Relating well to people: a mixed-methods evaluation of preventive care implementation for Aboriginal and Torres Strait Islander people in mainstream, urban general practice

Abstract

IntroductionThere is potential for health gain by Aboriginal and Torres Strait Islander people in Australia through better primary health service in urban areas. Preventive health care delivered with social sensitivity is critical to addressing chronic disease. In the mainstream urban general practice setting, three key linked processes of Indigenous identification, health checks and immunisation for Indigenous people should be improved.BackgroundThe history and current lived experience of Aboriginal and Torres Strait Islander people influence access to mainstream health care services. Known access facilitators in urban areas are low cost, convenience and delivery in a culturally safe setting by practitioners with compatible values and professional culture. In contrast to community controlled health services, mainstream general practices have few practitioners with Indigenous care experience, and low levels of Indigenous identification and Indigenous health check delivery.This thesis presents the development, implementation and evaluation of an intervention in Brisbane designed to address known and suspected barriers to Indigenous people’s access to preventive care in mainstream urban general practice.The following research questions were considered:1.     Based on the best evidence, what intervention by Division of General Practice and Public Health Unit staff was appropriate and feasible to promote increased coverage of Indigenous health checks and immunisation in mainstream urban general practices?2.     What were the effects of the intervention targeting mainstream practitioners on Indigenous identification, immunisation and health checks, and what were the other effects?3.     How could existing barriers to immunisation and health checks in mainstream general practice be overcome?MethodsThe Promoting Indigenous Preventive Care in General Practice (PIPCGP) study used a realist-inspired framework of enquiry and a mixed methods approach. Division of General Practice and Public Health Unit staff used existing resources to provide intensive practice support through an educational workshop, package of activity support materials, progressive audit and feedback, and ongoing contact over twelve months. Seventeen General Practices in two intervention groups were enrolled. Audit data were gathered at the practice, returned to practices, and collated for evaluation purposes. In-depth interviews were conducted with 35 participants, including clinical and non-clinical staff of practices and Indigenous community members.ResultsThe inner suburban group had low attrition, showed a steep rise (78%) in Indigenous patient numbers, and increased health check delivery. Half the Indigenous children aged 2 to 5 years had immunisation data missing from their record prior to intervention, which was rectified. Child immunisation coverage for all vaccines, including Indigenous-specific vaccines, was 46% at the end of the period. The outer suburban group had a high attrition rate of 50%.Preventive care processes for over two thousand Indigenous patients were included in the study. Increased Indigenous identification came from both current and new patient groups. Practices with higher health check activity had staff experienced in Indigenous health, were already delivering checks prior to intervention, and increased their activity. Few low activity practices had previously undertaken checks, and half of these commenced.  Difficulties reported were a low level of patient willingness to undergo a check, and organisational processes: poorly adapted electronic records, long consultation time, and uncertainty about sharing assessment components between team members.Indigenous identification was welcomed, was associated with acknowledgement of culture, and helped build relationships. Providers experienced in Indigenous health aligned with patients in emphasising the staff-patient relationship as a barrier to preventive care, and provided guidance on relationship building. Other providers focused solely on practical barriers. Most providers and community members expressed the need for links between practices, the Indigenous community, and Indigenous organisations.DiscussionThe PIPCGP study confirms that Indigenous identification can be quickly improved in mainstream General Practices, and highlights an additional range of practical and social issues to be addressed in increasing access to preventive care. These include knowledge of the Indigenous immunisation schedule, improved completeness of immunisation record keeping, and teamwork to plan adequate time and cooperation for health checks. Information system deficits exist in Indigenous identification recording, on-screen activity prompt and recall/ reminder. The success factor of staff experienced in Indigenous health enabled a patient relationship-building focus and influenced system change in the practice.ConclusionMainstream practice efforts to strengthen patient-centred care of chronic disease, should include Indigenous cultural and relationship-focused training for staff, Indigenous patient service planning and quality improvement. A continued dialogue and partnership between Community Controlled Health Services and Primary Health Networks, with the assistance of Public Health Services, is essential to support practices with concentrations of Indigenous patients. Supply of general practice information systems in Australia which support tailored care for Indigenous people could be another lever for change, as could more detailed activity monitoring linked to financial incentives to provide high quality preventive care.