Understanding the utilization of primary health care services by Indigenous men: a systematic review

Like other Indigenous peoples from colonized countries including New Zealand, Canada and the Unites States of America, Aboriginal and Torres Strait Islander people experience worse health outcomes than their non-Indigenous counterparts [1]. Although there have been improvements in the life expectancy among Australian males in the last 30 years, there has been little improvement noted in the life expectancy gap between Aboriginal and Torres Strait Islander men and their non-Indigenous counterparts, currently estimated to be 10.6 years [2, 3]. Although there are issues with comparing data across countries [4], the data clearly shows life expectancy gaps between Indigenous peoples from Australia, New Zealand, Canada and America and their non-Indigenous counterparts [5].

Against virtually all markers of health and social status, across the life span, Aboriginal and Torres Strait Islander people are the most marginalized and disadvantaged in Australian society [6]. Internationally, the health disparities of Aboriginal and Torres Strait Islander people “are as large as those seen in any other high-income country”[7] (p. 1). Aboriginal and Torres Strait Islander men are at a particularly elevated risk of psychological illness, drug and alcohol issues, engagement with the justice system, suicide and self-harm [8‐10]. These issues not only contribute to poor quality of life, but contribute to the onset and severity of a range of health conditions, including cardiovascular and metabolic diseases [9].

Adverse historical and contemporary traumas experienced by Aboriginal and Torres Strait Islander men have been directly linked to their current adverse health profiles [11, 12]. The enduring sociocultural effects of colonization continues to have a detrimental effect on the health and social and emotional wellbeing of Indigenous people [13‐19]. Prior to colonization Indigenous men and women “had defined roles according to age and gender”[19] (p.5). Colonization significantly altered the role of the Indigenous man [8, 20‐23]. Traditional power and authority that Indigenous men had was often taken from them as a consequence of direct conflict and government policy, with significant impacts on specific roles as family protectors and providers for their community [22].

Aboriginal and Torres Strait Islander males are constantly being portrayed by perpetuating negative stereotypes such as being lazy, always drunk, are violent, uneducated, primitive, and being problems, all of which can hinder improvements to their health status and has led to the development of health and social policies that continue to suggest that these men are responsible a range of issues facing Indigenous families and communities. Consequently, health disparity is “being seen as a result of Aboriginal people’s own failings. Worse still, they are being actively marginalized from influencing any path to potential solutions”[24] (p.97).

Primary health care services are critical to providing both clinical and social and emotional support for Aboriginal and Torres Strait Islander people. Brown suggests that “improving access to primary care stands as a critical target for improving health status among Indigenous Australians”[25] (p.815). However, primary health care services remain underutilized by Aboriginal and Torres Strait Islander men [26‐28]. The reasons for this are not well documented or described and are likely to be complex. Current health system approaches fail to acknowledge that Aboriginal and Torres Strait Islander men have requirements for accessing and utilizing health systems that are different to Aboriginal and Torres Strait Islander women and their non-Indigenous counterparts [24]. Strategies are required to improve access and ultimately health outcomes among Aboriginal and Torres Strait islander men.

In Australia, health systems need to acknowledge the needs of all of their clients if the health and wellbeing of all Australians is to improve. However, such a health system cannot exist “without consideration of the ways in which culture intersects with issues of poverty and equity, including access and utilization of health care, individual and institutional racism, and a lack of cultural competence on the part of health providers and programs”[17] (p.2). Unfortunately, little action has been taken in this regard. The reorienting of services to decrease or remove barriers to care, and ensuring that the services are acceptable, of high quality and sensitive to the needs and demands of Aboriginal and Torres Strait Islander men remains a difficult task [25].

To meet the needs of Aboriginal and Torres Strait Islander people, Aboriginal Community Controlled Health Services (ACCHS) have been established [29]. There are 143 ACCHS in Australia, providing comprehensive primary health care services to local Aboriginal and Torres Strait Islander people [29]. The ACCHS are controlled by local community representatives and ‘represent the only truly effective and culturally valid mode of delivering effective and sustainable primary health care services to Aboriginal Peoples’ [29]. Similar comprehensive Indigenous primary health care services have also been established in New Zealand, Canada and America [30].

This review aims to (i) better understand the utilization of primary health care services by Indigenous men, and (ii) assess the effectiveness of strategies aimed at increasing the utilization of primary health care services by Indigenous men. This review had two research questions: 1) What factors impact the utilization of primary health care services by Indigenous men? 2) What strategies have been implemented to increase utilization of primary health care services by Indigenous men and how effective were they?

Prior to commencing the review, a search of the Joanna Briggs Database of Systematic Reviews and Implementation Reports, the Cochrane Library, CINAHL, PubMed and PROSPERO revealed that no systematic review (either published or underway) has been conducted on this topic.

The authors developed and published a review protocol for this comprehensive systematic review [31]. This comprehensive literature review was guided by the Joanna Briggs Institute guidelines for systematic review and synthesis of qualitative data [32]. Studies from New Zealand, Canada and America were also included in the review due to the countries shared experience with colonization and their high disparity of health and wellbeing between the Indigenous and non-Indigenous peoples within each country.

