Beliefs, understanding and interpretation stem from shared values, social relations within and between the family and the community, past experiences, cultural identity, and values[, ]. Like many other cultures[, ], notions of 'living well', 'sickness' or 'illness' present a complex, dynamic picture in Indigenous populations. Concept of health and wellbeing range from 'absence of symptoms of illness' to a more complex and holistic view of health as the consequence of physical, environmental, mental, and spiritual balance. Lifestyle factors, a person's social relationship with others and harmony with their culture are considered interrelated influences on health. Thus, there is poor compatibility between the underlying principles of the Western reductionist medical system and traditional Indigenous health beliefs[, ], or even those more recently socially constructed, which shape their care-seeking and willingness to engage with services. Changing community narratives by respecting Aboriginal culture, through education and improving life circumstances and trust of the health system will be important to change the constructs within which cancer beliefs are framed. Health care providers must consider, respect and respond to these needs if they are truly committed to improving Indigenous health outcomes.
The overall pessimistic attitude of Aboriginal people towards cancer as a 'killer' resonates with that of many other cultures [, ]. Participants' understanding that cancer can often be delayed or overcome with timely Western medical treatment was limited. They had limited access to relevant information, and the shame attributed to cancer and reluctance to talk about it meant stories of survival were not widely disseminated. Appropriately targeted education campaigns, Aboriginal cancer support services and opportunities for Aboriginal survivors of cancer to be advocates in their communities are needed.
Traditional beliefs are not simply displaced by western biomedical understanding, they can co-exist. A study of Indigenous Australian and Papua New Guinean health science students showed that the Indigenous university students conceptualized health and illness in a way which accommodated biomedical science within an integrated scheme of mental, physical and spiritual well-being. Education in western health care did not alter their core philosophy towards life and their spiritual belief system. Therefore, ensuring services are culturally appropriate is important for all Indigenous people, including those with higher levels of education and living in urban areas.
Many Aboriginal people retain a preference for using bush medicine and traditional healing, even for a "western" disease like cancer. The "doctor-dependent, hospital-based, curative western health care model" for treating cancer does not generally recognize, and incorporate traditional systems for healing. However, the combined use of both types of expertise can optimise the response to various health problems, including cancer.
Participants argued for cross-cultural educational initiatives where western cancer support entails an understanding, acknowledgement and acceptance of Aboriginal belief systems and that they are different to western understandings. Aboriginal people also need to understand that western understandings are different. Consideration of cultural differences is essential for health care providers to fully appreciate the impact of this disease on patients' physical and mental well-being. Mutually appreciative understanding of cultural differences is a key to encouraging Indigenous people's willingness to participate in health care to enhance early detection, develop appropriate interventions and ultimately improve cancer outcomes.
Paramount to cancer being curable is diagnosis at a stage before spread, when treatments are most effective. The association of cancer with death reflects the tragic reality that Indigenous people are often diagnosed with cancer at an advanced stage, and consequently die within a short period of diagnosis [, , ]. Participants commented that some people who develop symptoms consistent with cancer avoid assessment and diagnosis, preferring to hide their symptoms, again a phenomenon not restricted to Aboriginal people. In this way, they avoid confronting their diagnosis and potential mortality for a period of time. This situation needs to be approached through effective education about risks, symptoms and treatments for cancer. In addition, reducing barriers in access, providing more culturally secure health service provision, increasing the visibility of Aboriginal cancer survivorship and focusing attention on the importance of early diagnosis are strategies that can enhance cancer mortality in Indigenous communities.
The study was undertaken only in Western Australia, and it may not reflect the views of Aboriginal people throughout Australia who have different cultural traditions and beliefs. Men were under-represented in our participants which may be due to the primary interviewer being female, the predominance of women among the ARG members and in the community-based health workforce, and the higher utilisation of health services by women compared to men[, ]. Another limitation was that participants needed to be able to speak English, and this proficiency in English would undoubtedly have some affects on acculturation and exposure to western understandings of health and illness.