One Size Does not Fit All – A Realist Review of Screening Asymptomatic Atrial Fibrillation in Indigenous Communities in Australia, Canada, New Zealand, and the USA

Abstract

The true prevalence of atrial fibrillation (AF) is underestimated because asymptomatic AF is underdetected. Adverse consequences of AF such as stroke may occur before AF is diagnosed. Current guidelines recommend opportunistic screening of AF in the general population for patients 65 years and older; however, this might not be suitable for Indigenous people. Screening for AF meets the World Health Organization criteria for successful routine screening, yet little is known about successful implementation of AF screening in Indigenous communities. This study uses a realist review methodology and framework to identify what works, how, for whom, and under what circumstances for AF screening in Indigenous communities. Eight databases and gray literature were searched for studies targeted at AF screening in Indigenous communities. Realist analysis was used to identify context-mechanism-outcome configurations across 11 included records. Some mechanisms that improve AF screening in Indigenous communities were identified. Salient enablers of AF screening in Indigenous communities include opportunistic nonclinical settings, portable electrocardiogram devices, and increasing training in Indigenous health-care workers. Tailoring follow-up protocols that are geographically and culturally appropriate to the settings is important. Prominent barriers included lack of cultural safety, fear of abnormal results, and time-poor environments. A middle-range theory is proposed in combination with the Indigenous health promotion tool model. Indigenous populations require earlier screening and culturally safe approaches for AF detection and pathways to treatment. A novel AF screening strategy is required. This realist review provides lessons learned for the successful implementation of AF screening and treatment programs for Indigenous communities.