The acceptability and utility of Indigenous youth health assessments: a narrative systematic review

Keywords: appropriateness, e-health, health assessments, holistic, Indigenous, primary health care, utility, youth.

Youth, the period between childhood and adulthood, is marked by significant psychological and biological development, second in scale only to early childhood (Viner et al. 2012; Patton et al. 2016). During this time, which we define as people aged 12–24 years, individuals acquire the physical, cognitive, social and economic resources that influence identity formation, and lay the foundation for health and wellbeing later in life (Patton et al. 2016; Azzopardi et al. 2020).

Indigenous youth go through the same life-stage transitions as non-Indigenous youth, and can draw on deep wells of cultural knowledge, family connection and connection to the lands of which they are the traditional custodians (Haswell et al. 2013; Tremblay et al. 2018). However, they also contend with the impacts of ongoing colonisation and racism. Thus, Indigenous youth are at greater risk of psychological distress and mental health issues (Australian Indigenous HealthInfoNet 2020).

Despite being infrequent attenders, primary health care (PHC) is often where Indigenous youth first link with the health system as independent agents. Therefore, PHC has an important role in identifying and ameliorating psychological distress and risky behaviours (Tylee et al. 2007; Wilson et al. 2007; Zieve et al. 2017). Even when they do attend, youth do not usually seek help for psychosocial issues (Bailey et al. 2016), which makes each interaction an important opportunity for preventative health care and/or health interventions. PHC-based health assessments have been proposed as a mechanism to improve access to recommended, regular screening and preventative healthcare for Indigenous people (Mayers and Couzos 2004). Health assessments, defined as a comprehensive assessment to detect and manage risk factors (Si et al. 2014), are a common element of health care in some countries, such as Australia (Holland 2010), but the uptake of government funded health assessments in Australia by Aboriginal and Torres Strait Islander youth remains low (Australian Institute of Health and Welfare 2018).

Although Indigenous youth typically underutilise PHC services, a PHC-based health assessment that addresses Indigenous youth health priorities, underpinned by Indigenous conceptions of health, may benefit those accessing health services. This systematic review synthesises evidence regarding the utility and acceptability of PHC-based health assessments for improving the health and wellbeing of Indigenous youth.

We used the Joanna Briggs Institute approach and the Preferred Reporting Items for Systematic research and Meta-analyses (PRISMA) statement for conducting and reporting this systematic narrative review (Moher et al. 2009; Aromataris and Munn 2020).

We searched the following databases: PubMed, CINAHL, Embase, Scopus via EBSCOHOST, and 16 grey literature databases to identify text that contained key words in the title and abstract. Keywords included ‘health check’, ‘health assessment’ and ‘youth’. Search strategies are available in Supplementary Tables S1 and S2.

Papers were included if the majority (>50%) of participants were 12–24 years of age (inclusive), and were Indigenous to Australia (Aboriginal and/or Torres Strait Islander), New Zealand (Māori), Canada (First Nations, Inuit and Métis), the USA (American Indian, Native Alaskan and Native Hawaiian), arctic regions of Sweden, Norway, Finland and Russia (Sámi), and Taiwan. Papers that included non-Indigenous and Indigenous populations within the age range were included if data on Indigenous youth were presented separately. We did not exclude papers based on language, and considered both published and unpublished studies.

A ‘health assessment’ was defined as a comprehensive and/or holistic review of an Indigenous youth’s health. Therefore, only studies reporting on health assessments that covered a minimum of two health domains (multidomain) were included. Here, domains were defined as a single social determinant of health, mental health condition or biomedical measure involving a single bodily system. Studies were included where health assessments were conducted in PHC, or in other settings if overseen by PHC services. Papers that did not meet the inclusion criteria were excluded from the analysis.

Peer-reviewed papers detected using database searching were imported to the bibliographic software Endnote 20 (Clarivate Analytics, Philadelphia, PA, USA) by one reviewer (JF) and duplicates removed. Studies were then assessed for inclusion based on title and abstract by two reviewers (JF and GS). The full text publications of potentially eligible papers were then retrieved and assessed against the inclusion criteria in accordance with the PRISMA statement (29).

