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Table 2 General characteristic of the studies

From: Leave events among Aboriginal and Torres Strait Islander people: a systematic review

First Author and year of publication

Type of study


Data collection methods

Participants and settings


Primary Studies



Einsiedel et al. (2013) [24]

Prospective cohort study

To prospectively identify risk factors for self-discharge Among Aboriginal patients

Individual patient interviews to collect demographic details, understanding of diagnosis and management, alcohol consumption, history of self-discharge, use of traditional healer, social problems, loneliness, and perceptions of the hospital. Univariable and multivariable analysis of risk factors and self-discharge

Aboriginal patients > 14 years in the general medical units at Alice Spring Hospital

-Univariate analysis:

Male gender,

Age < 45 years, history of self-discharge, desire to drink alcohol, town camp residence, dissatisfaction with treatment and urge to leave hospital

-Multivariate analysis:

Desire to drink alcohol,

Transfer to tertiary centre, past history of self-discharge, male, past history of alcohol dependence

Not studied

Wright (2009) [25]

Comparative retrospective cross-sectional study

Examine difference between Aboriginal and non-Aboriginal people who did not wait to see the medical officer:

1. Examine relationship between triage category assigned and Aboriginal status. 2.Examine relationship between variables did not wait and Aboriginal status

3. Examining relationship between variables discharge against medical advice and Aboriginal status

Data from Emergency Data Information System about Aboriginal status, presenting problem, age, sex, triage category, day and time of presentation, mode of arrival, time waited

All presentations to four emergency departments in the North Coast Area Health Service of NSW between January 2006 and December 2006

-Aboriginal people who did not wait were two times more likely to have arrived by ambulance than non-Aboriginal people

-The majority of Aboriginal people who did not wait were young adults (20–24 years) and children

-The majority of Aboriginal people who did not wait presented during evening on Monday, Tuesday and Sunday

- Strong association between triage 4 (less severe symptoms or injuries) and “did not wait” or “Discharge Against Medical Advice (DAMA)”

Not studied

Katzenellenbogen et al. (2013) [26]

Cross-sectional study

Investigate demographic and clinical factors that predict Discharge Against Medical Advice (DAMA) in patients with first admission for Ischemic Heart Disease with Focus on the differences in risk of DAMA in Aboriginal and non-Aboriginal patients

Data from person-linked file of all admissions to any WA hospital in 1985–2008 with a discharge diagnosis of Ischemic heart disease. Univariate and multivariate logistic regression models to determine predictor of discharge against medical advice and logistic regression modelling applied separately to Aboriginal and non-Aboriginal patients

Aboriginal and non-Aboriginal people admitted to any hospital in WA aged 25–79 years with first-ever admission for Ischemic heart disease

-Aboriginal patients were more likely to DAMA if they had fewer comorbidities

-Drug and alcohol dependence was associated with DAMA in Aboriginal and non-Aboriginal patients

-Metro hospital and rural residence was associated with DAMA for Aboriginal patients

Not studied

O’ Connor et al. (2021) [27]

Pre-post study

To further explore the likelihood of a causal association between study activities and the decrease in self-discharge rates which occurred during the study intervention period

Linear regression was used to examine the relationship between numbers of interpreter bookings made per month and self-discharge rates

Data was collected from Interpreter bookings between 1 April 2016–31 March 2019 provided by the NT Aboriginal Interpreter Service and leave events were recorded from separations data at the Royal Darwin Hospital

Not studied

Significant inverse association was present between interpreter bookings and likelihood of self-discharge among Aboriginal inpatients

Franks and Beckmann (2002) [28]

Qualitative study

To clarify perceptions of Take Own Leave (TOL) among hospital and community health staff and patients including Definition of TOL, who is likely to TOL, Administrative response to TOL, perceived impact of TOL, Reasons of TOL, proposed solutions to TOL

Semi-structured list of open-ended questions: Interviews with patients and staff of Alice Spring Hospital and two remote Central Australian communities and three focus groups in the hospital with health education staff, medical staff, and nurses at the hospital

Patients, hospital health staff and community health staff of Alice Springs Hospital and two remote Central Australian communities from different language groups

Nurses and doctors speaking rudely, being away from family, heard doctor saying that they were better and though they could go, felt better and did not understand importance of completing treatment, alcohol withdrawal, fear of medical treatment or being send away, previous stories of bad treatment in hospitals and people dying in hospital, sorry business, children or other family at home who need care, job,language barriers, lack of effort from doctors to explain, different perceptions and expectations of health models, unfamiliar hospital environments and lack of understanding of hospital procedures like isolation or restricted diets

More Aboriginal staff specially language speakers, having Aboriginal health worker in each ward, cultural awareness from staff, provide cultural training before start working,community education about hospital environments and procedures, spaces for family visits, access to outdoor spaces, Aboriginal art, more patients receiving treatment at home

Askew et al. (2021) [29]

Qualitative study

To increase understanding about the causative and contextual factors that culminate in people self-discharging and identify opportunities to improve the hospital experience for all

Semi-structured interviews with five Aboriginal and/or Torres Strait Islander people and six non-Indigenous people who had self-discharged from a major tertiary hospital in Brisbane

11 participants (5 Indigenous aged 43–63) from Princess Alexandra Hospital

Use of medical jargon, not enough time taken to explain medical condition, conflicting information from different doctors, perception of staff being rude and alienating, racism, stereotypes, demeaning attitudes, lack of understanding of Aboriginal culture, uncomfortable spaces, responsibilities at home, lack of economic resources for transport and treatment

