Exploring the lived experiences of Indigenous Australians within the context of alcohol and other drugs treatment services: A scoping review

Abstract

Issues

Substance use among Indigenous peoples has been extensively researched in the Australian context. However, syntheses of existing research focused on Indigenous Australian peoples' experiences of alcohol and other drug (AOD) treatment are limited. This review sought to fill this gap.

Approach

A scoping review using three databases, and the Google search engine, examined empirical and grey literature relating to Indigenous Australian peoples' lived experiences of accessing and undergoing AOD treatment. The review was not restricted to intervention type, treatment setting, substance, or individual characteristics (e.g., age or gender). The experiences of staff of Indigenous Australian service providers were excluded.

Key Findings

Twenty‐seven articles were reviewed, with most research (n = 12) conducted in New South Wales. Our secondary analysis of existing research found three themes: the role of culture, the value of holistic strength‐based services, and the influence of organisational components for Indigenous Australian service users in AOD treatment settings.

Implications and Conclusion

Despite diversity of experiences, our review highlights the importance of integrating culture and facilitating holistic strength‐based approaches to AOD treatment for Indigenous Australian peoples. While our review is limited by the findings and biases contained within the literature reviewed, the paucity of literature relating to the experiences of Indigenous Australian peoples within AOD treatment settings warrants further attention.

Key points.

• Culture impacts Indigenous peoples' experiences of substance abuse treatment, but needs to be integrated appropriately into alcohol and other drugs (AOD) treatment, that is, tailored to the local community context in line with Indigenous self‐determination.

• There is a paucity of research capturing the voices and lived experiences of Indigenous Australians in substance abuse treatment settings in Australia. Further research is warranted, but must be undertaken in line with ethical approaches to Indigenous research.

• Service providers, policy makers, and practitioners need to better integrate Indigenous cultures into AOD service design and delivery to facilitate programs that are holistic, utilise strength‐based approaches, and prioritise self‐determination for Indigenous Australians in the context of AOD treatment.

1. INTRODUCTION

In Australia, 1,283 alcohol and other drug (AOD) treatment agencies were operating in 2018–2019, providing around 220,000 treatment episodes to approximately 137,000 clients aged 10 years and over [1]. These treatment episodes comprised the three pillars of harm minimisation, the overarching approach of the National Drug Strategy 2017–2026 [2]. Treatment may include counselling for AOD use, residential treatment and withdrawal services, safe injecting rooms and needle exchange programs. While accounting for only 3% of Australia's population aged 10 and over, Indigenous peoples ¹ represented 17% of clients within AOD treatment services [1].

In settler‐colonial countries like Australia, where settler occupation continues [3], colonisation has resulted in paternalism towards Indigenous peoples, along with oppression of Indigenous peoples, their cultures, knowledges and voices [4, 5, 6]. The National Indigenous Drug and Alcohol Committee [7] suggests that interventions are more effective when Indigenous peoples' cultures are respected and when Indigenous peoples can exercise self‐determination, that is, their community and individual right to control and manage their own affairs without interference [8], articulated within the United Nations Declaration on the rights of Indigenous peoples [9]. In the AOD sector, recovery success for Indigenous peoples is best facilitated by Indigenous ownership—and control—of solutions, including AOD interventions [7, 9].

Indigenous peoples' right to self‐determination is stipulated in the National Agreement on Closing the Gap [10], an approach drawn between the Coalition of Aboriginal and Torres Strait Islander Peak Organisations and all Australian governments. This closing the gap approach centres four priority reforms to improve various socioeconomic, wellbeing and health outcomes for Indigenous peoples, and 16 updated targets, including minimising harm due to substance misuse [11].

To facilitate effective AOD treatment however, cultural safety is imperative because it can “enhance personal empowerment” and subsequently improve service delivery [12, 13, 14]. Since cultural safety is best enabled by people of the same culture [12], respecting Indigenous peoples as experts in their lives is pertinent to effective, culturally safe, and appropriate AOD services for Indigenous peoples. At this juncture, it is imperative to better understand the lived experiences of Indigenous peoples within AOD treatment settings in Australia, whereby lived experiences refer to unique personal perspectives and subjective experiences, choices and options that influence identity [15].

