Characteristics of Indigenous primary health care models of service delivery: a scoping review protocol

Abstract

Review objective 

The objective of the scoping review is to identify and describe within the existing literature the characteristics (values, principles, components and suggest practical applications) of primary health care models of service delivery for Indigenous people. More specifically, the review question is:

What are the characteristics (values, principles, components and suggested practical applications) of primary health care models of service delivery for Indigenous people?

Findings from this scoping review will inform two systematic reviews. One of these will explore the acceptability and the other the effectiveness of identified characteristics.

Methodology 

The scoping review will follow the JBI Scoping Review methodology as outlined in the 2015 Joanna Briggs Institute Reviewers' Manual.^1,2

Background 

Indigenous populations in colonized countries experience worse health outcomes relative to their non-Indigenous counterparts.³ In Australia, in the period 2010 to 2012 the estimated gap in life expectancy between Aboriginal and Torres Strait Islander Australians compared to non-Indigenous Australians was 10 years⁴ Similar gaps in life expectancy between Indigenous and non-Indigenous have been demonstrated in other countries, such as New Zealand,⁵ Canada⁶ and the United States⁷

The gap in life expectancy and the health disadvantage experienced by Indigenous people is in part the result of mainstream health services not adequately meeting the health needs of Indigenous people and Indigenous people's inability to access mainstream services^4,8,9 Part of the solution has been the establishment of primary health care services for and in many cases run by Indigenous people. Indigenous primary health services have been developed to provide culturally appropriate services that meet the needs of local Indigenous communities.

In Australia, the first Aboriginal medical service was established in 1971 in Redfern, New South Wales, by “community activists in response to ongoing discrimination against Aboriginal people within mainstream health services to address the poor health and premature deaths of Aboriginal people, and to provide a culturally appropriate system of health care”.^10(para1) There are now over 150 Aboriginal Community Controlled Health Services in Australia.¹¹ Aboriginal Community Controlled Health Services are underpinned by common values such as culture, cultural respect, integrity, inclusion, self-determination, community control, sovereignty and leadership.^12-14

Similar models of Indigenous health services exist in other countries, such as Māori health providers in New Zealand,¹⁵ First Nations and Inuit Health Authorities in Canada,^16,17 and the Indian Health Services in the US.¹⁸ In New Zealand, Māori health providers deliver health and disability services to Māori and non-Māori clients. The difference between Māori health providers and mainstream services in New Zealand is that Māori health services are based on kaupapa, a plan or set of principles and ideas that informs behavior and customs,¹⁹ and the delivery framework which is distinctively Māori.²⁰ First Nations and Inuit Health Authorities in Canada coordinate and integrate health programs and services to achieve better health outcomes for First Nations people.¹⁶ These community-based services largely focus on health promotion and prevention. First Nations and Inuit Health Authorities work under a unique health governance structure that includes local First Nations' leadership, based on the philosophy of self-governance and self-determination, which represent and address the health needs of First Nation communities.²¹ The Indian Health Service (IHS) in the US is responsible for providing comprehensive health services to American Indians and Alaska Natives. The IHS aims to raise the physical, mental, social and spiritual health of American Indians and Alaska Natives to the highest level, and its goal is “to ensure that comprehensive, culturally acceptable personal and public health services are available and accessible to American Indian and Alaska Native people”.^22(para3) The IHS “grew out of a special government-to-government relationship between the federal government and Indian Tribes”.^22(para1)

Evidence suggests that “a strong primary health care sector is essential to the health and wellbeing of a population, and that a strong primary health care sector is associated with better population health, reduced costs of health care provision, and greater efficiency within the system”.^23(p9) A study of Aboriginal Canadians shows that poor access and ineffective primary health care services were directly related to increased avoidable hospital admissions.²⁴ In addition, a recent study in Australia focusing on the costs and the health outcomes associated with primary care use by Indigenous people with diabetes in remote communities in the Northern Territory demonstrates that improved access to primary health care which is responsive to the needs of Aboriginal and Torres Strait Islander people is both cost-effective and associated with better health outcomes.²⁵

Given the strong link between primary health care and health outcomes^23,25 and the significant contribution Indigenous health services make towards reducing the health disadvantage experienced by Indigenous people, it is important to understand the characteristics that support the delivery of health provided by Indigenous health services and their unique models. While there is not a clear definition in the literature about what a model of care or model of service delivery is, for the purpose of this review, it will encompass all factors involved in the delivery of care including but not limited to the vision, values and strategies that underpin the delivery of care, healthcare services and programs, governance and leadership, workforce, organization and supply, and infrastructure and other resources.

The aim of this scoping review is to determine the characteristics of Indigenous primary health care models of service delivery by drawing on existing literature that look at the way in which services are delivered in this setting.

