Examining the role of Indigenous primary healthcare across the globe in supporting populations during public health crises

ABSTRACT

When health systems are overwhelmed during a public health crisis regular care is often delayed and deaths result from lapses in routine care. Indigenous primary healthcare (PHC) can include a range of programmes that incorporate treatment and management, prevention and health promotion, as well as addressing the social determinants of health (SDoH) and a focus on redressing health inequities. We examined how Indigenous PHC mobilises and innovates during a public health crisis to address patient needs and the broader SDoH. A rapid review methodology conducted from January 2021 – March 2021 was purposefully chosen given the urgency with COVID-19, to understand the role of Indigenous PHC during a public health crisis. Our review identified five main themes that highlight the role of Indigenous PHC during a public health crisis: (1) development of culturally appropriate communication and education materials about vaccinations, infection prevention, and safety; (2) Indigenous-led approaches for the prevention of infection and promotion of health; (3) strengthening intergovernmental and interagency collaboration; (4) maintaining care continuity; and (5) addressing the SDoH. The findings highlight important considerations for mobilising Indigenous PHC services to meet the needs of Indigenous patients during a public health crisis such as the COVID-19 pandemic.

KEYWORDS:

• Indigenous primary healthcare
• public health crisis
• pandemic
• social determinants of health
• Indigenous populations

Background

Primary healthcare (PHC) is a core component of the health system (World Health Organization Alma-Ata, 1978), and a first, or only, point of contact for families over time with professionals who can facilitate access to specialist care and support. PHC is a critical foundation of health and wellbeing at every stage of life (WHO Alma-Ata, 1978) and crucial during public health crises. PHC marks the beginning of a continuous health process (Muldoon et al., 2006; Wright & Mainous III, 2018) being inclusive of health promotion (e.g. hand hygiene), disease prevention (e.g. vaccinations), health maintenance, education, and rehabilitation (WHO Alma-Ata, 1978). The 2008 World Health Organization (WHO) World Health Report called for a worldwide renewal of PHC, including reorientation towards person-centred care rather than focusing on the presence or absence of disease alone (WHO Alma-Ata, 1978; WHO World Health Report, 2008). Furthermore, community participation is a key principle of PHC and patients are encouraged to participate in making decisions about their own health, in identifying the health needs of their community, and in considering alternative approaches to addressing those needs (van Weel & Kidd, 2018).

Addressing the Social Determinants of Health (SDoH) through PHC

Increasing focus on health inequities has brought renewed attention to two related health policy discourses which are inextricable from each other—PHC and the SDoH (Rasanathan et al., 2011). The Commission on Social Determinants of Health (CSDH) defined the SDoH as ‘the structural determinants and conditions of daily life responsible for a major part of health inequities between and within countries (Commission on Social Determinants of Health, 2008).’ SDoH provide a lens that illuminates the systemic causes of health inequities while identifying ways to address them; PHC is well-positioned to address the SDoH in that health equity is a core value of PHC systems (Baum et al., 2013; Pinto & Bloch, 2017; Rasanathan et al., 2011). Strong systems of PHC have demonstrated their ability to advance health equity, lower health costs, and improve overall population health (Starfield et al., 2005; van Weel & Kidd, 2018). Despite the significant overlap between the principles of PHC and the need to better address the SDoH, there is still a substantial gap in both the understanding and implementation of PHC to effectively close gaps in health equity (Andermann, 2016).

Disparities in effective PHC services are most pronounced for Indigenous populations worldwide for whom the SDoH disproportionately impacts health (Reading & Wien, 2009; United Nations, 2007). Indigenous people across different countries descent from the populations who inhabited the country before the arrival of European settlers, and how irrespective of their legal status, retain their own social, economic, cultural and political institutions (United Nations, n.d.). Maybury-Lewis (2002) states that ‘Indigenous peoples are defined as much by their relations with the state as by any intrinsic characteristics that they may possess.’ Improving population health among Indigenous people across the globe requires addressing the SDoH through PHC, including a focus on health promotion and public health initiatives (Harfield et al., 2018; Rasanathan et al., 2011). Stemming from the longstanding and continuing impacts of colonisation, inequalities in physical, social, and mental health are amplified by the exclusion of Indigenous peoples in mainstream PHC services (Horrill et al., 2018; Reading & Wien, 2009). Indigenous peoples are often unable to access PHC to have their needs effectively met (Davy et al., 2016; Harfield et al., 2018; Kim, 2019; Reading & Wien, 2009). In response, exemplar models of Indigenous PHC organisation that adequately meet the needs of Indigenous peoples and communities have been promoted to reaffirm opportunities for Indigenous health advancement (Harfield et al., 2018). Indigenous-driven and -led PHC services derive from the principles and values of whom they serve (Harfield et al., 2018). Furthermore, Indigenous PHC services are characterised as culturally appropriate, holistic, accessible, and self-determined, and can include a range of comprehensive programmes that incorporate treatment and management, prevention and health promotion, as well as addressing the SDoH and how they contribute to health inequities (Harfield et al., 2018).

Role of PHC during a public health crisis

While both PHC and public health are interconnected parts of providing equitable healthcare, they often operate in relative isolation which is illuminated during times of health system stress such as during a pandemic. Pandemics shift the way in which PHC is delivered whereby regular care is often postponed (Rawaf et al., 2020). During the current global pandemic of COVID-19, PHC services are managing the reallocation of healthcare resources and the after-effects of patients who are suspected to have or confirmed to have COVID-19 (Rawaf et al., 2020). When health systems are overwhelmed during outbreaks, deaths caused by lapses in routine care can increase dramatically (PHCPI, 2018). Despite knowing this, healthcare systems necessarily shift their focus and resources to emergency and intensive care services (Blumenthal et al., 2020). This situation is further exacerbated for Indigenous PHC, which already faced the realities of under-resourcing, the aforementioned inequities in SDoH, and jurisdictional complexities in health service responsibilities. These inequities were glaringly apparent during the 2009 H1N1 pandemic when Indigenous people made up approximately 10% of all deaths from H1N1 (Driedger et al., 2013) and thus highlight the need to reconsider approaches to sustain Indigenous PHC while aiming to support public health goals. There are important lessons shared in the literature on how Indigenous PHC mobilises to address population needs during a public health crisis, and which components of a PHC system facilitate and enable Indigenous PHC to continue to provide services. This review aims to identify, appraise, and summarise emerging research evidence to support recommendations to strengthen Indigenous PHC responses during the COVID-19 pandemic.

Methods

A rapid review methodology was purposefully chosen given the urgent need to understand the role of Indigenous PHC in a public health crisis. The review was undertaken from January to March 2021 by the Indigenous Primary Health Care and Policy Research (IPHCPR) Network (www.iphcpr.ca) and informed by rapid review methods outlined by the National Collaborating Centre for Methods and Tools (Dobbins, 2017). Rapid reviews provide a timely, valid and balanced assessment of available evidence related to a particular policy or practice issue (Watt et al., 2008). The process for a rapid review of evidence is characterised by developing a focused research question, a less developed search strategy, evidence searches, and then more simplified data extraction and quality appraisal of the identified literature when compared to traditional systematic reviews (Watt et al., 2008). The following questions were used to guide the rapid review: How does Indigenous PHC mobilize to address patient and community needs during a public health crisis? What are the components (organization, systems, programs, providers, communities) of the response? A protocol has been registered with the University of Alberta Education and Research Archive (https://doi.org/10.7939/r3-bpf3-by13) and published on the Open Science Framework Registries (osf.io/3tkgr).

Search strategy

The search was conducted on November 19th, 2020 and had no exclusion criteria around dates. The earliest manuscript that was reviewed was from 1946. The search strategy was set to identify PHC responses to pandemics and epidemics among Indigenous populations, specifically structures of service delivery, health policy, resource allocation, and organisation of care on Indigenous health outcomes. A list of Indigenous populations identified in the sources reviewed, who are called, variously, Indigenous, tribal, native, or Aboriginal in different parts of the world, can be found in Appendix A. Two search term filters were used: population and outcome. The population filter was built to identify international Indigenous populations by combining general, country-specific, and tribe-specific search terms, while the outcome filter was developed to include COVID-19, general pandemics, and general epidemics; the results of these two searches were combined with the Boolean operator ‘AND.’ The search was restricted to English, French, and Spanish languages. Of note, because of the limited research in this area, the search strategy did not filter for countries that have established Indigenous PHC services. MeSH terms and subject headings were included synergistically in the search for robustness. Searches were conducted in Medline, Embase, CINAHL, and Web of Science databases by researchers at the Alberta SPOR SUPPORT Unit. Results of the searches were exported to Covidence systematic review software, where duplicates were removed. Search strategies are available in Appendix A.

