Enablers and barriers to the implementation of primary health care interventions for Indigenous people with chronic diseases: a systematic review

All five synthesised findings were relevant to the implementation and sustainability of a CD intervention; however, the design attributes are needed to be considered prior to implementation. Attributes to incorporate in the design phase of an intervention included obtaining sufficient funding, developing an evaluation framework, planning for adequate workforce resourcing, and engaging with communities.

Whilst sufficient funding enabled the implementation and sustainability of an intervention, Indigenous-specific services often needed to rely on a multitude of short-term government funding arrangements which threaten their sustainability and result in overwhelming reporting requirements [43]. Funding arrangements between Indigenous community-controlled health services and governments tend to be more complex than those between governments and general practice or tiers of government in Australia and elsewhere [44]. One of the key issues to be considered during the design phase is therefore adequate funding for both the implementation and sustainability of an intervention.

Findings from this review also identified the need to measure the impact of an intervention, whilst recognising this could be difficult in more challenging service environments. The lack of evaluation of interventions and, in general, PHC programmes in Indigenous health is a recognised limitation in the Australian health care setting [45]. Evaluation can improve service delivery and contribute to an evidence-base to inform policy decisions [46].

Community engagement was considered critical in the pre-implementation and planning stage to inform the design of an intervention and for sustainability. Involving communities in the design and implementation of interventions assists in ensuring that their particular health concerns are addressed in a culturally sensitive manner [47]. Sufficient workforce resourcing was also found to be crucial for successful intervention implementation, particularly where interventions relied on the capacity of an already overburdened workforce. In Australia, the largest proportion of the medical workforce is practicing in urban areas which has resulted in shortages in regional, rural and remote areas [48]. This indicates the need for innovative models of delivery to achieve adequate staffing in geographically isolated areas, as well as improved workforce incentives which may be beyond the scope of what an intervention can achieve.

A factor particular to interventions intended for Indigenous people was the employment of local health workers who facilitated implementation. It was recognised in the literature that the roles of IHWs extended beyond those stated in position descriptions, a conclusion shared by them and their non-Indigenous colleagues. Indigenous Health Workers acted as cultural mentors to non-Indigenous staff and assisted in the provision of a culturally safe service. However, IHWs faced some unique barriers to participate in the implementation of CD interventions. More so than other professionals, IHWs found that the available training in CD management was not always relevant to the scope of their practice, and the skills they gained were not easily transferrable to other workplace settings. In addition, findings from this review suggest that these important members of the workforce were often excluded from decision making and lacked appropriate support for carrying out their work. As IHWs are particularly important for interventions intended for Indigenous communities, their participation in all levels of decision-making is crucial [49] and it is important to ensure they are not isolated, excluded or discriminated against in the workplace.

The significant emphasis on partnerships in the included studies may in part be due to the ongoing nature of living with and managing a CD. For Indigenous people, whether they live in Australia, New Zealand or the US, relationships with healthcare providers are particularly complex. This is primarily due to historical policies and practices that excluded Indigenous people from society [49]. These social injustices continue to have a profound effect on the lives of Indigenous people today [50]. The institutionalised discrimination and poor treatment of Indigenous patients by health care providers that still exists in many places today means that developing respectful and safe relationships with providers is particularly important for this patient group to ensure they are appropriately supported when seeking care [51]. A trusting relationship enables Indigenous people to access an intervention, and to achieve this may require more time, effort and understanding on behalf of the provider.

Two care pathways were clearly identified: one was within the local service and the other pathway was one that required access to referral services. Particular to Indigenous people was the lack of identification of Indigenous ethnicity at the point of care. Not having an Indigenous identifier in the state and national medical databases is thought to directly hamper efforts to meet the health needs of these people [52]. Findings pertaining to external clinical pathways also highlighted a lack of provider knowledge about external health services which could support improved health outcomes. It was clear that lacking awareness of other available services inhibited the ability of primary care providers to access the best possible care for their patients.

