Enablers and barriers in providing telediabetes services for Indigenous communities: A systematic review

Abstract

A systematic review of studies which reported on telediabetes services within Indigenous communities was undertaken in June 2016. The aim of this study was to identify enablers and barriers associated with the delivery of telehealth services for diabetes care amongst Indigenous people. A total of 14 articles met the study inclusion criteria, reporting work in Canada, Australia, India, and the US. Key enablers included the use of cultural and spiritual elements, acknowledgement of local beliefs and traditions, and appropriate community engagement. The involvement of Indigenous health workers was also very important because of their role in communication in local language, helping clinicians understand the community, and the transportation of patients. The main barriers associated with telediabetes services were the potentially high fail-to-attend rates, lack of technical skills associated with the operation of telehealth equipment, and the lack of availability of local staff. Knowledge of the enablers and barriers associated with the delivery of healthcare services to Indigenous communities is important when planning a telediabetes service.

Keywords

Diabetes telemedicine telehealth Indigenous Aboriginal

Introduction

There are more than 370 million Indigenous people living throughout 70 countries worldwide.¹ Access to high-quality healthcare services for Indigenous people is hindered by distance, limited access to specialists,^2,3 and cultural and economic factors.⁴ Since the majority of Indigenous people live in rural and remote locations, ensuring fair and equitable access to health services can be challenging.⁵ The lack of specialist health services in Indigenous communities is partially compensated by primary care provided by Indigenous medical centres, which deliver both acute care services and chronic disease programs.⁶ Consequently, the opportunity to develop telehealth services in partnership with primary care services seems a logical method of supporting people living with chronic diseases such as diabetes.⁷

The increasing prevalence of diabetes amongst Indigenous populations is well described.^8–10 The use of telehealth to deliver specialist diabetes care (telediabetes) has been reported to be clinically and economically effective amongst non-Indigenous patients.¹¹ Successful telehealth services rely on a variety of factors, which support feasibility, acceptance amongst patients, and sustainability. Appropriate funding allocations, dedicated support staff, user training and education, access to telehealth equipment, availability of specialist services, and effective change management are important requirements.¹² However, it cannot be assumed that the same findings apply to telehealth services for Indigenous populations.¹³

The aim of this systematic review was to summarize published research on telediabetes services for Indigenous patients, with a particular focus on enablers and barriers associated with the service.

Methods and materials

Search strategy

A combination of search terms was used to search the PubMed, Scopus, Embase, and Informit databases (Table 1). These combinations included keywords as well as medical subject headings (MeSH) terms, and Emtree terms unique to the Embase database. Hand searching of reference lists of included articles was also conducted. The searches were completed in July 2016.

Table 1.

Query syntax.

Database	Syntax
PubMed, and Informit	(Telemedicine [MeSH] OR telemed[All fields] OR tele[All fields] OR teleconsultation [All fields] OR teleconsult[All fields] OR (Remote consultation)[MeSH]) AND (Diabetes[All fields] OR Diab[All fields] OR Diabetes Mellitus[MeSH]) AND (Indigenous [All fields] OR (Health service, Indigenous) [MeSH] OR Indigen[All fields] OR Aboriginal [All fields] OR Aborigin [All fields] OR Tribal [All fields] OR Native [All fields] OR (First nations) [All fields] OR native* [All fields] OR Indian OR Inuits [MeSH] OR Maori [All fields] OR Eskimo [All fields] OR Islanders[All fields])
Embase	(Telemedicine [Emtree] OR Teleconsultation [Emtree]) AND (Diabetes Mellitus [Emtree]) AND (Indigenous Healthcare [Emtree] OR Indigenous Australian [Emtree] OR Indigenous people [Emtree] OR Alaska Native [Emtree] OR American Indian [Emtree] OR Native Hawaiian [Emtree] OR First Nation [Emtree] OR Eskimo [Emtree] OR Inuit [Emtree] OR Maori [Emtree])
Scopus	(teleconsult* OR Telemed) AND Diab AND (Indigenous OR Indigen* OR Aboriginal OR Aborigin* OR Tribe OR Native OR (First nations) OR native* OR Indian OR Inuit OR Maori OR Eskimo OR Islanders)

Inclusion and exclusion criteria

We included articles which described specific telehealth services for Indigenous patients with diabetes. Services included screening, medical consultation, and diabetes education. Abstracts, reports, and short communications were included in the review. Only articles published in English were included in the review.