Selection criteria

The Population, Intervention, Comparator, Outcomes, and Design (PICOD) framework was employed to develop the eligibility criteria for this rapid review (see Table 1). Eligibility criteria were defined as follows: (1) focused exclusively on Indigenous peoples in Canada (First Nations, Métis, and/or Inuit) and other Indigenous populations across the globe, (2) focused on pandemics or epidemics involving influenza-like infections (CDC, 2018; World Health Organization Europe, n.d.), (3) focused on the PHC response during a public health crisis in Indigenous communities, and/or (4) identified how core PHC functions were mobilised during the public health crisis examined, including collaboration and coordination between community departments (e.g. housing, health, family and social services, etc.) and addressing the social determinants of health, and/or (5) focused on Indigenous models of health and wellness, including the role of culture and Indigenous ways of knowing. Studies were excluded if they reported on non-communicable diseases, sexually transmitted and blood-borne infections (STBBIs), foodborne illnesses or other non-influenza-like infectious diseases. Primary empirical studies, theoretical studies, reviews of empirical studies and implementation studies were also included. For title and abstract screening, each source was independently evaluated twice by three authors (KF, AS, AH) and any disagreements were resolved by discussion until a consensus was reached.

Table 1. PICOD statement.

Population	Indigenous peoples impacted during a public health crisis
Intervention	PHC programmes, services, or interventions that address Indigenous patients’ health needed or improve health outcomes. Specifically investigating Indigenous-focused programmes/services/interventions based on the adoption of western programmes/services/interventions for an Indigenous context along with Indigenous-led which refers to programmes/services/interventions that are driven by Indigenous peoples
Comparator	N/A
Outcomes	Indigenous peoples’ well-being, informed by access to necessary PHC services during a public health crisis; and related to equity and social determinants of health
Study Design	Primary empirical studies (qualitative, quantitative, or mixed-methods), theoretical studies; reviews of empirical studies; implementation studies

Grey literature search

An additional search was also conducted using Google and Google Scholar to identify studies not published in indexed journals and grey literature sources. Studies relating to PHC initiatives undertaken by governmental and/or Indigenous organisations may be disseminated through websites, news articles or open-access databases. The search was restricted by country to capture relevant data from Canada, the United States, circumpolar countries, Australia, and New Zealand. The grey literature search was restricted to the countries listed above as all but one primary research article from the systematic search was either from New Zealand, Australia, or Canada. In addition, due to the rapid timeframe of this review, and the need to provide timely evidence and guidance to key stakeholders working in Indigenous PHC, we limited the countries we searched and only looked to the first 50 results that were generated in google which were then screened for inclusion. The same inclusion criteria were applied to the grey literature search. Grey literature was excluded if it was a narrative or anecdotal account of Indigenous peoples’ and/or organisations’ experiences during a public health crisis with no further discussion on mobilising or responding to patient and/or community needs during a public health crisis.

Data extraction

Data was extracted into a data extraction form in Microsoft Excel that included the source title, publication date, location, description of the public health crisis, the PHC setting, health outcomes measures, and SDoH supported (refer to Appendix B for the data extraction form) by the same three researchers. Two authors (KF, AS) performed full-text reviews of selected screened articles to verify which met the inclusion criteria.

Data synthesis

A thematic analysis was undertaken using Maxwell’s (2005) and Miles and Huberman’s (1994) qualitative analysis technique of descriptive and pattern coding. Extracted data was open-coded by two researchers (KF, AS) and then categorised to identify patterns, similarities, and differences throughout the data. Disagreements in data analysis were resolved through discussion until researchers (KF, AS) reached a consensus. Themes were reviewed and verified by a public health and health policy researcher (SM), an Indigenous PHC provider (LC), and an Indigenous health services researcher (CB).

Quality assessment

The quality of each study was evaluated using the Joanna Briggs Institute (JBI) critical appraisal tools (Aromataris & Munn, 2020). Quality assessment was completed by one reviewer (EP) and verified by a second reviewer (TK); any conflicts were resolved through consensus. An adapted JBI Text and Opinion tool from the National Collaborating Centre for Indigenous Health was employed to reflect Indigenous Ways of Knowing in the quality evaluation of these studies (National Collaborating Centre for Methods and Tools & National Collaborating Centre for Indigenous Health, 2020). This required the inclusion of two additional questions to the JBI appraisal tools. Articles were scored high, moderate or low quality following the National Collaborating Centre for Methods and Tools & National Collaborating Centre for Indigenous Health (2020) guidelines. Grey literature was not critically appraised for this rapid review.

Findings

Study characteristics

A total of 3387 records were identified in the peer-reviewed literature search which was reduced to 3375 after removing duplicates. After title and abstract screening, a total of 61 articles remained for full-text review. Following full-text review, a total of 25 peer-reviewed primary research and opinion, commentary or report articles met inclusion criteria and underwent data extraction (refer to the PRISMA flow chart in Figure 1). From the grey literature, a total of 22 sources met inclusion criteria (Page et al., 2021). The peer-reviewed studies (Table 2), commentaries/opinion pieces (Table 3) and grey literature (Table 4) included Canadian, Australian, New Zealand, and South American Indigenous populations and varied between the H1N1 and COVID-19 pandemic public health crises. Noteworthy, while other public health crises were included in the search (e.g. SARS, MERS) there were no records outside of H1N1 and COVID-19 that fit our inclusion and exclusion criteria.

Figure 1. PRISMA flow diagram outlines the article selection process.

Table 2. Peer-reviewed primary research.