Access to an intervention was facilitated by employing IHWs, providing care in safe spaces and accepting the supportive role of family in a patient’s care. Employment of local Indigenous people facilitated access to services for Indigenous patients and their families. This finding is consistent with another study that found Indigenous patients were more likely to feel comfortable accessing care in a service where Indigenous clinical, reception, paramedical and/or administrative staff were employed [53]. Also healthcare provided in safe spaces that have physical and cultural meaning to Indigenous people facilitated access to care. Spaces can work to engage and empower people or to marginalise and suppress people [54]. In the mainstream health care system, spaces are often dominated by a Western perspective. However, with thought, time and energy, health care spaces can become less of a barrier and more of an enabler by ensuring that Indigenous people find them acceptable and welcoming. Finally, patients identified the supportive role of family in encouraging relatives to seek care and maintain the lifestyle changes often required for CD management. There are additional benefits that flow from involving family in CD care, including the possibility of younger generations having the opportunity to learn about CD risk factors, which could lead to them being motivated to adopt a healthier lifestyle [23]. However, it should be noted that the converse can also result. Not all community members have had positive experiences in accessing health care and this factor may, therefore, adversely influence their peers. Indigenous people’s encounters with health care services that have led to negative perceptions include feelings of not being taken seriously, having their personal circumstances disregarded and experiencing discriminating attitudes and behaviours from providers who have negative stereotypes about Indigenous peoples [55].

Following the meta-synthesis, three features relating to all 29 categories of enablers and barriers identified in this review emerged. Over and above the five synthesised findings, these three features further clarified important characteristics of the identified enablers and barriers.

The enablers and barriers identified by this review were not fixed but variable concepts, capable of moving along a continuum from an enabler to a barrier and vice versa, and in some cases fulfilling the role of both. Consider the complexity of multiple funding streams, for example. Whilst administratively, funding agreements with several organisations were identified as a barrier, receiving funding from multiple sources facilitated the purchase of additional resources. Equally, if staff, who were initially unwilling to participate in the intervention, could be persuaded that the intervention would be able to deliver real benefits to their community, this barrier could become an enabler. Therefore, rather than fixed concepts, it may be helpful to think of enablers and barriers as potential drivers for change, that require consideration during the planning/design, implementation and/or ongoing management of an intervention.

Another feature identified in this systematic review was the degree to which PHC interventions could influence drivers for change. It appeared that drivers for change could be directly influenced through the design and implementation of an intervention in only certain circumstances. For example, the decision to employ an IHW is completely within the control of the intervention. Conversely, it is unlikely that any design feature could directly influence government funding models. This suggests that the work of an intervention would be better served by focusing on those drivers for change over which they had at least some influence.

The final feature identified in this review was that the drivers for change were likely to be inter-related. However, the extent to which they impacted on each other was not entirely clear, nor was the level of importance that could be attributed to any one of the drivers for change. For example, employing IHWs to help facilitate engagement with the community may contribute to creating a welcoming and comfortable atmosphere and assist with delivering a culturally safe service. However, employing IHWs could also exacerbate the issue of them being excluded from decision-making and having limited support for carrying out their work. Another systematic literature review found that in “difficult to service” communities (i.e. geographically rural and remote locations), workforce shortages became less of an issue when funding, governance, management and leadership, as well as linkages with community agencies and infrastructure were addressed [45]. The authors attributed this outcome to a systematic approach to addressing health system gaps, which they termed “environmental enablers” and “essential service requirements” of sustainable primary care services (p 120) [45]. This suggests that addressing some drivers for change may limit the negative impact of others, in particular those which may be potentially more difficult to influence.

Even though a rigorous search strategy was employed, it is possible that relevant studies may have been missed. In addition, whilst the intention of the review was to evaluate literature specific to interventions conducted in Australia, NZ, Canada and the US, the vast majority of studies were undertaken in Australia, and no studies from Canada contributed to the review findings. Therefore, these results may not thoroughly reflect experiences in all of the predetermined countries of interest, particularly Canada. Studies that did not include an identifiable intervention but, instead, investigated experiences of patients with a CD, and provider or policy maker perspectives on CD services or care were also excluded from this review. Although these studies did not meet the inclusion criteria, their data may have contributed perspectives on what we have come to call “drivers for change”. Finally, much of the research in this review represented the perspective of the service provider, less so that of the patient and the community and, least of all, that of the policy/decision maker. Even though the findings from service providers often reflected organisational or interpersonal enablers and barriers, structural level factors such as governance, collaboration with funders, policy implementation and resourcing are unequivocally related. The inclusion of decision makers in the design, implementation and sustainability of CD interventions is necessary to help promote or redress structural enablers or barriers. Further research is required to make explicit the opinions and perspectives of policy makers to establish whether there are additional drivers for change and, hence, further actions required to enhance implementation.