An initial search of literature was conducted to establish whether there are studies with findings available to answer the review question, and whether there is a systematic or scoping review addressing the knowledge gap currently underway or published. There are no systematic or scoping reviews published or underway that address the question proposed by this review.

Inclusion criteria

Types of participants

Individual participants are not a feature of the scoping review and therefore will not be considered in the study selection.

Concept

The concepts of interests are the characteristics (values, principles, components and suggested practical applications) of models of service delivery implemented within an Indigenous health service.

Within the literature a number of different terms such as service delivery models of care and service frameworks have been used interchangeably to articulate the way in which services are or should be operationalized. For the purposes of this review a service delivery model includes all factors involved in the delivery of care. Including, but not limited, to:

• The vision, values and strategies that underpin the delivery of care
• The healthcare services and programs available to clients
• Governance and leadership
• Workforce organization and supply
• Infrastructure and other resources.

For the purpose of this review all characteristics of a model of service delivery, either in part or as a whole, will be considered.

Context

The context is settings where primary health care services are provided predominantly to Indigenous peoples. Indigenous peoples are defined as^26(para1):

"Indigenous populations are communities that live within, or are attached to, geographically distinct traditional habitats or ancestral territories, and who identify themselves as being part of a distinct cultural group, descended from groups present in the area before modern states were created and current borders defined. They generally maintain cultural and social identities, and social, economic, cultural and political institutions, separate from the mainstream or dominant society or culture."

Primary health is defined as^27(para3):

"…socially appropriate, universally accessible, scientifically sound first level care provided by health services and systems with a suitably trained workforce comprised of multi-disciplinary teams supported by integrated referral systems in a way that: gives priority to those most in need and addresses health inequalities; maximizes community and individual self-reliance, participation and control; and involves collaboration and partnership with other sectors to promote public health. Comprehensive primary health care includes health promotion, illness prevention, treatment and care of the sick, community development, and advocacy and rehabilitation."

Types of sources

All qualitative, quantitative, economic and mixed methods studies will be considered for inclusion. In addition reviews and systematic literature reviews of programs that meet the inclusion criteria will also be retrieved. Grey (unpublished) literature will also be included. Conference papers will not be included.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of PubMed and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. In addition, academics from universities with expertise in Indigenous health services will be contacted and asked to identify literature (particularly grey literature) that meets the review inclusion criteria.

Articles will be assessed for inclusion based on the previously mentioned inclusion criteria examining them by title and abstract. Full text of the articles will be retrieved if it meets the inclusion criteria or if further examination is required before excluding the article. Two reviewers will independently confirm if the full text article meets the inclusion criteria. Any disagreements will be decided by a third reviewer. Multiple articles from the same program/project will be linked and treated as one for the purposes of data extraction and presenting the results.

Studies published in English will be considered for inclusion in this review, and studies published from September 1978 will be considered for inclusion in this review. September 1978 is the date that the Declaration of Alma Ata was adopted at the International Conference on Primary Health Care,²⁶ and subsequently the growth of primary health care internationally.

Databases to be searched

PubMed

EBSCO CINAHL

Embase

Informit

Mednar

Trove.

Search terms

The initial search terms include: Aboriginal, Aborigine, Indigenous, first nation, Maori, Inuit, American Indian, primary health care, comprehensive primary health care, medical service, health service, community care, community health care, model.

Charting the results

The results of each study (including qualitative, quantitative and other study types) will be extracted by at least two independent reviewers with the assistance of QSR International's NVivo 10 software, a qualitative analysis software package.²⁷ QSR International's NVivo 10 software will assist with charting of results, and for sorting and clarifying of data. Data that cannot be recorded in NVivo 10 software will be recorded in a separate charting table (Appendix I). To prevent bias, publications of which one of the reviewers has a conflict of interest will have the data extracted by two other reviewers. The reviewers involved in charting the results will meet as a group to review and pilot the extract of data from two to five studies using NVivo 10 software before reviewers independently extract data.

Presenting the results

Results will be presented as a map of the data extracted from the included papers, to be further refined by the reviewers toward the end of the review process, when there is greater awareness of the contents of the included studies. It is expected however that the key overarching characteristic of the service delivery models identified will be presented and described within the results section of the review.

Conflicts of interest

In accordance with the Conflicts of interest and Cochrane Reviews manual (2.2.4), any included studies in this scoping review that were authored by one of the review authors will be assessed for quality and have the data extracted and checked by the other reviewers, limiting any bias that may occur.²⁸

Acknowledgements

The authors would like to acknowledge the Centre of Research Excellence in Aboriginal Chronic Disease Knowledge Translation and Exchange (CREATE) leadership group, comprising national representatives of the Aboriginal Health Sector who provide advice and guidance on CREATE's program of work and are supportive of this review.

This research was supported by National Health and Medical Research Council (NHMRC) Grant No 1061242. The published material is solely the responsibility of the individual authors and do not reflect the views of NHMRC.