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Table 2 Characteristics related to health care service access and accessibility

From: Access to primary health care services for Indigenous peoples: A framework synthesis

Stage One: Perceptions of Needs and Desire for Health Care
Patients’ Ability of to Perceive–two papers
Very few studies included identified issues relating to Indigenous peoples’ ability to perceive that health care was needed. Of those that did, perceptions were hampered by a denial that a problem existed, low self-esteem and judgement that was impeded by substance abuse [39]. One other study noted that awareness of services was limited for those Indigenous peoples who were not already accessing services [40].
Services’ Approachability – ten papers
A number of papers identified strategies used by Indigenous health care services to increase the approachability of services.
• Raising awareness about services was achieved by working with patients as well as with the patient’s family and their community as a whole [4143]. In some instances community representatives were employed to encourage people to utilize services that were available [39], while in others health care providers went into the community to promote and educate people about when and how to seek health care [44].
• Building a positive reputation was believed to be important because it meant that people felt confident in referring others to the service [45, 46]. Services also worked with community members in order to reinforce that their concern was for the health and wellbeing of the community as a whole [47].
• Providing health care within the community helped to raise the profile of services [48], improve health literature and at the same time provided staff with an occasion to opportunistically offer services to people who were in need of assistance but had not yet sought care [39, 49, 50].
Stage Two: Health Care Seeking
Patients’ Ability to Seek–eight papers
Prioritizing the needs of others over themselves often prevented Indigenous peoples from seeking health care [39, 51]. The ability to seek care was also limited when culturally appropriate services were not available [39, 47, 49, 5255] or where concern for maintenance of confidentiality was raised [49].
Services’ Acceptability – 19 papers
The acceptability of services provided for Indigenous peoples was paramount to improving access. In particular this related to providing services that understood and were able to account for the values, beliefs and understandings of the communities they served.
• Providing culturally appropriate care was achieved by seeking out and understanding the cultural values and beliefs of the community [39] including gender specific spaces [44, 54]. It is based on respect, social justice, participation, equality, access, learning and collaboration [50], incorporating for example local language(s), beliefs, gender and kinship systems [47]. Importantly, culturally appropriate care is free from any racism or discrimination [44].
• Employing culturally appropriate staff who understand and respect the cultural values and beliefs of the community was considered to be an important aspect of acceptable health care [56]. While Indigenous health care staff were the preferred option [47], where not available, ensuring that non-Indigenous staff received appropriate cultural training was crucial [8, 57].
• Broadening models of care to encompass a more holistic sense of health including aspects of social, emotional and cultural wellbeing [42, 43, 50, 58] was considered important. In some instances this also involved providing more traditional methods of health care including partnering with traditional healers [41, 44, 49, 56, 59, 60]. A more holistic model also encompassed interventions targeting the social determinants of health including food distribution [44] and housing programs [52, 54].
• Offering a welcoming environment where the community felt comfortable and at ease was important for encouraging community members to access care [44, 61]. This was achieved through the use of cultural artefacts [51], local language [62] and comfortable surroundings [44].
Stage Three: Health Care Reaching
Patients’ Ability to Reach–eight papers
Transport was considered to be the main factor which inhibited Indigenous people from reaching services [63, 64] followed by a lack of communication services including telephones [65]. The lack of transport was further exacerbated when health care services were located outside of peoples’ communities [39, 40, 45, 51, 53].
Services’ Availability and Accommodation – 23 papers
Given that many of their patients were often hampered in accessing care either by distance and/or through a lack of transport, Indigenous health care services often went to great lengths to ensure that patients were able to engage with health care.
• Delivering outreach services in a variety of settings [48, 66] including rural, remote [51, 67] and urban [68] communities. Outreach staff attended patients in their own homes [49, 50, 69] and within organisations such as prisons [42]. As well as providing generalist care, outreach services focused on maternal and child health, screening [39, 51], social and emotional wellbeing [41, 70], health promotion programs, and dental care [50, 71]. Outreach services were considered to be a crucial part of a comprehensive model of care [72], particularly for frail aged and disabled Indigenous peoples [54, 67], those had no access to transport [63, 65] and lived significant distances from the health care service [73].
• Providing transport was frequently noted as an effective way of improving availability of services [8, 39, 50, 51, 54, 61, 63]. Where communities were situated in particularly remote areas, transport could extend to the use of small planes to ferry people to and from appointments [51].
• Providing flexible appointments was another way in which some services sought to make health care more available including walkin services [44, 54] and less structured approach to appointments [8]. In some instances this also included extended opening hours [40, 44, 50, 65, 74, 75] and the use of electronic health records which can be reviewed outside by patients and staff outside of scheduled appointments [75, 76].
Stage Four: Health Care Utilization
Patients’ Ability to pay–six papers
The cost of health care was a key barrier to accessing health care for Indigenous peoples [53, 64]. In some cases patients could only afford part of the cost while others did not have the means to pay at all [65]. Patients in some cases lived below the poverty line [39]. It was not just the cost of the service that was prohibitive, but also associated costs of travelling to and in some cases remaining at the health care service for extended care [74]. People often made choices based not only on quality but also on cost [40, 55].
Services’ Affordability–14 papers
Providing affordable services often proved difficult for many of the Indigenous health care services included in this review primarily because patients were often unable to afford the true cost of care and funding from other sources was limited.
• Providing cost effective care was considered crucial for ensuring accessibility of health care for Indigenous peoples on low incomes [77]. This often meant reducing charges to many patients [56, 65] or providing free services [44]. In some instances cost effective care also extended to the provision of free medicines [78] and dental care [71], particularly in the case of low income earners [64].
• Managing within constrained budgets was an issue that hampered some services from offering cost effective care. In some instances the cost incurred in providing care was greater than the normal charge to patients [56]. One service reported having to limit some of the more expensive services such as outreach visits due to lack of funding [54]. Services reported receiving insufficient economic support to provide the care that was needed [44, 51, 64, 79, 80].
Stage Five: Consequences of Accessing Health Care
Patients’ Ability to Engage–three papers
Engaging with both individual patients and the community more generally took time and patience [46]. Communities that felt a sense of ownership over the service were more likely to engage and then importantly remain engaged with health care services [76]. It was also the case that patients were more comfortable talking about their health with an Indigenous staff member or while participating in cultural activities that some Indigenous services offered to community members [54].
Services’ Appropriateness–17 papers
Many of the Indigenous health care services attempted to engage with the communities they served, and in some cases the service was owned and managed by local Indigenous peoples. Appropriateness of services also related to ensuring a sense of holistic care whereby barriers to accessing any service were reduced.
• Engaging with community to determine their needs was considered crucial to ensuring the acceptability of services [8, 41, 45, 50, 51, 81].
• Ensuring community ownership whereby services that are initiated, planned, governened and managed by the local community was believed to result in the most appropriate cultural models [40, 56, 58, 82].
• Coordinating care meant that patients received a holistic service from a multi-disciplinary team with no internal barriers to access [41, 49, 75]. For some Indigenous peoples with high needs this extended to coordinated home services [62].
• Integrating services improved the ability of the service to meet the holistic needs of the community [44, 56, 72] by ensuring that patients were supported to access care not available within the Indigenous health service [41, 46, 50, 62, 70].