“We are everything to everyone”: a systematic review of factors influencing the accountability relationships of Aboriginal and Torres Strait Islander health workers (AHWs) in the Australian health system

Abstract

BackgroundHealth policy in Australia positions Aboriginal and Torres Strait Islander Health Workers (AHWs) as central to improving Aboriginal and Torres Strait Islander peoples’ health, with high expectations of their contribution to closing the gap between Indigenous and non-Indigenous health outcomes. Understanding how AHWs’ governance and accountability relationships influence their ability to address such health inequities has policy, programme and ethical significance. We sought to map the evidence of AHWs’ experiences of accountability in the Australian health system.MethodsWe followed an adapted qualitative systematic review process to map evidence on accountability relations in the published literature. We sought empirical studies or first-person accounts describing AHWs’ experiences of working in government or Aboriginal community-controlled services anywhere in Australia. Findings were organised according to van Belle and Mayhew’s four dimensions of accountability – social, political, provider and organisational.ResultsOf 27 included studies, none had a primary focus on AHW governance or AHWs’ accountability relationships. Nonetheless, selected articles provided some insight into AHWs’ experiences of accountability across van Belle and Mayhew’s four dimensions. In the social dimension, AHWs’ sense of connection and belonging to community was reflected in the importance placed on AHWs’ cultural brokerage and advocacy functions. But social and cultural obligations overlapped and sometimes clashed with organisational and provider-related accountabilities. AHWs described having to straddle cultural obligations (e.g. related to gender, age and kinship) alongside the expectations of non-Indigenous colleagues and supervisors which were underpinned by ‘Western’ models of clinical governance and management. Lack of role-clarity stemming from weakly constituted (state-based) career structures was linked to a system-wide misunderstanding of AHWs’ roles and responsibilities – particularly the cultural components – acting as a barrier to AHWs working to their full capacity for the benefit of patients, broader society and their own professional satisfaction.ConclusionsIn literature spanning different geographies, service domains and several decades, this review found evidence of complexity in AHWs’ accountability relationships that both affects individual and team performance. However, theoretically informed and systematic investigation of accountability relationships and related issues, including the power dynamics that underpin AHW governance and performance in often diverse settings, remains limited and more work in this area is required.

Working Well: Strategies to Strengthen the Workforce of the Indigenous Primary Healthcare Sector

“…Professional development opportunities for IHWs may have improved over the last few decades [35], however, this study identified ongoing issues such as IHWs not having opportunities to implement new learning in the workplace after the completion of training [8,35] and feeling underutilised in the workplace [8]. Strategies to address these issues include enhancing IHW roles, providing greater opportunities to apply skills in practice, improving IHW training, and ensuring that IHWs have opportunities to work to their full scope of practice [11,39].…”

“…In rural and remote healthcare in general, opportunity for career advancement is an important catalyst for retention [10]. The frustration experienced by IHWs in regard to lack of opportunities for career progression in both government and ACCHS sectors is well established [35], with such limited career pathways causing some IHWs to look for work outside the health sector [8]. This issue can be addressed through the development and implementation of succession plans and strong, clear career pathways [8,11,39].…”

The community health worker as service extender, cultural broker and social change agent: a critical interpretive synthesis of roles, intent and accountability

“…43 In Australia, the Aboriginal and Torres Strait Islander Health Workers provide cultural mentorship to non-Aboriginal and Torres Strait Islander colleagues and advocate for culturally appropriate care. 28 Programmatic, social, management and political dynamics can shape the feasibility of cultural brokerage. For example, Brazilian CHWs felt their ability to elicit information about community needs was dependent on the long-term nature of their relationship with the neighbourhoods in which they work, 40 suggesting frequent staff turnover might constrain cultural brokerage.…”

“…[22][23][24][25] Despite the fact that governmental CHW programmes generally entail the expectation that CHWs foster health system accountability to the community (and vice-versa), an accountability lens has not been widely applied to studies on CHWs, outside of several exceptions. [26][27][28][29] MeTHods This paper is a modified CIS. CIS is iterative and inductive, and it entails synthesising data across a diverse body of empirical literature and the development of new analytic propositions, synthesising arguments and questions.…”

Non‐clinical eye care support for Aboriginal and Torres Strait Islander Australians: a systematic review

“…This may be because of the restricted availability of Indigenous interpreters and the shift in the role of AHWs from providing cultural support to activities requiring greater clinical skills and responsibilities . The limited availability of personnel to fulfil the linguistic and cultural needs of patients has reportedly resulted in burnout among the declining number of AHWs who act as both family or community members and clinicians . Cultural liaison officers and advisors can also facilitate cultural safety, but the lack of specific funding and supportive programs are barriers to establishing such positions.…”