Reference	Publication Year	Research Type	Location	Pandemic	Indigenous Led / Focused	Key Findings	Quality Appraisal
Massey, P., Pearce, G., Taylor, K. A., Orcher, L., Saggers, S., & Durrheim, D. (2009). Reducing the risk of pandemic influenza in Aboriginal communities. Rural and Remote Health, 9(1290). https://doi.org/10.22605/RRH1290	2009	Qualitative study	Australia	H1N1	Led	Five identified solutions to reduce negative impacts of pandemic response: (1) Local resource person (2) Clear communication (3) Access to health services (4) Households and funerals (5) Social and community support issues.	Moderate
Rudge, S., & Massey, P. D. (2010). Responding to pandemic (H1N1) 2009 influenza in Aboriginal communities in NSW through collaboration between NSW Health and the Aboriginal community-controlled health sector. New South Wales Public Health Bulletin, 21(2), 26. https://doi.org/10.1071/nb09040	2010	Case study	Australia	H1N1	Led	Developed an appropriate response to protect Indigenous people by: (1) Identifying local 'go to' people (2) Presentating information that is simply, clear and demonstrates respect for local culture (3) Informing sick people on where to go to get help and how to get there without infecting others (4) Delivering infection control messages that are aligned with the reality of life in Indigenous communities, and recognise the importance of attending family and cultural gatherings (5) Ensuring Indigenous people have a say in how support is provided. From this a National Emergency Strategy for Remote Indigenous Communities, called Keeping our mob safe was developed.	Moderate
Charania, N. A., & Tsuji, L. J. (2011). The 2009 H1N1 pandemic response in remote First Nation communities of Subarctic Ontario: barriers and improvements from a health care services perspective. International journal of circumpolar health, 70(5), 564–575. https://doi.org/10.3402/ijch.v70i5.17849	2011	Qualitative study	Canada	H1N1	Focused	Successful components of pandemic response included receipt and distribution of vaccines, and anti-virals. Barriers included stable supply of PPE, human resources and training, communication and community awareness.	High
Massey, P. D., Miller, A., Saggers, S., Durrheim, D. N., Speare, R., Taylor, K., Pearce, G., Odo, T., Broome, J., Judd, J., Kelly, J., Blackley, M., & Clough, A. (2011). Australian Aboriginal and Torres Strait Islander communities and the development of pandemic influenza containment strategies: community voices and community control. Health Policy, 103(2–3), 184–190. https://doi.org/10.1016/j.healthpol.2011.07.004	2011	Qualitative study	Australia	H1N1	Focused	Development of pandemic influenza containment strategies lead to the following themes: (1) Importance of family and ways of life, traditional medicine/practices (2) Housing challenges for quarantine/isolation (3) ‘Ask us, listen to us, share with us.	High
Charania, N.A., Tsuji, L.J. (2012). A community-based participatory approach and engagement process creates culturally appropriate and community informed pandemic plans after the 2009 H1N1 influenza pandemic: remote and isolated First Nations communities of sub-arctic Ontario, Canada. BMC Public Health 12(268) https://doi.org/10.1186/1471-2458-12-268	2012	Qualitative study	Canada	H1N1	Unclear	Four rounds of revisions to existing community pandemic plans were undertaken following the H1HN1 pandemic. A summary of primary modifications included: (1) Clarification around roles and responsibilities in the following categories-surveillance, antivirals and antibiotics, health services, and supplies. (2) Community specific context (3) Community engagement in planning.	High
Gray, L., MacDonald, C., Mackie, B., Paton, D., Johnston, D., & Baker, M. G. (2012). Community responses to communication campaigns for influenza A (H1N1): A focus group study. BMC Public Health, 12(205). https://doi.org/10.1186/ 1471-2458-12-205	2012	Qualitative study	New Zealand	H1N1	Unclear	Residents discussed desire of delivery of key health messages for H1N1 or other health to outline about specific actions that they could take to protect themselves and their families and to mitigate any consequences. Transparent and factual communication where both good and bad news is conveyed by people who they could trust.	High
Charania, N. A., & Tsuji, L. J. (2013). Assessing the effectiveness and feasibility of implementing mitigation measures for an influenza pandemic in remote and isolated First Nations communities: a qualitative community-based participatory research approach. Rural and remote health, 13(4), 2566. https://doi.org/10.22605/RRH2566	2013	Qualitative study	Canada	H1N1	Led	Participants reported lack of resources (e.g. supplies, monies, trained personnel), poor community awareness, overcrowding in homes, and inadequate healthcare infrastructure presented barriers to the implementation of mitigation measures. The importance of engaging local key informants in pandemic planning was emphasised to gain valuable community-specific insight regarding the design and implementation of more effective and feasible mitigation strategies.	High
Driedger, S. M., Cooper, E., Jardine, C., Furgal, C., Bartlett, J. (2013) Communicating Risk to Aboriginal Peoples: First Nations and Metis Responses to H1N1 Risk Messages. PLoS ONE 8(8): e71106. https://doi.org/10.1371/journal.pone.0071106	2013	Qualitative study	Canada	H1N1	Focused	Explored perspectives towards the management of pandemic H1N1 which include: Aboriginal lives are valued less, being Aboriginal is a risk factor, and racism impacted the management of the H1N1 pandemic. The article provided a ‘What not to do’.	High
Kaplan, H. S., Trumble, B. C., Stieglitz, J., Mamany, R. M., Cayuba, M. G., Moye, L. M., … Gurven, M. D. (2020). Voluntary collective isolation as a best response to COVID-19 for indigenous populations? A case study and protocol from the Bolivian Amazon. The Lancet, 395(10238), 1727–1734. https://doi.org/10.1016/s0140-6736(20)31104-1	2020	Case study	South America	COVID-19	Led	A collaborative effort to develop and implement a multiphase COVID-19 prevention and containment plan focused on voluntary collective isolation and contact-tracing. Sources of resilience are described that can be applied to the development of strategies for prevention and mitigation of COVID-19 mortality in Indigenous populations.	High

Table 3. Peer reviewed opinion, commentary, and reports.

Reference	Publication Year	Location	Pandemic	Indigenous Led / Focused	Key findings	Quality Appraisal
Crooks, K., Casey, D., & Ward, J. S. (2020). First Nations peoples leading the way in COVID -19 pandemic planning, response and management. Medical Journal of Australia, 213(4), 151. https://doi.org/10.5694/mja2.50704	2020	Australia	COVID-19	Led	Description of the development of the national management and operational plans and national COVID-19 guides, through an Advisory Group which works on principles of shared decision making, power sharing, two-way communication, self-determination, leadership and empowerment.	High
Finlay, S., & Wenitong, M. (2020). Aboriginal Community Controlled Health Organisations are taking a leading role in COVID-19 health communication. Australian and New Zealand Journal of Public Health, 44(4), 251–252. https://doi.org/10.1111/1753-6405.13010	2020	Australia	COVID-19	Led	Description of the Aboriginal Community Controlled Health Organizations (ACCHO) communications strategies around the COVID-19 pandemic.	High
Fitts, M. S., Russell, D., Mathew, S., Liddle, Z., Mulholland, E., Comerford, C., & Wakerman, J. (2020). Remote health service vulnerabilities and responses to the COVID-19 pandemic. Australian Journal of Rural Health, 28(6), 613–617. https://doi.org/10.1111/ajr.12672	2020	Australia	COVID-19	Focused	Discussion of initiatives implemented to maintain existing health system function and optimise front-line workforce capacity, including telehealth, workforce training and general practice-led respiratory clinics.	High
Hengel, B., Causer, L., Matthews, S., Smith, K., Andrewartha, K., Badman, S., … Guy, R. (2020). A decentralised point-of-care testing model to address inequities in the COVID-19 response. The Lancet Infectious Diseases. https://doi.org/10.1016/s1473-3099(20)30859-8	2020	Australia	COVID-19	Focused	Outline of a framework for the implementation of decentralised point-of-care PCR testing, using and expanding an existing network of GeneXpert platforms introduced for the diagnosis of sexually transmitted infections, which aims to improve access to timely COVID-19 testing in remote communities.	High
