This is the first comprehensive review since 2014[13] to present the the barriers and enablers of implementing chronic disease prevention and management programs for Aboriginal and Torres Strait Islander people. The enablers and barriers found in this study have several policy and practice implications that should be considered in design, implementation, and funding targets for future chronic disease prevention and management programs.
The most striking addition to our findings, relative to the 2014[13] review, is the acknowledgment of Aboriginal and Torres Strait Islander culture (including staff, protocols, leadership, practices and ways of doing business) as a key enabler to engagement and care delivery. Partly, this is attributable to this review’s narrower focus on the Australian context. It also likely reflects a broader shift over the last decade in the approach to conceptualising and delivering primary health care for Aboriginal and Torres Strait Islander people. All studies included in this review made some acknowledgement of culture, albeit with variations in how deeply culture was considered as an enabler of care. Our review team grappled with how best to reflect this focus on culture, given that it is both a distinct concept and intimately embedded in all thematic domains. Ultimately, we have chosen to keep Aboriginal and Torres Strait Islander culture as a separate domain to ensure that culture is given independent consideration, in addition to attention within other thematic domains. It is evident that access to culturally appropriate, affordable and comprehensive services are vital for preventing and managing chronic conditions [53]. There is no one-size-fits-all approach for models of care for Aboriginal and Torres Strait Islander communities, and programs must be tailored to local context. Recent studies have identified numerous opportunities for improving access to primary care services: creating welcoming spaces, improving the cultural safety of healthcare services, building strong trustworthy relationships between patients and providers, and building primary healthcare workforce capacity [34, 54, 55]. The span of this theme is necessarily broad, encompassing Aboriginal and Torres Strait Islander leadership, physically welcoming spaces, training for non-Indigenous staff, time to build trusting relationships. Ensuring that culture is prospectively and proactively considered in funding and delivery primary care for chronic disease should be a priority for practitioners and policy makers.
There is clear evidence that addressing holistic needs of Aboriginal and Torres Strait Islander people enables greater engagement, rather than a narrow clinical focus on physical aspects of health. This requires primary care services to acknowledge and address the broader social and cultural determinants of health for Aboriginal and Torres Strait Islander people. Many of these have a direct impact on both chronic disease risk factors and capacity to access care, including poor access to healthy and nutritious food, inadequate housing, rurality, lack of transportation, and financial barriers [56–58]. Enablers of chronic disease care, such as outreach services, transportation, and referrals networks to other allied health and community groups are more likely to be effective where holistic approaches are adopted. This is consistent with data from the Australian Institute of Health and Welfare highlighting the experiences of social inequity in Aboriginal and Torres Strait Islander communities and the positive impact on health outcomes when inequities are improved [59]. Previous studies[13, 60] have identified various obstacles to accessing primary health care services which include inadequate infrastructure, inflexible and inadequate funding to care for people holistically Therefore, it is crucial that primary health care initiatives take a holistic and systematic approach to program design, considering the impact of social and cultural determinants on the health of individual, family members and their communities, with every attempt to reduce systemic barriers to access to healthcare where possible.This is only possible when funding mechanisms and models of care are flexible enough to account for local and individual contexts.
The profound impact of workforce was clear throughout this review. Recruiting, training, and retaining staff was found to be a key barrier to implementing and maintaining holistic patient-centred chronic disease prevention and management programs [13, 61]. Evidence has shown that Aboriginal and Torres Strait Islander people prefer support delivered by Aboriginal and/or Torres Strait Islander staff and clinicians who have a better understanding of Indigenous wellbeing [60, 62]. Despite the growth of the Aboriginal and/or Torres Strait Islander health workforce over time, this expansion has not matched the Aboriginal and Torres Strait Islander population growth [63]. Unsurprisingly, Aboriginal and/or Torres Strait Islander Health Workers play an essential and unique role in delivering culturally safe and holistic care. However, a demanding work environment, low salary, inadequate support,[64] and demanding cultural brokerage with non-Indigenous colleageus[65],[64] contribute to burnout and poor retention rates of Aboriginal and Torres Strait Islander primary care staff. This requires urgent attention, within individual primary care providers and through the National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework and Implementation Plan 2021–2031[66]. Given the ongoing need for the non-Indigenous workforce in fulfilling workforce gaps required to deliver services for Aboriginal and Torres Strait Islander people, building cultural competence, continuing appropriate training and education pathways and strategies, providing job security and adequate remuneration are also crucial to address primary care workforce issues including overburdening of the Aboriginal and Torres Strait Islander workforce [55, 65, 67]. Our findings highlighted the need to develop the overall chronic disease workforce, with a specific focus for recruitment and retention of Aboriginal and Torres Strait Islander Health Workers and Practitioners and providing cultural safety training for all non-Indigenous staff. Alongside this, funding arrangements (for example an Indigenous knowledge allowance) should be in place for cultural mentorship/education that is taken on by the Aboriginal and/or Torres Strait Islander health workforce through their work with non-Indigenous colleagues.
