Effective health and wellness systems for rural and remote Indigenous communities: a rapid review

Abstract

Background: The Canadian healthcare system bares a long legacy of colonisation and assimilation of Indigenous values and approaches to health and wellness. This system often perpetuates social and health inequities through systemic racism, underfunding, lack of culturally appropriate care and barriers to access care. Current funding legislation policies enacted across federal, provincialand territorial governments do not necessarily uphold Indigenous Peoples’ rights to self-determination, health and wellness. We summarise literature on promising Indigenous health systems and practices that prioritise and/or improve rural Indigenous Peoples’ health and wellness. Objective: The impetus for this review was to provide information on promising health systems, while Dehcho First Nations developed a health and wellness vision. Methods: Documents were gathered from indexed and non-indexed databases to obtain literature from peer-reviewed and non-peer reviewed sources. Two reviewers independently 1) screened titles, abstracts and full texts to ensure they met the inclusion criteria, 2) gathered relevant data from all included documents and 3) identified major themes and sub-themes. Reviewers then discussed and reached consensus on the themes. Results: Thematic analysis revealed six themes for effective health systems for rural and remote Indigenous communities: 1) access to primary care, 2) multi-directional knowledge exchange, 3) culturally appropriate care, 4) training and building community capacity, 5) integrated care and 6) health system funding. Conclusion: Effective health and wellness systems must support Indigenous ways of knowing and doing in healthcare models based on collaborative partnerships with community members, health providers and government agencies.

summary

• Sustainable health and wellness funding plans must be provided through federal, provincial, territorial and state partnerships.

• Indigenous core values, culture and knowledge must be integrated within mainstream health systems.

• Indigenous Rightsholders must inform all plans for altering or implementing Indigenous health systems.

• Non-Indigenous cultural safety and competency training can improve care.

KEYWORDS:

• Indigenous
• health
• healthcare
• partnerships
• policy
• self-determination
• self-governance
• sovereignty

Introduction

The Canadian health system operates through national standards set in place by the federal Department of Health Canada [1]. These standards are meant to ensure that people in Canada have access to high-quality, equitable and safe health services. Included in these national standards are services for First Nation and Inuit communities [1]. The federal government is responsible for providing funding to provincial and territorial governments to meet national standards; however, policies such as the 1876 Indian Act, written by federal government for registered First Nation members, fail to mention healthcare funding allocations for non-status First Nations people [2].

In Canada, while it is the responsibility of provinces and territories to meet federal standards to receive federal funding, provinces and territories manage and deliver health services within their jurisdictions [1,3]. However, the 1985 Canada Health Act does not address how funding applies to non-status or off-reserve First Nations, Inuit and Métis Peoples [2]. Literature that points to the importance of legislative clarity between the federal, provincial, territorial and regional governments suggests a shared goal of maintaining and improving overall population health status. However, active discriminatory policies, such as the 1876 Indian Act and the 1984 Canada Health Act, do not clearly articulate Indigenous health guidelines; thus, governments are protected from using their funds to address the complex Indigenous health needs [4]. The provincial and territorial governments petition the responsibility of Indigenous health funding onto the federal government and contrariwise.

The integration of federal, provincial and territorial governments alongside regional governments, Indigenous authorities and private healthcare adds to the complexity of providing sustainable health services [5]. Presently, there continue to be ongoing financial jurisdiction ambiguities between federal, provincial, territorial and regional healthcare systems, which breach Indigenous communities’ rights to healthcare [6,7]. The Assembly of First Nations [8] highlights this pitfall and announces the need to “move away from … short-term funding and towards sustainable and long-term funding that is responsive to … the needs and priorities of [Indigenous Peoples]” (p. 4). For example, the First Nations and Inuit Home and Community Care (FNIHCC) programme was created by Health Canada to provide “comprehensive, culturally sensitive, accessible and responsive” care to First Nation and Inuit communities [8](p. 80). The FNIHCC included an extensive and unsustainable list of essential services. To meet budgets, loopholes were created within hospitals to cut down on medical equipment and medically necessary medication [8](p. 82). Altogether, such incoherent management and delivery of healthcare services and programmes creates dysfunctional access to health services and programmes for Indigenous Peoples.

The current federal, provincial, territorial and regional governments are unable to provide legislative clarity to improve health and wellness outcomes [4,6,9]. Across Canada, Indigenous Peoples continue to be disproportionately burdened by the lack of government coordination and commitment to determine how to best allocate healthcare funding for Indigenous nations, with the nations [4,6,9]. Structural and systematic inequities embedded in colonial policies and resource allocations are directly connected to increased rates of health co-morbidities and lower life expectancies, as compared with non-Indigenous populations across Canada [10]. A growing body of literature suggests that the part of the poor health and wellness of Indigenous Peoples is attributed to the lack of coordinated funding for appropriate health services [4,8–11].

The Truth and Reconciliation Commission (TRC) of Canada was developed to educate people on the history and impacts of the residential school system and articulate a roadmap for reconciliation with specific calls to action [12]. Throughout the TRC’s development, residential school survivors and their families shared about painful experiences of the racism at residential schools. Each TRC call to action identifies actions to address long-standing injustices that Indigenous communities continue to face. Call to action #20, addressing health, calls on the federal government to recognise the distinct health needs of the First Nations, Inuit and Métis (FNIM) Peoples.

