Background: Health 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. Methods: We 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. Results: Of 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. Conclusions: In 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. Keywords: Community health workers, Aboriginal and Torres Strait Islander, Health system, Accountability, Governance, Power relations, Universal health coverage * Correspondence: firstname.lastname@example.org College of Public Health, Medical and Veterinary Sciences, James Cook University, James Cook Drive, Townsville, QLD 4810, Australia Nossal Institute for Global Health, University of Melbourne, Melbourne, VIC 3010, Australia Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Topp et al. International Journal for Equity in Health (2018) 17:67 Page 2 of 17 Introduction unusual within the broad spectrum of CHW roles inter- Globally, community health workers (CHWs) have a long nationally . history in health systems. In the years immediately after the landmark Alma Ata Conference of 1978, CHWs were Training and registration lauded as an important pillar of primary health care. In- AHWs currently require a minimum qualification of a deed, there is now well-established evidence on the role of Certificate III in Aboriginal and/or Torres Strait Islander CHWs and community-based health action in supporting Primary Health Care. Aboriginal and Torres Strait Is- improved health outcomes, particularly for marginalised lander Health Practitioners (AHPs) are the registered or vulnerable populations [1, 2]. Yet the governance and members of the AHW workforce. National Registration leadership challenges surrounding the integration of for AHPs was introduced in 2012 under the National CHWs into national health systems are complex and not Registration and Accreditation Scheme (NRAS) adminis- all efforts have been successful. As early as 1981, tered by the Aboriginal and Torres Strait Islander Health community health advocates were asking whether Practice Board of Australia. To achieve registration and CHWs were truly positioned to be liberators cap- practitioner status, an individual must hold a minimum able of enabling citizen participation in health through in- Certificate IV in Aboriginal and/or Torres Strait Islander dividual and communal empowerment, or, whether they Primary Health care with the option to specialise in either were simply lackeys for an over-burdened health system community care or clinical care. Various technical and ? Nearly forty years later, this question is still relevant, further education (TAFE) institutions or specialist colleges as community health workers – including Australia’sAbo- (e.g Batchelor Institute) around Australia provide Certifi- riginal and Torres Strait Islander Health Workers (AHWs) cate III and IV qualifications. Multiple options for further – are being placed in pivotal roles as part of national pro- specialisation include mental health, family health, sexual grams that seek to accomplish universal health coverage, health, health education, hospital liaison, drug, and alco- or in Australia’s case ‘close the gap’ between Indigenous hol services [4, 8]. AHWs (encompassing AHPs) may be and non-Indigenous health outcomes [4, 5]. employed by state or territory health departments to work The role of AHWs evolved in northern Australia during in government hospitals or primary care services; by Abo- the 1950s. Initially employed as leprosarium workers and riginal community controlled health services; or by other later as medical assistants in the Northern Territory [6–8], entities delivering health and allied services. Remuneration AHWs became important members of primary health is dependent on the employing organisation, but AHWs services Australia-wide through the 1970s and 80s; this and AHPs are typically among the lowest paid in both paralleled the development of Aboriginal community government and non-government organisations [12, 13]. controlled health services who championed their role . Robust and up-to-date data on the AHW workforce is Initial conceptions of the AHW role were similar to that lacking. Among all Australian states and territories, only the of community or primary healthcare workers in the inter- Northern Territory maintains a comprehensive database of national context with a focus on primary health care tasks AHWs who, under Northern Territory law, must all achieve such as health education, basic health care, and commu- registration as a practitioner in order to be employed. Based nity health action. But as the AHW role developed in the on census data, however, there were 1256 AHWs Northern Territory, a notable feature of AHW practice Australia-wide in 2011, double the number of AHWs re- became the emphasis placed on ‘cultural brokerage’ and corded in 1996 . Of these, 72% (n = 908) were female, and the focus on provision of culturally safe and comprehen- just over half (56%) were trained to a certificate IV level or sive primary health care services to Aboriginal and Torres higher, and thus eligible for registration. Eighty nine AHWs Strait Islander people [7, 8]. These features are particularly (7%) had a bachelor’sdegreeorhigherin2011. important in both the historical and contemporary con- texts in which AHWs work, in which Aboriginal and Challenges, Tensions & Gaps in knowledge Torres Strait Islander populations have experienced, and Health policy in Australia continues to position the AHW continue to experience, a high burden of disease and poor workforce as central to improving Aboriginal and Torres access to mainstream government health services . In- Strait Islander peoples’ health (see for instance Table 1), deed, the cultural component of AHWs’ work, which in- with high expectations of the role’scontribution to the cludes helping to foster community trust and wellbeing, is Close the Gap agenda and achievement of universal health now embodied in policy definitions of ‘AHWs’ [4, 8, 10] coverage [5, 14]. Yet, as is being experienced in CHW pro- and the profession is explicitly linked to self-identification grammes in other countries [1, 15–17] serious challenges and community recognition as an Aboriginal and/or exist in relation to the implementation and governance of Torres Strait Islander person. The culturally constituted the AHW profession. Lack of state or national scopes of component of the AHW role clearly distinguishes it from practice for example, have resulted in pressure on individ- other Australian health professions, but is not necessarily ual AHWs to fulfil ambitious localised terms of reference Topp et al. International Journal for Equity in Health (2018) 17:67 Page 3 of 17 Table 1 Summarised policy timeline in the development of the AHW role Year Key developments 1950s – 1990s � The first AHW roles commenced with the employment of Aboriginal women as leprosarium workers and hospital assistants in Northern Territory in the 1950s and 60s. � Development of the role in the 1970s and 80s followed national recognition of the need for an accessible and culturally safe workforce to address government or ‘mainstream’ health service gaps for Aboriginal and Torres Strait Islander peoples, and adopted a primary health care focus. � Australia’s first Aboriginal community controlled health service was established in Redfern in 1971, with services subsequently established Australia-wide. The developing community-controlled sector championed the role of AHWs as key members of multidisciplinary primary healthcare teams. � AHWs were recognised as a professional group in the Northern Territory through the Northern Territory Health Practitioners and Allied Health Professionals Registration Act 1985, which addressed restrictions on entry, registration, title, practice and disciplinary provisions. � National competency standards were developed for AHWs in 1996, although these were not universally adopted. 