Review question/objective
There are two key objectives of this comprehensive systematic review. The first is to understand the experiences of Indigenous men utilizing primary health care services. The second is to assess the effectiveness of strategies implemented by primary health care services that seek to enhance or improve the utilization of primary health care services by Indigenous men, including the perceptions and experiences of Indigenous men in relation to these strategies. Due to similar health inequalities faced by Indigenous men in Australia and certain parts of the world, literature from New Zealand, Canada and America will also be assessed in this review.
The key questions are:
1. What are the experiences of Indigenous men with primary health care services?
2. What is the effectiveness of strategies aimed to increase utilization by Indigenous men with primary health care services, including the perceptions and experiences of the Indigenous men in relation to these strategies?
This review will synthesize both qualitative and quantitative findings in an attempt to develop recommendations useful for practice and policy related to primary health care.
Background
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, which is currently estimated to be 10.6 years.1,2
Aboriginal and Torres Strait Islander men experience worse health outcomes than any other population group in Australia. 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.3 Unfortunately, the "disparities in health outcomes experienced by Indigenous Australians are as large as those seen in any other high-income country".4(p1)
Aboriginal and Torres Strait Islander men are also at elevated risk of psychological illness, drug and alcohol issues, engagement with the justice system, suicide and self-harm.4-6 These issues not only contribute to poor quality of life and illness in their own right, but are likely to be contributors to a range of health conditions, including cardiovascular, and metabolic diseases.7
Adverse historical and contemporary traumas of Aboriginal and Torres Strait Islander men have been directly linked to their current adverse health profile.8,9 Perpetuating negative stereotypes of Aboriginal and Torres Strait Islander males as "problem males", can hinder improvements to their health status, and has led to the development of health and social policy that continues to suggest that these men are responsible for an array of issues, without providing the necessary support, infrastructure or political will to reverse Aboriginal and Torres Strait Islander male health and social disadvantage.10 As a consequence, the Indigenous Australian 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".11(p97)
Primary health care services are critical to providing both clinical and social/emotional support, and "improving access to primary care stands as a critical target for improving health status among Indigenous Australians".4(p97) Unfortunately, primary health care services remain underutilized by Aboriginal and Torres Strait Islander men.12-14 The reasons for this are complex and not well documented or described.
Regardless, strategies are required that specifically meet the needs of these high risk individuals, and should be developed to suit Aboriginal and Torres Strait Islander men so as to improve access and ultimately health outcomes.
Despite several policy initiatives that have been launched in recent times to improve the prevention and management of chronic diseases for Aboriginal and Torres Strait Islander Australians, these polices have been funded and implemented without the necessary evidence to support them.10 Current health system approaches fail to acknowledge that utilizing health systems by Aboriginal and Torres Strait Islander men is different to that by Aboriginal and Torres Strait Islander women and their non-Indigenous counterparts.11
However, there is a growing national movement of Aboriginal and Torres Strait Islander men and their non-Indigenous counterparts who have identified male focused health spaces as an important intervention to improve engagement, social connectedness, cultural safety and self-healing.15-19 Additionally, many commentators have discussed the significance of Aboriginal and Torres Strait Islander men's groups as a means to increasing health and wellbeing.10,13,20,21
To date little action has been taken and the development of male specific health programs has received limited financial support, and, as a result, reorienting these 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 remain an extremely difficult task.22
The review team proposes to conduct a comprehensive systematic review to better understand the effectiveness of strategies implemented to increase the utilization of primary health care services by Indigenous men from Australia, New Zealand, Canada, and America. The review will attempt to develop recommendations useful for practice and policy related to primary health care.
The review will consider published and unpublished quantitative and qualitative evidence using the Joanna Briggs Institute (JBI) comprehensive segregated approach for conducting systematic reviews.
Prior to this 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.
Inclusion criteria
Question 1:
What are the experiences of Indigenous men with primary health care services?
Types of participants/population
Papers will be included if the majority of the participants in the study are men (aged 18 years and older), who are Indigenous to Australia (Aboriginal and/or Torres Strait Islander), New Zealand (Maori), Canada (First Nations) and America (native American).
Phenomena of interest
Studies that investigate the experience of clients with primary health care services will be included.
Context
Qualitative studies that explore client views or experiences relating to barriers and enablers to access or their experience with primary health care services will be included.
Types of studies
Qualitative studies to be included will be descriptive, ethnography, phenomenology and grounded theory studies, action research and evaluations, including developmental evaluations.
Published expert opinion will also be considered for inclusion.
Question 2:
What is the effectiveness of strategies aimed to increase utilization by Indigenous men with primary health care services, including the perceptions and experiences of the Indigenous men in relation to these strategies?
Types of participants/population
Papers will be included if the majority of the participants in the study are men (aged 18 years and older), who are Indigenous to Australia (Aboriginal and/or Torres Strait Islander), New Zealand (Maori), Canada (First Nations) and America (native American).
Types of intervention
The review will consider studies on services that implement strategies or programs to increase health service utilization by Indigenous men:
Quantitative component: studies that evaluate health service utilization/access.
Qualitative component: studies that investigate client views or experiences related to these strategies.
Context
The review will consider studies whose context is primary health care services.
Acute care, chronic disease management, tertiary care or short term rehabilitation clinics will not be considered.
