A systematic review on assessment and management of preventive cardiovascular care in primary health for Aboriginal and Torres Strait Islander women and men

Keywords: Aboriginal and Torres Strait Islander peoples, Australia, cardiovascular disease prevention and control, health equity, Indigenous peoples, primary health care, systematic review, women.

Preventive primary health care (PHC) is essential to tackle the burden of cardiovascular disease in Australia (The Royal Australian College of General Practitioners 2018). Well-established guidelines exist for the assessment and management of risk for those without existing disease, with significant efforts invested to translate these guidelines into clinical practice (National Vascular Disease Prevention Alliance 2012; The Royal Australian College of General Practitioners 2018). Despite this, it is likely significant gaps remain in evidence-based primary health care for specific sub-populations, such as those defined by ethnicity, gender, socioeconomic status and geography (Peiris et al. 2009; Banks et al. 2020).

To identify and address gaps, the challenge exists to understand which population groups are less likely to receive guideline-recommended care. Risk assessment and management have been prioritised, recognising burden for the Aboriginal and Torres Strait Islander population, opportunity to reduce lifetime risk through disease prevention and disparities in provision of evidence-based care (Better Cardiac Care Forum 2014; Australian Institute of Health and Welfare 2019b; Bailie et al. 2019). However, uptake of guideline-recommended care has been identified as sub-optimal, further hampered by inconsistency in evidence-based guidelines (Australian Institute of Health and Welfare 2019b; Agostino et al. 2020; Paige et al. 2020). In regard to women, some evidence suggests gender is associated with differentials in care. Hyun et al. (2017) found fewer women receive absolute cardiovascular risk (ACVR) assessment, and fewer younger women receive guideline-recommended therapies. The intersectionality of racism and sexism is identified as a driver of health inequities for Aboriginal and Torres Strait Islander women (McBride et al. 2021). Among the Aboriginal and Torres Strait Islander population, gender differences exist in cardiovascular health; 59% of women report prevalent disease compared to 41% of men (Australian Institute of Health and Welfare 2015c). Given the evidence of inequities for Australian women, we sought to explore whether there were gender differentials in receipt of evidence-based care among the Aboriginal and Torres Strait Islander population.

This paper describes a systematic literature review examining the published evidence on the provision of cardiovascular risk assessment and management for Aboriginal and Torres Strait Islander women, and the existence of gender differentials in receipt of guideline-recommended care.

A mixed-method comprehensive systematic review was applied to synthesise knowledge from qualitative and quantitative research (Aromataris and Munn 2020). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines were followed (Moher et al. 2009). An Aboriginal Women’s Advisory Group oversaw the conduct of the review to ensure appropriate interpretation and presentation of results.

The population of interest was Aboriginal and Torres Strait Islander women in Australia. The phenomena of interest were: receipt of a Medicare Benefits Schedule (MBS) Health Assessment, assessment of ACVR and/or assessment and management of individual cardiovascular risk factors. The review considered studies where assessment and management occurred in primary health services; exclusion occurred where care was not undertaken within the service or care was provided at an outreach program. Comparison to Aboriginal and Torres Strait Islander men was included. Quantitative, qualitative and expert opinion peer-reviewed and grey literature published in the period 1 January 2010–30 June 2020 in English were considered for inclusion, providing a 10-year observation window.

PubMed, Emcare, Embase, Scopus, PsychInfo, ProQuest, ATSIHealth via Informit Online, Web of Science and Australian Indigenous Health Bulletin were searched in August 2020. Reference lists of included studies were subsequently searched. A search algorithm was developed based on keywords and reviewed by a librarian (Box 1, Supplementary Table S2). Screening, review and assessment were undertaken using Covidence (Veritas Health Innovation). Two reviewers (KM, AD) screened the title and abstract, a third (NH) adjudicated. One reviewer (KM) completed a full-text review, a second reviewer (JN) undertook a 20% audit, a third (NH) adjudicated. Authors of full-text studies without gender-specific results were contacted for any gender-specific analysis. Included full-texts were independently assessed by two reviewers (KM, JN) for methodological validity using the Joanna Briggs Institute (JBI) design-specific tools (Aromataris and Munn 2020) and the Aboriginal and Torres Strait Islander Quality Appraisal Tool (Harfield et al. 2020).

