” Implications for public health: To increase utilisation of primary health care services in Indigenous Australian communities, and help close the gaps between the health status of Indigenous and non-Indigenous Australians, Indigenous community leaders and Australian governments should prioritise implementing effective initiatives to support quality health care provision by ACCHOs.
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Objective: To synthesise client perceptions of the unique characteristics and value of care provided in Aboriginal Community Controlled Health Organisations (ACCHOs) compared to mainstream/general practitioner services, and implications for improving access to quality, appropriate primary health care for Indigenous Australians.
Method: Standardised systematic review methods with modification informed by ethical and methodological considerations in research involving Indigenous Australians.
Results: Perceived unique valued characteristics of ACCHOs were: 1) accessibility, facilitated by ACCHOs welcoming social spaces and additional services; 2) culturally safe care; and 3) appropriate care, responsive to holistic needs.
Conclusion: Provider-client relationships characterised by shared understanding of clients’ needs, Indigenous staff, and relationships between clients who share the same culture, are central to ACCHO clients’ perceptions of ACCHOs’ unique value.
The client perceptions provide insights about how ACCHOs address socio-economic factors that contribute to high levels of chronic disease in Indigenous communities, why mainstream PHC provider care cannot substitute for ACCHO care, and how to improve accessibility and quality of care in mainstream providers.
“I just, just ah come here on my one day off and sit out here, have a talk with my mates…there’s always someone you know here… it’s a social event too…”29(p200)
“We share a lot. You know when you meet people you talk about things…If we go in and I know someone we’ll have a good yarn…?”29(p200)
Synthesised Finding 2: The way ACCHOs delivered care was highly valued. Clients valued staff taking the time to know and care for clients; personalised care tailored to self-perceived need; continuity of care; and appropriate communication. Clients related that they experienced feelings of belonging and confidence when accessing services with these service qualities. Four categories of findings informed this synthesised finding. The first was that clients experienced and valued staff, including doctors, taking their time with them.29 In the words of one client: “That’s the thing AMSs do really well, they take their time. There are not time limits”.29 ACCHOs providing healthcare in a personalised way tailored to client needs was the second category. These findings indicated that clients perceived ACCHOs as delivering care in a way that was responsive to their background27 by people who understood them.29 Clients also reported that the way staff provided care made them feel: known;29,33 less isolated (belonging);29,33 more confident;28 less anxious;30 cared for;30 accepted;28,29,30 supported;29 and encouraged.30 The third category was provision of information in a way that was understandable.27,30 Continuity of care was the last category, described as ongoing care and support for various problems in a client’s life over time.27,29
Synthesised Finding 3: Particular qualities of ACCHO staff were highly valued. These included Aboriginal identity of some of the ACCHO workforce, including AHWs; and staff who understood Indigenous clients and therefore behaved respectfully. Two categories informed this synthesised finding. The first was that clients valued the following behavioural qualities of staff: respectful and non-judgemental behaviour;27 staff taking time to know the client’s background and listen to their needs;29 sensitivity, kindness and reassurance;25,26 and trustworthiness.28,29 One said the way ACCHO staff allowed clients to talk about anything made you “feel at home”.27 The second category concerned how clients valued the Aboriginal identity of some ACCHO staff29,33 and the employment of AHWs.28 The following client voice illustrates how some clients described the value of AHWs:
“It was a whole new world…she was like a social worker I guess, we could talk to them individually, she was lovely. She explained everything, she took you in to how you know it all worked and was going to happen…you couldn’t have found so much difference between her, and the doctors who just tell you.”28(p6)