2000s – current � A 2000 report, Training Re-Visions: A National Review of Aboriginal and Torres Strait Islander Health Worker Training by the Commonwealth Office for Aboriginal and Torres Strait Islander Health addressed AHW training priorities following a national review. � The National Aboriginal and Torres Strait Islander Health Worker Association (NATSIHWA) was established in 2009 as the peak national body for AHWs and Practitioners in Australia, following Australian Government commitments to strengthen the AHW workforce as part of ‘Closing the Gap’. � The National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework (2011–2015) prepared for the Australian Health Ministers’ Advisory Council, emphasised the role of AHWs in achieving equitable health outcomes for Aboriginal and Torres Strait Islander peoples. � Health Workforce Australia’s National Health Workforce Innovation and Reform Strategic Framework for Action (2011–2015) emphasised the need to increase the number of AHWs working in the health sector to improve Aboriginal and Torres Strait Islander health. � Health Workforce Australia’s Aboriginal and Torres Strait Islander Health Worker Project Final Report (‘Growing Our Future’) released in 2011 articulated policies and strategies to strengthen and sustain the AHW workforce in Australia. � From 1 July 2012, AHWs who have gained Certificate IV in Aboriginal and/or Torres Strait Islander Primary Health Care Practice can register as an Aboriginal and Torres Strait Islander Health Practitioner under the National Registration and Accreditation Scheme. AHWs are not required to register unless deemed necessary for employment purposes. Health Practitioners previously regulated by the NT Boards are now regulated under the national Scheme. � The National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework (2016–2023), developed within the context of the National Aboriginal and Torres Strait Islander Health Plan 2013–2023, guides Aboriginal and Torres Strait Islander health workforce policy to build a strong and supported health workforce capable of providing culturally-safe and responsive health care. without sufficient support, supervision or resourcing [18, health system, is attained when governments respect, pro- 19]. Challenges relating to the ways in which AHWs bal- tect, and fulfill the right to health, and when health sector ance (sometimes competing) obligations to their commu- employees are treated respectfully. Yet despite their import- nities and their clinical service managers also exist [4, 12]. ance, exploration of these concepts and experiences of Such issues appear to be contributing to difficulties in health service governance and accountability (NB: not clin- both recruitment and retention, with substantial numbers ical governance) are still emerging fields and a largely of unfilled AHW posts nationally pointing to ongoing and neglected area of research in relation to Aboriginal and potentially intensifying issues of job satisfaction that Torres Strait Islander health care in Australia. bring the very sustainability of the role into question. Access to healthcare for socially marginalised or vulner- Conceptual framework: Governance and accountability able groups, including Aboriginal and Torres Strait Islander Following recent public administration and health systems peoples, is mediated by the governance of services [20, 21]. scholars [22, 23, 25, 26], we understand accountability as Drawing on public administration and development theory, one lens that may help improve our understanding of as- health systems researchers increasingly acknowledge that pects of AHW governance and performance. Although governance of health services should be understood not used variably in different disciplines, contemporary scholar- simply as the formal rules and infrastructure enabling ship generally frames accountability as dispersed, relational health service delivery, but as the complex network of rela- and multi-directional . In the context of health systems tionships and informal (practical) norms that arise from and health services, this emphasis on the dispersed and constant interaction among health workers, and between multi-directional nature of accountability is critical given health workers and their clients [21–24]. Cleary et al.  themultipleindividualand institutional stakeholders net- among others have noted that at the sub-national level, worked across multiple levels of service administration and governance approaches must enable and sustain service re- delivery. ‘Vertical’ or ‘bureaucratic’ accountability, referring sponsiveness, including by promoting system learning and to service providers’ accountability to their government accountability. Accountabilityfor health,as a featureof a employer, thus co-exists and interacts with horizontal Topp et al. International Journal for Equity in Health (2018) 17:67 Page 4 of 17 accountability (intra- and inter-organisational relationships AHW ‘voice’ was absent. AHWs’ experiences of account- at thesamelevel)and ‘social,’ ‘political’ or ‘downwards’ ac- ability had to be described through AHWs’ own reflections countability (flowing from funders, planners and providers on the nature and challenges of their roles. Studies that towards service users or citizens). Haloran  and Fox et failed to obtain or report appropriate ethical approvals were al.  describe these relationships as existing within an ‘ac- excluded. We also excluded studies reporting on AHW-led countability eco-system,’ a term designed to draw attention programs if they included no meaningful data about AHW to their co-existence and interactive and sometimes experiences within those programs. Although not empirical inter-dependent nature. studies, several commentaries authored or co-authored by Van Belle and Mayhew [26, 29]posit that thereare four di- AHWs reflecting directly on personal experiences in the mensions of accountability in local health systems, including workplace were included as highly authoritative accounts of health services, namely – provider, organisational, political relevance to the review topic. and social accountability. The provider dimension focuses on We searched MEDLINE, CINAHL, Scopus and Informit health workers’ relationship with their direct clients. The or- (health suite and social sciences suite) for peer-reviewed ganisational dimension focuses on how responsive an organ- publications and dissertations and theses using the follow- isational unit – e.g. a health facility or district health service ing terms: (“health worker” OR “health practitioner” OR – is to its stakeholders more broadly, encompassing internal “health professional”) AND (Austral* OR “New South relationships among staff, and upwards and downwards rela- Wales” OR “Northern Territory” OR Queensland OR tionships to catchment communities and funders. The polit- Victoria OR Tasmania) AND (Indigenous OR Aborigin* ical dimension of accountability examines regulatory and OR “Torres Strait Islander” OR “oceanic ancestry group” higher-order management relationships. Finally, the social di- OR “oceanic ancestry groups” OR australoid* OR “Austra- mension is described as focusing on relationships that en- lian race” OR “cultural competence” or “cultural compe- hance equity and social justice. The choice of this framework tencies”). Subject terms were also used in the searches in was deliberate and based on its non-prescriptive nature, Medline and CINAHL. Search terms were refined in con- which made it appropriate for exploratory work. The frame- sultation with a university librarian. work acknowledges overlap and interaction between the four Following a number of pilot searches, we removed the dimensions, but provides a useful starting point for analysis search terms ‘accountability,’ ‘transparency,’ ‘answerability’ and of the different ‘flows’ of accountability experienced by ‘social responsibility,’ as they introduced a large number of ir- AHWs. Using a systematic qualitative literature review, this relevant (non AHW-related) records while yielding no new paper thus seeks to explore the state of evidence about the records of interest for the review. The terms used in the final way accountability relations in these different dimensions are searches enabled identification of a full range of articles in- experienced by AHWs in Australia. corporating AHW experiences and practice for consideration against other criteria. Duplicates were removed and titles Methods and abstracts were screened by the first and second author This review was designed to map the available evidence against inclusion criteria. Two authors independently base. The process followed standard qualitative systematic reviewed full texts of all included articles with disagreement review steps [30–33] but adapted quality criteria to be resolved by consensus (Fig. 1). Hand searches were more inclusive. Since the data accessed were publicly subsequently conducted of the reference lists of selected available and previously published, formal ethical consid- articles as well as of the Aboriginal and Islander Health erations and confidentiality procedures were not required. Worker journal, applying the same selection criteria. Search strategy and selection criteria Analysis We sought examples of empirical studies or first-person ac- We used thematic analysis to identify and categorise the data counts describing AHWs’ experiences of working in gov- from selected articles using van Belle and Mayhew’s typology ernment or Aboriginal community-controlled health of accountability dimensions as an overarching guide. Close services anywhere in Australia. No date restrictions were and repeated reading of the papers allowed identification of applied. No language restrictions were applied; however we specific experiences directly or indirectly related to AHWs anticipated papers reporting on AHWs would be exclu- accountability relationships. For example, we looked for find- sively reported in English. Due to the difficulty in ensuring ings reporting or discussing AHW responsibilities, experi- a systematic approach, grey literature were excluded from ences and perceptions of issues such as training, supervision, the formal search. Included studies reported either directly respect, recognition, appreciation, scope of work, team work, or indirectly on AHWs and equivalent roles (e.g. Strong power relations, autonomy and decision making authority, Women Workers) delivering care to Aboriginal and/or feedback mechanisms and resourcing. This was possible Torres Strait Islander Australians in any health care setting since included articles were required to describe AHWs’ in Australia. We excluded quantitative studies in which the self-reported experiences and perceptions. Where available, Topp et al. International Journal for Equity in Health (2018) 17:67 Page 5 of 17 Fig. 1 Literature search and study selection we also extracted data on the perceptions of professional importance of some issues may be unintentionally under- or health workers and community members. Such experiences over-emphasised. We have attempted to be as transparent as formed the basic codes that enabled data extraction. First possible in reporting of the origins and focus of included levelcodes were groupedintogroundedthemes, andsubse- works as well as in highlighting a range of gaps in knowledge quently organised according to their relevance against the that this review has identified. As the purpose of this review four dimensions of accountability synthesised by van Belle was to map the evidence base relating to AHW accountabil- and Mayhew . We followed an iterative process of reflec- ity, selected articles were not assessed for the quality (as in tion on the appropriateness of the mid-level themes, and standard systematic reviews) beyond an assessment of their their categorisation under the four dimensions, resulting in relevance and depth of analysis with regards to issues of several rounds of adaptation and re-grouping. Interpretation AHW governance and accountability. Finally, a note on no- of the AHW experience was conducted using an overarching menclature: we predominantly use ‘Aboriginal and Torres lens of intersectionality, which has regard for the intersecting Strait Islander peoples,b ’ ut ‘Indigenous Australian’ is used identities and experiences of the Aboriginal and Torres Strait where the review discusses findings of included papers that Islander peoples’ health workforce. This lens enabled us to use this alternative terminology; both are widely used no- consider how potentially interlocking systems of power menclature to describe Australia’sFirst Nation’s peoples. within Aboriginal and Torres Strait Islander communities, in clinic settings, and across the broader health service domain Findings were impacting on AHWs’ ability to fulfil an ambitious pol- Characteristics of selected articles icy remit. Our findings are based on 27 studies published between 1995 and 2017 (Table 2). Twenty four studies were re- Limitations ported in peer-reviewed journal articles, the majority of Articles included in this review were published or readily which (n = 21) used qualitative research designs employing available studies, commentaries books and reports. Several semi-structured interviews with AHWs and other staff older government reports (c.1980) found in the reference and/or patients. The remaining three peer-reviewed lists of included articles could not be accessed, but these are papers were commentary or opinion pieces written by unlikely to have reported AHW perspectives directly, as was AHWs. One thesis, one monograph, and a book were also required for inclusion in this study. As the findings of this re- included. For ease of reference, we use the generic term view reflect the data found in the included publications, the ‘papers’ when referring to all the above sources. Topp et al. International Journal for Equity in Health (2018) 17:67 Page 6 of 17 � � � � � � � � � � � � � � � � � � � � � � � � Table 2 Summary and Key Data Extracted from Review Articles Author (date) Title Journal/publication Study type & methods Focus location & organisational setting Key themes relating to AHWs’ accountability relationships in the four domains Tregenza, J. Rhetoric and reality: Monograph Empirical: intersectional 26 Remote and Social & Abbott, K. Perceptions of the lens using mixed Regional communities AHWs ‘agents’ to improve health status and agents of social change in 1995  roles of Aboriginal methods; semi- in Central Australia the community Health Workers in structured interviews;. (Northern Territory) Being Aboriginal and part of the community gives strength in role Central Australia 294 AHWs from 26 Provider communities. AHWs seen as main providers of healthcare in the community Political/Organisational Clear power differentials with non-Aboriginal colleagues, with AHWs are ‘bottom of the rung’ Perception that further education could enhance power and status Non-Indigenous co-workers’ & supervisors’ perceptions of role frequently divergent with their own and a source of tension McMasters, Research from an Australian & Non-empirical: Central Australia Political A., 1996  Aboriginal health New Zealand experiential/opinion High expectations of AHW by mainstream health system worker’s point of view Journal of Public Political/Organisational Health Demanding responsibilities of the role, compounded for AHWs from remote communities, at odds with levels of knowledge and power Tensions between Western and Indigenous models of health promotion Hecker, R. Participatory action Australia New Empirical: ACCHO in Pitjantjatjara Political (1997)  research as a strategy Zealand Journal empowerment lens Lands, remote South Access to practical training ad hoc for empowering of Public Health using participatory Australia Organisational aboriginal health action research Perception that opinions not valued and no representation on key workers health service committees Jackson, D. Towards (re)conciliation: Journal of Empirical: feminist lens, Undisclosed Australian Political et al., 1999 (re)constructing Advanced qualitative descriptive; health service settings Role confusion involving inconsistent definitions of role and scope  relationships between Nursing in-depth interviews Organisational/Political Indigenous health Power dynamics interfere with capacity for cross-professional workers and nurses collaboration Cultural advocacy role key but un- or under-recognised by other professions Provider Complex lines of responsibility to local community, family and bio-medically oriented health services Dollard, J.S. Aboriginal Health Aboriginal and Empirical: qualitative Various health service Political/Organisational et al., 2001 Worker Status in South Islander Health descriptive; settings in South Lack of satisfaction with status compared to other staff linked to lack  Australia Worker Journal questionnaire (n = 74), Australia of professional and role recognition; inequality compared to other in depth interviews professionals (e.g. pay and qualifications required for appointments) (10), and 4 focus group Limited capacity to voice concerns at high levels due to vertical power discussions (n = 35) structures Organisational Perception of being ‘jack of all trades but master of none’ Williams, C. Aboriginal health Journal of Empirical: Sociological Variety of health Social 2003  workers, emotional Occupational lens placing AHWs service settings, South Experience of strong sense of obligation to care for family and kin of labour, obligatory Health and within institutional Australia patient as well as patient community labour and Safety Australia context; qualitative Community advocacy and cultural brokerage role crucial to AHWs occupational health and New descriptive; interviews Organisational and safety Zealand of 29 AHWs AHWs seen as point of contact for all Aboriginal patients regardless of health problem - causing tensions due to conflicting understandings of role Political/Organisational Experiences of racism from non-Aboriginal co-workers Genat, B. Aboriginal Health Book Empirical: Ethnographic Urban Aboriginal Social (2006)  workers: Primary Health based on 6 AHWs Community Controlled AHWs experience strong sense of obligation to Aboriginal clients but Care at the Margins. experiences & Service in Western tensions around perception that they should be available 24/7 interviews with Australia Political/Organisational colleagues and AHWs lack voice and status within organisation and sector, that undermines professional capacity Topp et al. International Journal for Equity in Health (2018) 17:67 Page 7 of 17 � � � � � � � � � � � � � � � � � � � � � Table 2 Summary and Key Data Extracted from Review Articles (Continued) Author (date) Title Journal/publication Study type & methods Focus location & organisational setting Key themes relating to AHWs’ accountability relationships in the four domains community clients in Provider late 1990s Professional identity of AHWs is tenuous, undermined by weak understanding of the role by colleagues and even clients Mitchell, M. The Aboriginal health Medical Journal Non-empirical: Aboriginal Community Political et al., 2006 worker of Australia experiential/opinion Controlled Challenges in cross-jurisdictional variation in definitions of role,  Organisation, competencies and skills recognition Organisational Townsville, Queensland Different scope of work for AHWs in ACCHO setting compared with mainstream health service setting - reflecting a ‘social model of health’ versus a ‘disease model of health’ Social Experience of being ‘everything to everyone’, incorporating community demand and expectation for after work hours Organisational Perceptions of co-workers limited understanding of AHW role and impact on teamwork Provider/Organisational Reflections on intersection of cultural and social norms relating to age and clan/family groups with workplace dynamics