Selection process

The title, keywords, and the abstract were screened to determine eligibility for inclusion. Full text reviews were carried out if abstract summaries were inconclusive. Screening was undertaken by two authors.

Data extraction and quality assessment

The full text of articles meeting the inclusion criteria were read and data extraction was undertaken. The data extraction fields are summarized in Table 2. Articles were excluded if barriers and enablers were not reported. Enablers and barriers did not need to be the primary outcome measure in the selected studies; hence, we included articles where barriers and enablers were described elsewhere in the paper.

Table 2.

Data extraction.

Data extraction category	Fields
Article information	Author, country, year of publication, type of article (journal article, conference abstract, letter to the editor, report), and study design
Service	Telehealth modality (video conferencing, store and forward, remote monitoring, hybrid), diabetes subspecialty (e.g. diabetic retinopathy screening, diabetes education), and service description
Context	Barriers to delivering telediabetes service, identified solutions to barriers, enablers for successful delivery of telediabetes services, and key findings

The quality of included articles was assessed using a modified Cultural Identity Interventions Systematic Review Proforma tool.¹⁴ This tool was developed to help bridge the gap between traditional review tools and Indigenous health by incorporating measures to comply with Indigenous specific health values and guidelines.¹⁴ The tool comprises three domains with a rating scale (high–moderate–low) for each. The three domains were study design assessment; adaptability of the service; and Indigenous responsibilities in the research process. We chose the first two domains since they were more generic and aligned well with our search strategy. Two reviewers independently performed the data extraction and quality assessment. In cases where consensus was not reached, a third reviewer was used to judge the quality assessment and adaptability scoring.

Review procedure

The systematic review protocol was registered with PROSPERO (CRD42016033151). Findings of the review were reported using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines with a narrative synthesis.¹⁵

Results

A total of 14 articles were included in the review. The process of screening and selection of articles is shown in Figure 1.

Figure 1.

Selection of studies after review and application of inclusion and exclusion criteria.

There were six articles from Canada, six from Australia, and one article from India and the US. Articles were published between 1996 and 2015.

Characteristics of the telediabetes services

Eleven (78%) articles described diabetic retinopathy (DR) screening. Four articles provided other clinical investigation or consultation services in addition to DR screening.^16–19 Store-and-forward telehealth methods were mainly used for DR screening. Images were captured by a visual technician travelling to distant communities,^17,18,20 or a local Indigenous health worker trained in fundal photography.^6,21,22 Grading of ophthalmic images was carried out remotely (teleophthalmology) by an ophthalmologist at a different centre.

In six (43%) of the interventions, clinical investigations were conducted at the referring site and findings were reported to the provider of specialist services. These services included medical history-taking and general examination, vascular risk factor identification, pathology (urine for albumin, HbA1c, plasma glucose, serum cholesterol, serum creatinine), blood pressure measurements, and diabetes education. Diabetes education was delivered using some method of telehealth in five interventions. These included services of diabetes specialists,²³ diabetes nurse educators,^17,18 diabetes educators,²⁴ and computerized information kiosks,²⁵ to provide diabetes-related health information. Videoconferencing was used in one intervention – to deliver medical consultations with diabetes specialists.²³

Enablers and barriers

Cultural appropriateness (use of cultural and spiritual elements, acknowledgement of local beliefs and traditions, and appropriate community engagement) was recognized as an enabler of telediabetes services. Arora et al. reported increased patient satisfaction and improvement in-patient attendance – from 20% to 85% after inclusion of cultural and spiritual ceremonies, as part of the service.²⁶ Participation of Indigenous health workers (IHWs) was important in making telediabetes services culturally acceptable to the local community.

