Prior to commencing the 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.
The authors developed and published a review protocol for this comprehensive systematic review [31]. This comprehensive literature review was guided by the Joanna Briggs Institute guidelines for systematic review and synthesis of qualitative data [32]. Studies from New Zealand, Canada and America were also included in the review due to the countries shared experience with colonization and their high disparity of health and wellbeing between the Indigenous and non-Indigenous peoples within each country.
Inclusion criteria
Each research question had their own inclusion criteria. Only the criteria related to the types of participants/population were the same for both searches.
Question 1: What factors impact the utilization of primary health care services by Indigenous men?
Types of participants/population
Papers will be included if most of the participants in the study are men (aged 18 years and older) and 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: 2) What strategies have been implemented to increase utilization of primary health care services by Indigenous men and how effective were they?
Types of participants/population
Papers will be included if most of the participants in the study are men (aged 18 years and older) and 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, 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.
Papers were included if they met the inclusion criteria for one of the review questions. Qualitative papers that had explored client views or experiences related to barriers and enablers to access or their experience with primary health care services were included for the first review question. Papers that described the implementation of strategies or programs that aimed to increase health service utilization by Indigenous men were included to answer review question two.
For this review a primary health care center was defined as a health service outside an inpatient setting where patients can directly access, such as general practices, outpatient treatment and allied health services. Studies that were based in an acute care setting, or were focused on participants with a chronic condition, tertiary care or rehabilitation clinic were not included. Mixed methods publications that included a qualitative component which met the inclusion criteria were also included.
Expert opinion publications were reviewed if they discussed/offered opinions to the barriers and enablers for Aboriginal and Torres Strait Islander men utilizing primary health care services and were authored by Aboriginal and Torres Strait Islander men. Advice from male Aboriginal and Torres Strait Islander health research experts was sought to confirm the papers author(s) were indeed considered experts in the field and were Aboriginal and/or Torres Strait Islander men. These expert opinion papers were assessed for quality and contributed to the discussion of the paper, however, as they are not research studies, they are not described in the results section of this review.
Search strategy
A four-step search strategy was employed to find peer-reviewed publications and grey literature. Key words (listed in the review protocol) were used to search PubMed to identify additional keywords and index terms [32]. A search was then undertaken across four databases; PubMed, CINAHL, Informit (Indigenous collection) and Embase. The following databases and websites were also searched for grey literature; ProQuest, Trove, the National Aboriginal Community Controlled Health Organisation website, Australian Indigenous HealthInfoNet, National Library of Australia and the Lowitja Institute. The reference list of included publications was searched for additional studies. In addition, relevant experts were also asked if they were aware of additional missing studies. The final two steps did not result in additional papers being included.
The search strategy in PubMed was as follows, this was modified as required in the other databases: Indigenous[tiab] OR Aborigin*[tiab] OR Torres Strait Islander[tiab] OR Inuit[tiab] OR Maori[tiab] OR American Indian[tiab] OR Native American[tiab] OR First Nation[tiab] OR Oceanic Ancestry Group[Mesh] OR “American Native Continental Ancestry Group”[Mesh] AND strateg* OR utilis* OR access* OR approach* OR tactic* OR engag* OR intervent* OR program* AND Primary health[tiab] OR primary care[tiab] OR “Health Care Quality, Access, and Evaluation”[Mesh] OR “Primary health care”[Mesh] OR “Health Services, Indigenous”[Mesh]. The search of data bases was conducted on the 15th of March 2015, was restricted to those published in English, with no date restrictions.
The lead author, KC, identified articles that appeared to meet the inclusion criteria from their title and abstract. The full text of these articles was retrieved and reviewed by KC and SH to confirm if they met the inclusion criteria.
Assessment of methodological quality
The methodological quality of included studies was assessed by KC and SH using standardized critical appraisal instruments. The Joanna Briggs Institute (JBI) have produced a suite of critical appraisal tools to assess the quality of publications for the purposes of systematic review. The suite includes tools designed for the review of different types of publications. Qualitative papers (or qualitative components of mixed methods papers) were assessed using the JBI Qualitative Assessment and Review Instrument (JBI-QARI) [32]. Textual papers were assessed using the JBI Narrative, Opinion and Text Assessment and Review Instrument (JBI-NOTARI) [32]. When the reviewers had differing opinions on an article’s quality, it was resolved by discussion and if needed a third party was consulted.
Data extraction
Data extraction was assisted using standardized tools. JBI-QARI for qualitative data, and JBI-NOTARI for textual data [32]. Two reviewers each completed data extraction on the included papers, then cross-checked each for completion and accuracy.
Data synthesis
The articles that met the inclusion criteria for research question one was read several times over to extract the findings related to participants experiences with primary health care services. Information was extracted from the results and discussion sections of the papers. The factors impacting the three studies were combined as were findings that were the same or similar. The barriers and enablers for Indigenous men accessing primary health care services were grouped into organizing themes (Table 4). Data synthesis was not conducted on the expert opinion manuscripts, as they did not describe qualitative findings from a study, however, the manuscripts have contributed to the discussion.