Table 6.

Enablers and barriers associated with Indigenous adolescents accessing primary health care services, by study setting^a

		Enablers		Barriers
		Urban	Non-urban	Urban	Non-urban
Supply	Appropriate package of services	• Care that meets the needs of adolescents [83] • Provision of additional services: telehealth [90] and transport [83] • Flexible approach to care and pathways [70]	• Adolescent appropriate care that centres adolescents, families and community [69] and is designed for adolescents [52, 72, 88] • Provision of additional services: outreach [52, 55], interpreter [52], transport [61, 87], and social support such as ‘Women’s nights’, and health hardware like condoms [87] • Flexible approach to care [88] • Engagement staff to engage with and follow up adolescents [88] • Availability of gender-matched health care providers [52] • Technology and adolescent specific tools/assessments assist with the health and wellbeing assessment of adolescents [72]	• Services not available when required [70, 85] • Not receiving care that is needed [90] • The disconnect between health services [70] impacted continuity of care • Limited access to health hardware – condoms and other forms of contraception [70] • Workforce challenges: appropriately aged and gendered providers [83]	• Services not available when required [55, 68, 87], including specialist services [59], outreach [68, 69], and transport [52] • Wait times [52, 88] • A lack of follow up and recall makes it difficult for staff to provide care [88] • Limited access to health hardware – condoms and other forms of contraception [61, 87] • A lack of staffing and resources [88], including within the community prevented the provision of services and care needed, e.g., emergency housing, in-community alcohol and drug rehabilitation services, psychotherapy, and financial assistance [68] • Workforce challenges: transient nature of the providers in remote communities [52, 66]
	Providers’ competencies	• Providers who built trust, respect, and relationships with adolescents and families [83] • Providers who maintain privacy and confidentiality [83] and were honest and non-judgmental [83] were seen to have positive provider qualities	• Providers who engaged in the community [68] and built trust, respect, and relationships with adolescents and families [52, 55, 66, 69, 88] • Providers who maintain privacy and confidentiality [52, 88] and were open, respectful, patience, non-judgemental, had a wholistic approach, an open door policy [88], were flexible [52, 69, 79], and went above and beyond their role [88] were seen to have positive provider qualities, which provided a positive experience [61, 87] • Provides who listen and had good communication skills [52, 88]		• A lack of provider privacy, confidentiality, and trust [52, 66, 79] • Previous negative experience with providers [61, 68, 69, 87] • Providers reluctant to engage with adolescents and their families [68] • Provider isolation is a challenge for those working in remote communities [69]
	Facility characteristics	• Services with same day appointments, walk-ins [83]	• Location of services [68] • Welcoming and safe space [55, 68, 69] • Being able to book appointments [52]		• Location of services [55, 68, 79], transport including proximity to public transport [61, 79, 87], opening hours [79], and inability to pre-book appointments [55] • A lack of separate entrances and waiting rooms for men and women meant facilities were not culturally appropriate, and privacy of waiting rooms was also an issue [52, 55, 88]
	Equity and non-discrimination	• Low or no cost services [83, 90]	• Low or no cost services [69]	• Cost of services [70]	• Cost of services [79] and adolescents personal circumstances [61] • Experience of embarrassment, shame, or fear [52, 55, 61, 66, 68, 69, 79, 80, 87]
	Cultural safety	• Adolescents sought out Indigenous specific services [83] or services that provided culturally safe environments and care, which reflected adolescents’ culture and beliefs [83] • The presence of Indigenous workforce and their role in the provision of culturally safe care [85]	• Culturally safe environments and care [52, 55, 61, 69, 72, 87] • Cultural protocols were observed with providers and adolescents being the same gender [52] • Indigenous workforce and their role in the provision of culturally safe care [52, 61, 69, 87]	• Many providers had inadequate training: cultural [70]	• Colonisation and intergenerational trauma impacts adolescents and their family’s ability to engage with and access care [68] • No Integration or disconnect between traditional & cultural practices [69, 80] • Absence of cultural protocols: restrictions around family relationships, skin groups and gender [69] and lack of a separate entrance and waiting room for men and women [55] inhibits access • A lack of Indigenous health care providers [52, 69] and the challenges they face working and being from the community [68] • Absence of culture and language [69] prevented families from understanding care • Many providers had inadequate training: limited or no understanding of two-spirit and gender and sexuality in the Indigenous context [65]
Demand	Adolescent health literacy	• Health literacy: awareness of services [56]	• Adolescents’ willingness to seek health care [61, 87] • Adolescents support other adolescents by providing advice and reassurance to reduce shame in relation to seeking help [87] • Delivery of health promotion in adolescent settings, e.g., in schools, and incentives [88]		• A lower level of health literacy [52, 55, 61, 68, 69, 79, 88] and health seeking behaviours – attitude [55] and perceived need for help [69] or prioritising their own health [52] were barriers to adolescents seeking care and navigating the health care system • Adolescents’ ability to maintain appointments [61, 87]
	Community support		• Family and community engagement [68, 69]	• A lack of guidance on how to communicate with adolescents about safe sex, mental health, and suicide [89] • Fear of child welfare services and police involvement [85]	• A lack of family engagement and support [55] and involvement in treatment decisions [69] • Family issues: competing priorities of parents [69] • Fear of child welfare services and police involvement [68, 69]
	Data and quality improvement
	Adolescents’ participation		• Adolescent engagement beyond health care: cultural and other activities [65]		• Disempowerment especially among females and LGBTQI adolescents [66]

^aTable includes results from studies which could be characterized by study setting (urban or non-urban)