Extraction was undertaken by one reviewer (KM) and reviewed by a second (JN) using adapted JBI extraction tools in Microsoft Excel (Microsoft Corporation; Aromataris and Munn 2020). Measures of risk assessment and management were based on comprehensive risk assessment guidelines for management of absolute cardiovascular disease risk (National Vascular Disease Prevention Alliance 2012). MBS health assessment was reported as a nationally recognised comprehensive assessment that includes cardiovascular risk factors and an indicator for funding (Australian Institute of Health and Welfare 2019a; Finlay 2019). Where studies were part of a series, all were included and cross-referenced. WebPlotDigitizer (version 4.4; A. Rohatgi, https://automeris.io/WebPlotDigitizer) was used to extract data where only graphs were available. Findings are reported in a narrative summary given the heterogeneity in information sources and measurement for each phenomenon of interest.

Sixteen studies reported assessment and management of cardiovascular risk for Aboriginal and Torres Strait Islander women in PHC services (Fig. 1). Studies were assessed for methodological and Aboriginal and Torres Strait Islander cultural and contextual relevance and validity; none were excluded on quality (Supplementary Appendix S1, Table S1a–d). Table 1 provides an overview of included studies. Table 2 details the assessment and management results by each study.

Fig. 1.  PRISMA diagram.

Table 1.  Details of studies included in systematic literature review.

Table 2.  Summary of systematic literature review findings, by measure of cardiovascular risk assessment and management.

Nine studies reported the proportion of Aboriginal and Torres Strait Islander peoples to have received an MBS health assessment.

Age-specific and age-standardised estimated proportion of population to receive an assessment within the past 12 months was reported in four studies. After age standardisation, a greater proportion of Aboriginal and Torres Strait Islander women received an MBS health assessment compared to men (36% vs 31% in 2018). From 2004–05 to 2017–18, there was approximately a 30% increase in the proportion of women and men receiving assessments (Australian Institute of Health and Welfare 2019a).

Six studies reported the age-specific proportion of clients to receive an MBS health assessment within the preceding 2 years in services funded primarily for Aboriginal and Torres Strait Islander peoples. Proportions were similar by gender, and higher in older age groups. By 2018, the proportion was between 45% and 59% across all age groups.

Five studies reported ACVR assessment for Aboriginal and Torres Strait Islander peoples by gender.

Three studies reported the age-specific proportion of clients with information available to calculate an ACVR score in the preceding 2 years for people aged 35–74 years; there was little difference in the proportion of women and men (Australian Institute of Health and Welfare 2019b).

Two studies reported the odds ratio of Aboriginal and Torres Strait Islander women with information to calculate (or recorded) ACVR within the preceding 2 years. Matthews et al. (2017) reported women aged ≥20 years were less likely than men to have ACVR recorded, but not at a level of statistical significance. Hyun et al. (2017) reported Aboriginal and Torres Strait Islander women aged ≥35 years were less likely to have information recorded; this difference was not statistically significant. When analysed by age group, Aboriginal and Torres Strait Islander women aged 35–54 years were significantly less likely to have information recorded to calculate ACVR compared to men of the same age (Hyun et al. 2017).

Seven studies reported recording of smoking status in the preceding 2 years, predominantly from Aboriginal Community Controlled Health Organisations (ACCHOs) and Government PHC services. Across most studies and ages, women had a slightly higher proportion compared to men. In 2018, approximately three quarters were having assessments recorded.

Three studies reported smoking interventions. In the Australian Aboriginal and Torres Strait Islander Health Survey 2012–2013 (AATSIHS), 40% of women and 47% of men self-reported discussing quitting or reducing smoking status with their doctor in the previous 12 months, regardless of smoking status (Australian Health Ministers’ Advisory Council 2015). Data from the same survey were reported for current smokers, with similar proportions by gender across age groups (Australian Institute of Health and Welfare 2015b). Crinall et al. (2017) reported 62% of women aged 15–34 who were current smokers had received a brief intervention in the previous 2 years.

