This study identified a variety of factors perceived to influence Aboriginal patients’ HCU from the time of their cardiac event to 6–12 months post-event. The main findings and contributions of this work can be summarised in five key points.
The first contribution is the development of a culturally sensitive HCU matrix that is adapted to the needs of Aboriginal people living in central Australia. The matrix addresses important factors influencing HCU not previously identified for socially disadvantaged populations, such as Aboriginal people. For instance, Schepper’s (2006) adaptation of Andersen’s model  does not address racism as a barrier to HCU among ethnic minorities, even though it is noted that such populations are often victims of discrimination and segregation. Institutional racism in the Australian health care system has previously been documented [31, 32] and our findings demonstrate that patients or stories of significant others who experienced racism are less likely to use health services in the future. Similarly, issues such as previous experiences, mistrust, fear and competing priorities are not included in the above-mentioned HCU frameworks. In the present analysis, these factors represented important barriers among Aboriginal people and need to be considered in efforts aimed at improving HCU. Participants described communication issues at various levels as the most important factor influencing HCU. Andersen (1995) does not address communication problems as a potential barrier to HCU and although Scheppers (2006) lists communication issues at the patient and provider level, the role family members play in facilitating clinician-patient communication and the health system’s need to provide appropriate services to ensure and support intercultural communication is not dealt with. Andersen’s model uses a Westernised approach to understanding HCU and does not consider barriers such as lack of cultural awareness or need for family involvement. To our knowledge there is no existing research that specifically addresses the barriers to HCU among Aboriginal cardiac patients in Australia.
Second, even though this study aimed to assess barriers and facilitators to HCU, the emphasis of participants’ stories primarily reflected barriers to HCU even where facilitators such as ALOs were noted. In this instance, where ALO’s were present, participants emphasised the insufficient number of ALOs. Most barriers encountered at the health system level thus point to limited or absent enabling factors (or inhibitors), such as lack of cultural awareness amongst health care providers and minimal ALOs . Focus should be placed on providing system level supports to enable improved HCU and thus effect change at the Individual level. This interpretation is consistent with health promotion strategies that emphasize changing environments to enable improved interactions between individuals and the systems with which they interact .
Third, this study indicates that Aboriginal cardiac patients have a poor knowledge of their illness which affects the management of their chronic illness, perceived need for future HCU, and overall health outcomes. Low levels of health literacy have been found to negatively affect health outcomes and is considered to be a more accurate predictor of health status than determinants of health such as, socioeconomic status, education, employment, race or gender . Low literacy skills also predict the degree with which individuals engage in the health system and their understanding of their chronic illness . There is an urgent need for health literacy to be integrated at the system level to improve patients’ quality of care and health outcomes. Upstream approaches of integration include developing policies and practices to support health literacy initiatives that are culturally appropriate and sensitive, ensuring organisational development and ongoing capacity building opportunities for health staff.
Fourth, the findings reveal a severe breakdown in cardiac patients’ continuity of care following discharge. Various communication and system level barriers affect patients’ ability to receive test results, follow-up care and cardiac rehabilitation services. A disjunction between Primary Care and Hospital System services means that most cardiac patients fail to receive essential post-event health services. The Australian National Health Performance Committee identified continuous care as one of the nine domains required for effective quality health performance . Management of chronic illness such as CVD requires continuous clinical care, which incorporates a patient centred approach that is adapted to patients’ needs and supports self-management. Future research and action in this area is warranted.
Fifth, our findings point to the importance of family involvement as patients’ alternate support systems, assisting where the health care system unequivocally fails. The health care system’s expectation for family members to accurately interpret complex medical terminology without training is unrealistic and leads to misinterpretation and communication breakdown, in some cases extreme and ultimately life-threatening [37–39]. Family involvement should be offered to patients systematically during consultations, hospital admissions and transfers, in informed consent procedures and following discharge where important lifestyle modifications, regular follow-up care and adherence to medication are essential to support self-management and positive patient outcomes.
The factors influencing HCU identified in this study were confirmed in a recent pilot study focusing on improving Aboriginal cardiac patients’ journey for those living in remote areas of the Northern Territory . The potential for positive improvements in HCU were demonstrated through small and inexpensive systemic changes to the health system, e.g. employment of a full-time remote liaison nurse and the development of culturally appropriate clinical pre- and post- surgery procedures. The factors influencing health care utilisation and impacting on quality of care for Aboriginal patients have been addressed in a recent article, which proposes a collaborative model of hospital based care to improve health service delivery for Aboriginal patients .
Study limitations include the time constraint of a four-month data gathering period. A longer period may have provided for more information from participants and recruitment of greater numbers of Aboriginal cardiac patients. This study did not recruit family members or kin of Aboriginal cardiac patients who died prior to accessing health services, out of respect to the deceased and their families. It is possible, however, that Aboriginal cardiac patients who died prior to accessing health services may have encountered the greatest barriers to HCU. Study results might therefore under represent the extent of the barriers faced by Aboriginal cardiac patients. The use of a fundamental qualitative descriptive design to guide the study relied on individual’s own perceptions to explain a situation, while directly influencing their own use of health services. As such, these perceptions may not fully explain the factors affecting HCU. The development of a culturally sensitive matrix for HCU is limited by being derived from a single study. The matrix provided a sound method of categorising participants’ stories; however it is not an exhaustive list of all possible factors influencing HCU among Aboriginal cardiac patients in central Australia. Future research in this area is warranted to further build on the findings, to ensure a comprehensive and complete culturally sensitive framework that maps the relationships between the factors influencing HCU at various levels and its impact on health outcomes. Transferability of results requires caution as findings may not be representative of Aboriginal people and cardiac patients, and health care providers in other settings in rural and remote Australia.