IHW participation in the delivery of telediabetes services was commonly reported as an enabler. The specific roles of IHWs included: communication of local language, helping clinicians understand the community, and transportation of patients. Similar findings have been reported in tele-oncology,²⁷ ear health screening,^28,29 and primary care,³⁰ where IHWs were considered integral to the success of the service.

Barriers associated with the delivery of telediabetes services included the lack of technical skills associated with the operation and maintenance of retinal cameras and the collection of clinical information. This highlights the importance of effective training programs for local staff responsible for screening.^31,32 Karagiannis and Newland found that 76% of images captured by IHWs were of good quality following a two-week intensive training program.²² Credentialing has also been reported to improve the quality of images collected by health workers.³³ Improved camera technology and automation³⁴ may simplify the technical skills required and reduce training requirements.

The difficulty in recruitment of patients for screening and interval-appropriate repeat screening was another barrier identified. Conducting imaging and clinical consultation services on the same day can help improve screening/rescreening rates.³³ Fail-to-attend rates of clinic appointments were a commonly reported barrier amongst many services.^26,33 For the management of chronic diseases, continuity of care through screening and monitoring is important for the early detection of complications. Chen and Harris described lack of awareness of the importance of screening and limited availability of screening resources to be major barriers amongst Indigenous people with chronic renal disease.³⁵ Enablers and barriers identified in the selected articles are listed in Table 3.

Table 3.

Enablers and barriers to telediabetes services.

Description		Context
Author reference/ country	Service/modality	Enablers	Barriers	How barriers were overcome	Key findings
Arora et al.,²⁶ Canada	DR screening; S&F	Spiritual ceremonies before and after each clinic; local workers who spoke local languages provided education; acknowledgement of local beliefs and traditions	Poor attendance; not feeling at ease with the hospital-based screening	Clinics were made appealing to patients by incorporating Indigenous cultural elements	Attendance rates increased from 20% to 85% within a two-year period
Barry et al.,²¹ Australia	DR screening; S&F	Trained local health staff provided education and transport	Difficulty of maintaining camera equipment during transport; poor quality of images	Custom built foam-moulded cases for transport of equipment; increasing staff training	High number of patients identified with various stages of eye disease. Program 1: 41.5% of patients with DR (n = 2543); Program 2: 22.6% patients with DR (n = 164); Program 5: 15.6% DR+ (n = 77)
Dawson et al.,¹⁸ Canada	DR and Clinical Ix.; S&F	–	Delay in follow-ups	–	DR screening over the first six years of the service – 1221 assessments on 750 people with type 2 DM
Dawson et al.,²⁴ Canada	Clinical Ix. and DE; Audio visual	Audio-visual material included messages from local Indigenous people	–	–	Included screening and education for diabetes patients. Three education programs: Circle of diabetes self-management for adults; Our spirit lives on program; Health warriors program
Dean and Mclean,²³ Australia	Clinical consultation and DE; VC	Telehealth trained local health staff member	Scheduling issues; lack of staff training	Direct links with primary care team	Increasing number of teleconsultations during the first four years of service (Yr. 1: 15; Yr. 2: 45; Yr. 3: 263; Yr. 4: 365)
Diamond et al.,²⁰ Australia	DR screening; S&F	–	Inferior quality of retinal images associated with photography of undilated pupils	Pupil dilation prior to DR screening	Image quality improved with pupil dilation; but the overall proportion of inadequate images remained similar different between the techniques
Jin et al.,¹⁷ Canada	DR screening, DE and Clinical Ix.; S&F	–	Waiting period for clinical decisions	–	Mean service cost per client was less than the cost of each patient travelling to a tertiary centre
Joshi et al.,²⁵ India	DE; Health information kiosks	–	Accuracy about information provided by patients could not be validated	–	Increased awareness. 79% of the tribal people did not know that they had diabetes previously
Karagiannis and Newland,²² Australia	DR screening; S&F	–	Un-interpretable slides; Lack of training; poor working environments	–	Skill improvement. IHWsere trained for two weeks and 76% of slides were interpretable
Kim and Driver,¹⁹ Canada	DR screening, Clinical Ix. and DE; S&F	Pre-intervention community engagement	–	–	Screening was conducted on 524 diabetes patients from 43 First Nations communities. Telehealth staff rated the service positively for overall user satisfaction, system quality, information quality, etc.
Mak et al.,³³ Australia	DR screening; S&F	–	Recruitment of patients for screenings and rescreening difficult; problems with transport of camera	–	Positive relationship between credentialing health staff and the quality of images; >90% of retinal photographs were of excellent or adequate quality
Mansberger et al.,³⁶ USA	DR screening; S&F	–	Poor quality retinal images increasing referrals	Pre-intervention training of retinal photographer in the use of the camera	Better access to services. Patients receiving telemedicine services were much more likely to receive a DR screening within the first year compared with traditional surveillance group (94% vs 56%, p < 0.001)
Murray et al.,⁶ Australia	DR screening; S&F	–	Shared single camera being rotated; de-skilling of staff during intervals	Shorter rotation cycles implemented	1318 Indigenous patients screened. 21% with diabetic retinopathy; 19% with non-proliferative retinopathy; photograph quality was generally high and not related to qualifications, certification, or experience
Rudnisky et al.,¹⁶ Canada	DR screening and Clinical Ix.; S&F	–	Separate clinic dates for clinical and imaging services	–	The median time in progressing to proliferative retinopathy was 7.6 years