Papers selected for inclusion were assessed using the Mixed Methods Appraisal Tool (Hong et al. 2018; Table 1). The same two reviewers (JF and GS) who conducted the study selection also independently reviewed included studies using the appropriate critical appraisal tools. Disagreements were resolved by consensus. Studies were not excluded based on quality appraisal.

Table 1.  Methodological quality of included studies.

The data extraction tool was customised and piloted to ensure information, extracted independently by JF and GS, responded to the review’s aims. Extracted data included: (1) study type, (2) countries where studies were conducted, (3) setting in which health assessments were administered, (4) participant demographics, (5) description of the health assessment and who administered it, and (6) effectiveness of the health assessment. Effectiveness measures included mortality, hospitalisation, disability, new diagnosis, morbidity and quality of life, referrals, follow up, brief intervention, and social and cultural determinants of health.

Owing to the heterogeneity of the included studies, meta-analysis was not considered appropriate. Instead, we conducted a narrative synthesis of extracted data.

Ethics approval was not sought, as no primary data were collected. This study is a systematic review of existing research.

Initial searching yielded 3352 records. Once duplicates were removed, we reviewed the titles and abstracts of 3061 studies. Of these, 28 full-text articles were retrieved for further review. Seven met the inclusion criteria. The study selection process is detailed in the PRISMA flow diagram (Fig. 1).

Fig. 1.  PRISMA diagram.

Characteristics of included studies are presented in Table 2. The studies were published between 2013 and 2019, and included four mixed methods studies (Goodyear-Smith et al. 2016; Harriss et al. 2018; Maari Ma Health 2018; Thabrew et al. 2019), two qualitative studies (Nori et al. 2013; Barraza et al. 2016) and one cross-sectional study (Fagan et al. 2013). The health assessments were conducted within PHC services in the four Australian studies (Fagan et al. 2013; Nori et al. 2013; Harriss et al. 2018; Maari Ma Health 2018). The two New Zealand studies used high schools with co-located PHC clinics (Goodyear-Smith et al. 2016; Thabrew et al. 2019), whereas the USA study was led by the San Diego American Indian Health Center (Barraza et al. 2016).

Table 2.  Characteristics of included studies.

Included studies measured quality of life, social and cultural determinants of health, and biomedical measures (Table 2). Only Barraza et al. (2016) assessed quality of life using qualitative data.

All, but one, youth health assessments were administered by a variety of health professionals, either singularly or in teams, including Aboriginal Health Workers (Fagan et al. 2013; Nori et al. 2013; Harriss et al. 2018; Maari Ma Health 2018), nursing staff (Fagan et al. 2013; Goodyear-Smith et al. 2016; Harriss et al. 2018; Maari Ma Health 2018; Thabrew et al. 2019) and general practitioners (Goodyear-Smith et al. 2016; Maari Ma Health 2018; Thabrew et al. 2019) (Table 2).

In four studies, the health assessments were administered using digital technology (Table 2). The two New Zealand studies used a self-administered assessment on an electronic tablet that provided a summary of issues to the nurse and/or doctor for reference during the subsequent consultation (Goodyear-Smith et al. 2016; Thabrew et al. 2019). Maari Ma Health (2018) used a self-administered health assessment on an electronic tablet with a Youth Health Worker available for support, and Nori et al. (2013) used a desktop computer. The health assessments in the remaining studies were administered using pen and paper only. One of these was completed by the youth (Barraza et al. 2016), and the others by health professionals (Fagan et al. 2013; Harriss et al. 2018).

Quantitative and qualitative components of the mixed methods studies were assessed separately in addition to assessing the study overall (Hong et al. 2018; Table 1). Many included studies had methodological limitations. Four studies lacked a clear statement of the research aims and research questions (Fagan et al. 2013; Nori et al. 2013; Goodyear-Smith et al. 2016; Harriss et al. 2018). Cross-sectional data relevant to this review were extracted from a cohort study, and although this study did not address confounding factors, the risk of bias was considered to be low (Fagan et al. 2013). Three of the four mixed methods studies were considered to have high methodological rigour (Goodyear-Smith et al. 2016; Maari Ma Health 2018; Thabrew et al. 2019), but the fourth study was found to have limitations owing to concerns about the reporting of their qualitative components (Harriss et al. 2018; Table 1).