Kerrigan, V., Lee, A. M., Ralph, A. P., & Lawton, P. D. (2020). Stay Strong: Aboriginal leaders deliver COVID-19 health messages. Health Promotion Journal of Australia, 32(S1), 203–204. https://doi.org/10.1002/hpja.364	2020	Australia	COVID-19	Led	Targeted materials created in response to community concerns for people with pre-existing chronic conditions, most vulnerable to the threat of COVID-19. Video message tailored for patients with comorbidities focussed on wellness.	High
Moodie, N., Ward, J., Dudgeon, P., Adams, K., Altman, J., Casey, D., Cripps, K., Davis, M., Derry, K., Eades, S., Faulkner, S., Hunt, J., Klein, E., McDonnell, S., Ring, I., Sutherland, S., & Yap, M. (2020). Roadmap to recovery: Reporting on a research taskforce supporting Indigenous responses to COVID-19 in Australia. The Australian journal of social issues, 10.1002/ajs4.133. Advance online publication. https://doi.org/10.1002/ajs4.133	2020	Australia	COVID-19	Focused	Taskforce developed 4 recommendations that aimed to consider the social determinants of health, poverty, the need for the importance of equitable, needs-based funding and social security payments to address deep poverty. They acknowledge the negative impacts of social isolation policies, concerns around family safety and over policing.	High
Banning, J. (2020a). Why are Indigenous communities seeing so few cases of COVID-19? Canadian Medical Association Journal, 192(34). https://doi.org/10.1503/cmaj.1095891	2020	Canada	COVID-19; mention of SARS and TB	Focused	Low COVID numbers due to communities taking initiative and extraordinary public health measures taken by Indigenous communities by connecting virtually, set up trailers for self-isolation, and made roadblocks to control access to their communities	Moderate
Banning, J. (2020b). How Indigenous people are coping with COVID-19. Canadian Medical Association Journal, 192(27). https://doi.org/10.1503/cmaj.1095879	2020	Global	COVID-19	Unclear	Indigenous-led ways of staying safe and coping during the pandemic: include going out on the land, participating in traditional activities and communities coming together to take care of each other	Moderate
Close, R. M., & Stone, M. J. (2020). Contact Tracing for Native Americans in Rural Arizona. New England Journal of Medicine, 383(3), e15.	2020	United States	COVID-19	Led	Integrated, intensive response plan, which included: intensive contact tracing- identifying those at highest risk in the household (often crowded home environments), performing rapid testing on newly identified contacts; a team of physicians who visited people who have tested positive; and public health nurses who call high-risk contacts to verify they are remaining asymptomatic through the incubation period.	High
Dyer, J. (2020). Practicing infection prevention in isolated populations: How Navajo Nation took on COVID-19. Infection Control Today, 24(8), 24–26. https://www.infectioncontroltoday.com/view/how-the-navajo-nation-took-on- covid-19	2020	United States	COVID 19	Focused	Prompt action and culturally sensitive care solutions- including reducing clinics, increasing access to testing, repurposing hospital rooms to prepare for an influx of patients, reorienting/deploying staff, develop PPE tracker, patient education, contact tracing, quarantine measures/isolation hotels, outreach (by Navajo speaking care providers).	High
Eades, S., Eades, F., McCaullay, D., Nelson, L., Phelan, P., & Stanley, F. (2020). Australia's First Nations’ response to the COVID-19 pandemic. The Lancet, 396(10246), 237–238. https://doi.org/10.1016/s0140-6736(20)31545-2	2020	Global	COVID-19	Focused	Indigenous-Led response was effective through giving power and capacity to Indigenous leaders.	High
Groom, A. V., Jim, C., LaRoque, M., Mason, C., McLaughlin, J., Neel, L., … Bryan, R. T. (2009). Pandemic Influenza Preparedness and Vulnerable Populations in Tribal Communities. American Journal of Public Health, 99(S2). https://doi.org/10.2105/ajph.2008.157453	2009	United States	General Pandemic Preparedness	Led	Considerations and recommendations. Tribes must depend on close cooperation with state and county health departments to receive resources to support pandemic influenza preparedness planning. Resources include access to the Strategic National Stockpile, assistance with purchasing antiviral medications, and support in administering pandemic influenza vaccine. In addition, improving tribal public health legal infrastructure and using legal tools such as mutual aid agreements will help address jurisdictional issues and carry out community mitigation strategies within tribal communities. Example of Indigenous led resource – Pandemic Influenza Storybook – American Indian family demonstrated how traditional native knowledge exemplified ‘modern’ principles of disease containment that led to their survival.	High
Herceg, A., Sharp, P. G., Arthur, C. G., & Tongs, J. A. (2010). Pandemic (H1N1) 2009 influenza in an urban Aboriginal medical service. Medical Journal of Australia, 192(10), 623–623. https://doi.org/10.5694/j.1326-5377.2010.tb03655.x	2010	Australia	H1N1	Led	Responses to H1N1 including enhanced infection control, influenza testing procedures, electronic data collection and obtaining of oseltamivir. A pre-existing influenza pandemic plan, internal public health capacity, good working relations with local health agencies, on-site dispensing and service-specific protocols were important features of their response.	High
Hernandez, S., Oliveira, J. B., Mendoza Sosof, C., Lawrence, E., & Shirazian, T. (2020). Adapting antenatal care in a rural LMIC during COVID-19: A low literacy checklist to mitigate risk for community health workers. International Journal of Gynecology & Obstetrics, 151(2), 289–291. https://doi.org/10.1002/ijgo.13332	2020	South America	COVID-19	Led	Training of local maternal child health workers using a low literacy check list was perceived as successful.	High
Jardim, P. de, Dias, I. M., Grande, A. J., O’keeffe, M., Dazzan, P., & Harding, S. (2020). COVID-19 experience among Brasil’s indigenous people. Revista Da Associação Médica Brasileira, 66(7), 861–863. https://doi.org/10.1590/1806-9282.66.7.861	2020	South America	COVID-19	Led	Describes the importance and impact of bottom-up leadership among Indigenous communities, and that Indigenous peoples participate in the design, implementation, and evaluation of COVID-19 response strategies.	High
Richardson, L., & Crawford, A. (2020). COVID-19 and the decolonization of INDIGENOUS public health. Canadian Medical Association Journal, 192(38). https://doi.org/10.1503/cmaj.200852	2020	Global	COVID-19	Unclear	Recognition of impacts of colonialism, social inequities, Indigenous self-determination, leadership, and knowledge have been successful in protecting Indigenous communities in Canada during the COVID-19 pandemic, and these principles should be at the forefront when planning public health approaches with Indigenous Peoples.	High
Richardson, K. L., Driedger, M. S., Pizzi, N. J., Wu, J., & Moghadas, S. M. (2012). Indigenous populations health protection: A Canadian perspective. BMC Public Health, 12(1). https://doi.org/10.1186/1471-2458-12-1098	2012	Canada	H1N1	Focused	This source discusses a workshop that brought together stakeholders, policy decision makers, and researchers from a wide array of disciples, each with the common goal of improving the health status of Canada's Indigenous populations and build stronger links between theory, policy and practice. A set of recommendations were generated.	High
Jenkins, R., Burke, R. M., Hamilton, J., Fazekas, K., Humeyestewa, D., Kaur, H., … Balajee, S. A. (2020). Notes from the Field: Development of an Enhanced Community-Focused COVID-19 Surveillance Program — Hopi Tribe, June—July 2020. MMWR. Morbidity and Mortality Weekly Report, 69(44), 1660–1661. https://doi.org/10.15585/mmwr.mm6944a6	2020	United States	COVID-19	Led	A piloting of a surveillance programme out of a collaboration between Indian and state programming and the federal CDC to enhance COVID-19 surveillance and to deliver health education in two villages; House-to-house COVID-19 surveillance and education was feasible, as evidenced by the use of 10 staff members to screen 141 persons in <10 h, and well-accepted, as indicated by a 5% household refusal rate.	High
Rosenthal, E. L., Menking, P., & Begay, M.-G. (2020). Fighting the COVID-19 Merciless Monster. Journal of Ambulatory Care Management, 43(4), 301–305. https://doi.org/10.1097/jac.0000000000000354	2020	United States	COVID-19	Led	Description of the Navajo Community Health Representative (CHR) role in the pandemic.	High

