Table 4.

Enablers and barriers associated with Indigenous adolescents accessing primary and community-based mental health services from the perspective of adolescents and health care providers and parents/guardians/community members

		Enablers		Barriers
		Adolescents	Health care providers and parents/guardians/community members	Adolescents	Health care providers and parents/guardians/community members
Supply	Appropriate package of services	• Care is holistic [82] • Availability of providers and services [60], including outreach services [53, 67], and transport [73] facilitated access • Flexible approach to care and pathways facilitated by providers which ensured care was received [73, 82] • Continuity of care between providers and services, including referrals [53] • Funding for services and resources [54]	• Adolescent appropriate care that centre adolescents, families, and community in the delivery of care [58] • Availability of providers and services [57, 74], and reduced waiting times [58] • Provision of services including multi-disciplinary team [58], outreach services [58, 67, 74], and transport [59, 67] facilitated access • Flexible approach to care and pathways facilitated by providers which ensured care was received [59] • Continuity of care between providers and services, including referrals [58] • Funding for services and resources [58] • Social media to promote services and increase engagement with adolescents [58]	• Services not available when required [61, 77, 84]	• Services not available: outreach services [67] and access to specialist services including adolescent specialist [58, 59] at Indigenous primary health care services [59] • The disconnect between health services – Indigenous, mainstream and specialist services [59], and the division of child-adolescent and young adult services [57] impacted continuity of care • The absence of appropriate adolescent tools, guidelines, and established pathway [59] impeded assessment and care • A lack of sustainable funding and resources [85] affected service provision
	Providers’ competencies	• Providers who engaged in the community [53], and built trust, respect, and relationships with families and adolescents [73, 84] were able to facilitate health seeking behaviour, health service engagement and access to care • Providers who maintain privacy and confidentiality [84], were able to communicate with adolescents [73], and had positive provider qualities [84] were more likely to engage with adolescents • Providers received education and training: Indigenous culture [73, 82], were able to acknowledge family’s spiritual and cultural beliefs [60]	• Providers who engaged in the community [58], and built trust, respect, and relationships with families and adolescents [57–59, 67] were able to facilitate health seeking behaviour, health service engagement and access to care • Positive provider qualities [58, 59] were more likely to engage with adolescents • Providers received education and training: mental health [57]	• A lack of provider privacy and confidentiality [84] hindered adolescents’ health service access • Previous negative experiences with providers impacted adolescents’ future health seeking behaviour [53] • A lack of specific training and experience Indigenous cultural [54], mental health [54]	• A lack of provider privacy and confidentiality [59] and trust in providers [64] hindered adolescents’ health service access • A lack of specific training and experience in adolescent health [59] and Indigenous culture [59]
	Facility characteristics	• Location of service [53, 73] and opening hours [73] made services more accessible to adolescents • Welcoming and safe space [84] made services more inviting	• Services opening hours [58] made services more accessible to adolescents • Welcoming and safe space [58] made services more inviting	• Transport [63] is a barrier to adolescents accessing services	• Location of services including proximity to public transport [59]
	Equity and non-discrimination			• Cost of services [64, 77] • Embarrassment, shame, or fear [53] often prevent adolescents from seeking and accessing services	• Cost of services [64] • Embarrassment, shame, or fear [57, 80] often prevent adolescents from seeking and accessing services
	Cultural safety	• Adolescents sought out services that provided culturally safe environment and care [53, 54, 60] and the inclusion and centring of culture [73, 82] • Provision of traditional health practices [53, 60] and cultural activities [67] • Indigenous workforce and their role in the provision of culturally safe care [53, 82]	• Adolescents sought out services that provided culturally safe environment and care [74] • Provision of traditional health practices [57, 67] and cultural activities [67] • Indigenous workforce and their role in the provision of culturally safe care [57, 59, 74, 85]	• A lack of culturally appropriate services [53, 84] • Absence of cultural protocols: gender differences between adolescents and providers [53] • A lack of Indigenous health care providers [53]	• A lack of culturally appropriate services [59, 64, 67] including access to Indigenous specific health services [67] • No integration or disconnect between traditional and cultural practices [67, 80] • A lack of Indigenous health care providers [67]
Demand	Adolescent health literacy		• Health literacy [57, 58] and health seeking behaviour [57] including awareness of services [58, 67] enabled adolescents to seek care and navigate the health care system	• Adolescent perceived need for help [77] prevented them from seeking care • Adolescents lacked independence in relation to health seeking [84]	• Adolescents’ ability to make and maintain appointments [59]
	Community support	• Parent/family and community engagement and involvement in care [67, 73, 82]	• Health literacy and health seeking behaviours of families [57, 58] • Parent/family and community engagement and involvement in care [57, 58, 67, 74]	• A lack of community engagement and involvement in services and programs [54]	• A lower level of health literacy of parents and families [57] hindered adolescents’ access to care • A lack of community engagement and involvement in services and programs [54, 57, 58] • Family issues and reliance on family [59] impeded adolescents’ access to care • Fear of child welfare services and police involvement [85]
	Data and quality improvement	• Adolescents desired an opportunity to provide feedback on the quality of service [73] • Evaluation of cultural competencies within service delivery [53]
	Adolescents’ participation	• Self-determination and empowerment of adolescents [73, 82] and their involvement in care and decision making [60, 67, 73, 82]	• Adolescent engagement with services through cultural and other activities [58] and their involvement in care and decision making [67]		• No adolescent engagement in care and services [57]