Recording of blood pressure was reported in four studies. Crinall et al. (2017) found women aged 15–34 years were significantly more likely to have blood pressure recorded compared to men. Hoy et al. (2014) and Stewart et al. (2012) found similar patterns in adults of all ages. The AATSIHS found over three quarters of those at high risk, but without cardiovascular disease, received blood pressure assessment in the previous 2 years; this was similar between genders (Australian Institute of Health and Welfare 2015b).

Two studies reported blood pressure management. Of those aged 15–34 years with hypertension (≥140/90 mmHg), 32% of women and 27% of men had a management plan recorded (Crinall et al. 2017). Hyun et al. (2017) reported prescription of blood pressure and/or cholesterol medications for clients aged ≥35 years. There was no statistically significant variation between genders. Women aged 35–54 years were less likely to receive prescriptions (OR: 0.65; 95% CI: 0.53–0.80) compared to men.

Three studies reported recording of cholesterol status in the preceding 2 years. Crinall et al. (2017) and Stewart et al. (2012) also found little variance by gender. Hoy et al. (2014) reported triglyceride, high-density lipids and low-density lipids, with the greatest proportion of clients having triglyceride recorded (women: 59% vs men: 53%).

Two studies reported management of cholesterol. Crinall et al. (2017) reported recording of a cholesterol management plan for clients aged 15–34 years who had not met blood lipid targets; approximately 15% of women and men had a plan recorded.

Weight was reported in one study, waist circumference and BMI each recorded in two studies. Hoy et al. (2014) reported recording of weight, waist circumference and BMI in the preceding 2 years in one ACCHO. For all three measures, a greater proportion of women had the result recorded; weight was the most commonly recorded measure (women: 79% vs men: 69%). Panaretto et al. (2013) reported weight circumference recorded in the preceding 6 months; one in six women had the measure recorded. Crinall et al. (2017) reported recording for BMI in the preceding 2 years for clients aged 15–34 years, finding no significant difference by gender.

Two studies reported management of weight as a cardiovascular risk factor. Approximately half of participants aged ≥15 years self-reported a discussion of reaching a healthy weight with a doctor in the preceding 12 months, regardless of weight (Australian Health Ministers’ Advisory Council 2015). Crinall et al. (2017) reported that for overweight or obese clients aged 15–34 years, 42% of women and 41% of men had a brief intervention recorded, and 13% of women and 8% of men had a referral for weight management recorded.

No studies reported nutrition assessment. One study reported nutrition management for cardiovascular risk management, documenting 43% of women and 46% of men aged ≥15 years self-reported discussions with a doctor about healthy food or improving diet in the preceding 12 months (Australian Health Ministers’ Advisory Council 2015).

No studies reported physical activity assessment. The AATSIHS found 28% of women and 33% of men aged ≥15 years self-reported a discussion with a doctor about increasing physical activity in the preceding 12 months (Australian Health Ministers’ Advisory Council 2015).

Six studies reported the age-specific proportion of clients with alcohol consumption recorded in the preceding 2 years. There was consistently a higher proportion of men with assessment across years and age groups; significance was not reported (Hoy et al. 2014; Australian Institute of Health and Welfare 2019b).

The AATISHS documented participants aged ≥15 years having a discussion on drinking alcohol in moderation with a doctor in the preceding 12 months, regardless of alcohol intake. There was variance by gender (women: 8% vs men: 26%) (Australian Health Ministers’ Advisory Council 2015).

No studies reported assessment or management of social and emotional wellbeing factors.

Assessment of haemoglobin A1c (HbA1c) was reported in one study, blood glucose in three studies. Hoy et al. (2014) reported women aged ≥15 years were more likely to have HbA1c recorded (65% vs 51% for men) and blood glucose (77% vs 66%) in the preceding 2 years. Crinall et al. (2017) found similar results for blood glucose testing to Hoy et al. (2014) in young people. Stewart et al. (2012) reported 73% of women and 80% of men aged ≥35 years without diabetes had blood glucose assessed.

Crinall et al. (2017) reported 15% of women and 18% of men had a management plan recorded if blood glucose was recorded as elevated in the preceding 2 years for clients aged 15–34 years.