Table 4. Grey literature sources.

Reference	Publication Year	Source Type	Location	Pandemic	Indigenous Led / Focused	Key findings
NCCIH Communications Officer, L. (2016). Pandemic Planning in Indigenous Communities: Lessons Learned from the 2009 H1N1 Influenza Pandemic in Canada. National Collaborating Centre for Indigenous Health. https://www.nccih.ca/495/Pandemic_planning_in_Indigenous_communities__Lessons_learned_from_the_2009_H1N1_influenza_pandemic_in_Canada.nccih?id=176	2016	report	Canada	H1N1	Led	Lessons Learned: (1) Prevention planning (improved housing, equal access to social material, empower communities, increase healthcare resources, culturally appropriate policies) (2) Effective emergency response (medical resource and supplies delivered in timely manner, access to health care, government collaboration, surveillance, public health interventions) (3) Communication (improve messaging by ensuring messages are clear and consistent, timing is critical, targeted approach, reliable, culturally specific, shift historical power imbalances, deliver by local representatives)
NSW Health. (2019, July 3). Pandemic preparedness: pandemic planning with Aboriginal communities. Retrieved August 1st, 2021from https://www.health.nsw.gov.au/pandemic/Pages/engaging_aboriginal_communities.aspx	2019	website content	Australia	Influenza	Led	Considerations provided when developing pandemic services for Aboriginal communities, including: the importance of family and particular ways of life in Aboriginal communities; the realities of living that make it challenging to stop the spread of influenza in Aboriginal communities; the need to have plans focus on effective communication, understanding and respect; the need for an ongoing process of engagement and consultation with Aboriginal communities and their health services; the reality of large and extended families living in a single house, or multiple houses which an Aboriginal person considers ‘home’.
Cousins, B. (2020, October 23). Indigenous mobile health unit combines traditional and modern medicine for treatment. CTVNews. https://www.ctvnews.ca/health/indigenous-mobile-health-unit-combines-traditional-and-modern-medicine-for-treatment-1.5157289.	2020	news article	Canada	COVID-19	Led	A Mobile Health Unit in Toronto combines traditional Indigenous treatments and modern medicine to help care for the city’s homeless and most vulnerable people.
Kennedy, B. (2020, December 28). Bringing a COVID-19 vaccine to Black and Indigenous communities distrustful of the health system has unique challenges. Here are some places to start. thestar.com. https://www.thestar.com/news/gta/2020/12/28/bringing-a-covid-19-vaccine-to-black-and-indigenous-communities-distrustful-of-the-health-system-has-unique-challenges-here-are-some-places-to-start.html.	2020	news article	Canada	COVID-19	Led	Discussion of Anishnawbe Health Toronto's capacity for vaccination programme, and request of allocation of vaccines. Highlighting of province announcement of a nine-member COVID-19 Vaccine Distribution Task Force, made up of health, business and political leaders and includes three people of colour. Confidence by Anishnawbe Health Toronto that if called upon to distribute the vaccine it will ‘definitely’ lead to more uptake within the city’s Indigenous populations, stating, ‘We’re better connected to our community and better able to reach out to them.’ Sentiments were echoed that the advice of other experts that partnering with trusted community organisations will be key, along with providing information in a transparent and non-judgmental way.
OCHA. (2020, November 6). Colombia responds to COVID-19 with an intercultural health model – Colombia. ReliefWeb. https://reliefweb.int/report/colombia/colombia-responds-covid-19-intercultural-health-model.	2020	news article	South America	COVID-19	Focused	The Alta Guajira health authorities, the PAHO/WHO, supported and financed, implemented an intercultural health model with 16 Indigenous community health workers who carry out surveillance and other essential health services.
Australian Government Department of Health. (2020, June 12). Keeping remote Aboriginal and Torres Strait Islander communities safe from COVID-19. Partyline. https://www.ruralhealth.org.au/partyline/article/keeping-remote-aboriginal-and-torres-strait-islander-communities-safe-covid-19.	2020	news article	Australia	COVID-19	Unclear	Discussion of use of Point-of-care tests in remote Western Australian communities resulting in those tested being able to stay within community, connected to their support networks. while awaiting results and prevented costly and potentially stressful evacuation of the patients. Two online COVID-19 training modules were also developed for remote area Aboriginal and Torres Strait Islander healthcare workers.
Roberts, L. (2020, May 11). Aboriginal Territorians are ‘significantly represented’ in disease outbreaks, but not coronavirus. ABC News. https://www.abc.net.au/news/2020-05-04/coronavirus-nt-aboriginal-outcomes-show-lessons-for-future/12188762.	2020	news article	Australia	COVID-19	Focused	Discussion of effectiveness of COVID-19 health messages being adopted well, due to having been development by Aboriginal people, health groups and organisations. Outlined ongoing fundamental challenges which may increase risk and spread of pandemics in Aboriginal communities.
Danila Dilba Health Service. (2020, May 28). Senate Select Committee on COVID-19. Parliment of Australia. https://www.aph.gov.au/DocumentStore.ashx?id=b4cd6f4c-b97a-4b91-a5d5-c7bd31ff92f0&subId=684214.	2020	report	Australia	COVID-19	Focused	Description of intensive planning undertaken by the Danila Dilba Health Services to modify every aspect of operations, from rapid implementation of telehealth services, urgent sourcing of PPE and flu vaccinations, scaling up ICT to enable telehealth, work from home and other innovations, modifying clinic hours, staff training and redeployment planning to protect vulnerable frontline workers, and rapid upscaling of internal information to inform and educate all staff.
Business Partnerships Platform. (2020, May 1). Telehealth platform tested in India trialled in Indigenous communities in Australia. Bussiness Partnerships Platform. https://thebpp.com.au/blog/telehealth-platform-developed-in-india-to-be-trialed-in-indigenous-communities-in-australia/.	2020	website content	Australia	COVID-19	Unclear	Description of first stage of trial undertaken in three Indigenous community controlled primary health services on the Mid North Coast of New South Wales. The partners are modifying and improving the platform for the Australian primary health service setting. A planned second stage aims to bring the patient management platform, on a cloud-based patient management system with in-built telehealth capabilities to the primary health services in the Aboriginal Community Controlled Health Services (ACCHS) network. Within Australia, there are currently about 300 of such primary health services with the majority in rural remote areas.
Anishinabek News. (2020, August 27). The North Bay Indigenous Hub sees continued success throughout the pandemic. Anishinabek News. https://anishinabeknews.ca/2020/08/27/the-north-bay-indigenous-hub-sees-continued-success-throughout-the-pandemic/.	2020	news article	Canada	COVID-19	Focused	Highlighting of Indigenous Hub flexibility to transition providing remote support for community and Elders. Virtual visits, and an Elder’s basket exchange was implemented as weekly check-ins to determine needs and offer support. PPE supplies were also provided to each First Nation.
Henderson, W. (2020, April 20). Province introduces new supports for remote, rural and Indigenous communities during COVID-19 pandemic. The Drive FM. https://www.thedrivefm.ca/2020/04/20/province-introduces-new-supports-for-remote-rural-and-indigenous-communities-during-covid-19-pandemic/.	2020	news article	Canada	COVID-19	Led	Outline of BC Emergency Health Services (BCEHS) resources added to its fleet. A further 55 ground ambulances added throughout the province, including six in Northern Health. In addition, seven fixed-wing aircraft and helicopters were prepared for BCEHS for medical transport. Discussion of exploration of faster testing methods, including GeneXpert test kits, taking less than 45 min to complete. A priority was given to more rural and remote sites where the instruments for testing are already in place in B.C. and used in First Nations Health Authority, Northern Health, Interior Health, Vancouver Coastal Health and Fraser Health. Additional GeneXpert instruments were set to arrive.
First Nations Health Authority. (n.d.). First Nations Virtual Doctor of the Day – How It Works. First Nations Health Authority. https://www.fnha.ca/what-we-do/ehealth/virtual-doctor-of-the-day/how-it-works.	2020	website content	Canada	COVID-19	Focused	Implementation of Virtual Doctor of the Day programme, with physicians, including Indigenous providers, offering culturally safe primary care in a timely manner.
Dreise, H., & Ali, S. (2020, April 15). COVID -19: A practical tool for preparedness and planning in an Indigenous primary care setting in Canada. The College of Family Physicians of Canada. https://www.cfp.ca/news/2020/04/15/04-15-1.	2020	Report	Canada	COVID-19	Led	Description of framework developed, and effort made to streamline the process of identification, isolation and testing of the patient which fulfil the screening criteria for testing via nasopharyngeal swab.
Johnsen, M. (2020, July 17). Why Māori healthcare providers want mobile clinics to become a regular fixture. RNZ. https://www.rnz.co.nz/news/te-manu-korihi/421463/why-maori-healthcare-providers-want-mobile-clinics-to-become-a-regular-fixture.	2020	news article	New Zealand	COVID-19	Focused	Discussion of successful, high rate of testing for COVID-19 among Maori due to the presence of mobile clinics.
Hostetter, M., & Klein, S. (2020, September 30). Learning from Pandemic Responses Across Indian Country. Commonwealth Fund. https://www.commonwealthfund.org/publications/2020/sep/learning-pandemic-responses-across-indian-country.	2020	website content	United States	COVID-19	Focused	Discussion of innovations that emerged as a result of COVID-19 and their effectiveness.
Obed, N. (2021). Inuit Governance and Self Determination in Planning and Responding to the COVID-19 Pandemic. ITK Inuit Tapiriit Kanatami. Retrieved January 18, 2021, from https://www.nccih.ca/Publications/lists/Publications/Attachments/VS/Natan%20Obed%20-%20NCCIH%20Virtual%20Series%20-January%2013%202021%20(PDF).pdf	2020	Report	Canada	COVID-19	Led	Discussion of how pandemic demonstrated the importance of bringing care closer to home and exploring possibilities on how to achieve.
Jones, T. (2021, February). Rapid service design and cultural safety; Learnings from our General Practitioner Led Respiratory Clinics in Western Nsw. The Health Advocate. https://www.google.ca/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwjquNPP_YXvAhUPqp4KHecDAh8QFjAYegQIIhAD&url=https%3A%2F%2Fahha.asn.au%2Fsystem%2Ffiles%2Fdocs%2Fpublications%2Fthe_health_advocate_-_feb_2021_web.pdf&usg=AOvVaw2lv1Rp5_gxUg6TniM5mSdp.	2021	News article	Australia	COVID-19	Focused	Outline of two of nine clinics being AMS or ACCHO led and encouraging the use of the COVID-19 resources available from the Aboriginal Health and Medical Research Council and NSW Health to support Aboriginal patients attending the clinics.
Saskatchewan Health Authority. (2021, March 1). Working together to support immunization. https://www.saskhealthauthority.ca/news/stories/Pages/2021/March/Working-together-to-support-immunization.aspx.	2021	website content	Canada	COVID-19	Focused	Sharing of pipe ceremony held to initiate journey that includes community Elders supporting immunisation clinics in Regina for First Nations and Métis people greater than 70 years of age.
Saskatchewan Health Authority. (2021, February 17). Mobile COVID-19 testing meeting community at points of need. https://www.saskhealthauthority.ca/news/stories/Pages/2021/February/Mobile-COVID-19-testing-community.aspx.	2021	website content	Canada	COVID-19	Focused	Highlighting of daily mobile testing work in Saskatoon that began January and trending rise in number of those tested. An example provided where at outset, about five people a day were tested, increasing to 27, as awareness of the service and trust continued to grow. Sense shared that initiative ‘has provided us an opportunity to be better and serve better.’
Divisions of Family Practice. (n.d.). Virtual Care During COVID-19: Rebuilding Trust and Increasing Access for Katzie First Nation. Divisions of Family Practice. https://divisionsbc.ca/ridge-meadows/blog/katzie-first-nation-virtual-care.	2021	website content	Canada	COVID-19	Focused	Successful implementation of virtual visits to community members at the Katzie Health and Community Centre.
Draaisma, M. (2021, February 20). Over 8,000 Indigenous people now vaccinated against COVID-19 in Northern Ontario. CBCnews. https://www.cbc.ca/news/canada/toronto/operation-remote-immunity-vaccination-update-ontario-indigenous-communities-1.5921847.	2021	news article	Canada	COVID-19	Focused	Outline of Operation Remote Immunity launch, a campaign led by Ornge, an ON air ambulance service, that aimed to vaccinate adults in 31 fly-in First Nations communities and Moosonee in Northern Ontario. Discussed use of Maad'ookiing Mshkiki — Sharing Medicine website to decrease vaccine hesitancy, with operational goal to have all first and second doses in the 31 fly-in communities and Moosonee completed by the end of April.
WCH Indigenous Health. (n.d.). Maad'ookiing Mshkiki – Sharing Medicine. Women's College Hospital. Retrieved February 17, 2021, from https://www.womenscollegehospital.ca/research,-education-and-innovation/maadookiing-mshkiki%E2%80%94sharing-medicine.	not specified	website content	Canada	COVID-19	Led	Highlighting of barriers identified by communities, service providers, decision-makers, Elders and Knowledge Keepers as a lack of culturally safe and relevant educational materials about vaccination.