and their impact on patient relationships Harris, A. The Aboriginal Mental Australian Empirical: qualitative Remote community Political et al. (2007) Health Worker Program: e-journal for the descriptive; audits of health centres, Lack of consensus on AHWs role in clinical settings  The challenge of Advancement of client records, Northern Territory Organisational supporting Aboriginal Mental Health participant observation, Role confusion and varied expectations of AHWs involvement in mental and semi-structured GPs resisting responsibility for proactive mentoring role health care in the interviews Assumption that AHWs are universally culturally skilled, not requiring remote community formal support or development context Provider Role ambiguity and unclear cultural legitimacy source of individual strain and ‘burnout’ Hooper, K. Health professional Australian Empirical: qualitative Aboriginal and Political et al., 2007 partnerships and their Journal of Rural descriptive; in-depth mainstream health and Lack of role clarity a barrier to communication and service planning  impact on Aboriginal Health interviews human service Provider health: an occupational organisations in rural Cultural advocacy and brokerage role central to efficacy of AHWs therapist’s and and remote North Not having an AHW trained in OT undermines continuity of care Aboriginal health Queensland worker’s perspective Abbott, P. Expanding roles of Contemporary Non-empirical: Australia-wide, with Social et al., 2008 Aboriginal health Nurse commentary with mini-cases focused on Central nature of Cultural brokerage to role  workers in the primary mini-cases an AMS in Western Provider care setting: seeking Sydney Rarely ‘off duty’ recognition Political Lack of recognition and limited career opportunities Organisational Experience more autonomy within community controlled health services Stamp, G.E. Aboriginal maternal Rural and Empirical: qualitative Regional South Social et al., 2008 and infant care Remote Health descriptive; semi- Australia Community advocacy perceived to be crucial part of AHW role  workers: partners in structured interviews Organisational caring for Aboriginal with 5 AMIC workers Two-way partnership model with midwives emphasising mutual mothers and babies and 4 midwives equivalence and valuing cultural knowledge of AHWs builds community trust in service Political/Organisational Overcoming initial staff resistance to new AHW roles and agency Topp et al. International Journal for Equity in Health (2018) 17:67 Page 8 of 17 � � � � � � � � � � � � � � � � � � � Table 2 Summary and Key Data Extracted from Review Articles (Continued) Author (date) Title Journal/publication Study type & methods Focus location & organisational setting Key themes relating to AHWs’ accountability relationships in the four domains Taylor, K. Exploring the impact Australian Empirical: qualitative Cardiology department Social et al., 2009 of an Aboriginal Health Health Review descriptive; open-ended in a tertiary hospital, Community advocacy and brokerage work crucial to helping  Worker on hospitalised interviews with 4 Western Australia Aboriginal patients Aboriginal experiences: cardiology nurses, 3 Provider lessons from nurses, 2 doctors, 2 AHWs seen as point of contact for all sociocultural needs of cardiology social workers, 2 AHWs, Indigenous patients 12 recent Aboriginal Organisational clients Other staff tend to understand AHW role purely in terms of social and education functions despite clinical training, capacity and interest Lloyd, J. The influence of J Health Serv Empirical: qualitative All sectors of the Political/Organisational et al., 2009 professional values on Res Policy descriptive; semi- health system in Diverging views between AHWs and other professionals on scope of  the implementation of structured interviews Darwin, Alice Springs health care role including responsibility towards addressing social Aboriginal health with 35 frontline health and remote Aboriginal determinants of health policy professionals communities, Northern Territory Peiris, D. Building better systems BMC Health Empirical: theory-driven 7 health services (6 Social et al., 2012 of care for Aboriginal Services (‘Candidacy’) health community-controlled Extension of AHW work beyond official hours  and Torres Strait Research system assessment and 1 government): Provider/Organisational Islander people: involving group two urban, one inner AHWs embody a community governance model and cultural findings from the interviews with 37 regional, two outer brokerage role important but family obligations and kinship relations Kanyini health systems health staff regional, and two can sometime affect capacity to deliver health care assessment remote, Queensland. Dawson, A.P. Aboriginal health International Empirical: social- Urban, rural and Social et al., 2012a workers experience Journal for ecological lens using remote health services Widespread social acceptance and normalisation of tobacco use in the  multilevel barriers to Equity in Health qualitative descriptive in South Australia community quitting smoking: a methods; in-depth Provider qualitative study interviews and focus Sense of professional responsibility for promoting smoking-cessation groups Organisational Tacit acceptability of smoking in the workplace despite guidelines to the contrary Provider Smoking as way to cope with stress of being ‘everything to everyone’ Dawson, A.P. ‘I know it’s bad for me BMC Health Empirical: qualitative Urban, rural and Provider et al., 2012b and yet I do it’: Services descriptive; in-depth remote health services Conflict between professional responsibility to promote smoking  Exploring the factors Research interviews and focus in South Australia cessation and social norms around tobacco use. that perpetuate groups High value placed on community relationships and trust smoking in Aboriginal Organisational/Provider health workers - a Smoking as a coping mechanism for stresses caused by job and qualitative study financial insecurity including salary disparities and short term contracts, high staff turnover, lack of value and recognition by local and broader health system & Organisational Browne, J. A qualitative evaluation Australian and Empirical: qualitative ACCHOs and state Political et al., 2013 of a mentoring program New Zealand evaluative; interviews health services in Uneven power dynamics with other health care providers  for Aboriginal health Journal of Public (phone / face to face) Victoria workers and allied Health health professionals King, M. Issues that impact on Australian Empirical: qualitative Two Aboriginal Political/Organisational et al., 2013 Aboriginal health Journal of Rural descriptive; ‘discussion community controlled Non-recognition of qualifications and lack of incentives to develop and  workers’ and registered Health schedule’ with 17 and seven mainstream use new skills nurses’ provision of participants from nine health services in Far Tension between Western models of health promotion work and diabetes health care in health services (5 of Western New South culturally appropriate engagement with community rural and remote whom were AHWs) Wales Organisational health settings Perception of being ‘glorified taxi drivers’ transporting patients, with limited time available to apply expertise Poor communication with health service managers perpetuates role confusion Provider Cultural advocacy and brokerage work source of pride and sense of uniqueness Topp et al. International Journal for Equity in Health (2018) 17:67 Page 9 of 17 � � � � � � � � � � � � � � � � � Table 2 Summary and Key Data Extracted from Review Articles (Continued) Author (date) Title Journal/publication Study type & methods Focus location & organisational setting Key themes relating to AHWs’ accountability relationships in the four domains Rose, M. ‘Knowledge is power’: Doctor of Empirical: Social A variety of Social 2014  Aboriginal Education Thesis ecological lens; communities (rural, Being Aboriginal and part of the community gives strength in role Healthworkers’ - University of qualitative descriptive; regional, urban), New Provider perspectives on their Technology, in-depth, semi- South Wales Community advocacy and brokerage work key component of role practice, education and Sydney structured interviews Political/Organisational communities with 9 health workers Clear power differentials with non-Aboriginal colleagues, where AHWs in diverse roles are ‘bottom of the rung’ Perception that further education could enhance power and status Provider Co-workers’ and community perceptions of role sometimes divergent and a source of tension Deshmukh, T. ‘It’s got to be another Australian Empirical: qualitative AMS in Western Social et al., 2014 approach’:an Family Physician descriptive; in-depth Sydney, New South AHWs’ strong sense of connectedness and embeddedness in  Aboriginal health interviews Wales community worker perspective on Political/Organisational cardiovascular risk Perceptions of being undervalued by health system and other health screening and professionals education Jennings, W. Yarning about health Aust J Prim Empirical: qualitative Urban community Organisational et al., 2014 checks: barriers and Health semi- controlled AMS, Doctors perceived to have more