We found a diversity of health assessments for Indigenous youth that were developed in different ways for specific communities, adapted from previously developed tools and with varying levels of co-creation with youth. None of the included studies reported on the impact of the health assessment on health outcomes.

New diagnosis was an outcome measure in four of the seven studies (Table 3). Sexually transmitted infections (STIs) were diagnosed in 547 of 3083 participants (18%) by Fagan et al. (2013), and in 11 of 30 participants (37%) by Goodyear-Smith et al. (2016). Thabrew et al. (2019) reported new diagnoses of eating or weight problems in 70 of 110 participants (63%), physical inactivity in 43 of 110 participants (39%), concerns about sexual health in 24 of 110 participants (22%), and depression and anxiety in 11 of 110 participants (10%). Harriss et al. (2018) reported new diagnoses of psychological distress in 42 of 350 participants (24%), and Goodyear-Smith et al. (2016) found six of 30 participants (20%) had depression and 11 of 30 (37%) had anxiety.

Table 3.  New diagnoses, morbidity and social determinants of health measured in the included studies.

Using the Home, Education, Eating, Activities, Drugs and alcohol, Suicide and depression, Sexuality, and Safety assessments (HEEADSSS) and/or YouthCHAT tools, the two New Zealand studies found high proportions of youth were affected by social determinants of health (Goodyear-Smith et al. 2016; Thabrew et al. 2019; Table 3).

Health assessments were co-created with Indigenous youth (Nori et al. 2013; Barraza et al. 2016), youth in general (Goodyear-Smith et al. 2016; Thabrew et al. 2019) or community members (Fagan et al. 2013; Harriss et al. 2018). Barraza et al. (2016) conducted focus groups with Indigenous youth to co-create a self-assessment tool. Nori et al. (2013) facilitated eight community meetings with Aboriginal youth to co-create a health assessment that was youth friendly, culturally appropriate and addressed their key health concerns, including cultural connection, concerns about safety, sexual health, social and emotional wellbeing, smoking, and substance use. The study by Goodyear-Smith et al. (2016) adapted YouthCHAT from the generic eCHAT health assessment through input from, and piloting by, adolescents. The study conducted by Maari Ma Health (2018) used the TickiT assessment, which is a HEEADSSS assessment on an electronic tablet, developed with non-Indigenous youth in Canada.

Two health assessments conducted in Far North Queensland, Australia, were developed specifically for Indigenous youth without documented consultation or co-design with youth (Fagan et al. 2013; Harriss et al. 2018). The study by Fagan et al. (2013) reported that the local Public Health Unit was interested in targeted STI screening for Aboriginal and Torres Strait Islander youth with a subsidiary aim of screening for chronic diseases. Harriss et al. (2018) reported on a health assessment conducted in the Aboriginal community of Yarrabah where, responding to community concerns, the health assessment was expanded in 2014 to include the adapted Patient Health Questionnaire-9 items (aPHQ-9).

Four studies, using self-administered digital technology for the health assessment, reported that youth found the apparent privacy and confidentiality enabled by this approach increased their willingness to disclose sensitive information regarding bodyweight, sexual health and safety concerns, such as bullying and violence (Nori et al. 2013; Goodyear-Smith et al. 2016; Maari Ma Health 2018; Thabrew et al. 2019). For clinicians, administration of health assessments using electronic tablets was quicker, and assisted subsequent face-to-face consultations. Nori et al. (2013), using both a digital and paper-based health assessment template, reported that youth preferred the digital version and especially preferred options like tick boxes rather than open-ended written text boxes. These results are consistent with findings from Goodyear-Smith et al. (2016), who found that electronic, tablet-based health screening provided consistent results, led to more disclosure, reduced staff time, kept youth busy while they were waiting, and allowed youth to structure thoughts and prioritise the issues they wanted help with. Furthermore, Māori youth felt clinicians knew what their health concerns were before they walked through the consultation door, and clinicians felt it was easier to address these concerns because of their prior identification through the health assessment (Goodyear-Smith et al. 2016). Barriers to digital health assessments included connectivity problems, slow internet speed, and literacy and language difficulties (Nori et al. 2013; Goodyear-Smith et al. 2016; Maari Ma Health 2018; Thabrew et al. 2019).