Health: Call to Action 20: In order to address the jurisdictional disputes concerning Aboriginal people who do not reside on reserves, we call upon the federal government to recognize, respect, and address the distinct health needs of the Métis, Inuit, and off-reserve Aboriginal peoples [13].

Call to action #20 also draws attention to jurisdictional ambiguities, particularly for Indigenous communities living in urban and off-reserve locations. Entangled funding from multiple levels of government interferes with the equitable distribution of health services that impact the accessibility and availability of healthcare within Indigenous communities [9, 6]. In order to provide culturally safe health services to Indigenous Peoples, healthcare services, systems and programmes of services must be provided within a reasonable geographic distance [6,9]. Although urban Indigenous communities are closer in proximity to health and wellness services, these services often lack culturally appropriate care, as the larger urban demographic tends to favour the healthcare practices of the non-Indigenous population [10].

The United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP) outlines a decades-long declaration of Indigenous rights created by and for Indigenous Peoples [14]. UNDRIP highlights that rights to self-determination are essential to dignity and wellbeing decision-making [15]. While Canada endorsed UNDRIP in 2010, it was not until one decade later that the federal government introduced Bill C-15, which aims to align pre-existing Canadian laws with UNDRIP values [15].

The Canadian federal government proclaims a primary mission to “protect, promote and restore the physical and mental well-being of residents of Canada” [16,]; however, there is little evidence of Indigenous ways of knowing and doing as a determinant of health and wellness in healthcare training, delivery, resource allocation and data [17–21,]. The Assembly of First Nations created the Health Transformation Agenda, a document with the intention to achieve equitable health and wellness outcomes for First Nations [8]. The lessons and directions from Indigenous rightsholders are of upmost importance to build appropriate and effective health systems. The Health Transformation Agenda (emphasises the resilience and innovation of Indigenous Peoples in their mission to optimise the health and wellness systems in their communities. Pathways towards building holistic, culturally safe care remain at the forefront of their mission [10].

Holistic healthcare includes place-based culture and wellness practices, including medicinal and healing knowledges that are developed and delivered in partnership with Indigenous communities accessing the healthcare [10,11]. Inuit Tapiriit Kanatami (2014) explains how culture and language are central to identity and community belonging as well as being good mental health and well-being. In short, Indigenous self-determination and access to cultural practices are inherently tied to each other and improve health status [22, 7,8,10,23,24]. Effective health and wellness systems in rural and remote Indigenous communities require federal, provincial and territorial government honour promises of equitable access to care, self-determination and self-governance. Our review aims to fill a gap of synthesised knowledge on effective healthcare coordination of services and governance structures with(in) Indigenous nations and communities in settler colonial countries.

This review was initiated by Dehcho First Nations (DFN) to help inform the planning and visioning of a DFN-led health and wellness system. Co-author Kristen Tanche is Dehcho Dene from Liidlii Kue First Nation and at the time of the review and writing this paper, was the Regional Health and Wellness Coordinator of DFN. DFN approached Dr Melody Morton Ninomiya, a non-Indigenous researcher of Japanese and Swiss-German Mennonite upbringing and descent, to conduct a review of existing literature to support the DFN Health and Wellness work. Brianna Stefanon, a non-Indigenous health science student of Italian descent, was invited to conduct the rapid review under the academic supervision of Morton Ninomiya and guidance from Morton Ninomiya, Kristen Tanche and Kathy Tsetso. Tsetso is a retired Chief Executive Officer for Dehcho Health and Social Services and, at the time of this review, a Health and Wellness Advisor to DFN. Tanche and Tsetso guided and participated in the screening, thematic analysis and writing process of this review to ensure the needs and interests of DFN were met.

Objective

The primary objective of the rapid review was to synthesise and summarise promising reforms in Indigenous healthcare systems or coordination of systems, within rural and remote communities. In short, we looked for evidence from research on effective Indigenous health systems, coordination and governance structures that have shown to improve rural and remote Indigenous Peoples’ health and wellness.

Methodology

A rapid review was the preferred method of conducting research as it aligned with the objectives of Dehcho First Nations and projected timeline of the project. Typically, a rapid review uses components of a systematic review that are simplified to produce reputable information in a more time-efficient manner [25,26]. This type of review is chosen when researchers are seeking to collect widespread data about a topic within a shorter time frame as compared to a systematic review of literature. The guidelines outlined in the Cochrane Rapid Review Methods Group were used as the review was brought on by key rightsholders of Dehcho First Nations, Tanche and Tsetso [25]. Cultivated from this partnership, the information produced by the review informs community health and wellness decision-making for Dehcho First Nations.

Search strategy

Data was collected from published and grey literature sources that ranged from peer-reviewed journal articles, reports, guidebooks and websites.

Data was collected using the purpose, content and context (PCC) framework to organise the search terms [27]. The PCC framework was chosen as it is an adaptable framework and does not impose outcomes or expectations on the literature. This framework could capture discreet and all-encompassing terms in relation to population, concept and context of literature. In Table 1, a complete summary of all search terms can be found to highlight the strategy that was used to collect data using the PCC framework.