authority by community members descriptive;  enablers in an urban structured interviews Brisbane, Queensland and also by other staff within health service Aboriginal medical with clinical staff - 8 Provider/Social service AHWs and 3 Aboriginal Cultural brokerage component of AHW role engenders community nurses trust Co-ownership approach to health between AHWs and community, and advocacy activity, key to role Provider Cultural and social norms relating to gender, age & family background are in tension with some of AHWs’ professional obligations Hengel, B. Barriers and facilitators Sexual Health Empirical: qualitative Pirmary health centres Social et al., 2015 of sexually descriptive; in-depth in Queensland and Community connectedness promotes trust and improves access to  transmissible infection interviews Northern Territory clients. testing in remote Provider/Social Australian Aboriginal Gendered cultural norms and cultural relationships influence communities: results appropriateness and ability to deliver care depending on gender and from the Sexually family connections of AHW staff Transmitted Infections in Remote Communities, Improved and Enhanced Primary Health Care (STRIVE) Study Lowell, A. Supporting Aboriginal BMC Pregnancy Empirical: program Five remote Provider/Political et al., 2015 knowledge and & Childbirth evaluation; semi- communities, Northern Smoking ceremony for new babies and use of traditional medicine  practice in health care: structured interviews Territory seen by AHWs as an important part of a broad and continuous lessons from a with 76 participants process of promoting health and wellbeing that occurs throughout life qualitative evaluation (incl 15 Strong Women - but this type of work and approach is under-recognised by broader of the strong women, Workers)’ analysis of health system and is sometimes at odds with policy. strong babies, strong reports Political/Social culture program Under-recognition of cultural dimensions of health care increases com munity dependence on mainstream services under a biomedical model of service delivery, to the detriment of both AHWs and community members affecting job Australian Empirical: grounded Rural and remote local Organisational Cosgrave, C. Factors et al., 2016 satisfaction of Health Review theory study; semi- health districts and Role clarity difficulties impacting cross-professional collaboration  Aboriginal mental structured interviews community mental Perception among some non-Indigenous providers that AHWs are health workers working health services (NSW responsible for ‘anything Aboriginal’ Topp et al. International Journal for Equity in Health (2018) 17:67 Page 10 of 17 � � � � � � � � � � � � Table 2 Summary and Key Data Extracted from Review Articles (Continued) Author (date) Title Journal/publication Study type & methods Focus location & organisational setting Key themes relating to AHWs’ accountability relationships in the four domains in community mental Health), New South Perception among some non-Indigenous providers that Aboriginal health in rural and Wales clients always want to see Aboriginal health worker remote New South Political Wales Inequity in career pathways and remuneration as against qualifications and nature of work Social Perception of being ‘everything for everybody’ Tensions relating to service provision to clients with whom there may be family business or personal issues. Kirkham, R. Emotional labour and Women & Birth: Empirical: Anangu Bibi Birthing Social et al., 2017 aboriginal maternal Journal of the phenomenological Program, run at Port Connection with community enhances trust in AHW but  infant care workers: the Australian qualitative study; 30 Augusta Hospital and simultaneously exposes them to emotional stress invisible load College of in-depth interviews involving Country Provider Midwives with staff and clients Health, South Australia Experiences of tension between cultural and community obligations, and health service (clinical/institutional expectations. Personal and professional roles blurred Organisational Perceptions of other professionals’ lack of respect for, and misunderstanding of, AHW role and capacity Political Institutional barriers to greater agency and professional aspirations of AHW Conway, J. The barriers and BMC Health Empirical: multiple case Rural and urban health Provider et al., 2017 facilitators that Services studies; in-depth centres including AMSs Managing ‘dual relationships’ with health service managers and  Indigenous health Research interviews in five Australian states members of the community workers experience in Challenge of maintaining professional boundaries their workplace and Social communities in Tensions regarding smoking - social pressure to smoke versus providing self- undermining role model capacity management support: a multiple case study Topp et al. International Journal for Equity in Health (2018) 17:67 Page 11 of 17 None of the studies focused directly on AHW govern- We are everything to everyone – Family ties and cultural ance or accountability. However, nearly half of the in- obligation cluded qualitative studies (n = 11) were focused on the AHWs’ connection with community, while described as es- experiences of AHWs in the workplace, including AHWs’ sential to developing client and community trust and as a relationships with other health professionals and perspec- source of personal satisfaction and pride, also resulted in tives on their workplace. The other qualitative studies AHWs feeling like they are ‘everything to everyone’ [12, 38]. were evaluations of new programs or models of health AHWs in multiple studies described feeling like they were care involving AHWs (n = 7), AHW perspectives on spe- never off-duty even after work hours [6, 37, 38]. A blurring cific models of care (n = 2) and two studies focused on the of private and professional life was also described , with challenges AHWs themselves faced in quitting smoking. AHWs feeling a responsibility to help people in the commu- The organisational settings of the studies described in the nity: ‘you’ve got to give them something, or help in some included papers were varied and included those focused only way’ . The high community expectation experienced by on Aboriginal community controlled health services (n =6), some AHWs was also described [38, 39] and included fear of only government services (n = 3) or both community con- blame if and when something went wrong . AHWs in trolled and government services (n = 6). In 12 studies the one study described how such demands were personally health service operator was undisclosed. Study locations in- challenging and could also create professional problems re- cluded urban, rural and remote communities across almost lating to clinical governance or confidentiality . The close all Australian states and territories. South Australia had the connection of many AHWs with their community and per- largest representation of studies (n = 7), followed by the ceived greater susceptibility to community conflicts, grief, Northern Territory (n =5), New South Wales (n =4), and blame were described as a significant source of emo- Queensland (n = 3), Western Australia (n =2) and Victoria tional labour for AHWs . Peiris et al.  and Genat  (n = 1). A further four studies had an Australia-wide focus, also noted that these responsibilities were often invisible to with one focused jointly on Queensland and the Northern AHWs’ non-Indigenous professional colleagues. Nonethe- Territory. less, in at least one study  there was a perception among AHWs that Aboriginal and Torres Strait Islander clients pre- ferred to see doctors and saw them as having more authority Findings of the review to provide clinical advice than AHWs. We present the findings according to themes reflected in the data organised according to each of van Belle and Organizational dimensions Mayhew’s four dimensions of accountability – provider, Power relations and workplace hierarchy organisational, political and social. We start with the social AHWs in a number of studies reflected on their position dimension, as this was described as being most important within a workplace hierarchy. In Jackson et al. , AHWs by AHWs themselves. described how nurses in their health service positioned themselves as ‘in charge’ of AHWs, even when this was not Social dimensions of accountability their role. In Rose’saccount,anAHW workingina Serving community social work department of a NSW health service described AHWs’ sense of connection and belonging with their local her position in the hierarchy as ‘bottom of the rung,w ’ ith the communities was recognised in all papers as a key attri- non-Aboriginal social workers as her line managers. Genat bute of their role and was frequently discussed alongside a and Kirkhametal.  