DR: diabetic retinopathy; DE: diabetes education; Ix.: investigations; S&F: store and forward; DM: diabetes mellitus; Yr.: year; IHWs: Indigenous health workers; VC: videoconferencing.

Quality assessment

The assessment made using the modified version of the Cultural Identity Interventions Systematic Review Proforma¹⁴ showed that study design assessment was classified as high (21%), moderate (36%), or low (43%). The ability to adapt the program/study elsewhere was scored high (25%), moderate (50%), and low (25%).

Discussion

The present review has identified a number of important enablers and barriers associated with the delivery of telediabetes for Indigenous people. Some of the key considerations included engagement with the community; involvement of the IHWs; appropriate staff training; choice of equipment; and reliable processes for appointment scheduling and clinic coordination. Unique to certain communities were the traditional activities (such as welcome ceremonies), which were planned as part of the service. A more comprehensive review of the grey literature (such as service web sites, service provider reports) and the qualitative examination of other clinical services for Indigenous populations may have revealed other enablers and barriers; however, this was not within scope of the present study.

This systematic review was focused on specific factors relevant to the delivery of telediabetes services to Indigenous people. The barriers and enablers identified in this review are similar to telehealth services for other specialties. In addition to the barriers and enablers identified in our study, other important considerations include funding for telehealth and the use of Indigenous healthcare facilities for the delivery of telehealth consultations.³⁶ Additional barriers include regulation of health workers (scope of practice) and lack of available workforce^37,38 These findings may be useful as a guide to planning and implementing new telediabetes services.

Limitations

Our review was limited to telediabetes services in the published literature. It is likely that there are other telediabetes services not reported in the scientific literature, which could have contributed to the findings.

Conclusion

Knowledge of the barriers and enablers associated with the delivery of health services within Indigenous communities is important when planning telehealth. In the right circumstances, the delivery of telediabetes services is promising, especially in circumstances where specialist services are not available or difficult to access.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was conducted with the support of the Centre of Research Excellence in Telehealth, funded by the National Health and Medical Research Council (NHMRC) (grant number APP1061183) and the Diabetes Australia Student Scholarship fund.

References

The United Nations. Permanent forum on Indigenous Issues. Who are Indigenous People?, http://www.un.org/esa/socdev/unpfii/documents/5session_factsheet1.pdf (accessed 23 July 2016).