Table 1. Summary of PCC Search Strategy Framework and Search Terms from Published Literature Sources: PubMed, ProQuest and CINAHL.

(P)opulation	(C)oncept	(C)ontext
“indigenous people*”	health	“Rural health care”
Inuit	“Public health”	“Rural health service*”
metis	“health care”	Canada
“native north America*”	“community health”	“United States”
“pacific islander people*”	“wellness program*”	Australia
“Alaska* native*”	“health service*”	“New Zealand”
“native American*”	“delivery of health care”	“American native continental ancestry group”
Indian, North America (MeSH Term)	planning organisations, health (MeSH Term)	ancestry group, oceanic (MeSH Term)
“Dene”	health services, community (MeSH Term)	“small town”
“Dehcho”	health services, indigenous (MeSH Term)	“on-reserve”
“native people*”	“Competent health care”	“on reserve”
services, Indigenous Health (MeSH Term)	“delivery of health services”	“off-reserve”
“Torres strait islander*”	accessibility, health services (MeSH Term)	“off reserve”
Maori	“social determinants of health”	“fly-in”
	“health promotion”	“fly in”
	“health equity”
	“health service needs and demand”
	“health care delivery”

Note: All data was filtered for being published in English and between the years 2010–2020.

Published literature was retrieved from PubMed, ProQuest and CINAHL databases. Two filters were applied to the initial search results to include articles 1) published within 2010–2020 and 2) written in English.

The grey literature search included the National Indigenous Studies Portal, Arctic Health Publications Database, Inuit Studies, Native Health Database, Pan American Health Organization (PAHO), University of Manitoba Health Sciences Libraries Aboriginal Health Collection and the Thunderbird Partnership Foundation (Table 2). Across all databases, keywords included the following keywords or combination of keywords: health care, healthcare, health system, health service, indigenous, rural, remote, outcom*, impact, meaningfully engag×. The search did not include traditional Indigenous medicines or systems as it was not within the scope of this review.

Table 2. Quantitative Summary of Grey Literature Sources and Included Search Results.

Grey Literature Platform	Number of Results	Number of Results that Fit Inclusion Criteria
National Indigenous Studies Portal/iPortal Indigenous Studies Research Tool	5	2
Arctic Health Publications Database	35	8
Inuit Studies	0	0
Native Health Database	93	19
Pan American Health Organization (PAHO)	3	0
University of Manitoba Health Sciences Libraries Aboriginal Health Collection	11	0
Centre for Addictions and Mental Health (CAMH)	5	0
Thunderbird Partnership Foundation	84	12
Total Before Duplicates Removed: 41
Total After Duplicates Removed: 37

All search results were uploaded to Covidence™, an online platform that organises and tracks systematic (and other) reviews. All search results were imported into Covidence™ where duplicates were removed. After de-duplication, 957 published literature documents and 37 grey literature documents remained in Covidence (Table 2 & Figure 1). In total, the Covidence platform contained 994 papers from both the published and grey literature before screening (Figure 1). Titles and abstract screening as well as the full-text screening were independently done by two reviewers. For any disagreements, the two people who reviewed the title and abstract virtually met to reach consensus.

Figure 1. PRISMA Chart of Published and Grey Literature Searches.

Screening criteria

All co-authors were involved in finalising the inclusion and exclusion criteria. Included papers reported research on rural and remote Indigenous communities in Canada, the United States of America, Australia and Aotearoa (New Zealand), which included communities with evidence of self-governance related to health and wellness supports; studied more than one service or initiatives; described the coordination and types of services; benefitted Indigenous Peoples; contained evidence suggesting meaningful involvement of Indigenous communities in the research. Papers were excluded if they studied a single programme or service or specific disease; did not demonstrate meaningful engagement with Indigenous communities; or were reviews, commentaries or discussion articles.

Data gathering

The co-authors met to review and finalise what information would be recorded from each paper. For each included paper, we recorded demographic data, level of Indigenous involvement, jurisdictional involvement, resources and conditions needed to reach effective health status, level of Indigenous self-governance, structure of health and wellness governance, study focus, types of health and wellness services, key findings, recommendations and wise practices. Following the data extraction, Stefanon reviewed the extracted data from the two reviewers to create a consensus entry for each included document that included information from both reviewers for analysis. The consensus entries were exported from Covidence into an Excel file for thematic analysis.

Thematic analysis

We used inductive thematic analysis as the method for identifying, sorting themes, summarising and reporting themes that are present within the data set [28]. Inductive analysis is a useful method for providing rich details emerging from data and linking similarities between data points. Combinations of our team met weekly to debrief and assess the research process, compare and discuss codes. Koch [29] suggests that data is dependable when multiple researchers reviewing the same data and perception can arrive at the same or comparable conclusion as the previous reviewer. We believe that our thematic findings are dependable, based on the level of agreement and consensus reached among team members. Confirmability was applied within the Covidence platform by utilising the “Notes” option for researchers to input their comments and observations from each article. Our team maintained open communication throughout the review to maximise rigour and agreement between all team members.

Results

Our search results identified a total of 1,015 peer-reviewed documents from publication databases and 41 documents from the grey literature search. After de-duplication and screening, a total of 15 documents were included for analysis. We followed the Preferred Reporting Items for Systematic and Meta-Analyses (PRISMA) protocol to report the number of documents gathered, removed and included (Figure 1).