similarly describe the desire by AHWs to serve Aboriginal and Torres Strait Is- structurally-embedded nature of the clinical hierarchy, which lander peoples within their localities. Connection with, requires AHWs to ‘go through the hierarchy to ask permis- and responsibility to, community was reflected on as es- sion’ to deliver on their aspirations; this was seen to inhibit sential to developing trust with patients and enabling their ability to carry out important aspects of their work. AHWs to be effective in their work, as well as imbuing a Workplace power differentials were seen to impact on profound source of satisfaction and pride. Specifically, AHWs’ autonomy, decision-making capacity and pos- building rapport with patients through knowledge of the ition within workplace teams , and to manifest in community and recognising family connections was noted limited capacity of AHWs to use their experience and by AHWs to enable their health care role [34, 35], to give qualifications with Aboriginal clients . However, a them strength and confidence , and to encourage distinction was observed between AHWs’ experiences of community members to come to the service . Simi- workplace hierarchy in ‘mainstream’, or state or territor- larly, community representation among health care staff y-run, health services versus in Aboriginal community in the form of AHW roles was seen to increase the ‘candi- controlled health services. For example, Aboriginal com- dacy’ of Aboriginal and Torres Strait Islander communi- munity controlled health services were noted as operat- ties to health services . ing under the direction of an elected community board Topp et al. International Journal for Equity in Health (2018) 17:67 Page 12 of 17 which was described as changing the relationship be- development of the AHW profession (discussed further tween AHWs and non-Indigenous colleagues . Al- below). The pervasive lack of understanding of, and respect though not uniform, AHWs working within Aboriginal for, the AHW role among colleagues and institutions was community controlled health services more frequently described as leading to lower self-worth and stress among described their work as with, rather than for, the doctor AHWs . – in contrast to a more hierarchical structure in govern- ment services [6, 41]. A holistic vs biomedical approach to health Related to the issue of cultural value, several studies de- Role confusion and undervaluing of the role scribed the dissonance between their culturally-constituted A pervasive, system-wide, lack of understanding of and holistic philosophy of health and the dominant bio- AHWs’ role was discussed in various studies, and was re- medical model of health operating in most service settings ported as a barrier to AHWs working to their full capacity . This dissonance operated at both an organisational for the benefit of patients, broader society and their own and inter-personal level. At the organisational level, several professional satisfaction [6, 7, 12, 35, 38, 40, 42–46]. In papers reflected on the different philosophical approaches many of these papers, the lack of understanding of the to health care between mainstream and Aboriginal commu- AHW role fed into (and was simultaneously compounded nity controlled health services [37, 38]. Mainstream services by) a general undervaluing of AHWs by non-Indigenous were seen to focus on a ‘disease-model approach,’ and Abo- colleagues and was reflected in the different perspectives riginal community controlled services were seen as being on the role as reported by AHWs and other professional concerned with a broader ‘social model of health’ . health workers’ in the same service . General under- Mitchell et al. reportedthata ‘lack of cultural sensitiv- valuing of AHWs was characterised in several studies by ity’ was observed within mainstream services as compared underutilisation of AHWs’ clinical skills and training. In with Aboriginal community controlled services. Peiris et al. three articles, for example, AHWs perceived that a signifi-  described positive experiences of an AHW working cant proportion of their time was wasted being ‘glorified within an Aboriginal community controlled service, attrib- taxi drivers’ or ‘a taxi service’ for patients, limiting the utable in part to the governing board being composed of time they had available to comprehensively apply their ex- community members . Mirroring the focus of the Abo- pertise [7, 35, 44]. AHWs in several studies further noted riginal community controlled sector, the AHW role itself that non-Indigenous staff simply did not understand the was described as representing a comprehensive primary cultural component of the role beyond the ‘interpretative’ health care approach underpinned by Aboriginal concepts function played by AHWs, and so found it difficult to of health . characterise or place value on it [38, 47]. Genet and At the individual and inter-personal level, tensions be- Tregenza and Abbott  both noted that while some tween the AHWs,’ and nurses’ and doctors,u ’ nderstandings non-Indigenous health workers did value the cultural of health were often discussed in relation to health promo- component of AHWs’ work, this was framed predomin- tion work. Culturally appropriate forms of community en- antly in terms of AHWs’ capacity to facilitate their own gagement were described by AHWs as being necessary for clinical practice, rather than as an important and intrinsic health promotion work to be effective in Aboriginal and component of AHWs’ own profession. Torres Strait communities, but these approaches were per- Limited understanding of the AHW role was also seen to ceived by many AHWs to be under-recognised within lead to a lack of recognition of the diversity of roles played established models of health promotion and were therefore by AHWs [6, 35], difficulties experienced by AHWs being not supported or understood by other health professional accepted into workplace teams [12, 38], confusion about colleagues . Similarly, effective engagement with com- role boundaries [36, 48], exclusion of AHWs from clinical munity was seen by AHWs in two studies as requiring ‘go- service delivery functions , and challenges in determin- ing out’ into community to talk with people in situ, often ing appropriate services for clients . Mitchell et al.  outside of the clinic and outside of working hours [44, 49]. reflected that the issue of skills utilisation was different for AHWs working within the ‘mainstream’ versus the com- Cultural brokerage munity controlled sector: AHWs working within main- Despite reported undervaluing of cultural aspects of the stream services are often tied to specific clinical areas or to AHW role, cultural brokerage was recognised by multiple non-clinical work such as transport; whereas AHWs work- actors as a defining feature of AHWs’ role [6, 36, 37]. This ing within Aboriginal community controlled health services part-interpretative, part-advocacy function required AHWs experienced a broader clinical scope and have input into to draw on their understanding of community issues and developing health programs. Rose  suggests that the priorities to enable colleagues and the broader system to re- widespread confusion around AHW roles arises in part spond to Aboriginal and Torres Strait Islander peoples’ from the complexity of policies that have informed needs. Tangible tasks related to cultural brokerage included Topp et al. International Journal for Equity in Health (2018) 17:67 Page 13 of 17 cultural mentorship of non-Aboriginal and Torres Strait Is- Political dimension lander colleagues , reflecting Aboriginal patients’ con- Career structure cerns as part of their own concerns , giving voice to In a number of studies representing views across several patients who may feel reticent to access the service  decades, AHWs reported feeling as if they were ‘jack of all and speaking up with confidence when government health trades but master of none’, with insufficient professional services were taking an approach that’snot ‘our way’ . standing or opportunities for career progression or mobil- Peiris et al. also noted an advocacy function played by an ity. Tregenza and Abbott  reported widespread frus- Aboriginal community controlled service on behalf of Abo- tration among AHWs working in both government and riginal clients in liaising with the local hospital, operationa- Aboriginal community controlled sectors in central lised through their AHW staff . In their wide-ranging Australia, with the lack of clarity around roles, responsibil- survey of AHWs in the Northern Territory, however, Tre- ities and opportunities to progress professionally. Report- genza and Abbott  noted that doctors and nurses ing findings from a mixed methods study that included a placed more emphasis on the cultural brokerage role than questionnaire, Dollard et al. , reported that two-thirds AHWs did, as it became a critical enabler of their own of the 74 AHWs surveyed reported feeling dissatisfied (clinical) practice, rather than as a platform for strength- with their status compared to other staff in their organisa- ened recognition of the centrality of Aboriginal and Torres tion. Reasons given in open-ended responses included lack Strait Islander peoples’ conceptions of health. of recognition as a professional, and inequality in relation to pay and work conditions when compared to other Responsible for ‘anything aboriginal’ health professionals. Mitchell et al.  reflected on the Several studies in both urban hospital and remote primary lack of agreed national, or even state-based scopes of prac- care settings reflected on the way non-Indigenous providers tice for AHWs as an ongoing barrier to the development drew a connection between AHWs’ Aboriginality and a