Themes

Our synthesis yielded five main themes that highlight the role of Indigenous PHC during a public health crisis: (1) development of culturally appropriate communication and education materials about vaccinations, infection prevention, and safety; (2) Indigenous-led approaches for the prevention of infection and promotion of health; (3) strengthening intergovernmental and interagency collaboration; (4) maintaining care continuity; and (5) addressing the SDoH. Table 5 summarises the main components of an Indigenous PHC system such as organisations, systems, programmes, providers, and communities that facilitate and enable PHC delivery during a public health crisis.

Table 5. Components of a Primary healthcare (PHC) system.

	Components of a Primary Healthcare (PHC) System
PHC Response	Organisations	Systems	Providers	Communities
Development of culturally appropriate communication about infection prevention, mental health, safety and health promotion	Indigenous health service organisations deliver culturally relevant communication and education materials to patients	Government authorities and the health sector engage Indigenous communities in the design of effective and appropriate messaging about risks and safety	Indigenous and non-Indigenous PHC providers can utilise the communication educational materials/resources to support patients. Utilising local community health workers who have built trust and relationship with communities to deliver information related to safety and protection	Engaging Indigenous (e.g. Elders, Knowledge Keepers, youth) communities to both create and disseminate important messages related to safety, infection prevention, and protection of health
Indigenous-led approaches for the prevention of infection and promotion of health	Isolation centres and rapid testing services for Indigenous peoples set up by Indigenous health services. Home visits and mobile testing sites set up for Indigenous communities	Government authorities collaborating with Indigenous health services and communities to support coordinated responses to infection prevention and access to necessary health, mental health, and social supports.	Training and hiring local community health workers to support access to necessary infection prevention and protection as well as health services.	Expand Indigenous-led community-based programmes and services for adults, youth and families responded to the health and social needs of Indigenous communities
Strengthening intergovernmental and interagency collaboration	Indigenous communities, Indigenous health service organisations, and government-run Indigenous health programmes collaborate to respond to disease prevention and promote health	Government, health sector, Indigenous leadership and cross-sector collaboration	Interprofessional PHC teams provide comprehensive and coordinated care and are ideally equipped to support those populations most at risk of adverse health outcomes during a pandemic	Consistent communication and collaboration with Indigenous communities
Maintaining care continuity	Indigenous health service organisation support home-based care to ensure continued access to routine health services	The adoption of virtual care within some Indigenous health services was also reported to support continued access to services and supports during the COVID-19 pandemic	Community health workers support routine care such as, self-management for those living with a chronic disease, and supporting connection to a PHC provider	Continued operation of community-based programmes and services for adults, youth and families responded to the health and social needs of Indigenous communities
Addressing the SDoH	Indigenous health service organisations and communities mobilised to support the health and social and economic needs of communities	Indigenous health service organisations developed and provided culturally-relevant resources to promote the safety of Indigenous peoples	Community healthcare workers provided care that encompassed factors of housing, and food security within the community to not only provide surface-level care during a pandemic but rather sustainable interventions tailored to the needs of the community.	Resources within communities were expanded and leveraged to support the social needs of Indigenous peoples during a pandemic

Development of culturally appropriate communication and education materials

As stated in the Alma-Ata declaration, PHC ‘includes education concerning sanitation, immunization, prevention and control of endemic disease’ and also ‘addresses the main health problems in the community, providing promotive, preventative, curative and rehabilitative services accordingly’ (WHO Alma-Ata, 1978). Based on these components of the declaration, public health messaging, health promotion, infectious disease communication and education is an important role for PHC. While many sources discussed culturally appropriate communication and education, most of the time they did not directly link back to PHC or PHC was not a part of the development of these materials. However, it is understood that communication and educational materials that were developed, were implemented and carried through in PHC settings.

Several empirical studies included in this rapid review detailed lessons learned from the 2009 H1N1 pandemic in relation to effective communication and education which provided an opportunity for informing PHC responses to the current crisis of COVID-19 (Charania & Tsuji, 2011; Charania & Tsuji, 2012; Driedger et al., 2013; Gray et al., 2012; Herceg et al., 2010; Massey et al., 2009; NCCIH Communications Officer, 2016; Richardson et al., 2012; Rudge & Massey, 2010). The H1N1 pandemic highlighted a need to localise communication and engagement with Indigenous communities so that Indigenous peoples can trust the messages being conveyed to them, know where to go to access healthcare services, and are well-prepared to support themselves and their families in a public health crisis (Charania & Tsuji, 2011; Gray et al., 2012; Massey et al., 2009; NCCIH Communications Officer, 2016). It was reported that during the H1N1 pandemic, information shared by Canadian health agencies with Indigenous communities was often inconsistent, misleading, or contradictory (NCCIH Communications Officer, 2016). Learning from the H1N1 outbreak, several local Indigenous health service organisations mobilised during the COVID-19 pandemic through community engagement and promoting culturally-relevant and safe communication and education about the virus to communities; which are necessary components of a successful pandemic response (Henderson, 2020; Kerrigan et al., 2020; First Nations Health Authority).

Of the sources included, there was strong evidence in support of reliable and culturally-appropriate communication around vaccinations, infection prevention, and safety within PHC settings to address patient needs during a public health crisis (Crooks et al., 2020; Finlay & Wenitong, 2020; Gray et al., 2012; Kennedy, 2020; Kerrigan et al., 2020; Massey et al., 2009; Moodie et al., 2020; NCCIH Communications Officer, 2016; NSW Health, 2019; Roberts, 2020; Rudge & Massey, 2010). Scholars highlighted the need for information about virus spread, infection prevention and vaccination from sources Indigenous communities could trust (Gray et al., 2012; NCCIH Communications Officer, 2016). One moderate quality empirical study, a commentary and a few grey literature sources described initiatives developed by health sectors and Indigenous health organisations that engaged Indigenous community leaders and/or communities during H1N1 and COVID-19 in the creation and dissemination of important messages related to safety, infection prevention, stress reduction and health promotion (e.g. pre-existing chronic conditions) (Hostetter & Klein, 2020; Kerrigan et al., 2020; Roberts, 2020; Rudge & Massey, 2010). For example, in a news article by Draaisma (2021) the author described the design of educational materials including videos, fireside chats and other resources that draw upon the expertise and wisdom of community members, elders, knowledge keepers, traditional practitioners, and Indigenous physicians, to support Indigenous peoples in northern Ontario to make informed choices about the COVID-19 vaccines. These resources are shared on the Maad’ookiing Mshkiki — Sharing Medicine website, developed in collaboration with several Indigenous-focused organisations and groups located in Toronto, Ontario including the Centre for Wise Practices in Indigenous Health at Women’s College Hospital, the Indigenous Primary Health Care Council, Anishnawbe Health Toronto, the Indigenous Health Program at University Health Network and Shkaabe Makwa — an Indigenous-focused branch of the Centre for Addiction and Mental Health.