Comparator
The quantitative component of this study will consider studies that evaluate and investigate primary health care services that implement a strategy to increase service utilization by Indigenous men. This may be a group of men who received the strategy compared to a group of men who did not receive the strategy or a study that compares services that did and did not receive the strategy. This review will also consider studies that have no comparator.
Types of outcomes
The quantitative component of this question will consider studies that include, but not limited to, the following outcome measures; occasions of care and client numbers.
Types of studies
Quantitative studies to be included are randomized controlled trials (RCTs), non-randomized controlled trials, economic evaluations and costing studies (including model-based studies), retrospective and prospective cohort studies, case control studies, health service studies, health service evaluations, analytic cross-sectional studies and descriptive epidemiological study designs.
Qualitative studies to be included will be descriptive, ethnography, phenomenology and grounded theory studies, action research and evaluations, including developmental evaluations.
Mixed methods studies will also be considered for this review.
Search strategy
The search strategy will aim to find both peer-reviewed publication and grey literature. A four-step search strategy will be utilized in this review. An initial search of PubMed using the key words listed below, 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. Studies will be included if they are written in English. A second search using all identified keywords and index terms will then be undertaken across the following databases, PubMed, CINAHL, Informit (Indigenous collection) and Embase.
This database search will include articles published in English from the date of the search back until database inception.
To identify grey literature the following databases and websites will be searched; ProQuest, Mednar, Trove, Australian Indigenous Health Bulletin, Australian Institute of Aboriginal and Torres Strait Islander Studies, the National Aboriginal Community Controlled Health Organisation (NACCHO) website, Australian Indigenous HealthInfoNet, National Library of Australia and the Lowitja Institute.
The reference list of included publications will be searched for additional studies. Finally relevant experts will also be consulted to identify any missed publications.
The lead author will identify articles that meet the inclusion criteria from their title and abstract. The full text of all articles that cannot be excluded will be retrieved and reviewed by two independent reviews to confirm if they meet the inclusion criteria. If the two reviewers have differing opinions on an article's inclusion, it will be resolved by discussion or consultation with a third independent reviewer. Articles excluded at this full text review will be listed in a table in an appendix indicating the primary reason it was excluded.
Initial keywords to be used will be:
Population of interest:
Aboriginal OR Indigenous OR Torres Strait Islander OR Islander OR Oceanic Ancestry Group OR New Zealand AND first nations OR first nation OR Maori OR American Native Continental Ancestry Group OR Eskimo OR Inuit OR native AND Canada OR American Indian OR Indian OR Native Hawaiian OR Hawaii Native OR Native American OR Amerindian OR Samoan OR ethnic minorities AND America OR Alaska
Phenomena of interest:
Strategies OR utilize OR access OR approach OR tactic OR engagement OR intervention OR program
Setting/intervention:
Primary health care OR preventive health service OR community networks OR delivery of health care OR general practice OR clinic OR primary OR outpatient
Assessment of methodological quality
The JBI program for the comprehensive review management system (JBI-CreMS) will be used to assist in this review. The methodological quality of studies selected for retrieval will be assessed by two independent reviewers. If the reviewers have differing opinions on an articles quality, it will be resolved by discussion or consultation with a third independent reviewer. This will be done by using standardized critical appraisal instruments from JBI.
The quantitative papers selected for retrieval will be assessed using the JBI Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Qualitative papers selected for retrieval will be assessed using the JBI Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix II). Textual papers will be assessed using the JBI Narrative, Opinion and Text Assessment and Review Instrument (JBI-NOTARI) (Appendix III).
Mixed methods papers will have their qualitative, quantitative and textual components assessed for quality separately using the appropriate tool.
Data extraction
If multiple publications are found for a single study, they will be combined for data extraction. Standardized data extraction tools from JBI for each data type will be used: JBI-MAStARI for quantitative data JBI-QARI for qualitative data, and JBI-NOTARI for textual data (Appendices IV, V and VI).
Similar to methodology used for the assessment of quality, mixed method papers that include more than one type of data will have each data type extracted separately using the appropriate tool.
Data synthesis
Consistent with the JBI 2014 Reviewers Manual: Methodology for JBI Mixed Methods Systematic Reviews,23,24 the synthesis of data will be conducted in two stages. Firstly, the data within each JBI System for the Unified Management, Assessment and Review of Information, (JBI-SUMARI) module (JBI-QARI, JBI-MAStARI and JBI-NOTARI) will be aggregated to generate synthesized findings, including a meta-analysis of quantitative data if appropriate. Where the pooling of data is not possible the findings will be presented in a narrative form. The synthesis may also be presented in tabular form or in figures.
Secondly, all synthesized findings will be combined to produce the overall findings for the review questions.
Conflicts of interest
The authors have no conflicts of interest to declare.
Acknowledgements
KC was supported by a Fellowship (100702) from the National Heart Foundation of Australia, Freemasons Foundation Centre for Men's Health, Faculty of Health Sciences, University of Adelaide, and the CMV Foundation Aboriginal Research Scholarships 2014. Financial support for this review was received from Oxfam Health and Wellbeing Supporting Innovating Grants 2014. KC would also like to acknowledge the significant mentoring and administrative support from the Wardliparingga Aboriginal Research Unit within the South Australian Health and Medical Research Institute.
References