Not studied

Kerrigan et al. (2021) [30]

Qualitative study

To present Aboriginal language speaking patient experiences and perspectives of hospital care when access to interpreter-mediated communication is consistent

Participant interviews, researcher field notes from shadowing doctors, doctors’ reflective journals, interpreter job logs and patient language lists

Six Aboriginal language speaking patients (five Yolŋu and one Tiwi), three non-Indigenous doctors and five Aboriginal interpreter staff at the Royal Darwin Hospital were purposefully sampled

feeling frustrated and disempowered due to communication issues, use of medical jargon by doctors, responsibilities at home, feeling disrespected by demeaning comments based on stereotypes, uncomfortable hospital spaces, lack of cultural awareness

Use of interpreters increased patient satisfaction and access to services to meet social determinants of health which resulted in reduced self-discharge and re-admissions


 Aboriginal Health Policy Directorate (2018) [21]

Mixed methods

1. Review relevant policies and recording processes 2. Outline TOL recording and coding pathways 3. Examine rates of TOL in WA 4. Summarise information about contributing factors and impacts received through consultation 5. Provide strategies for improving TOL

Consultation through a template in early 2017 with health service providers, Aboriginal Health Council WA, Health Consumer’s Council, WA Primary health Alliance, Mental Health Commission, and senior WA health staff

Western Australia

Racism and stereotyping, distrust of health services, unwelcoming hospital environments, lack of Aboriginal workforce, Communication and language barriers, family and cultural obligations, social disadvantage, stereotypes about alcohol and drugs, stereotypes about mental health, unstandardised admission and discharge procedures

Cultural competency training for workforce, consultation and partnership to improve coordination, increase use of interpreters, develop culturally appropriate resources, enhance communication with patient and family, create culturally friendly spaces and spaces for family, Increase Aboriginal workforce, address social determinants of health, consider service availability and distance, training staff to reduce stereotyping associated to alcohol and drugs, training to identify and manage intoxicated or withdrawal patients, appropriate assessment and service delivery for mental health conditions, address mental health conditions stigma, culturally appropriate policies procedures and practices throughout pre- admission, admission and discharge, use telehealth to allow patients to communicate with family, Increased understanding of patterns and causes of leave events

 Clinical Excellence Commission (2020) [22]

Mixed methods

Report the findings of the "Diagnostic phase " of the NSW Health's Strategic Priority 2.1. were they focused on clinician and expert perspectives about the contributing factors for TOL and how would they like to improve the provision of care for Aboriginal peoples

1. Literature review of peer-reviewed and grey literature 2. Consultation with clinicians and providers in NSW public health facilities 3. Consultation with other national bodies 4. Consultation with industry bodies involved in care of Aboriginal patients 5. Visits to far West local Health District and Western NSW local Health District

New South Wales

Interdependent levels of responsibility:

1. System: improving Aboriginal representation in workforce an appointing Aboriginal leader

2. Organisation: ensuring that patients feel safe, welcomed and understood. 3.Community: establishing relationships with communities to strengthen Aboriginal identity and community control

4. Individual: Need of cultural awareness and sensitivity in workforce and increase patient understanding of their condition and process of care

Shared understanding of the definition of TOL, DAMA, did not wait etc.… Build shared accountability for the appropriate treatment of Aboriginal patients, environments to be more friendly including physical facilities, waiting rooms, Wi-Fi, kid areas, access to water, phone charging. Increase in awareness of importance of family and carers, promote rapport building and shared decision making between practitioners and families, improvement in identification of Aboriginal status, increase representation of Aboriginal staff, more flexible models of care adapted to patient needs, enhancement of relationships between hospital services and primary health services, coordinated approach to measuring and reporting leave events to support learning and improvement

 Henry et at. (2007) [23]

Mixed methos

1. “Explore reasons underlying patient self-discharge” 2. “Determine if the behaviour is associated with patient non-compliance and/or resource constrains” 2. “Explore duty of care consequences of self-discharge” 3. “Identify ways to prevent self-discharge” 4. “Assess costs and benefits of options to manage these patients” 5. “Interview patients who had left hospital prematurely”

1. Statistical and economic data analysis from reports of all Northern Territory hospitals between 1999–2004

2. Twelve semi structured Interviews and 6 focus groups with staff in hospitals

3. Six interviews and 1 focus group with Aboriginal Health services and interviews with 30 Aboriginal patients

Royal Darwin Hospital: Key Health service stakeholders including Administrators, doctors, nurses, Aboriginal liaison officers, Aboriginal health workers, Nursing directors, Social Work department, department of Policy Officers and informants of their own hospitalisation or people known to them

Linguistic communication issues, different understanding about disease, treatment and health not respected, use of jargon, discomfort with medical environments and procedures, fear to die in hospital or be referred to other cities, pay bills, send money to family, children at home who need care,sorry business, cultural ceremonies, loneliness, boredom, long periods without family, alcohol and substance withdrawal, transport costs and availability, racism and attitudes from staff

Cultural awareness training, implementation of cultural security and policy procedures in hospitals, patient education about hospital systems, policies, support structures and services available, western concepts of germ and need of fasting. Increase Indigenous staff and their availability including interpreters, flexibility to meet patient needs like exercise, family meetings, bush walks. Information about patient background in the door, better discharge plans, family meetings by telephone, increase support services to meet needs, develop consistent terminology and approaches for identification and recording of self-discharge

  1. aAll quantitative results reported in the table were statistically significant