While there were several references about the importance of communication in native Indigenous language (Kerrigan et al., 2020), emphasis was placed on delivering culturally safe and culturally relevant communication that went beyond translation to Indigenous languages; rather applying modes of communication that reach Indigenous peoples (e.g. through storytelling), and providing customised information resources that were grounded in Indigenous histories, cultures and worldviews (Groom et al., 2009; Hostetter & Klein, 2020; NCCIH Communications Officer, 2016). Application of this was noted in several non-empirical sources including commentaries, opinion pieces and news articles published during the COVID-19 pandemic that described the development of culturally relevant materials on infection prevention and vaccines that are centred on Indigenous values and knowledge (Draaisma, 2021; Dyer, 2020; Roberts, 2020; Saskatchewan Health Authority, 2021a). For example, a grey literature source describing the COVID-19 response in Navajo Nation shared posters with public health messages such as ‘how to safely hold a ceremony’ and ‘how to safely take part in a sweat lodge.’ (Hostetter & Klein, 2020). In another source, recommendations for infection control were presented for cultural ceremonies in the province of Saskatchewan (Saskatchewan Health Authority, 2021a). Moreover, these types of resources can be equally promoted by providers in the mainstream PHC system to support effective communication and messaging to Indigenous patients. Although many of the sources cited in this theme were Indigenous-focused, learnings from H1N1 and the current COVID-19 pandemic have strongly suggested that Indigenous-led approaches are often quicker to respond and more effective (Banning, 2020a; Crooks et al., 2020; Dyer, 2020; Finlay & Wenitong, 2020).

Indigenous-led approaches for prevention of infection, meeting care needs and promotion of health

Some sources identified where mainstream supports were inadequate and Indigenous health organisations and services stepped in to fill the gaps using Indigenous-led approaches (Dyer, 2020; Hostetter & Klein, 2020; Johnsen, 2020; Kerrigan et al., 2020; Roberts, 2020). For example, one article discussed why COVID-19 transmission was lower than expected in Australian Indigenous communities from the perspective of an Aboriginal Medical Services Officer. Their perspective was that while the government was focused on public health orders such as restricting travel to protect Indigenous communities, Indigenous health groups and organisations focused on messaging to community to promote social distancing and hygiene practices (Roberts, 2020).

Several sources described the way Indigenous health service organisations and communities mobilised to support the health and social needs of communities. For example, Navajo Nation and providers from Indian Health Services (IHS) medical facilities and Urban Indian Health Programs worked together on disease prevention during the COVID-19 pandemic by distributing personal and protective equipment (PPE) and by implementing a community health workers model (CHW) (Rosenthal et al., 2020; Hostetter & Klein, 2020). Several sources described the importance of training and hiring local CHWs (Rosenthal et al., 2020) as a way to utilise the strengths and knowledge within the community (Massey et al., 2009). CHWs support the delivery of information related to safety and protection (e.g. about vaccines, how to prevent the spread of the virus), assess the risks of mental health distress, self-management for those living with a chronic disease, and promoting the health and social well-being of individuals. CHWs were promoted as a bridge for patients to support enhanced access to necessary health and mental health services and connection to other PHC services (Fitts et al., 2020; OCHA, 2020; Rosenthal et al., 2020; Rudge & Massey, 2010). The importance of CHWs was highlighted in a commentary that discussed the risk incurred by rural and remote health services that rely heavily on short-term outreach healthcare providers who come from outside the community which increases the risk of introduction of infection and transmission (Fitts et al., 2020). Thus, CHWs would mitigate this risk. However, the sources reviewed did not provide information about how this could be done, such as with the allocation of funding and resources to support their role.

Additionally, several sources outlined how partnerships between health sectors and Indigenous organisations led to the development of Indigenous-specific preparedness frameworks for rapid testing, isolation, and limiting spread (Dreise & Ali, 2020; Henderson, 2020). There were several examples describing the implementation of rapid testing which included mobile testing units for Indigenous peoples throughout the COVID-19 pandemic, particularly in rural communities (Cousins, 2020; Johnsen, 2020; Saskatchewan Health Authority, 2021b). In addition, commentaries and grey literature sources revealed successful efforts by health authorities, PHC, CHWs, and community members to decrease transmission of COVID-19 using public health messaging and isolation centres (sometimes supported by PHC) (Banning, 2020b; Close & Stone, 2020; Dreise & Ali, 2020; Dyer, 2020; Hostetter & Klein, 2020; Kaplan et al., 2020; Massey et al., 2011; Moodie et al., 2020). In the declaration of Alma-Ata, they state PHC ‘requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of PHC, making the fullest use of local, national and other available resources; and to this end develops through appropriate education the ability of communities to participate.’ Community-led isolation centres and other community-based programmes then are a component of primary healthcare.

Furthermore, the health and social needs of Indigenous peoples were supported by relying on PHC community-based programmes and services for adults, youth and families (Australian Government Department of Health, 2020; Jones, 2021). One innovative programme in Navajo Nation called the colored paper project had community staff members drive past Elders’ homes twice daily (Hostetter & Klein, 2020). The Elders would use coloured paper in their windows to signify their needs, green signified that the Elder did not need support, red signified the need for medical support, yellow signified the need for resources or supplies (e.g. toilet paper), and blue signified the need for company or social support (Hostetter & Klein, 2020). The sources identified in the review describe outreach services and community-initiated responses that were implemented by Indigenous health service organisations and communities often in partnership with the health sector to slow down the spread of the virus in communities, however no specific outcome measures were reported on the success of these interventions.

Strengthening intergovernmental and intersectoral collaboration for PHC delivery

Several high-quality sources included in this rapid review described the importance of strong intergovernmental collaboration and relationship between provincial/state/territorial government health agencies and local health service organisations to achieve the goals of PHC in the context of a pandemic (Charania & Tsuji, 2012; Fitts et al., 2020; Groom et al., 2009; Henderson, 2020; Herceg et al., 2010; Jenkins et al., 2020; OCHA, 2020; Richardson et al., 2012). In a qualitative study, consistent and regular intergovernmental meetings with Indigenous communities fostered trust among stakeholders during the H1N1 pandemic and allowed for clear communication and transparency which may not have been possible without the mobilisation of local Indigenous health services (Gray et al., 2012). During the COVID-19 pandemic in Canada, the federal government worked with Indigenous Nations to provide funding and resources for communities to support their pandemic response. The need to strengthen collaboration, trust and relationships between the federal government and Indigenous Nations in the current pandemic context was described to not repeat past harms inflicted on Indigenous people from previous pandemics. The disturbing example that occurred during the H1N1 outbreak where the federal government sent body bags to four Manitoba First Nations communities instead of shipments of antivirals, hand sanitisers and flu kits is a notable example of what not to repeat in future public health emergencies (Driedger et al., 2013).

Maintaining care continuity

PHC services should help maintain care continuity during a pandemic, with continued access to other health services and supports (Laupacis, 2020). Scholars highlighted the importance of equitable, reliable and consistent access to regular health services for Indigenous peoples and communities during a public health crisis (Banning, 2020a; Charania & Tsuji, 2011; Charania & Tsuji, 2013; Cousins, 2020; Dyer, 2020; Henderson, 2020; Kaplan et al., 2020; Massey et al., 2009; First Nations Health Authority; Hengel et al., 2020; Johnsen, 2020). One source highlighted an excellent example of self-determination when they described how providers from Indian Health Services and Urban Indian health programmes in Navajo, Mississippi Choctaw Nation worked together to support routine care and ensure continued access to essential services by conducting household visits. The adoption of virtual care within some Indigenous health services was also reported to support continued access to services and supports during the COVID-19 pandemic (Business Partnerships Platform, 2020; Danila Dilba Health Service, 2020; Fitts et al., 2020; Divisions of Family Practice; Anishinabek News., 2020).

Addressing the social determinants of health

In a published presentation by the National Collaborating Centre for Indigenous Health, they highlight how the pandemic has impacted all social determinants of Inuit health making access to PHC more difficult as medical travel was impacted (Obed, 2021), this could be transferable to all Indigenous populations. Indigenous health service organisations and communities mobilised to support the health, social and economic needs of communities by developing and implementing culturally-relevant resources to promote the safety of Indigenous peoples (Dyer, 2020; Kerrigan et al., 2020; Rudge & Massey, 2010). As PHC is often inaccessible to Indigenous communities, examples of programming that addressed inequalities in physical, social, and mental health were noted. For example, virtual care and virtual health promotion, mobile testing and vaccine centres, and innovative programmes such as the colored paper project all provide better access to PHC services for Indigenous peoples (Cousins, 2020; Divisions of Family Practice, n.d.; First Nations Health Authority, n.d.; Hostetter & Klein, 2020; Johnsen, 2020; Saskatchewan Health Authority, 2021b). In British Columbia Canada, during the pandemic they launched the Virtual Doctor of the Day program, with physicians, including Indigenous providers, offering culturally safe PHC in a timely and accessible manner (First Nations Health Authority, n.d.). Community healthcare workers are another great example in which SDoH are addressed as this role encompasses factors of care that include considerations and support around housing, and food security (Hernandez et al., 2020; OCHA, 2020). Thus, not only providing surface-level care during a pandemic but rather sustainable interventions tailored to the needs of the community. While there are several barriers to addressing SDoH in Indigenous communities, COVID-19 also provided opportunities for Indigenous communities to have autonomy in the pandemic response to create meaningful outcomes on the SDoH as highlighted above.