Chronic disease management requires multidisciplinary team input for effective care delivery [68]. When optimally resourced, primary care can serve a coordinating role in patient care, and effectively ensure patients have access to all allied health and specialist care they need [69]. Therefore, in order to engage Aboriginal and Torres Strait Islander people with chronic disease care and maintain continuity of care, there needs to be established, streamlined, and practitioner-friendly systems in place [69, 70]. A lack of integrated IT systems, poor infrastructure, and poor communication between primary care team members were found in this review to impede provision of such care. Previous research highlighted the feasibility of system integration through utilising continuous quality improvement processes and community co-design [71]. Infrastructure investment such as internet access, in-house IT support and automated systems for follow-up care, is urgently required to ensure that patients who do present or engage with primary care, are retained in the system and are able to access the multidisciplinary care required for chronic disease management.
Effective engagement of Aboriginal and Torres Strait Islander communities and their leadership in program design, delivery and evaluation of chronic disease programs is integral to improving Aboriginal and Torres Strait Islander health and increasing access to primary care services [72, 73]. Previous studies have identified the following factors that enable engagement of Aboriginal and Torres Strait Islander communities: employment of local Aboriginal health workforce; trust and relationships; Aboriginal and Torres Strait Islander leadership; availability of flexible services to address holistic needs of local communities; benefits of engagement in service design and delivery; cost of participation and recognition of local Aboriginal knowledge and cultural traditions on study design implementation and dissemination [72, 74–76]. These enablers align with those reported in health service research that involved engagement of Indigenous and marginalised communities in international context [77]. Similarly, this review identified a range of impeding factors to engagement of Aboriginal and Torres Strait Islander people with primary health care. Key factors included: a fear or lack of trust on mainstream health facilities, lack of respect from health care providers, experiences of interpersonal and structural racism, lack of understanding of cultural differences to initiate an open discussion and a narrow concept of health that fails to consider Aboriginal definition of health by non-Indigenous health care workforce [78–80]. Therefore, trustful, and culturally safe engagement of Aboriginal and Torres Strait Islander communities through all aspects of the program design, implementation and evaluation is essential to program success, and where possible, the Aboriginal Health Workforce and ACCHOs should be utilised.
Policy and practice recommendations
This study identified several policy and practice recommendations (Table.3) that need to be considered for the implementation of chronic disease prevention and management programs for Aboriginal and Torres Strait Islander people in primary care.
Strengths and limitations
Strengths of the present study include i) the generation of an evidence summary required to guide policy and practice is a short time frame, ii) the application of iterative process from the design to completion of review with engagement of Aboriginal and Torres Strait Islander researchers and Thiitu Tharrmay Aboriginal Reference Group members, iii) a quality appraisal of the included studies using Aboriginal and Torres Strait Islander Quality Appraisal Tool that privileges Aboriginal and Torres Strait Islander people’s ways of Knowing, being, doing and iv) interpretation of findings validated by Aboriginal and Torres Strait Islander knowledge champions.
One limitation of this review was that search was restricted to only two databases as the decision makers seek the evidence is a short period of time and were based on peer reviewed articles published in English language. We also acknowledge that the findings might not be comprehensive as the review was conducted in short timeframe, limitations in key words used and subjected to publication bias, as we omitted published program reports, grey literature, and policy guidelines from our inclusion criteria. Moreover, our search was limited to specific databases and terms, which could result in overlooking articles present in other databases or identified through alternate search terms. Despite these limitations, this review is Aboriginal and Torres Strait Islander researchers led that allowed Indigenous perspectives and knowledge to be integrated in the evidence synthesis; ensuring findings are meaningful for the broader sector.