par- of the AHW role. This barrier may still be relevant to ticular responsibility or expectation to assist all Aboriginal AHWs despite the 2012 introduction of the National patients irrespective of presenting problem [12, 39, 41, 46]. Registration and Accreditation Scheme for Aboriginal and AHWs reported a sense of duty when a patient was identi- Torres Strait Islander Health Practitioners, due to its nar- fied as Aboriginal, which included a responsibility to look row focus on registered practitioners. after the patient’s families and relatives . However, the Reflecting on the range of policies that have influenced assumption by non-Indigenous staff, or health organisa- the development of the AHW role (see Table 1) over tions, that AHWs were responsible for ‘anything Aborigi- several decades, Rose  noted that the complexity of nal’ within their service, was also described as intrusive and multiple recommendations emerging from Common- as representing an inadequate grasp of the AHW role and wealth and state governments as well as from the Abori- client needs [12, 46]. This assumption included a percep- ginal community controlled health sector, was tion held by non-Indigenous staff that ‘Aboriginal clients… compounded by the jurisdictional and organisational dif- always want to see an Aboriginal worker’ (Cosgrave et al. ferences between states and territories, and between in- 2016), a concern echoed by Williams et al. as theyde- dividual community controlled health services, in policy scribed a situation in which all Indigenous clients in a hos- implementation, with stasis a frequent outcome. pital department were referred to the Aboriginal health team, regardless of the prevailing health concern or clients’ Professional development: ‘Knowledge is power’ preferences. Taylor et al.  similarly reported the experi- Education was described in a number of papers as offering ence of an AHW who, as the only Aboriginal staff member the possibility of increasing the power and agency of within a hospital department, was continually approached AHWs in the workplace [36, 39, 40]. Several papers from for all socio-cultural needs of Aboriginal clients, increasing the 1990s, [40, 41, 52] however, described comparatively the ‘social worker’ components of their role while limiting limited opportunities for further education available to their ability to use their clinical skills outlined in their job AHWs. Hecker et al.  reflected that access to training description. Harris et al.  and Tregenza and Abbott  and educational opportunities for AHWs at that time both highlight the problematic assumption that AHWs are were largely dependent on the motivations of the individ- automatically and sufficiently culturally skilled or experi- ual. The same paper also reported low standards of train- enced to manage complex demands relating to their cul- ing and lack of skills in English literacy and numeracy that tural mentorship or brokering role. Several papers created barriers to accessing those educational opportun- additionally described the demanding responsibilities expe- ities that did exist. More recent papers included accounts rienced by AHWs and high expectations from the system that suggest some improvements in access to education. in remote area services, relating to AHWs’ navigation of Rose  reported the account of one AHW who received cultural and linguistic challenges where English was a sec- training as an Aboriginal Health Education Officer, de- ond or third language [39, 41]. scribing how her education gave her additional confidence Topp et al. International Journal for Equity in Health (2018) 17:67 Page 14 of 17 and knowledge to meet both community and co-workers’ described in two papers exploring the reasons for high rates expectations, reflecting that ‘knowledge is power’.How- of smoking among AHWs responsible for chronic disease ever, without structural reforms relating to AHW career services, which found that smoking practices were rein- structure, King et al.  described a perception among forced by AHWs’ embeddedness in communities and some AHWs that more recently-acquired qualifications health services where smoking was normalised or at least were perhaps not worth the effort, given that after gaining practiced socially. This was, as well, found to be a response these they were offered no specific role or responsibility to to the stress arising from the multiple demands of their role use their new skills. [13, 54]. McMasters et al.  also described a clash be- tween some non-Indigenous or even institutional-based ex- Provider dimension pectations that AHWs should be giving lifestyle advice to Straddling different cultures Aboriginal clients, and AHWs’ own culturally-informed Multiple papers highlighted an overarching distinction, perspective that giving such advice was likely to be inter- and often tension, between the cultural and community preted by Aboriginal clients as a criticism and interfering. obligations and clinical and administrative aspects of the In Jackson et al. , AHWs described their experiences AHW role [34, 35, 40]. AHWs in one study reflected that balancing complex lines of responsibility, and instances of the AHW approach, in contrast to other health profes- incompatibility in their professional role with cultural ex- sional roles, was one of ‘co-ownership’ of health by both pectations relating to gender, age and kinship. Jennings et themselves and their community, because patients are al.  also reported female AHWs feeling reluctant to ‘our people’ . In Deshmukh et al.  an AHW simi- discuss some lifestyle modification behaviours with male, larly reflected that ‘as AHWs we are still the community’. and particularly elder male, clients, or with males from Lloyd et al.  contrasted the perspectives of AHWs with differing cultural groups. Hengel et al. described bar- those of nurses on the scope of their health care role, with riers to patient access relating to the nature of cultural re- nurses emphasising boundaries between ‘the clinic’ and lationships involving AHWs and members of the individual responsibility, and AHWs recognising the social community. In one study, being based in a rural health and economic determinants of the diseases presenting in service was seen to exacerbate challenges faced by AHWs the clinic. The clinical aspects of the role were described in navigating between Aboriginal and health service cul- in one study as ‘largely institutionalised’, and as favouring ture, since staff shortages in the area meant that AHWs ‘objectivity and maintenance of professional boundaries’ were expected to see patients with whom there were ten- . Reflecting a policy manifestation of the tensions, a sions due to family business, cultural taboo or personal situation was described in a Northern Territory govern- dynamics . These cultural challenges were also seen to ment program evaluation in which Aboriginal ‘Strong arise within the workplace, such as where older AHWs Women Workers’ were helping Aboriginal women to give carried their role as elders into their relations with other birth in local communities, against Departmental policy staff, with the potential for conflict . and without remuneration, because they believed this was better for the mother and baby . Partnership models and improved communication The need to straddle the two cultures was also described Several papers described the benefit to workplace dy- at a more interpersonal level with the need for AHWs to namics and ultimately healthcare delivery of the imple- constantly manage the expectations of non-Indigenous mentation of partnership models between AHWs and health professionals including managers . Reflecting on their non-Aboriginal colleagues [6, 55]. One of these de- tensions between the community-oriented versus scribed a peer-mentoring model between Aboriginal and clinic-oriented framing of their role, AHWs in Rose  non-Aboriginal health professionals, which was found to emphasised their community role as their ‘real’ role, involv- improve communication between staff and facilitate ing informal discussion with community members about more collegial relationships . A need for better com- complex issues, as compared with more ‘formal referrals’ or munication between health service managers and AHWs clinic-based tasks. An AHW in a much earlier study similarly was identified in another study that was seeking to ad- expressed their prioritisation of community responsibilities if dress poor communication by managers about the ob- any tensions were apparent . In some studies, however, jectives and targets of projects, and to break down AHWs reported frustration with the presumption that they organisational hierarchies . One AHW described should only or predominantly focus on culturally-informed the increased patient trust developed towards midwives counselling duties, expressing a desire to develop and/or bet- following initiation of a two-way partnership model be- ter utilise their clinical skills [7, 12, 18]. tween AHWs and midwives, within which the roles Beyond these overarching issues, many articles reflected were treated as ‘mutually equivalent’ . However, an- on specific tensions between cultural and professional obli- other program focused on implementing two-way gations. The challenges