There has been a paucity of evaluations of AOD treatment among Indigenous peoples that embody Indigenous voices [7]. International studies of Indigenous health and wellbeing indicate that colonisation and experiences of injustice influence the willingness and confidence of Indigenous peoples to engage with AOD treatment, and associated research, that captures their perspectives [16]. It is thus important to ascertain what research reviews Indigenous peoples' experiences of AOD treatment from a service user perspective.

Based on a preliminary search conducted in PROSPERO, we found no existing scoping or systematic reviews that explored the lived experiences of Indigenous Australian peoples in accessing or undergoing AOD treatment. While Fiolet et al. [17] conducted a systematic review to explore Indigenous people's experiences of interactions with health‐care professionals, it was not AOD specific. As Indigenous peoples' lived experiences of accessing and undergoing AOD treatment has not been previously reviewed, this scoping review aims to fill this gap by answering the research question: In relation to AOD treatment, what are the lived experiences of Indigenous Australians of accessing and undergoing AOD treatment services in Australia?. This review sought to synthesise the experiences of Indigenous Australian service users regarding the AOD treatment services that they received, as reported in the literature included in this review.

2. METHOD

This scoping review has been undertaken according to Arksey and O'Malley's [18] framework, with further enhancements by Levac et al. [19], to examine existing empirical and grey literature concerning Indigenous peoples' lived experiences of accessing and undergoing AOD treatment in Australia. The methodology, following the steps outlined in the Preferred Reporting Items for Systematic Reviews and Meta‐analyses Extension for Scoping Review (PRISMA‐ScR) checklist [20] are outlined in this section.

2.1. Population, concept, and context

The research question was formulated using the population, concept, and context mnemonic [21]. Studies selected included a focus on Indigenous Australian peoples, with attention to their lived experiences, within AOD treatment settings in Australia. The definitions of the key terms for the scoping review are presented in Table 1.

TABLE 1.

Population, concepts and context for the scoping review

Terms	Definitions
Population	The population for this scoping review were Indigenous Australian peoples who have accessed or undergone AOD treatment.
Indigenous Australian peoples	Peoples who are Aboriginal and/or Torres Strait Islander from the continent now known as Australia.
Access	Entry into or use of the health care system for the purpose of recovering from problematic substance use [22].
Concept	The lived experiences of Indigenous Australian peoples in relation to undergoing AOD treatment.
Lived experience	A representation and understanding of a person's experiences, choices, and options, and of how they influence their perception of knowledge. Lived experience addresses the uniquely personal perspective of people and how their experiences are formed by subjective aspects of their identity, including gender, sexuality, race, class, religion, political views, and other characteristics and roles that determine how they live their lives [15].
Context	The context of this scoping review was AOD treatment delivered in Australia.
AOD	Chemical substances that interact with the central nervous system and alter brain function, causing alterations in mood and/or behaviour [23]. As described in World Health Organization's [24] Lexicon of Alcohol and Other Drugs, the term ‘drugs’ in AOD commonly refers to psychoactive drugs. It is defined as a substance that affects mental processes (including cognition and affect) when ingested. Together with its equivalent term, psychotropic drug, this term is the most neutral and descriptive term for the whole class of substances, whether licit or illicit, relevant to policy design and service delivery. Professional terminology of ‘alcohol and other drugs’ seeks to assert that alcohol is also a drug that is taken, at least in part, for their psychoactive effects [24].
Treatment	An activity or care used to treat clients' alcohol or other drug use through health‐care provisions [25]. According to Odyssey House [26], the types of treatment may include: • Counselling/therapy; • Medication/pharmacotherapy; • Detox (drug withdrawal) services/withdrawal management—home‐based, outpatient or community residential; • In‐house/residential treatment programs/rehabilitation; • Supported accommodation; • Support and case management; • Information and education.

Abbreviation: AOD, alcohol and other drugs.

2.2. Eligibility criteria

Empirical and grey literature was included in the search to ensure comprehensive examination of the literature. The search was restricted to Indigenous populations in Australia and to literature published in English from 2009 onwards. This date was chosen to align with the first closing the gap targets in 2008, where a shift in how policymakers, service providers and practitioners approached Indigenous health and wellbeing issues was expected.