Discussion

Indigenous PHC service delivery models are defined by several characteristics including accessible health services, community involvement, culturally appropriate and skilled workforce, holistic healthcare and wellness, self-determination and empowerment, connection to culture, and coordination of intersectoral and multidisciplinary collaboration (Harfield et al., 2018; Montesanti et al., 2021). These unique characteristics demonstrate the importance of Indigenous PHC models in promoting and protecting the health of Indigenous communities during a public health crisis. Specifically, Indigenous PHC plays a key role by effectively communicating about infection prevention and vaccine safety to Indigenous patients and communities; offering rapid testing, administering vaccinations and personal protective equipment (PPE) to communities, working collaboratively across sectors, agencies, governments, and with other healthcare providers; and ensuring continuity of routine care for Indigenous peoples. Sources highlighted how Indigenous health service organisations worked directly with communities (leaders, Elders, Knowledge Keepers, youth) in the creation and dissemination of communication strategies and information resources to convey important messages related to safety, mental health, infection prevention, and protection of health. The findings also highlighted the need for delivering culturally safe and culturally relevant communication, engaging Indigenous communities in the planning of service delivery, and ensuring that the voices of communities are heard especially at a time when there is heightened stress and fears brought on by a public health crisis or emergency.

Key themes from the rapid review findings support aspects of Indigenous PHC service delivery which are known to effectively work. For instance, we found that maintaining care continuity was the focus of various PHC components, and research has shown that Indigenous peoples experience better overall health outcomes when care is not compartmentalised (Fraser et al., 2017). Intersectoral service coordination is also critical for ensuring a continuum of care across PHC and secondary care. Despite the widespread commitment to intergovernmental and intersectoral collaboration low levels of trust, legitimacy and goal consensus among collaborating entities impeded collaboration and relationship-building. Furthermore, developing culturally appropriate communications regarding infection prevention, safety, and mental health promotion was another prominent theme in the findings, and this is aligned with research that suggests that health information needs to be tailored to different population groups and acknowledge their social and cultural context surrounding their health (Van den Broucke, 2020).

The review findings also demonstrated how Indigenous PHC systems reorganised during a pandemic by establishing strong links to community-based programmes and services for children, youth and families, expanding home-based care, and improving access to care during the crisis, mainly through the hiring of CHWs. CHWs play an essential role in addressing risks to health and mental health in communities and delivering timely, accurate information about the crisis and ensuring that all patients or community members obtain access to culturally appropriate care and support (Rosenthal et al., 2020). Previous research studying the role of CHW during a public health crisis demonstrates that CHWs fulfil important and new service needs, and play meaningful roles in the context of strategies to improve the delivery of care (Schneider et al., 2008). There is a growing body of evidence that supports the role of Indigenous CHWs in providing valuable services and supports across health, wellness, and community support, including cancer prevention (Cueva et al., 2014), oral health (e.g. Braun et al., 2016), mental health promotion and substance use treatment (O'Keefe et al., 2021), and connecting patients to health or community resources (e.g. transportation services; Gampa et al., 2017). Indigenous CHWs also possess knowledge and understanding of local history, culture, community, and spirituality which may help maintain trust with community members. The building and maintenance of trust in communities is an invaluable component of the CHW model as the effects of colonialism and racism, both at institutional and individual levels, within the healthcare system have led to a lack of trust in the healthcare system for many Indigenous individuals and communities. Thus, CHWs represent a proven strategy for improving access to health services during a public health crisis, and their roles can be expanded to work closely with the PHC sector.

Research has shown that PHC delivery across some parts of the globe is characterised by prioritised narrow investments and disconnected systems, services, and providers that impede progress towards sustainable solutions for Indigenous PHC service delivery models and pose challenges to responding to crises that require an urgent and collaborative response (International Foundation for Integrated Care, 2020; Montesanti & Fayant, 2020; Valentijn et al., 2013). For Indigenous PHC models to be enacted during a public health crisis or emergency, governments need to reinforce financial commitments and responsibilities towards equitable PHC service infrastructure for Indigenous communities.

Additionally, governance is key to effective health emergency preparedness. A key supportive governance mechanism for PHC is participatory models that strengthen linkages between policymaking and community engagement; as well as successful approaches for Indigenous PHC must be anchored in the principles of self-determination for Indigenous peoples (United Nations, 2007). Direct involvement of community members in healthcare delivery strengthens public accountability in health systems and is a means to promote sustainability of pandemic supports provided through PHC. Sufficient community support enables preparedness strategies to be suited to the community’s needs and in turn, increases their likelihood of being sustainable. Conversely, lack of adequate community engagement contributes to low levels of community trust in mainstream health services and government, which has been shown to hamper PHC implementation, including critical emergency services (Bitton et al., 2019). Culturally-safe and culturally responsive care, along with the inclusion of Indigenous values in the design and delivery of healthcare services are important domains of responsiveness to consider during public health emergencies (Fitzpatrick et al., 2021) and to ensure sustainability of PHC strategies or interventions. At a clinical level, strong Indigenous-focused strategies improve acceptability of and demand for PHC services. For instance, research conducted by authors on this paper (SM, LC) found that concerns surrounding the COVID-19 vaccine among Indigenous peoples in Canada stem from years of mistrust with the Canadian healthcare system (Goveas et al., 2021). Previous negative experiences with the mainstream healthcare system and government have repeatedly been found to create a barrier to accessing healthcare among Indigenous peoples. Contemporary experiences with racism and discrimination also impede the development of trusting relationships with mainstream healthcare providers. Furthermore, globally, Indigenous peoples advocate for the right to self-determination, development, and administration of health programmes. Self-determination is about enabling communities to build capacity and effectively address the factors that impact the health of Indigenous peoples (Auger et al., 2016).

This rapid review found limited evidence reporting specifically on the outcomes from promising strategies or approaches used in Indigenous PHC settings to prevent infection and protect health during a public health crisis. Of the sources included, findings primarily described the design and implementation process of different interventions and strategies. Nonetheless, the review provides a compelling case for research to describe emerging innovations within Indigenous PHC contexts in response to public health crises. This knowledge has the potential to inform and support health systems to be more resilient for future public health emergencies but also to meet the challenges faced by Indigenous populations across the globe. Of note, COVID-19 is more prevalent in the evidence base compared to H1N1 for Indigenous populations. Possible explanations include that Indigenous communities are more interested and able to share their experiences, previous pandemics may not have had as extensive data written and/or published, information is more readily shared online, and there has been considerable interest from academic journals to publish COVID-19 research and data.

Strengths and limitations

In order to address the challenges that Indigenous communities face with accessing PHC during a public health crisis, information needs to be succinctly synthesised for governments and policy and decision-makers to utilise for future planning. A strength of this review is that to the best of our knowledge, there is no published review that synthesises both primary sources and grey literature in this topic area. In addition, we took an international approach for best representation allowing for the results to be transferable across a variety of Indigenous populations. While we did try to capture Indigenous populations globally in our search terms, some Indigenous populations, tribes and communities may have been missed, along with any studies which were not presented in English. In addition, our grey literature search was limited in countries we searched (Canada, United States, circumpolar countries, Australia, and New Zealand) and only looked to the first 50 results that were populated in google. Further, our rapid review did not make any distinctions between Indigenous identities and groups.

Conclusion

The findings from this rapid review highlight the potential of Indigenous PHC services to mobilise and meet the needs of Indigenous patients during a public health crisis such as COVID-19. There have been frequent public health crises that have disproportionately affected Indigenous populations across the globe over the past decade or more. Approaches to re-orienting health services to respond to the pandemic require a supportive policy environment and inter-governmental relationship and collaboration. Innovations in health service delivery introduced to support health during the pandemic need to be maintained for fostering resilient health systems against future public health emergencies but also to be able to meet the needs of Indigenous peoples. The COVID-19 pandemic has demonstrated most prominently that sovereignty, leadership, and knowledge of Indigenous communities is an essential foundation for public health during moments of crisis, and that building on existing relationships is a strong platform for service delivery.

Acknowledgements

We also wish to acknowledge Meghan Sebastianski (PhD) and Diana Keto-Lambert (MLIS) from the Alberta Strategy for Patient-Oriented Research (AbSPOR) SUPPORT Unit Knowledge Translation Platform for their assistance developing a search strategy and conducting the searches for the academic literature.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by Canadian Institutes of Health Research: [Grant Number 394291].