Synthesised Finding 4: A comprehensive, holistic approach to PHC was highly valued. The inclusion of non-clinical care, such as community events, group activities and enhanced supports available through community networks, had a positive impact on peoples’ wellbeing. Two categories informed this synthesised finding. The first was that non-clinical services, including ACCHOs’ social services, cultural events,33 and group activities such as diabetes camps30 and bush camps,33 were a valued characteristic. Clients pursued the opportunity group programs gave them to spend time with people who shared similar experiences, and to connect with community and culture.30,33 One client described the group-based activities as “a really great healing process”.33(p359) The second category of findings acknowledged and described perceived positive impacts of ACCHOs on client wellbeing.27,28,30,32 The impacts identified were: increased confidence;27,28 enhanced knowledge about how to manage conditions and actively engage in health decision making;30 pride in being part of the local Aboriginal community and its health service; better health;28,32 and better mental health.32
Comparisons of valued characteristics of care in ACCHOs and mainstream
Synthesis of findings from six of the included qualitative studies contrasting the value of care across the two sectors, identified three unique highly valued characteristics of care provided by ACCHOs compared to mainstream PHC providers.27–29,32–34
Synthesised Finding 6: ACCHO clients identified three unique highly valued characteristics of ACCHOs compared to mainstream PHC services: (1) accessibility, which clients described in terms of welcoming and safe spaces; (2) the way ACCHOs delivered care, in a culturally safe way tailored to need; and (3) comprehensive holistic care. The first point was that clients preferred ACCHOs because of their greater accessibility, which was related to additional services and their more welcoming environment.27,29,32,34 Clients described ACCHO waiting rooms as meeting and speaking environments “where people happen to be sick”,29 contrasted with mainstream services’ waiting rooms, described as quiet, formal sick places where you felt isolated.29 Clients signalled that relationships and support associated with companionship experienced in ACCHOs’ and Aboriginal staff were key to why ACCHOs were more accessible.32
“I used to go…all the way into [suburb] to see the AMS workers, and um I’d see a lot of people, it’s a great place to get together with a lot of people, a special place, and you see different ones, and have a yarn to…I’ve been away for a while, and um I always come back… In the [non-Indigenous] service you’re in, you’re out. There’s no friendliness…”28(p4–5)
“There’s always someone that you know, another family member or an old school chum or people you’ve played football with, and you’ve got that companionship there. If you were to go to the doctor’s surgery uptown and then just sitting there, oh god, I’m wishing to get out of there super quick.”33(p358)
“I was going to a doctor in Cleveland, and I didn’t feel comfortable there, but being here, where there’s other people around, yeah I felt comfortable when I came here the first time…there were Aboriginal nurses as well…and you could relate to them a bit more.32(p.6)
The second and third categories informing synthesised finding six, concerned differences in the way care was delivered across the two settings.27,29,3
Clients indicated they valued how staff in ACCHOs understood their holistic health care needs – signalled for example by references to be able to “talk to the AMS staff about anything and everything”– and were respectful,29(p202) and contrasted this with experiencing lack of understanding and inadequate care in mainstream PHC services.
Our systematic review identified a small body of studies reporting qualitative data on client perceptions that when synthesised offers useful insights into how Indigenous clients view the nature and value of care provided in ACCHOs, and comparison to in mainstream PHC providers. Importantly, the findings from the syntheses contrasting care across the sectors mirrored those from the synthesis of clients’ perceptions of ACCHOs’ characteristics and value. Overall, our synthesis points to three unique, highly valued characteristics of care provided in ACCHOs compared to in mainstream providers. The first is ACCHOs’ unique accessibility. Clients perceive ACCHOs’ welcoming environment, which includes a social, emotional and physical aspect and supports cultural safety; ACCHOs’ flexible, responsive and proactive approach to care provision; and ACCHOs’ additional services, including transport and outreach as factors contributing to ACCHOs unique accessibility. The second unique, highly valued ACCHO characteristic is ACCHOs’ culturally safe care. This was described by clients as care delivered by staff, many Aboriginal, who feel known to clients, understand client needs and respect culture, in an environment where clients feels comfortable, supported and that they belong. The third was comprehensive care, that is, care responsive to holistic health needs.