Study demographics

Geographic location

A total of 15 articles from Canada, the United States, Australia and Aotearoa were included for analysis: five from Canada, seven from Australia, one from both Canada and the United States and two from the United States. Aotearoa was included as one of the four countries during the screening process; however, no documents from Aotearoa met the inclusion criteria for our review.

Indigenous groups/nations/organisations

Some articles had specific and detailed descriptions of which Indigenous nations or communities were involved, whereas others did not (Table 3). Seven papers focused on Aboriginal and Torres Strait Islanders [22,30–32,37,38,41]. First Nations, Inuit and/or Métis (FNIM) Peoples were the focus in six articles [7,23,35,36,39,40]. American Indian and Alaskan Natives (AI/AN) were the focus in three articles [33,34,36].

Table 3. Summary of Demographic Data and Level of Involvement within Included Articles.

First Author, Citation	Country	Indigenous Groups/Nations/Communities	Focus of Article	Jurisdictional Involvement	Indigenous Involvement	Indigenous Self-Governance
Cairney et al., [30]	Australia	Aboriginal and Torres Strait Islander Peoples	Evaluating Health Services	Federal government and government bodies	Partnership between Indigenous organisation and government bodies	Indigenous institution at local/community level
Carroll et al., [22]	Australia	Aboriginal and Torres Strait Islander Peoples	Building Indigenous Capacity	Federal government and government bodies Aboriginal community-controlled health services (ACCHs)	Partnership between Indigenous organisation and government bodies	Indigenous institution at local/community level
Hayman et al., [31]	Australia	Aboriginal and Torres Strait Islander Peoples	Advancing Professional Knowledge and Training Services	Federal government and government bodies	Not clearly defined	ACCHs is controlled by Indigenous-governed communities
Freeman et al., [32]	Australia	Aboriginal and Torres Strait Islander Peoples	Evaluating Health Services	Aboriginal community-controlled health services (ACCHs)	Indigenous-led organizations/community-controlled services	ACCHs is controlled by Indigenous-governed communities
King et al., [33]	United States	American Indian and Alaskan Natives (AI/AN), specifically including Navajo Nation	Evaluating Health Services	Indigenous local-level programs	Partnership between Indigenous organisation and research team	State level
Lawrence and James, [34]	United States	American Indian and Alaskan Natives (AI/AN)	Building Indigenous Capacity	National-level programs Indigenous local-level programs	Indigenous-led organizations/community-controlled services	Indigenous institution at local/community level State level
Mathu-Muju et al., [35]	Canada	First Nations, Inuit, Métis (FNIM), specifically including First Nations of Manitoba, Inuit communities	Evaluating Health Services	Federal government and government bodies Indigenous local-level programs	Not clearly defined	Not clearly defined
Moorehead et al., [36]	Canada, United States	First Nations, Inuit, Métis (FNIM) American Indian and Alaskan Natives (AI/AN), specifically including Navajo Nation	Advancing Professional Knowledge and Training Services	Indigenous local-level programs	Partnership between Indigenous organisation and research team	ACCHs is controlled by Indigenous-governed communities
Panaretto et al., [37]	Australia	Aboriginal and Torres Strait Islander Peoples	Evaluating Health Services	National-level programs Aboriginal community-controlled health services (ACCHs)	Indigenous-led organizations/community-controlled services	ACCHs is controlled by Indigenous-governed communities
Reeve et al., [38]	Australia	Aboriginal and Torres Strait Islander Peoples	Evaluating Health Services	Indigenous local-level programs	Indigenous-led organizations/community-controlled services	Not clearly defined
Restoule et al., [7]	Canada	First Nations, Inuit, Métis (FNIM), specifically including Inuit communities	Implementing Health Services	National-level programs Federal government and government bodies	Partnership between Indigenous organisation and government bodies	National Indigenous Organizations
Ringer et al., [39]	Canada	First Nations, Inuit, Métis (FNIM), specifically including Cree	Building Indigenous Capacity	Indigenous local-level programs	Indigenous-led organizations/community-controlled services	Provincial and Territorial level
Thunderbird Partnership Foundation et al., [23]	Canada	First Nations, Inuit, Métis (FNIM), specifically including Sagamok Anishnawbek First Nation, Esketemc First Nation, Elsipogtog First Nation, Kwanlin Dün First Nations	Implementing Health Services	National-level programs	Indigenous-led organizations/community-controlled services	National Indigenous Organizations
Wright et al., [41]	Australia	Aboriginal and Torres Strait Islander Peoples	Building Indigenous Capacity	Federal government and government bodies Aboriginal community-controlled health services (ACCHs)	Partnership between Indigenous organisation and research team	ACCHs is controlled by Indigenous-governed communities
Young et al., [40]	Canada	First Nations, Inuit, Métis (FNIM), specifically including Inuit communities	Evaluating Health Services	Federal government and government bodies	Partnership between Indigenous organisation and government bodies	Provincial and Territorial level

Focus of the articles

The papers reported on one or more of the following four categories: 1) evaluating health services, 2) building Indigenous capacity, 3) implementing health services and 4) advancing professional knowledge and training services. Six articles focused on evaluating pre-existing health services such as outreach programmes [31,33,35] and services that combined Indigenous practices and euro-Western medicinal care [30,37,40]. Five articles focused on building Indigenous capacity through providing success stories of partnership programmes [34,41], engaging Indigenous communities to define improvement strategies [22,32,39] and creating Indigenous-owned and operated health initiatives [34]. Two articles reviewed the implementation of healthcare initiatives such as using a strengths-based approach to develop substance abuse programmes [23] and frameworks that guide First Nations-specific mental health programmes [7]. Two articles focused on advancing professional knowledge and training services by gathering representatives to integrate Indigenous ways of knowing and doing with conventional health practices [36] and train next-generation health professionals [31].