It has been well documented that the introduction of western diseases, enforced policies of genocide, assimilation, dispossession and deprivation, have all contributed to the poor health of Indigenous people in many countries [20, 37, 38]. The on-going colonization process continues to be a catalyst towards the poor health and social and emotional wellbeing of Indigenous people [11, 12, 14‐16, 18, 19]. Health services play a significant role in maintaining the health and wellbeing of individuals and populations. Their effectiveness is determined by several factors, none more so than their reach. Aboriginal and Torres Strait Islanders are known to utilize health services less often than non-Indigenous Australians, with Aboriginal and Torres Strait Islander men the population with the lowest utilization. The studies reviewed found that there are areas that could be improved to increase the accessibility of health services by Indigenous men. It is important to note that barriers to accessing services and negative experiences reduces the likeliness of patients returning and can lead to unhealthy coping strategies.

Modifications to primary health care services can reduce barriers for Indigenous men accessing care. Interviews with health service users provide valuable information identifying barriers, enablers and identifying potential strategies to improve service utilization. Common themes from the qualitative studies were Indigenous men feeling that services and staff were culturally inappropriate and racially discriminatory. Strategies to improve cultural appropriateness discussed by the research papers and Wenitong et al., include cultural safety/ competency training and the employment and utilization of Indigenous health staff. The re-orientation of health services to suit Indigenous men should be a collaborative process involving local Indigenous men and relevant stakeholders.

Negative attitudes that Indigenous men have about primary health care services impact their utilization. Indigenous men report feeling shame or that it is inappropriateness to discuss health issues, especially for issues such as sexual health and mental health, with a female health professional. Sometimes men want to speak to men and this can be a major barrier for Indigenous men. All expert commentaries (Briscoe, Hayman, Wenitong) discussed the importance of employing gender specific staff, especially for sensitive health issues. Examples of gender specific primary health care services and men’s groups were also discussed as examples of successful strategies for reducing shame and increasing the utilization of primary health care services by Indigenous men. The stigma around some health issues, such as mental health and sexual health is also a barrier to accessing services. The shifting of social norms around such stigmas will take significant time, in the meantime primary health care services should acknowledge the local stigmas that exist and work with local Indigenous men to find ways to make accessing service more appropriate.

There can also be feeling of distrust, particularly around confidentiality within the service. This is likely to be due to past experiences or community rumors. Primary health care services need to be aware of this, ensure all staff are following the strictest protocols for protecting client’s privacy and recognize that some staff that have relationships with clients may be inappropriate to be involved in the delivery of their care, data entry and handling of their information. Increasing the familiarity of Indigenous men with the service and staff may also help reduce feels of distrust. Participants from the Isaacs et al. study suggested group visits to services so that men become familiar with the services and importantly the staff [34].

There is a lack of information about health services available at local primary health care services and understanding the benefits of utilizing them. It was found that men feel that they do not have enough information on when to go and for what. Investing in education for men in these areas to help Indigenous men recognize health issues that require attention, the importance of annual health checks and where to go for what may increase the utilization of primary health care services by Indigenous men.

There are limitations to this study. The search for peer-reviewed literature was limited to four databases and did not include a search for online theses. The search for grey literature was restricted to Australia, likewise only expert opinions from Australian Aboriginal and/or Torres Strait Islander health experts were included. Although the review included literature from New Zealand, Canada and America, the purpose of the review is to inform primary health care services within the Australian context. The researchers being situated in Australia also reduced the ability to capture grey literature from other countries. Expert opinions published by non-Indigenous authors were not included, this decision was made to privilege Aboriginal and Torres Strait Islander voices and to highlight the importance of Indigenous leadership to improve Indigenous health [39].

There is a current lack of published research in this area. The inclusion criteria for this review only included papers where men were majority of the participants (over 50%). This included publications that included some male voices within broader papers of which most of the responses were from women. The research included [26, 33‐35] in this literature review has been conducted across multiple sites in Australia and in Hawai’i, throughout urban, rural and remote settings. One of the studies was specific to mental health services and another was specific to sexual health, therefore the results may not be generalizable to primary health care services.

The literature search found limited published research meeting the inclusion criteria. The factors impacting primary health care utilization described by Indigenous male participants were found within three studies [26, 33‐35]. In addition, the search found three expert opinion papers [27, 28, 36] but no published literature was found describing studies that have implemented and accessed the effectiveness of strategies to improve primary health care utilization by Indigenous men.

Of the studies identified, the factors impacting primary health care utilization shared many similarities. Indigenous men described factors impacting utilization which were categorized into the following organizing themes; health services, attitudes of Indigenous men and knowledge. Many of these findings echoed the sentiments of the three expert opinion papers [27, 28, 36].

The studies reviewed found that there are areas that could be improved to increase the accessibility of health services by Indigenous men. There were common themes found by the research including; the need for culturally appropriate services and staff, increased knowledge, distrust and fear of health services, shame and stigma especially around sensitive health issues. The evidence also highlighted the need for gender specific services and male health providers. Even though there is limited research that explores the barriers for health service utilization by Indigenous men, the evidence available supports the anecdotal evidence and expert opinion. The barriers and enablers identified in this review should be used to inform the development of new strategies to improve the utilization of health services by Indigenous men.

Currently there is insufficient data available on the utilization of primary health care services by Indigenous men. It is widely acknowledged that Indigenous men are underutilizing services, however, unless this information is shared we will not be able to track progress in the improvements of service utilization. Future research should focus on evaluating the implementation of men specific utilization strategies. It is through such evidence-based research that subsequent policies and programs can be made and implemented to improve Indigenous men’s health.