Authors
- Davy, Carol
- Kite, Elaine
- Aitken, Graham
- Dodd, Garth
- Rigney, Janice
- Hayes, Jenny
- Van Emden, Jan
Abstract
Review question/objective: The primary objective of this review is to systematically examine scientific literature that reports on strategies or interventions that have been or could be developed, or have been used by primary healthcare or aged care services to support the wellbeing of older Indigenous peoples.
More specifically the review questions are:
1. What are the attitudes, beliefs, expectations, understandings, perceptions and experiences of older Indigenous peoples being supported by these strategies or interventions?
2. What other strategies or interventions do Indigenous peoples believe primary healthcare or aged care services could implement to support the wellbeing of older Indigenous peoples?
3. What are the attitudes, beliefs, expectations, understandings, perceptions and experiences of primary healthcare and aged care service providers who have developed or implemented these strategies or interventions?
4. What other strategies or interventions do primary healthcare or aged care service providers believe could support the wellbeing of older Indigenous peoples?
Background: While often difficult to measure1, the life expectancy of Indigenous peoples from a number of different countries appears to be increasing. Between 2008 and 2012, the estimated life expectancy of Aboriginal and Torres Strait Islander peoples in Australia, for example, increased from 63 to 65 years for males and from 72 to 73 years for females.2 For a variety of reasons, including reduction in deaths from injury and some chronic diseases, similar trends have also been noted in Canada, United States and New Zealand.3-6
Perhaps in some cases, for the first time governments are needing to consider how to support and provide services to an increasing number of older Indigenous peoples.7 In Australia, the National Aboriginal and Torres Strait Islander Flexible Aged Care Program recognizes and attempts to address these emerging needs.8 Population aging and its health implications is an important issue for Canada's Indigenous peoples, with many Aboriginal seniors being forced into cities due to the lack of healthcare services and facilities in their rural and northern communities.9 The Canadian Government is taking steps to improve services provided to their Indigenous peoples. The First Nations and Inuit Home and Community Care program developed and implemented in the late 1990s, for example, focuses on case management, nursing care at home, some respite care and personal care service options.10 However, many of the current programs aimed at supporting older Indigenous peoples fail to address the issues which are deterring people from accessing these programs.2
A number of factors have been found to act as a barrier to Indigenous peoples seeking care, including language, affordability and problems navigating the healthcare system. For many Indigenous peoples, cultural issues also exacerbate these barriers.9,11 Health, for example, is not just about being free from illness, but for Indigenous peoples, is also a balance between physical, mental, emotional, cultural and spiritual wellbeing12-14 which is often not supported by western approaches.15 The particular focus on a biomedical model of care, rather than one that incorporates the central importance of family, kinship, community and Country, may be neither appropriate for nor acceptable to older Indigenous peoples.16,17 Discrimination and racism17, and the lasting effects of colonization, further contribute to the likelihood that older Indigenous peoples will be reluctant to utilize mainstream primary healthcare and aged care services.18
At the healthcare service level, improving understandings of Indigenous peoples' cultures and the factors that support their concepts of wellbeing is likely to improve the quality of care.19 At the same time, encouraging a more holistic concept of health which considers and accounts for the heterogeneity between and within Indigenous communities will encourage the uptake of services by older peoples.20 This may decrease preventable hospital admissions and associated costs to the healthcare system.21-23
Healthcare services that support the wellbeing as well as the acceptability of services for Indigenous peoples have a number of additional benefits. Providing effective and acceptable community centered care will mean that Indigenous peoples are able to live at home for as long as possible, thereby ensuring the presence of valuable community role models for younger people.24 In turn, remaining within or at least close to their communities provides an opportunity for family members who often encourage people to engage with care25 to contribute to and support the effective management of the older Indigenous peoples' health.26,27
Initial searches suggest there are a number of primarily qualitative studies28-33 which have attempted to understand how primary healthcare and aged care services can better support the wellbeing of Indigenous peoples in, for example, Australia34, East Asia and South East Asia35, and South Africa.36 Findings from these studies suggest that maintaining close connections with family and community members30-33,37-43 as well as continuing to celebrate spirituality, Country and culture29,40,43,44 may be particularly important for supporting the wellbeing of older Indigenous peoples. To our knowledge, however, this is the first systematic review that will identify and then synthesize evidence about what could support the wellbeing of older Indigenous peoples.
Article Content
Inclusion criteria
Type of participants
The populations of interest in this review are older Indigenous peoples, regardless of any medical conditions, their families or other members of the Indigenous communities. Given the significant life expectancy differentials experienced by many Indigenous people compared to non-Indigenous peoples, "older" for the purposes of this systematic review is defined as peoples over the age of 50.45
Indigenous peoples in the context of this systematic review, based on The Study on the Problem of Discrimination Against Indigenous Populations, by Special Rapporteur Jose R. Martinez Cobo, authorized in 1972 and reporting to the UN Sub-Commission on Prevention of Discrimination and Protection of Minorities in 1983, are defined as:
"Indigenous communities, peoples and nations are those which, having a historical continuity with pre-invasion and pre-colonial societies that developed on their territories, consider themselves distinct from other sectors of the societies now prevailing in those territories, or parts of them."46(p6)
In addition, the population of interest also includes all primary healthcare and aged care providers (e.g. doctors, nurses, administrators, healthcare workers, aged care workers, allied healthcare staff, etc.) who care for older Indigenous peoples within a primary healthcare and aged care setting.