Jurisdictional involvement & governance

We analysed documents for jurisdictional involvement of health services and programmes into two categories: 1) federal involvement and 2) Indigenous local level programmes.

Federal involvement

Five articles involved federal jurisdictional partnerships [7,23,31,34,37]. Federal programmes and organisations such as the National Native Alcohol and Drug Abuse Program (NNADAP) [23], the Leaders in Indigenous Medical Education (LIME) [37] and the National Aboriginal Community Controlled Health Organization (NACCHO) were established to improve the health and wellness of specific or broad Indigenous groups [31]. Six articles described how federal jurisdictions were involved in the maintenance or improvement of healthcare services [7,22,30,31,40,41]. Some federal initiatives such as the Mental Wellness Advisory Committee (MWAC) worked in tandem with non-Indigenous partners, federal/provincial/territorial networks and Indigenous mental health and addiction organisations [7].

Local Indigenous-controlled health services and programmes

The majority of articles reported on locally governed Indigenous programming aimed at improving community health [22,30,32–34,36–39,41]. One example garnered the collective urgency of key Indigenous health organisations (i.e. Good Health and Wellness in Indian Country (GHWIC), the Urban Indian Health Institute (UIHI) and other tribal organisations) and Indigenous recipients to review the prevention chronic diseases [34]. While reviewing the literature, the use of Aboriginal Community Control Health Services (ACCHSs) was prominently found to be effective towards community members in recognising their knowledge of health and wellness and providing cultural safe care [22,32,37,41].

Partnerships with Indigenous involvement organisations

The level of Indigenous involvement within research studies was not clearly or explicitly stated within any included articles; however, through conversations with Stefanon and Tsetso, it was agreed that authors wove Indigenous involvement into two categories: 1) partnerships between Indigenous organisations and government bodies and 2) partnerships between Indigenous organisations and research teams.

The partnerships with Indigenous organisations and government bodies included four articles [7,22,30,34]. One article explained how an Indigenous and an Australian federal partnership was upheld through a government endorsed partnership agreement, known as the Fitzroy Valley Health Partnership, with an ACCHS [22]. Another article mentioned The Assembly of First Nations partnership with Health Canada aimed to provide programmes for substance abuse in Indigenous communities [7]. Other articles described effective partnerships between Indigenous communities with provincial and territorial governments [Restoule et al., 2015, 31,42]. Restoule et al. (2016) discussed several instrumental partnerships that created a variety of programmes and services towards specific areas of health and wellness. For instance, the Mental Wellness Advisory Committee, focuses on addiction and mental health work together with the First Nations Mental Wellness Continuum which can “assist communities to define system-level changes” to support mental health (Restoule et al., 2016, p. 98).

The partnerships with Indigenous organisations and research teams were present in three articles [33,36,41]. The partnerships between Indigenous organisations and research teams included round table sessions and feedback from Indigenous Healers that informed the research regarding the interface of traditional healing and professional practice [36]. Another study looked at over 100 community health representatives from Navajo Nation and some acted as participants in a study to deliver primary health prevention and promotion programmes to the Indigenous residents within the Southwestern United States, specifically in Utah, New Mexico and Arizona [33].

Indigenous self-governance

Indigenous self-governed and -led health services and programming were organised at local, regional, province, state or national levels, as seen in Table 3. Five studies involved local Indigenous governance centred around community leaders and members [22,30,32,33,35]. Through the adoption of ACCHs, Freeman et al. [32] shared how Indigenous health and wellness advocacy had improved with non-governmental action. Four studies included the community ownership over their health services [31,36,37,41]. Organisations such as the Thunderbird Partnership Foundation have a national reach in Canada on First Nations culture-based substance use and mental health programming [23].

Defining and measuring success of Indigenous health system

The success of the healthcare programming and coordination were largely defined by good relational partnerships between federal, provincial/territorial/state governments and Indigenous-led nations and organisations [7,22,23,31,32,34,37,39]. Success of the coordinated healthcare systems was evaluated within 11 included articles (Table 4). Most articles met the primary objectives of their studies [7,23,30–32,35,37,38,40,41]. Some research teams conducted surveys to quantitatively assess outcomes [30,37,40]. Some successes were noted with a decrease in negative outcomes, such as decreased usage in hospital care [38] and decreased oral health conditions [35]. In four articles, community members directly communicated their opinions about the healthcare intervention through focus groups, interviews and community feedback [7,30,32,33]. Structural changes at an organisational level were also reported as means of success in two articles [39,41]. One research group reported receiving healthcare funding as reaching a successful outcome [41], while another detailed how funding maintained a long-standing commitment to comprehensive primary healthcare [32].

