | 0.007 | 1.29 (1.07–1.55) | 0.006 |
Rural Australian origin | | | | |
No | Reference | | Reference | |
Yes | 0.81 (0.66–1.00) | 0.049 | 0.79 (0.65–0.96) | 0.022 |
Qualification level | | | | |
Undergraduate | Reference | | Reference | |
Postgraduate | 0.95 (0.81–1.12) | 0.532 | 0.97 (0.82–1.14) | 0.722 |
Previous Indigenous experience |
No | Reference | | Reference | |
Yes | 0.84 (0.71–0.98) | 0.031 | 0.83 (0.70–0.98) | 0.028 |
Placement model | | | | |
Assisted/Supported | Reference | | Reference | |
Blended/Comprehensive | 1.25 (1.08–1.45) | 0.003 | 1.17 (1.00–1.36) | 0.047 |
Indigenous interaction within placement |
No | Reference | | | |
Yes | 2.35 (1.23–4.46) | 0.009 | 2.32 (1.24–4.34) | 0.009 |
Indigenous interaction (external) during placement |
No | Reference | | Reference | |
Yes | 1.03 (0.87–1.20) | 0.759 | 1.05 (0.90–1.22) | 0.555 |
Placement length (days)*** |
10-day minimum | Reference | | Reference | |
Per additional day | 1.003 (1.002–1.005) | < 0.001 | 1.002 (1.001–1.004) | 0.008 |
Placement year | | | | |
2019 | Reference | | Reference | |
2020 | 0.95 (0.76–1.18) | 0.658 | 0.89 (0.72–1.10) | 0.284 |
2021 | 1.17 (0.98–1.40) | 0.086 | 1.17 (0.98–1.40) | 0.091 |
2022 | 0.88 (0.65–1.20) | 0.415 | 0.91 (0.68–1.20) | 0.497 |
Indigenous identification | | | | |
No | Reference | | Reference | |
Yes | 0.42 (0.08–2.31) | 0.321 | 0.52 (0.10–2.62) | 0.430 |
Australian citizenship/permanent residency |
No | Reference | | Reference | |
Yes | 0.85 (0.66–1.08) | 0.185 | 0.87 (0.68–1.10) | 0.240 |
* Model (n = 489) includes students identifying as Indigenous (n = 4) or as non-citizens/non-permanent residents (n = 32). ** No student identified their gender as 'Other'. *** Modelled as a continuous variable; CI to third decimal place displayed for clarity. CI confidence interval |