High levels of trust and mutual understanding in the relationships between clients and health care providers, as well as close relationships between clients, were central themes in our syntheses. The presence of people from the local community, and involvement of Indigenous people in the service, was also central themes. Our synthesis therefore reinforces existing literature that has highlighted relationships,3,35 respect for culture and for Indigenous knowledge, and the involvement of Indigenous people in providing care, as central to Indigenous clients’ perceptions of accessible, appropriate and quality health care.
The description of ACCHOs’ characteristics and value compared to mainstream PHC providers highlights two distinct but equally important reasons why the care provided by mainstream providers cannot serve as a substitute for the care provided by ACCHOs for Indigenous clients. First, as has been previously noted,3 the characteristics of accessible and culturally safe care are such that mainstream PHC providers cannot achieve them using a tick-box approach and without fundamental change. Key elements, including the support offered by relationships amongst clients, will be difficult for mainstream providers to replicate. Second, mainstream services are not perceived by all Indigenous Australians as offering care that is responsive to holistic health needs. Moreover, mainstream PHC providers are ill-equipped to provide clients with a broad range of PHC programs tailored to self-perceived holistic health needs. They are focused on delivering clinical services designed largely to meet the needs of the majority, non-Indigenous population and to meet business objectives, and they are unlikely to transition to providing the additional services Indigenous Australians seek.
Additional insights on how ACCHOs improve Indigenous health
Our findings offer additional insights into the way ACCHOs contribute to improving the health and wellbeing of Indigenous Australians. Moreover, the clients’ references to positive impacts of ACCHOs on their confidence;27,28 on their knowledge about how to manage conditions and actively engage in health decision making;30 on their pride in being part of the local Aboriginal community and its health service; and on their mental health32 supports the conclusion of a recent review on ACCHOs’ impacts on Indigenous health,36 that ACCHOs are important not only because their health care helps to improve Indigenous Australians’ health, but also because of how they help to address the socioeconomic factors that contribute to high levels of chronic disease in Indigenous communities.
Strengths and limitations
The overall quality of the included studies was good. A second strength of our review is the steps we took to align our review methodology with the ethical and methodological requirements relating to research involving Indigenous Australians. These steps are important because they are called for by the unique standards for ethical research with Indigenous Australians, and because incorporating local contextual and cultural knowledge specific to Indigenous people adds to the credibility and relevance of the review findings and should aid their transferability into practice and policy.20,21
The small number of studies contributing to the syntheses, particularly the two comparing care across the sectors, is a limitation of our review. Neither the included ACCHO population nor the ACCHO client population were representations of their diverse total populations in Australia, potentially limiting the transferability of the findings. Another limitation relates to our inability (given data constraints) to explore potential variations in the perspectives of clients with different characteristics, e.g. males versus female, people of low and high socio-economic status. Third, whilst we did not extract findings from studies in which it was clear that the comparator was care in the hospital setting, we cannot be certain that references to “mainstream services” did not include this setting. We did not consider how clients’ perceptions of the characteristics and value of ACCHOs’ care compare with their perceptions of characteristics and value of other Indigenous PHC provider types. It is expected that Indigenous services, with high levels of local community involvement in the planning and delivery of their services, may be perceived by clients as having similar characteristics and value as ACCHOs. Fifth, there may be studies published since the end date of our search, that meet our review inclusion criteria, which may offer unique additional insights about how ACCHO clients perceive the characteristics and value of care provided by ACCHOs, and compared to mainstream providers, or they may confirm our synthesised findings.