Table 4. Included Articles with Themes Categorising the Measurement of Success and Who Defined the Success of the Coordination of Healthcare Services.

First Author, Citation	How was success measured?	Who defined success?
Cairney et al., [30]	Met primary objectives of study through statistical analysis Focus groups/interviews/community feedback	Research team and community members
Carroll et al., [22]	Not clearly defined	Federal/Provincial/Territorial/State Government(s) and Indigenous-led organisations
Hayman et al., [31]	Met primary objectives of study through increased positive outcomes	Federal/Provincial/Territorial/State Government(s)
Freeman et al., [32]	Met primary objectives of the study Received funding Focus groups/interviews/community feedback	Research team and Indigenous-led organisations
King et al., [33]	Focus groups/interviews/community feedback	Research team
Lawrence and James, [34]	Not clearly defined	Federal/Provincial/Territorial/State Government(s) and Indigenous-led organisations
Mathu-Muju et al., [35]	Met primary objectives of study through decreased negative outcomes	Research team and Federal government
Moorehead et al., [36]	Not clearly defined	Not clearly defined
Panaretto et al., [37]	Met primary objectives of study through statistical analysis	Federal/Provincial/Territorial/State Government(s)
Reeve et al., [38]	Met primary objectives of study through decreased negative outcomes	Research team
Restoule et al., [7]	Met primary objectives of the study Focus groups/interviews/community feedback	Federal/Provincial/Territorial/State Government(s) and Indigenous-led organisations
Ringer et al.,[39]	Structural change at an organisational level	Federal/Provincial/Territorial/State Government(s) and Indigenous-led organisations
Thunderbird Partnership Foundation et al.,[23]	Met primary objectives of study	Federal/Provincial/Territorial/State Government(s) and Indigenous-led organisations
Wright et al., [41]	Met primary objectives of study Received funding Structural change at an organisational level	Research team
Young et al., [40]	Met primary objectives of study through statistical analysis	Research team

Several authors identified how success was contingent on material, financial and personnel resources and conditions being met prior to initiating Indigenous healthcare system reform. Wright et al. [41] discussed the success of implementing a $2.3 million investment of federal funding over a three-year period into the Study of Environment on Aboriginal Resilience and Child Health (SEARCH), which enhanced access to specialised medical care, improved housing and building Indigenous capacity. A Canadian study that was federally funded over a seven-year period evaluated the utilisation of the Children’s Oral Health Initiative (COHI) in 25 Northern First Nations communities within Manitoba [35]. Freeman et al. [32] explained that public funding was a “critical supportive factor” (p.103) in the implementation and continuation of a wide range of health services necessary to sustain positive health and wellness outcomes.

Successful health outcomes in communities were attributed to strong governance structures [7,22,23,31,32,40,41], community readiness [22,31,33], community-driven projects [23], accessible proximity to services [37,39], open and honest communication [7,33,34,36] and building Indigenous capacity and strengths [30–32,37,39,41] as key conditions needed to enhance health status.

Effective health systems and coordination

Six themes that showcase health systems and coordination that are effective and benefit Indigenous Peoples in rural and remote communities include 1) access to primary care; 2) knowledge exchange and open communication; 3) culturally appropriate care; 4) training and building community capacity; 5) integrated care; and 6) funding.

Theme 1: access to primary care

Indigenous communities face challenges accessing appropriate healthcare services in a timely manner [9]. Rural and remote residents often travel outside of their home region for basic primary healthcare, with time, financial and emotional costs [32,40]. Primary care refers to the first point of contact within the healthcare and wellness system. Hospital ambulatory services are often used to gain access to healthcare services when primary care would be more appropriate [38,40]. Accessing primary care providers becomes a geographic challenge in pursuit of basic and necessary healthcare needs [32].

There is strong evidence to suggest that poor access to primary care facilities remains a barrier to health and wellness within Indigenous rural and remote communities [32,38]. For instance, Young et al. [40] documented 18 Indigenous groups of Northern Canada to have hospitalisation rates higher than the national average for conditions that could be handled within primary care settings. As a result, increasing the number of potentially avoidable deaths [40]. Research has shown that improving transportation and financial access to and from appointments outside of the home region improves primary care usage and health and wellness of the community [22,32,36]. Freeman et al. [32] discussed how availability of health and wellness resources is a necessity. The paper points to home visitations, free transportation services and hybrid appointment systems having a positive impact on the health and wellness of remote Indigenous groups.

Theme 2: knowledge exchange and open communication

Information exchange through respectful relationships is essential to prioritise relevant healthcare services and programmes with Indigenous ways of knowing and doing. In contexts where open lines of communication between Indigenous communities, researchers and healthcare professionals informed health policy provisions, services were more equitable and were reported to have more positive patient healthcare interactions and health outcomes [23,33]. For instance, in several studies, open communication through listening sessions and patient feedback were found to have the most favourable health outcomes for Indigenous Peoples [7,33,34,36]. Moorehead et al. [36] explained how the open communication during roundtable talk sessions led by Indigenous Healers residing in the United States and Canada to advance their professional knowledge and provided insight to Indigenous healing practices.

