title: Enablers and barriers to the implementation of primary health care interventions for Indigenous people with chronic diseases: a systematic review.
abstract: BACKGROUND
  Access to appropriate, affordable, acceptable and comprehensive primary health care (PHC) is critical for improving the health of Indigenous populations. Whilst appropriate infrastructure, sufficient funding and knowledgeable health care professionals are crucial, these elements alone will not lead to the provision of appropriate care for all Indigenous people. This systematic literature review synthesised international evidence on the factors that enable or inhibit the implementation of interventions aimed at improving chronic disease care for Indigenous people.
  
  
  METHODS
  A systematic review using Medical Literature Analysis and Retrieval System Online (MEDLINE) (PubMed platform), Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Excerpta Medica Database (EMBASE), ATSIHealth, Australian Indigenous HealthInfoNet via Informit Online and Primary Health Care Research and Information Service (PHCRIS) databases was undertaken. Studies were included if they described an intervention for one or more of six chronic conditions that was delivered in a primary health care setting in Australia, New Zealand, Canada or the United States. Attitudes, beliefs, expectations, understandings and knowledge of patients, their families, Indigenous communities, providers and policy makers were of interest. Published and unpublished qualitative and quantitative studies from 1998 to 2013 were considered. Qualitative findings were pooled using a meta-aggregative approach, and quantitative data were presented as a narrative summary.
  
  
  RESULTS
  Twenty three studies were included. Meta-aggregation of qualitative data revealed five synthesised findings, related to issues within the design and planning phase of interventions, the chronic disease workforce, partnerships between service providers and patients, clinical care pathways and patient access to services. The available quantitative data supported the qualitative findings. Three key features of enablers and barriers emerged from the findings: (1) they are not fixed concepts but can be positively or negatively influenced, (2) the degree to which the work of an intervention can influence an enabler or barrier varies depending on their source and (3) they are inter-related whereby a change in one may effect a change in another.
  
  
  CONCLUSIONS
  Future interventions should consider the findings of this review as it provides an evidence-base that contributes to the successful design, implementation and sustainability of chronic disease interventions in primary health care settings intended for Indigenous people.
authors.affiliation: Wardliparingga Aboriginal Research Unit, South Australian Health and Medical Research Institute, Adelaide, Australia. odette.gibson@sahmri.com.|University of South Australia, Adelaide, Australia. odette.gibson@sahmri.com.
authors.forename: Odette
authors.initials: O
authors.lastname: Gibson
authors.affiliation: Joanna Briggs Institute, University of Adelaide, Adelaide, Australia. karolina.lisy@adelaide.edu.au.
authors.forename: Karolina
authors.initials: K
authors.lastname: Lisy
authors.affiliation: Wardliparingga Aboriginal Research Unit, South Australian Health and Medical Research Institute, Adelaide, Australia. carol.davy@sahmri.com.|University of Adelaide, Adelaide, Australia. carol.davy@sahmri.com.
authors.forename: Carol
authors.initials: C
authors.lastname: Davy
authors.affiliation: Joanna Briggs Institute, University of Adelaide, Adelaide, Australia. ed.aromataris@adelaide.edu.au.
authors.forename: Edoardo
authors.initials: E
authors.lastname: Aromataris
authors.affiliation: Wardliparingga Aboriginal Research Unit, South Australian Health and Medical Research Institute, Adelaide, Australia. elaine.kite@sahmri.com.|University of Adelaide, Adelaide, Australia. elaine.kite@sahmri.com.
authors.forename: Elaine
authors.initials: E
authors.lastname: Kite
authors.affiliation: Joanna Briggs Institute, University of Adelaide, Adelaide, Australia. craig.lockwood@adelaide.edu.au.
authors.forename: Craig
authors.initials: C
authors.lastname: Lockwood
authors.affiliation: Joanna Briggs Institute, University of Adelaide, Adelaide, Australia. dagmara.riitano@adelaide.edu.au.
authors.forename: Dagmara
authors.initials: D
authors.lastname: Riitano
authors.affiliation: Wardliparingga Aboriginal Research Unit, South Australian Health and Medical Research Institute, Adelaide, Australia. katharine.mcbride@sahmri.com.
authors.forename: Katharine
authors.initials: K
authors.lastname: McBride
authors.affiliation: Wardliparingga Aboriginal Research Unit, South Australian Health and Medical Research Institute, Adelaide, Australia. alex.brown@sahmri.com.|University of South Australia, Adelaide, Australia. alex.brown@sahmri.com.
authors.forename: Alex
authors.initials: A
authors.lastname: Brown
mesh_terms: D006801:Humans; D001315:Australia; D002908:Chronic Disease / Q000628:therapy; D019091:Critical Pathways; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility; D006280:Health Workforce; D009520:New Zealand; D011320:Primary Health Care / Q000458:organization & administration; D011369:Professional-Patient Relations; D002170:Canada; D014481:United States; D000081034:Indigenous Peoples / Q000523:psychology; D000095283:Australian Aboriginal and Torres Strait Islander Peoples