Using quality improvement strategies to strengthen regional systems for Aboriginal and Torres Strait Islander eye health in the Northern Territory

Identifying best‐practice features of diabetic retinopathy treatment models for Aboriginal and Torres Strait Islander Australians

OBJECTIVE

Indigenous Australians are nearly three times more likely to have diabetes than non-Indigenous Australians. The prevalence of diabetes-related vision impairment for Indigenous Australians is 5.5% compared to 1.5% for non-Indigenous Australians, and treatment rates are lower for Indigenous Australians. Despite this situation, there is limited evidence on effective service delivery models for diabetic retinopathy care and treatment. This study seeks to identify best-practice features of diabetic retinopathy care that could be used to inform current and future service delivery models for Indigenous Australians with diabetic retinopathy.

SETTING

All states, territories and geographic remoteness categories in Australia.

PARTICIPANTS

Eight ophthalmologists engaged in providing eye healthcare to Indigenous Australians.

DESIGN

Semi-structured interviews were conducted. The Framework Approach was used to conduct a thematic analysis of the interviews to facilitate identification of key themes and issues that emerged from these discussions.

RESULTS

Seven best-practice features for service delivery of diabetic retinopathy treatment for Indigenous Australians were identified. These were: cultural safety, affordability and accessibility, partnerships with key stakeholders, timeliness, integration with primary care, clarity of guidelines, and clinician attitude and motivation.

CONCLUSION

The findings from this study identified seven best-practice features for diabetic retinopathy treatment. These have the potential to inform and influence how care is delivered to Indigenous Australians. Although further research is warranted to capture other service provider inputs and Indigenous end-user perspectives, these features in the meantime can begin to inform the decisions of the Indigenous eyecare sector on policy reforms and best-practice diabetic retinopathy treatment approaches.

Re-examining the gap: A critical realist analysis of eye health inequity among Aboriginal and Torres Strait Islander Australians

The prevalence of diabetes among Aboriginal and Torres Strait Islander (hereafter 'Aboriginal') Australians is three times greater than non-Aboriginal Australians, contributing to a greater risk of blindness from treatable and preventable ocular conditions, most prominently cataract and diabetic retinopathy. In rural and remote Aboriginal communities, blindness prevalence is higher, and ocular treatment coverage and uptake are lower. In collaboration with Aboriginal Community Based Researchers (CBRs), this study explored complex contingent factors that shape access to eye health services among rural and remote Aboriginal Australians living with diabetes. Interviews (n = 126) and focus groups (n = 12) were conducted with patients, primary care clinicians, and CBRs, in four rural communities in the Northern Territory and New South Wales. Factors internal and external to health systems were examined, drawing on Bourdieu's concepts of habitus, and doxa to understand agency and decision-making among patients and clinicians. The study used the ontology of critical realism, categorising contingent factors as underlying structures (generative mechanisms), and applying a decolonising approach that centred causal relationships and tensions between dominant (Western biomedical neoliberalism) and non-dominant (Aboriginal) value systems. Three forms of marginalisation; linguistic, economic, and cultural, were identified as the generative mechanisms that inhibit equitable eye health outcomes. Marginality is linked to structural factors that position Aboriginal culture as a barrier, and is reinforced through biomedical health systems, and the agents who operate in and influence them. In order to address eye health inequity, a shift in how Aboriginal cultural sovereignty is understood within health systems is needed, to position it as a strength that can facilitate eye care accessibility, and to support enhanced cultural responsivity among clinicians and service providers.

Eye care delivery models to improve access to eye care for Indigenous peoples in high-income countries: a scoping review

PURPOSE

Globally, there are ~370 million Indigenous peoples. Indigenous peoples typically experience worse health compared with non-Indigenous people, including higher rates of avoidable vision impairment. Much of this gap in eye health can be attributed to barriers that impede access to eye care services. We conducted a scoping review to identify and summarise service delivery models designed to improve access to eye care for Indigenous peoples in high-income countries.

METHODS

Searches were conducted on MEDLINE, Embase and Global Health in January 2019 and updated in July 2020. All study designs were eligible if they described a model of eye care service delivery aimed at populations with over 50% Indigenous peoples. Two reviewers independently screened titles, abstracts and full-text articles and completed data charting. We extracted data on publication details, study context, service delivery interventions, outcomes and evaluations, engagement with Indigenous peoples and access dimensions targeted. We summarised findings descriptively following thematic analysis.

RESULTS

We screened 2604 abstracts and 67 studies fulfilled our eligibility criteria. Studies were focused on Indigenous peoples in Australia (n=45), USA (n=11), Canada (n=7), New Zealand (n=2), Taiwan (n=1) and Greenland (n=1). The main disease focus was diabetic retinopathy (n=30, 45%), followed by 'all eye care' (n=16, 24%). Most studies focused on targeted interventions to increase availability of services. Fewer than one-third of studies reported involving Indigenous communities when designing the service. 41 studies reflected on whether the model improved access, but none undertook rigorous evaluation or quantitative assessment.

CONCLUSIONS

The geographical and clinical scope of service delivery models to improve access to eye care for Indigenous peoples in high-income countries is narrow, with most studies focused on Australia and services for diabetic retinopathy. More and better engagement with Indigenous communities is required to design and implement accessible eye care services.

Trust, culture and communication: determinants of eye health and care among Indigenous people with diabetes in Australia

Introduction

Our study aimed to identify factors that influence access to eye care and eye health outcomes for remote Indigenous Australians living with diabetes.

Methods

In collaboration with Indigenous Community-Based Researchers (CBR) and Aboriginal Community Controlled Health Services (ACCHS), a qualitative, participatory action research approach was taken, drawing on Indigenist and decolonising methodologies. The study was undertaken in four remote communities, in the Katherine region, Northern Territory and north-western New South Wales, Australia. Interviews and focus groups were undertaken with Indigenous adults aged ≥40 years living with diabetes (n=110), and primary care clinicians working in ACCHSs (n=37). A series of interviews with CBRs (n=13) were undertaken before and after data collection to add cultural insights and validation to participant accounts. Data were analysed inductively using grounded theory, in-depth discussion and NVivo V.11.

Results

More than one-third of all patients had little to no knowledge of how diabetes affects eye health. Limited access to health information and interpreters, language barriers, distrust of health providers and services, and limited cultural responsivity among non-Indigenous clinicians, were identified as determining factors in eye health and care.

Discussion

We outline a need to address gaps in trust and communication, through increased access to and resourcing of Indigenous language interpreters and cultural brokers, understandable and culturally sensitive diabetic eye health information and cultural responsivity training for non-Indigenous clinicians. Centring Indigenous cultures in healthcare practice will enable a shared understanding between clinicians and Indigenous patients, and subsequently more equitable eye health outcomes.