The two New Zealand studies utilised a ‘help question’ that asked youth if they wanted help today or in the future for each domain screened (Goodyear-Smith et al. 2016; Thabrew et al. 2019). The ‘help question’ supports the conversation between the youth and the clinician about health issues that the youth would like addressed, and facilitates shared decision making (Thabrew et al. 2019). Furthermore, the help question allowed youth to request intervention for health issues without the potential awkwardness of face-to-face dialogue (Goodyear-Smith et al. 2016).

Overall, the health assessments were well accepted. Youth in the study by Barraza et al. (2016) described the self-administered health assessment as positive, fun and enjoyable, and different to what they normally experienced in preventative health programs. Nori et al. (2013) reported that youth and community members found the health assessment to be acceptable and important.

Thabrew et al. (2019) compared acceptability of YouthCHAT and HEEADSSS for youth and school nurses. For youth, both were equally acceptable; however, nurses found YouthCHAT easier to answer in digital format, faster to administer than HEEADSSS, provided more health information and helped with subsequent answering of face-to-face questions (Thabrew et al. 2019).

Youth health clinic staff at Maari Ma Health (2018) reported that self-administered TickiT was acceptable and appropriate for staff and Aboriginal youth, with the youth being able to answer the questions on the electronic tablet without assistance.

Harriss et al. (2018) reported an evaluation of a Young Persons’ Check in Yarrabah, Australia, with additional mental health screening. The addition of the aPHQ-9, a psychological distress tool that was later adapted to the ‘Yarrabah aPHQ-8’, was well-accepted by staff and participating youth; however, only 35% of youth completed the screening tool, suggesting that there were barriers to the deployment of this screening tool.

Indigenous youth health assessments were most frequently used to detect psychological distress, sexual health concerns and adverse social determinants of health. One health assessment measured strengths, including how youth could find life balance according to an adapted Medicine Wheel (Barraza et al. 2016). None of the included studies measured health outcomes following administration of the health assessment. Cultural identity, impacts of colonisation and experience of racism, critical to health and wellbeing of youth, were absent in the health assessments.

Digital technology was preferred over paper-based technology owing to youth familiarity with electronic tablets, the opportunity to respond to sensitive health questions in private and quicker health assessment administration (Goodyear-Smith et al. 2016; Maari Ma Health 2018; Thabrew et al. 2019) compared with paper-based assessment. However, health assessments delivered using digital technology also presented problems with internet connectivity and language, especially when youth completed digital health assessment templates without support (Goodyear-Smith et al. 2016).

Generally, youth health assessments were well accepted. However, the only youth health assessment that was described as enjoyable by youth was also the only health assessment to measure strengths (Barraza et al. 2016), and was one of only two health assessments co-created with Indigenous youth (Nori et al. 2013; Barraza et al. 2016).

To our knowledge, this is the first review of the characteristics, utility and acceptability of Indigenous youth health assessments. The search strategy for this review involved a thorough search of online databases and grey literature. Another important strength of this review is its authorship by an Indigenous young person (JF), so all the included data have been analysed and reported through this lens (Box 1).

Limitations of this review include the sparsity of literature from the target countries. Six of the seven included studies were from Australia and New Zealand, with no studies meeting inclusion criteria from Canada, Taiwan or the arctic region Sámi people, limiting generalisability of findings. Of the included studies, many had significant methodological and reporting limitations, including a majority lacking a reported research question. Some studies did not report on the effectiveness outcomes at all, and none measured health outcomes following a health assessment. In addition, none of the included studies report on the impacts of colonisation and racism. Finally, only one of the youth health assessments evaluated strengths.

Primary health care-based health assessments can be an acceptable and useful means of documenting strengths, risk factors and social determinants of health regarding Indigenous youth. However, no data on health outcomes following health assessments were reported, and there is limited research regarding Indigenous youth health priorities and Indigenous youth views on health assessments. Acceptability of health assessments for Indigenous youth was most likely when they were co-created with Indigenous youth, adapted to local community needs, delivered by Indigenous Health Workers familiar with Indigenous youth, and used a combination of self-administered digital technology and face-to-face contact. Future research should focus on youth health priorities, and how these priorities inform future Indigenous youth health assessments.

Supplementary material is available online.

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

The authors declare no conflicts of interest.

This work was supported by the National Health and Medical Research Council (NHMRC) Emerging Leader Fellowship grant (APP1173857).