The search was not limited by other individual characteristics, such as age, gender or sexual orientation. However, Indigenous peoples' experiences of AOD treatment as service providers were excluded from inclusion. The search was not limited to particular psychoactive substances, types of AOD interventions or treatment settings to ensure exploration of diverse lived experiences. Only literature that contained data relating to lived experiences as told by Indigenous Australian service users rather than for instance, worker's evaluation of clients, was included in the review. The inclusion and exclusion criteria are presented in Table 2.

TABLE 2.

Inclusion and exclusion criteria

Inclusion criteria	Exclusion criteria
Literature written in English (including articles translated into English)	Literature written in other languages not translated into English
All types of literature, including but not limited to journal articles, books, government reports and other peer‐reviewed or non‐peer‐reviewed literature	NA
Published between 2009 and present	Articles published prior to 2009
All psychoactive substances, including but not limited to alcohol	NA
All types of AOD interventions, including but not limited to counselling, medication, and residential treatment program	NA
All treatment settings, including but not limited to hospitals, and residential or non‐residential facilities	NA
Indigenous population in Australia, which encompasses both Aboriginal and/or Torres Strait Islander peoples	Non‐Australian Indigenous populations and non‐Indigenous Australian populations
All individual characteristics, including but not limited to age, gender and sexual orientation	NA
Articles containing the lived experience of Indigenous Australian peoples accessing AOD treatment services	Does not contain discussions regarding lived experience of Indigenous Australian peoples in relation to undergoing AOD treatment, i.e., practitioner‐focused feedback, policy documents

Abbreviations: AOD, alcohol and other drugs; NA, not available.

2.3. Information sources

Comprehensive searches were performed in three databases: DRUG, Indigenous Collection and APAIS. These databases contained relevant to AOD treatment settings for Indigenous peoples in Australia. Database search strategies (Appendix 1, Supporting Information) were drafted by two authors (Author 1 and Author 2) and then reviewed by an independent university librarian. The search strategies were peer‐reviewed using the Peer Review of Electronic Search Strategies checklist [27]. The final search results were exported to RefWorks and duplicates were removed. The initial search was implemented in June 2019 across three databases. The reference lists of included studies were also searched manually for additional literature. A follow‐up search of the aforementioned three databases was conducted in May 2020 and March 2022 to identify any additional literature published after the initial search in 2019.

Two approaches were taken to identify relevant grey literature: an internet browser search and a manual search of repositories of evidence. First, an internet search using the Google search engine was conducted using relevant key search terms (Appendix 2, Supporting Information). The first 100 results, sorted based on relevancy ranking within the Google search engine, were reviewed for potentially relevant literature, as completed in previous scoping reviews (i.e., Pham et al. [28], Godin et al. [29]). As suggested by Godin et al. [29], this approach was taken to ensure that most relevant results were captured while keeping literature screening contained. Based on the outcomes of the Google search screening, further screening was considered unlikely to provide additional relevant literature. Instead, pertinent repositories of evidence were searched manually for additional relevant grey literature (Appendix 3, Supporting Information).

2.4. Selection of sources of evidence

Two authors (Authors 1 and 2) independently reviewed the titles and abstracts of literature obtained from the database search. Where literature did not include an abstract component, a keyword search of the literature was performed. Two authors then independently reviewed the full texts of literature included for full‐text review, convening at the end of each stage to discuss assessments and resolve disagreements. Results of the selection process are presented in the PRISMA flow diagram format [30].

2.5. Data‐charting process

A data‐charting template was jointly developed by two authors (Authors 1 and 2) to determine the relevant data items to be extracted. Author 1 then charted the data, while Author 2 verified the data for accuracy. Authors 1 and 2 discussed disagreements at the end of this process. Data extracted from each source of evidence included author names, the year of publication, article type, study design, location, size, year of study, substance, treatment type, setting, location, size, duration, demographic details (age and gender), and whether the study conducted was Indigenous‐led. To review lived experience data as reported within the included literature, narratives about the experiences of Indigenous Australian service users in accessing and undergoing AOD treatment were extracted and the emerging themes were charted as suggested by Lindseth and Norberg [31].