Mainstream practitioners that seek to improve the accessibility and quality of their care for Indigenous peoples should: 1) invest in understanding Indigenous clients’ needs and learn how to be respectful of Indigenous clients’ culture; 2) adopt a flexible and proactive approach to providing care for Indigenous people (for example, they need to be prepared to meet clients outside of normal operating hours and engage in outreach activities); and 3) invest in making the clinic welcoming for Indigenous clients, for example, by putting up posters and other artefacts that are representative of Indigenous culture. However, for many Indigenous Australians, the care provided by mainstream PHC providers will not be a substitute for ACCHO care tailored to meet holistic health needs of Indigenous clients and their communities. Australian governments therefore should remain committed to the implementation of community control and should prioritise reforms to make the funding and accountability arrangements more enabling of rapid growth in the ACCHO sector and more supportive of high-quality, comprehensive, effective service provision by ACCHOs. To this end, government should look to the recommendations offered by recent research on barriers and facilitators regarding implementing Indigenous community control in PHC which offers useful guidance on reforms required in funding and accountability frameworks.11,14,16–18 In addition to building better funding and accountability arrangements for the ACCHO sector, governments need to continue to prioritise initiatives, for example best practice guideline development and dissemination, that enable all relevant treatments for comprehensive holistic health care being informed by scientific evidence. Ensuring that all ACCHOs have access to, and have the capacity to use, appropriate continuous quality improvement systems, for identifying their strengths and where system change is required to further strengthen the service and improve the health outcomes for clients accessing these services, is also important.37
The qualitative evidence on how Indigenous Australian ACCHO clients perceive the characteristics and value of care provided by ACCHOs, and compared to in mainstream PHC providers facilitates understanding why mainstream PHC provider care cannot be a substitute for ACCHO care. It also offers insights into how ACCHOs address socioeconomic factors that contribute to chronic disease in Indigenous communities. This sends a cautionary note to policy makers intent on mainstreaming Aboriginal PHC and underscores the importance of implementing the reforms to the funding and accountability arrangements for ACCHOs, that have been identified as important to support ACCHOs’ delivering quality services that are effective and meet holistic needs of clients in Indigenous communities. Mainstream PHC practitioners can learn from best-practice examples in the ACCHO sector how to improve the accessibility and quality of their care for Indigenous clients.
Judith Gomersall (JG), Odette Gibson (OG), Judith Dwyer (JD), Alex Brown (AB) and Edoardo Aromataris (EA) led the conceptualisation of the review. JG and OG led the writing of the protocol. The research governance group established to guide the work of the NHMRC Centre of Research Excellence in Aboriginal Chronic Disease Knowledge Translation and Exchange (CREATE) reviewed the protocol. JG performed the search and abstract review. OG, Drew Carter (DC) and EA conducted the full text examination. EA, an experienced systematic reviewer, provided oversight during the search and study selection process. EA and Zachary Munn (ZM) provided technical advice about appropriate review method. Two non-Indigenous Australian members of the review team, DC and JG, assessed the quality of studies. Their assessments were reviewed by two Indigenous Australian members of the team, OG and Kootsy Kanuto (KK). Matthew Stephenson (MS), ZM and JG (all non-Indigenous Australians) extracted the data from the included studies. Two Indigenous members of the review team, OG and Kim O’Donnell (KO), reviewed their data extraction. KO, OG, MS, JG and DC participated in a workshop convened to develop an initial set of categories for the meta-aggregation. OG and JG then worked together on the meta- aggregation with OG’s perspective being privilege due to her unique insider Aboriginal knowledge. AB, a senior Indigenous Australian health researcher with expert knowledge of Aboriginal health and the Aboriginal health sector, guided JG through the second level analysis, the interpretation of the synthesised findings. JG, OG JD and EA led the writing of the paper, which was reviewed by all authors. The findings of the review were presented to representatives of the CREATE leadership group prior to submission of this article for publication, and feedback received integrated. The authors thank the participants of the CREATE leadership group for the invaluable guidance and time they provided during this review. We also thank Harold Stewart and Stephen Harfield for participating in the workshop held at the beginning of the synthesis stage of the review. Finally, we thank Sandeep Moola for assistance during the data extraction stage of the review.
The NHMRC (GNT1061242) supported this project. The contents of the published material are solely the responsibility of the Administering Institution, a Participating Institution or individual authors and do not reflect the views of NHMRC.