Coelho

Shankland

. Making the right to health a reality for Brazil's indigenous peoples: innovation, decentralization and equity. MEDICC Rev 2011; 13: 50–53.

Tibby

Corpus

Walters

. Establishment of an innovative specialist cardiac indigenous outreach service in rural and remote Queensland. Heart Lung Circ 2010; 19: 361–366.

Hayman

. Strategies to improve indigenous access for urban and regional populations to health services. Heart Lung Circ 2010; 19: 367–371.

Australian Bureau of Statistics. Population distribution, Aboriginal and Torres Strait Islander Australians, 2006–2007, http://www.abs.gov.au/ausstats/abs@.nsf/mf/4705.0 (2012, accessed 24 July 2016).

Murray

Metcalf

Lewis

. Sustaining remote-area programs: retinal camera use by Aboriginal health workers and nurses in a Kimberley partnership. Med J Aust 2005; 182: 520–523.

Daniel

Sulmasy

. Policy recommendations to guide the use of telemedicine in primary care settings: an American College of Physicians position paper recommendations for the use of telemedicine in primary care settings. Ann Intern Med 2015; 163: 787–789.

Young

Reading

Elias

. Type 2 diabetes mellitus in Canada's First Nations: status of an epidemic in progress. CMAJ 2000; 163: 561–566.

Ministry of Health New Zealand. Maori Health statistics – diabetes, http://www.health.govt.nz/our-work/populations/maori-health/tatau-kahukura-maori-health-statistics/nga-mana-hauora-tutohu-health-status-indicators/diabetes (2015, accessed 26 July 2016).

10.

Office of Minority Health – US Department of Health and Human services. Diabetes and American Indians/Alaska Natives, http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlID=33 (2016, accessed 27 July 2016).

11.

Zhai

Zhu

Cai

. Clinical- and cost-effectiveness of telemedicine in type 2 diabetes mellitus: a systematic review and meta-analysis. Medicine 2014; 93: e312–e312.

12.

Jarvis-Selinger

Chan

Payne

. Clinical telehealth across the disciplines: lessons learned. Telemed J E Health 2008; 14: 720–725.

13.

Kendall

Barnett

. Principles for the development of Aboriginal health interventions: culturally appropriate methods through systemic empathy. Ethn Health 2015; 20: 437–452.

14.

MacLean

Ritte

Thorpe

. Assessing compliance with Aboriginal and Torres Strait Islander health research guidelines within systematic reviews. aust indig Heal bull 2015; 15. . http://healthbulletin.org.au/articles/assessing-compliance-with-aboriginal-and-torres-strait-islander-health-research-guidelines-within-systematic-reviews/.

15.

Swartz

. The PRISMA statement: a guideline for systematic reviews and meta-analyses. J Pediatr Health Care 2011; 25: 1–2.

16.

Rudnisky

Wong

Virani

. Risk factors for progression of diabetic retinopathy in Alberta First Nations communities. Can J Ophthalmol 2012; 47: 365–375.

17.

Jin

Martin

Maberley

. Evaluation of a mobile diabetes care telemedicine clinic serving Aboriginal communities in Northern British Columbia, Canada. Int J Circumpolar Health 2004; 63(Suppl 2): 124–128.

18.

Dawson

Maberley

DAL

Martin

. Mobile diabetes telemedicine clinic: role in first nations care and treatment. Can J Diabetes 2009; 33: 195–195.

19.

Kim

Driver

. Teleophthalmology for First Nations clients at risk of diabetic retinopathy: a mixed methods evaluation. JMIR Med Inform 2015; 3(1): e10–e10.

20.

Diamond

McKinnon

Barry

. Non-mydriatic fundus photography: a viable alternative to fundoscopy for identification of diabetic retinopathy in an Aboriginal population in rural Western Australia? Aust N Z J Ophthalmol 1998; 26: 109–115.

21.

Barry

Constable

McAllister

. Diabetic screening in Western Australia: a photographer's perspective. J Vis Commun Med 2006; 29: 66–75.

22.

