What keeps you strong? How primary healthcare and aged care services can support the wellbeing of older Indigenous peoples: a systematic literature review protocol

Review question/objective The primary objective of this review is to systematically examine scientific literature that reports on strategies or interventions that have been or could be developed, or have been used by primary healthcare or aged care services to support the wellbeing of older Indigenous peoples. More specifically the review questions are: What are the attitudes, beliefs, expectations, understandings, perceptions and experiences of older Indigenous peoples being supported by these strategies or interventions? What other strategies or interventions do Indigenous peoples believe primary healthcare or aged care services could implement to support the wellbeing of older Indigenous peoples? What are the attitudes, beliefs, expectations, understandings, perceptions and experiences of primary healthcare and aged care service providers who have developed or implemented these strategies or interventions? What other strategies or interventions do primary healthcare or aged care service providers believe could support the wellbeing of older Indigenous peoples? Background While often difficult to measure1, the life expectancy of Indigenous peoples from a number of different countries appears to be increasing. Between 2008 and 2012, the estimated life expectancy of Aboriginal and Torres Strait Islander peoples in Australia, for example, increased from 63 to 65 years for males and from 72 to 73 years for females.2 For a variety of reasons, including reduction in deaths from injury and some chronic diseases, similar trends have also been noted in Canada, United States and New Zealand.3-6 Perhaps in some cases, for the first time governments are needing to consider how to support and provide services to an increasing number of older Indigenous peoples.7 In Australia, the National Aboriginal and Torres Strait Islander Flexible Aged Care Program recognizes and attempts to address these emerging needs.8 Population aging and its health implications is an important issue for Canada's Indigenous peoples, with many Aboriginal seniors being forced into cities due to the lack of healthcare services and facilities in their rural and northern communities.9 The Canadian Government is taking steps to improve services provided to their Indigenous peoples. The First Nations and Inuit Home and Community Care program developed and implemented in the late 1990s, for example, focuses on case management, nursing care at home, some respite care and personal care service options.10 However, many of the current programs aimed at supporting older Indigenous peoples fail to address the issues which are deterring people from accessing these programs.2 A number of factors have been found to act as a barrier to Indigenous peoples seeking care, including language, affordability and problems navigating the healthcare system. For many Indigenous peoples, cultural issues also exacerbate these barriers.9,11 Health, for example, is not just about being free from illness, but for Indigenous peoples, is also a balance between physical, mental, emotional, cultural and spiritual wellbeing12-14 which is often not supported by western approaches.15 The particular focus on a biomedical model of care, rather than one that incorporates the central importance of family, kinship, community and Country, may be neither appropriate for nor acceptable to older Indigenous peoples.16,17 Discrimination and racism17, and the lasting effects of colonization, further contribute to the likelihood that older Indigenous peoples will be reluctant to utilize mainstream primary healthcare and aged care services.18 At the healthcare service level, improving understandings of Indigenous peoples' cultures and the factors that support their concepts of wellbeing is likely to improve the quality of care.19 At the same time, encouraging a more holistic concept of health which considers and accounts for the heterogeneity between and within Indigenous communities will encourage the uptake of services by older peoples.20 This may decrease preventable hospital admissions and associated costs to the healthcare system.21-23 Healthcare services that support the wellbeing as well as the acceptability of services for Indigenous peoples have a number of additional benefits. Providing effective and acceptable community centered care will mean that Indigenous peoples are able to live at home for as long as possible, thereby ensuring the presence of valuable community role models for younger people.24 In turn, remaining within or at least close to their communities provides an opportunity for family members who often encourage people to engage with care25 to contribute to and support the effective management of the older Indigenous peoples' health.26,27 Initial searches suggest there are a number of primarily qualitative studies28-33 which have attempted to understand how primary healthcare and aged care services can better support the wellbeing of Indigenous peoples in, for example, Australia34, East Asia and South East Asia35, and South Africa.36 Findings from these studies suggest that maintaining close connections with family and community members30-33,37-43 as well as continuing to celebrate spirituality, Country and culture29,40,43,44 may be particularly important for supporting the wellbeing of older Indigenous peoples. To our knowledge, however, this is the first systematic review that will identify and then synthesize evidence about what could support the wellbeing of older Indigenous peoples.

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