Another example of knowledge exchange that garnered positive responses from patients was outreach visitation sessions from healthcare staff [33]. Visual aids such as leaflets and flip charts to map out health and wellness plans were shown to benefit clients because the communication was tangible and clear [33]. The healthcare professionals also reported that a communication strategy improved the authenticity of the information and helped them feel more comfortable delivering care.

Theme three: culturally appropriate care

Healthcare delivery systems for and within Indigenous communities must be culturally relevant and inclusive of Indigenous medicinal and healing ways of knowing and doing [23,30,32,36,41]. Reeve et al. [38] discussed the value of enlisting help from on-call traditional healers, Indigenous practitioners that offer healing based on local knowledge systems, as part of their health and wellness team. Indigenous communities have been documented to be the best positioned to determine the appropriateness of care in their communities [8,23,32].

Multiple studies highlighted the importance of community leaders playing a key role in informing local healthcare service needs [23,30,36,41]. Successful health and wellness programmes embedded relevant cultural values and traditions within them [23,30]. Community engagement is established through the feeling of acceptance in the physical space and being welcomed in a culturally meaningful way [32]. A key component to delivering appropriate healthcare is respecting and incorporating holistic care within Indigenous health systems [7,23,30]. Holistic care focuses on interconnected nature of spiritual, emotional, physical and mental wellbeing and the social determinants of health as influential contributors to one’s health and wellness [43]. The Tribal Journeys in British Colombia, Canada showcased the influence of Elders and Knowledge Keepers have on recovering substance-users [23]. During a two-week period, community members developed “canoe families” and travel along the west coast of British Columbia on a drug and alcohol-free passage. Along the coast, host communities offer their land and resources to the travellers. The guidance from Elders and Knowledge Keepers provides emotional and spiritual support to the participants of the programme.

Theme four: training and building community capacity

It is important that healthcare providers, especially providers who are not from the community they work in, are properly trained in cultural safety prior to providing health and wellness supports and services. Cultural safety training requires providers to continuously re-examine assumptions and biases while actively working to create or maintain an environment that is welcoming, safe and non-judgemental for patients and other non-local staff [39]. Employing Indigenous healthcare providers was also noted as an imperative action for positive health outcomes [32,38]. The recruitment and retention of Indigenous healthcare providers encourage members of Indigenous communities to develop more trustworthy relationships with the healthcare system [32,41]. Projects that encourage students and future health leaders can have a significant impact on the future health and wellness of remote Indigenous communities [31]. One project, the SEARCH programme, trained Indigenous students to learn about the health and wellness needs within their communities and encouraged them to pursue research in their field of interest. As a result, Indigenous students enrolled in the programme are more likely to pursue higher education and work in their communities [41].

Theme five: integrated care

Indigenous ways of knowing and doing, community involvement and organisational commitment are essential to effective service coordination and health status. For example, the Good Health and Wellness Indian Country (GHWIC) initiative created a partnership between the Urban Indigenous Health Institute (UIHI), Centre for Disease Control and Prevention (CDC), local Indigenous organisations and individual tribes to prevent chronic diseases for American Indian and Alaskan Natives (AI/AN) in the United States. The GHWIC became an AI/AN-owned and operated public health initiative that integrated medical knowledge of tribal partners with the CDC’s health guidelines. As a result, approximately 15,000 AI/AN experienced improved access to nutritious foods and physical activity [34]. Policies that prioritise patient feedback through care experience surveys and advisory roles have shown to help patients feel integrated in their care experience [39].

Another example of integrated care is a six-year Community Outreach and Patient Empowerment (COPE) programme that built a partnership between Navajo community health representatives and non-Indigenous health professionals. This programme improved collaboration between Indigenous and non-Indigenous health providers through the development of case management meetings, training sessions and access to electronic health records [33]. The training had improved communication and teamwork by approximately 45% and the referral process by the community health representatives improved by approximately 40%.

Healthcare facilities and spaces that integrated culture [23] directly contributed to improved health status [9]. In the Yukon territory, the Jackson Lake Wellness Team in Kwanlin Dün First Nation exemplifies the effectiveness of delivering culturally relevant mental health services to a diverse community of people, Indigenous and non-Indigenous people of Yukon, over the course of a 25-year period [7]. The mental wellness team included a team coordinator, clinical counsellor, cultural counsellor and community outreach workers to lead a four-week land-based prevention and aftercare programming.

Theme six: funding

Authors assert that successful healthcare delivery systems for Indigenous communities must be grounded in Indigenous experiences, cultures and ways of healing and maintaining wellness [23,30,36,41]. A positive example is the Mental Wellness Advisory Committee (MWAC), led by Indigenous and non-Indigenous health authorities, to establish community-driven multi-disciplinary mental wellness teams [7]. This committee understood that the uncoordinated funding for programmes and services and emphasised the need for funding and delivery of service [7]. The MWAC drew from community strengths to integrate clinical, cultural and community approaches to health and wellness.