of straddling the two cultures was learning based on cultural knowledge of AHWs Topp et al. International Journal for Equity in Health (2018) 17:67 Page 15 of 17 highlighted a number of challenges in both design and in descriptions of dissonance between AHWs’ cultural implementation of the model, including lack of consen- and professional identities as they tried to negotiate a sus on how two-way learning could lead to improved path between community expectations, requirements of outcomes and on what mechanisms are needed to sup- their often bio-medically oriented workplace, and their port the integration of AHWs into a particular practice own professional aspirations. These tensions are argu- environment . ably exacerbated by prevalent policy expectations that AHWs can address or improve health outcomes caused Discussion by profound, often inter-generational structural inequi- We conducted an adapted systematic review of the pub- ties linked to poverty and social marginalisation. lished literature to map the evidence relating to AHWs’ Despite reports of AHWs being ‘everything to everyone’ accountability relations in the Australian health system. and a ‘jack of all trades,’ the literature also demonstrated We found few studies with a primary focus on AHW gov- that AHWs often struggled to gain sufficient educational at- ernance and none with a primary focus on AHWs’ ac- tainment or professional opportunities in order to be able countability relationships. Nonetheless, data from a range to demonstrate mastery of their practice that would enable of empirical studies and AHW-authored commentaries them to progress in their career. Indeed, the reviewed lit- did provide evidence of AHWs’ workplace experiences erature highlighted the ambiguity of the AHW role and the and some insight into the accountability eco-system in large gap between the idealised capabilities and presumed which this unique cadre operate. centrality of the role within health provider teams, and the AHWs experience multiple and overlapping account- experienced reality of multiple and sometimes abilities in all four of the dimensions proposed by van mutually-exclusive obligations to community and the sys- Belle and Mayhew . Reflecting accountabilities in the tem. Power imbalances in AHWs’ workplaces stemming social dimension, AHWs’ sense of connection and be- from clinical hierarchies and vertical health administration longing within their community was frequently dis- structures meant that there were limited opportunities to cussed. In several articles [7, 37, 41] AHWs reported discuss or mediate the above-mentioned tensions. AHWs’ feeling a strong sense responsibility for ensuring that the felt their professional influence and status were limited, health service was accessible to and safe for ‘their many reportinghowthesamepower dynamicsandstruc- people’, and described their role as a critical mediator in tures, rooted in the biomedical approach of Australia’s ensuring such access. While described as essential to de- mainstream health system, in fact challenged and under- veloping trust and as a source of pride, connection with mined their own conceptualisation of health and wellbeing. community and the obligations it implied also came at a Perceptions of being under-valued and poorly supported by cost. AHWs in a number of studies reported being con- the health system at the macro and meso (state based car- stantly on duty and having a sense of being ‘everything eer structures) and micro (health facility) levels, were a to everyone’. These themes are reflective of findings common theme and mirror experiences elsewhere [59, 60]. from several recent studies of CHWs in both low and The review demonstrates evidence of complexity in middle-income settings which have highlighted the para- AHWs’ accountability relationships in literature spanning dox between the value of CHW connectedness to com- several decades. Yet this study also highlights the large munity, and the difficulties of simultaneously managing gaps in theoretically-informed and systematic investiga- community expectations and demands [18, 56–58]. tions of accountability relations and related issues includ- Obligations from the social domain overlapped with ing the power dynamics that underpin both governance those in both the organisational and provider dimen- and accountability arrangements for AHWs in the Austra- sions of accountability. AHWs in multiple studies re- lian health system. While various studies made reference ported having to straddle concurrent cultural obligations to the ‘dual role’ and AHWs’ straddling of ‘two cultures’, including those relating to gender, age and kinship, and most were descriptive in nature and defaulted to recom- the expectations of non-Indigenous colleagues and man- mending improved role clarity and clinical (often special- agers rooted in Western models of clinical governance ist) training for AHWs as the remedy. Few articles and management. Biomedical dominance combined with reflected meaningfully on the inherent tensions of a role lack of role clarity were linked to pervasive system-wide that is, at its core, culturally-constituted, but located misunderstanding of AHWs’ role and responsibilities – within a service environment shaped by vertical power re- particularly the cultural components – which in turn lations and (in many settings) a Western biomedical acted as a barrier to AHWs working to their full capacity model of healthcare. Nor, despite some observations re- for the benefit of patients, broader society and their own garding the challenges experienced by female AHWs, did professional satisfaction. Tensions between these ‘hori- we find evidence of gender analysis in relation to this zontal’ organisational accountabilities and the ‘down- highly feminised cadre of providers. Writing about CHW wards’ accountability to communities were highlighted programs more generally, others have noted that Topp et al. International Journal for Equity in Health (2018) 17:67 Page 16 of 17 questions remain relating to the influence of shared cul- research. SMT would like to acknowledge intellectual input from colleagues present at the 'Think-in' on Community Health Worker Voice, Power and ture and gender on CHW program effectiveness, and the Citizens' Right to Health workshop (June 2017) co-hosted by the Averting Ma- most appropriate methods of integrating culture into pro- ternal Death and Disability (AMDD) Program at the Mailman School of Public gram design and training . Health, Columbia University and the Accountability Research Centre (ARC) at American University. Tregenza and Abbott  and Genat et al.  both ex- plored these issues in greater depth, albeit in very different Availability of data and materials settings and drawing on data collected in the mid- and All data are available through the manuscript. late 1990s respectively. Yet several significant policy shifts Authors’ contributions have occurred in the AHW profession (see Table 1)and in SMT conceived and designed the study; SMT and AE conducted the searches, the policy landscape of the Australian health system (e.g. extracted and analysed the data and wrote the first draft of the manuscript. ST reviewed and provided critical feedback at each stages of data extraction, introduction of the Close the Gap initiative ) since this analysis and writing. All authors approved the final version of the manuscript. time. Up-to-date investigation of the governance arrange- ments and accountability relationships under the contem- Ethics approval and consent to participate This review utilized only publicly available and published data, thus formal porary policy architecture is required, including ethical approval was not required. theoretically-informed work, such as the study described by Peiris et al. , which seeks to understand whether Competing interests The authors declare that they have no competing interests. and how governance arrangements in both mainstream and community-controlled health services can better ac- Publisher’sNote commodate and support this complex role. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Conclusion Author details Health inequity among Aboriginal and Torres Strait College of Public Health, Medical and Veterinary Sciences, James Cook Islander peoples and non-Indigenous Australians is University, James Cook Drive, Townsville, QLD 4810, Australia. Nossal Institute for Global Health, University of Melbourne, Melbourne, VIC 3010, pronounced and for several decades AHWs have been Australia. Torres and Cape Hospital and Health Service, Community Wellness identified within commonwealth and state policies as Centre, Thursday Island Hospital Campus, Thursday Island, QLD 4875, important mediators of access toculturallysafe careand as Australia. a strategy to help close the gap between Indigenous and Received: 6 February 2018 Accepted: 17 May 2018 non-Indigenous health outcomes. Understanding how the governance and accountability relationships of AHWs in- References fluence their ability to address health inequities experienced 1. Schneider H, Nxumalo N. 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International Journal for Equity in Health – Springer Journals
Published: May 30, 2018
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