Hoy et al. (2014) reported recording of eGFR, proteinuria and urinary albumin:creatinine ratio (UACR) for cardiovascular risk assessment in the preceding 2 years. Women had a higher proportion of recording of all three biomarkers for chronic kidney disease compared to men (60% vs 54%).

The evidence suggests major gaps in the provision and management of guideline-recommended preventive cardiovascular care for Aboriginal and Torres Strait Islander women and men. However, there were no major variations in the receipt of assessment and management by gender. Studies reported recording of assessment for cholesterol, BMI, and waist circumference as low as one in three women. Management was only analysed in three studies. Women were less likely to have an intervention on alcohol consumption and younger women were less likely to be prescribed blood pressure and lipid-lowering medications. Improvements in cardiovascular risk assessment and management have been made over the past decade for Aboriginal and Torres Strait Islander peoples. For example, the proportion of women and men accessing PHC services with information to calculate ACVR and uptake of MBS health assessments have increased substantially over the past 15 years. Despite improvements, in 2018, just over half of all people aged 45–74 years had information available to measure ACVR.

Reporting of risk assessment and management is centred on clinical measures, there is a significant gap in the recording of social, emotional and behavioural protective and risk factors of cardiovascular health (Spurling et al. 2017). There were limited data on assessment and management of protective factors such as good nutrition or physical activity. Conversely, smoking and alcohol, behavioural risk factors, were reported in seven and six studies respectively. Reporting these measures of risk may perpetuate assumptions, biases and deficit narratives of Aboriginal and Torres Strait Islander health (Humphery 2001). Women were more likely to have a record of assessment completed for many individual risk factors. However, women were less likely to have a record of alcohol assessment and younger women were less likely to receive an ACVR assessment than men.

A publishing gap in sex and gender-specific data is evident. Twenty-four studies did not meet inclusion criteria as gender-specific data was not included; on follow up, no studies had gender-specific analysis available. Although this review does not identify substantial gender variation in risk assessment and management, data suggest variance in younger ages, which requires further investigating and reporting where sample size permits.

Variance in measures used and methods of measurement prevented meta-synthesis. Future studies into assessment and management of cardiovascular risk should consider benefits of replication for consistency of reporting over time and across services. Another evident gap was reporting of statistical significance of variation by gender, particularly in grey literature. The majority of data reported were accessed from Aboriginal and Torres Strait Islander funded services, with peer-reviewed literature predominately accessing data from ACCHOs. Only one study included data from mainstream general practice. Although quality improvement processes and independent reporting are recognised as beneficial, overburden of reporting on the ACCHO sector has been well-documented (Martin 2015; Finlay 2019). There is concern that a lack of scrutiny is applied to the practice of mainstream GPs with respect to evidence-based guidelines. Future studies could incorporate data from the community-controlled, government and mainstream general practice sectors and compare delivery of services across service type.

This systematic review sought to synthesise evidence of the provision of assessment and management of cardiovascular health for women without established cardiovascular disease, and compare by gender. There are evidence gaps in the provision of guideline-recommended cardiovascular health assessment and management, regardless of gender. There is opportunity for improving outcomes by addressing these gaps and enhancing assessment and management of cardiovascular risk. Emphasis on reporting of assessment and management sits within a predominantly biomedical frame of risk, with emphasis on monitoring, assessment and management of biomarkers of blood pressure, cholesterol and weight, and smoking and alcohol consumption, not protective behaviours around nutrition and physical activity. There is no evidence in the published literature of integration of social and emotional wellbeing, and little understanding of what assessment and promotion of protective behaviours is undertaken as part of preventive cardiovascular health measures in PHC. The available evidence suggests the opportunity exists to enhance the uptake of preventive cardiovascular care in the primary health setting for Aboriginal and Torres Strait Islander women, in conjunction with a focus on measuring and monitoring a more comprehensive approach to assessment and management.

Data sharing is not applicable as no new data were generated or analysed during this study.

All authors declare no conflicts of interest.

This work was supported by an NHMRC Postgraduate Scholarship (1134198), an NHMRC Centre of Research Excellence (1044897), an Australian Government Research Training Program Scholarship, and the Commonwealth Scholarships Program for South Australia. AB is funded by an NHMRC Fellowship (1137563).

Supplementary material is available online.