The need for funding extends beyond short-term and project-based funding into long-term, sustainable revenue in health domains that consider Indigenous community members that inhabit the area [32,34]. Within Australia, the Queensland government funded $7 million to create the Centre of Excellence (CoE) clinic which delivered a range of primary healthcare services and programmes to Aboriginal and Torres Strait Islanders [31]. Following the initial investment, the Minister of Health provided an additional $10.5 million to fund allied health professionals, research team and community outreach. The additional income helped to maintain and improve pre-existing health facilities and provide specialised services.

Furthermore, the $30 million per annum public funding provision for primary health care services led to improved social determinants and health for residents of remote regions of Australia. Approximately 70% of the overall budget was invested in individual-level treatment, 10% on group-level and 20% on community-wide public health promotion and prevention work [32]. Funding successes sparked community engagement across a comprehensive range of services, enabling a long-term commitment to Indigenous health and wellness systems.

Discussion

Our rapid review offers a small piece of a larger puzzle for Dehcho First Nations in Canada and we may affirm what other Indigenous nations experience and already know. Most studies in the review focused on Indigenous Peoples residing in Canada and Australia. According to the International Profiles of Health Care Systems , which assessed the healthcare service models across the Commonwealth, both the Australian and Canadian governments use a universal public insurance programme that is regionally administered [44]. Both Canada and Australia have acknowledged that health disparities for Indigenous Peoples are below the national standard [44]. In Australia, the coordination of care exists between the Indigenous community members and community-driven and -operated health services known as Aboriginal Community Controlled Health Organisations (ACCHOs). These organisations were created due to the inability of mainstream healthcare to engage Indigenous Peoples. In Canada, within the province of British Columbia, the First Nation Health Authority (FNHA) governs a wide range of programmes and services culturally tailored to the health and wellness for First Nations across the province [45]. Likewise, the province of Ontario has developed multidisciplinary primary healthcare models such as the Aboriginal Health Access Centres that provide Indigenous communities the right to lead health and wellness initiatives in a culturally safe way [44].

Many of the articles evaluated the effectiveness of Indigenous health programmes and services based on health outcomes experienced by patients receiving care and coordination across jurisdictions of health and wellness supports [30,32,35,37,38,40]. To analyse patient outcomes, several documents used statistical modelling to determine the effectiveness [30,33,37,38,40], others engaged participants through focus groups and interviews [7,32–34], and no authors mentioned local Indigenous cultural protocols used within the evaluation process.

An important finding from this review is the insufficient and misalignment of multi-level government funding for Indigenous healthcare services and programmes [4,9]. Many studies indicated funding as an indispensable resource [7,22,31,32,34,35,38,39] and deemed funding a requirement for infrastructure to reduce and minimise long-distance travel for community members [37], improve culturally safety by training and employing Indigenous staff and health professionals [23,30,31,39,41] and training non-Indigenous staff [23,34,35]. It is clear that increased and sustainable self-governance, resources and healthcare environments are essential to improving health and wellbeing of Indigenous communities internationally.

Our findings support the call for upstream structural and systemic changes needed to prioritise Indigenous culture, rights and wellbeing [30,32,37]. Governments must be more responsive to the healthcare infrastructure needs expressed by Indigenous communities, particularly in rural and remote regions [32]. Recurring wise and promising practices from our review affirm the importance of community partnerships with key Indigenous rightsholders built on open communication, mutual respect and valuing of Indigenous healing and cultural practices. Community conversations must be prioritised and valued, with resolutions aiming to highlight local Indigenous ways of knowing and doing. Training education and building Indigenous health provider capacity will help to decentralise health and wellness systems and improve medical adherence within communities. The most successful health interventions stem from community readiness and the understanding that one size does not fit all.

Strengths and limitations

This rapid review was conducted through the collaborative efforts of all co-authors, driven by Indigenous rightsholders with a responsibility and stake in how Indigenous health is governed, delivered and coordinated. The review had a strong desire to share knowledge with other Indigenous community rightsholders. Rapid reviews, unlike systematic reviews, are conducted in a shorter time frame with a simplified review process [26]. While we sought to include research from New Zealand, the final 14 articles did not include information regarding the Indigenous groups of New Zealand. A more in-depth and comprehensive systematic review is warranted.

Conclusion

Our rapid review provides an analysis of effective healthcare practices, systems and coordination of services intended for Indigenous communities with the aim to maintain or improve rural Indigenous Peoples’ health and wellness. Indigenous Peoples’ right to self-govern healthcare systems and practices serving Indigenous Peoples is a key finding that echoes what has been said in other studies, public inquiries and by Indigenous leaders globally [12,14,46]. Our review highlighted some examples of how community members, health professionals and governments have found ways to share knowledge, develop partnerships and advocate for mutual trust and respect. Integrating Indigenous ways of knowing into non-Indigenous healthcare models will facilitate positive impacts on the well-being of Indigenous Peoples.

Footnote if allowed: Within this paper, the official definition of Indigenous was used to rightfully regard organisation – through individual-level self-identification practices, distinct physical, social, economic and political systems, and recognise their ancestral land and environments. We humbly acknowledge the rich and diverse nations and cultures across many Indigenous Peoples.

Acknowledgments

We would like to thank Dr Debbie Chaves, a science librarian at Wilfrid Laurier University, for helping provide support and guidance in the search strategy development. We also thank Nicole Burns and Emily Wassmansdorf for assisting with the grey literature search.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary Material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/22423982.2023.2215553