The studies may be on the populations solely or may include other populations also, as long as data can be extracted on the populations of interest sample.
Phenomena of interest
The phenomena of interest are attitudes, beliefs, expectations, understandings, perceptions and experiences of the populations of interest arising from either experiencing (in the case of Indigenous peoples) or alternatively developing or implementing (in the case of service providers) strategies and interventions which aim to support the wellbeing of older Indigenous peoples. Given the evidence that family, community, spirituality, culture and Country support the wellbeing of older Indigenous peoples, these may include but will not be limited to, for example, interventions which ensure that older Indigenous peoples are able to return to Country for at least short periods of time. Interventions that would also meet the inclusion criteria could include those that ensure that Indigenous local languages are spoken by at least some of the healthcare or aged care service staff.
In addition to identifying the above strategies and interventions that have been implemented, this review will also include studies that report on the attitudes, beliefs, expectations, understandings and perceptions of the above populations of interest, and on what could support the wellbeing of older Indigenous peoples.
Given that there are numerous definitions of wellbeing within academic literature, this review will apply a flexible approach, deferring to definitions provided within the included papers.
Contexts
Studies will be considered for inclusion if they include older Indigenous peoples who are living within the country of origin. Studies will also be considered for inclusion if they include service providers who work within a primary healthcare or aged care service which provides care to older Indigenous peoples.
Primary healthcare is generally defined as first-contact, accessible, continued, comprehensive and coordinated healthcare provided by a single practitioner (e.g. GP, nurse practitioner) or a multi-disciplinary team of professionals in a community practice. For the purposes of this review, however, primary healthcare will also include healthcare delivered anywhere outside of the inpatient setting that patients can access directly, and therefore will also include outpatient treatment. Rural outreach services, where medical or allied healthcare professionals attend primary healthcare clinics for a limited period to provide clinical services to Indigenous communities, will also be included.
Rather than focusing only on residential facilities, this systematic review will consider a range of different services that are available to support older Indigenous peoples including aged care services provided in the home and community, as well as facilities that provide both temporary and long term live-in care. Facilities providing end-of-life care and palliative care will also be considered.
Types of studies
This systematic review will focus on English language papers from qualitative studies including but not limited to Indigenist, ethnography, phenomenology, grounded theory, action and feminist methodologies. The review will also include qualitative findings within mixed method, case study and case series studies. As it is likely that studies relating to attitudes, beliefs, expectations, understandings, perceptions and experiences of interventions or suggested interventions published at any time in the past may be as relevant as recently published studies to answering the questions posed by this review, no search range (dates) are included.
Search strategy
A three-step search strategy will be utilized. An initial limited search of MEDLINE 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 articles. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference list of articles selected for critical appraisal will be searched for studies which potentially match the inclusion criteria.
The electronic databases that will be searched include:
EBSCO CINAHL
MEDLINE
SCOPUS
PsychInfo
Embase.
Due to the vast number of country specific databases which could potentially be searched, Google will be searched to identify grey literature which meets the inclusion criteria. In addition, the following databases which include grey literature and are specific to Australia will be used:
Australian Institute of Aboriginal and Torres Strait Islander Studies
Australian Indigenous Health InfoNet.
While the Expert Advisory Panel will also be asked to provide advice on alternate key terms to ensure a maximum search strategy is developed, the initial key words, MeSH terms, title and abstract search terms will include:
older, elder, elderly, aged, ageing, aging,
and
[In the first instance] Indigenous, First Nation People/s, First People/s, First Nation/s, Ethnic Groups, Aboriginal.
[In addition, specific terms for Indigenous populations will be considered in stage two including] Torres Strait Islander, Inuit, Metis, Maori, American Indian, Native American, Ainu, Okinawans, Sami, Lapps and Laplanders
and
primary health care, primary healthcare, ambulatory care, outpatient, community care, general practice, nursing home, residential facility, aged care, respite care
and
wellbeing, well-being, well being, wellness, quality of life, resilience, promotion, prevention, preventive
Assessment of methodological quality
Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
Data extraction
Qualitative data and descriptive data will be extracted from papers included in the review using the standardized data extraction tool from JBI-QARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Authors will be contacted where the need arises, for example, to get access to publications or information not reported in the methods and results.
Data synthesis
Qualitative research findings will, where possible, be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality, and categorizing these findings on the basis of similarity in meaning. These categories will then be subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form.
Conflicts of interest
The authors declare that there are no conflicts of interest.
Acknowledgements
This systematic literature review is part of work which is supported by Helping Hand Aged Care Services. The primary author was also supported by National Health and Medical Research Council (NHMRC) Grant No 1061242. The published material is solely the responsibility of the individual authors and does not reflect the views of NHMRC.
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Appendix I: Appraisal instruments
Appendix II: Data extraction instruments
QARI data extraction instrument[Context Link]
Keywords: Indigenous; wellbeing; resilience; primary healthcare; aged care services; ageing