Karagiannis

Newland

. Mobile retinal photography. A means of screening for diabetic retinopathy in aboriginal communities. Aust N Z J Ophthalmol 1996; 24: 333–337.

23.

Dean D and Mclean A. A project to develop a telehealth model of care for people with diabetes in Far North Queensland, http://nrha.org.au/12nrhc/wp-content/uploads/2013/07/Dean-Deborah_ppr.pdf (2013, accessed 27 July 2016).

24.

Dawson

Nabih

deGoeij

. Diabetes and my nation: a model program for diabetes teaching and treatment in aboriginal communities. Can J Diabetes 2009; 33: 279–280.

25.

Joshi

Perin

DMP

Arora

. Using Portable Health Information Kiosk to assess chronic disease burden in remote settings. Rural Remote Health 2013; 13. . http://ruralhealth.org.au/12nrhc/wp-content/uploads/2013/07/Dean-Deborah_ppr.pdf.

26.

Arora

Kurji

Tennant

. Dismantling sociocultural barriers to eye care with tele-ophthalmology: lessons from an Alberta Cree community. Clin Invest Med 2013; 36: E57–E63.

27.

Mooi

Whop

Valery

. Teleoncology for indigenous patients: the responses of patients and health workers. Aust J Rural Health 2012; 20: 265–269.

28.

Nguyen

Smith

Armfield

. Cost-effectiveness analysis of a mobile ear screening and surveillance service versus an outreach screening, surveillance and surgical service for Indigenous children in Australia. PLoS One 2015; 10: e0138369–e0138369.

29.

Smith

Armfield

. A mobile telemedicine-enabled ear screening service for Indigenous children in Queensland: activity and outcomes in the first three years. J Telemed Telecare 2012; 18: 485–489.

30.

Hayman

White

Spurling

. Improving Indigenous patients' access to mainstream health services: the Inala experience. Med J Aust 2009; 190: 604–606.

31.

Main R. Rural optometry in Australia, http://www.ruralhealth.org.au/10thNRHC/thnrhc.ruralhealth.org.au/papers/docs/Main_Robyn_C1.pdf (2009, accessed 3 August 2016).

32.

Humphreys J and Wakerman J. Primary health care in rural and remote Australia: achieving equity of access and outcomes through national reform. A discussion paper, http://www.health.gov.au/internet/nhhrc/publishing.nsf/Content/16F7A93D8F578DB4CA2574D7001830E9/$File/Primary+health+care+in+rural+and+remote+Australia+-+achieving+equity+of+access+and+outcomes+through+national+reform+(J+Humph.pdf (accessed 23 August 2016).

33.

Mak

Plant

McAllister

. Screening for diabetic retinopathy in remote Australia: a program description and evaluation of a devolved model. Aust J Rural Health 2003; 11: 224–230.

34.

Haddock

Kim

Mukai

. Simple, inexpensive technique for high-quality smartphone fundus photography in human and animal eyes. Am J Ophthalmol 2013; 2013: 518479–518479. . https://www.hindawi.com/journals/joph/2013/518479/.

35.

Chen

Harris

. Challenges of chronic kidney disease prevention. Med J Aust 2015; 203: 209–210.

36.

Mansberger

Gleitsmann

Gardiner

. Comparing the effectiveness of telemedicine and traditional surveillance in providing diabetic retinopathy screening examinations: a randomized controlled trial. Telemed J E Health 2013; 19: 942–948.

37.

Caffery

Wickramasinghe

Bradford

. Outcomes of using telehealth for the provision of health care to Aboriginal and Torres Strait Islander people: a systematic review. Aust NZ J Publ Heal 2016.

38.

Jang-Jaccard

Nepal

Alem

. Barriers for delivering telehealth in rural Australia: a review based on Australian trials and studies. Telemed J E Health 2014; 20: 496–504.

39.

Brewster

Mountain

Wessels

. Factors affecting front line staff acceptance of telehealth technologies: a mixed-method systematic review. J Adv Nurs 2014; 70: 21–33.