2.6. Synthesis of results

A data‐driven approach was used to conduct a secondary analysis of data reported in included studies as this approach was considered most appropriate to review lived experiences data [32]. Authors 1 and 2 undertook thematic analysis of lived experience data reported in included studies using Braun and Clarke's [33] thematic analysis method. To identify patterns and themes, initial codes were generated and applied to the lived experience excerpts reported in included studies. Initial codes were then refined and collated into themes and sub‐themes. Narrative synthesis was used to summarise the lived experiences themes found in our secondary analysis of included literature, categorised by theme. A graphical representation was used to display the results of our secondary analysis.

3. RESULTS

3.1. Selection of sources of evidence

Following the removal of duplicates as well as the title and abstract screening process, the full texts of 66 articles were screened for eligibility. Of these, 33 articles were excluded for the following reasons: did not include contents related to AOD treatment (n = 5), did not contain discussion on service users' lived experience with respect to accessing or undergoing AOD treatment (n = 26), the experience was not specific to Indigenous Australians (n = 1), and a systematic review containing articles published prior to 2009 (n = 1). In total, 27 articles fulfilled the eligibility criteria and were included in this scoping review (Figure 1).

FIGURE 1.

Flow chart of article selection process. AOD, alcohol and other drugs

3.2. Characteristics and results of sources of evidence

All articles focused on Indigenous communities from diverse locations in Queensland, Victoria, Western Australia, New South Wales (NSW), South Australia and the Northern Territory. Consequently, there was significant Indigenous diversity evident in the articles, noting that Indigenous peoples are from more than 250 First Nations language groups throughout Australia [34].

Thirteen articles (48%) were classified as original research reports. Other article types included evaluation reports (n = 4, 15%), case study reports, annual reports, theses, magazines (each consisted of two articles, 7%), one perspective article (4%) and a government document (4%). Three out of the 13 original research reports were part of a wider, 2‐year study. Similarly, one thesis and one magazine article referred to a single study. Furthermore, the two case study reports discussed different aspects of the same drug and alcohol residential program. Shared authorship across articles was also noted, with 3 of 13 original research reports written by the same author. Two of the authors of one case study report also co‐wrote another case study report. Out of 27 articles, 10 (37%) were identified as Indigenous‐led, defined as either those published by Aboriginal Community‐Controlled Organisations or Indigenous authors (where reported within the article).

Thirteen articles (48%) focused on both alcohol and drugs misuse and eight articles (30%) focused only on alcohol misuse. Ten articles (32%) discussed treatment in residential program settings, 5 articles (16%) in community‐based education and brief intervention settings, while 14 articles (45%) referred to treatment in various other settings.

Seventeen articles (63%) did not specify participants' gender, while 10 (37%) focused on gender‐specific programs. In 11 articles that reported participants' ages, 8 (30%) focused on program participants 18‐year‐olds and over, 2 (7%) focused on programs where participants of all ages were eligible, and 1 (4%) focused on participants aged 13 years and older. A summary of the characteristics of sources of evidence is presented in Appendix 4 (Supporting Information). The data charted are presented in Table 3.

TABLE 3.

Summary of articles reviewed

Article			Study				Treatment
Author, year of publication	Article type	Indigenous‐led	Study design	Study location	Study size	Year of study	Substance	Treatment type	Treatment setting	Treatment location	Treatment size	Treatment duration	Age	Gender	Key themes
Nichols [35], 2010	Original research	Yes	Qualitative, semi‐structured interviews	Derby area of the West Kimberley region of north WA	84	2010	Alcohol	NR	NR	NR	NR	NR	NR	NR	Culture: Family.
Nichols [36], 2010	Original research	Yes	Qualitative, semi‐structured interviews	Derby area of the West Kimberley region of north WA	22	2010	Alcohol	Residential	Residential facility	Broome (7), ‘dry’ Aboriginal communities (6), Darwin (3), not disclosed (6)	NR	NR	NR	NR	Culture: Shared experience. Holistic and strength‐based approach: Managing change; learning skills; support. Organisational components: Location; staff; strategies and materials.
Anderson et al. [37], 2013	Case study	Yes	Ethnographic observations	St Kilda, VIC	NR	NR	Alcohol and other drugs	Residential	Residential facility	St Kilda, VIC	Winja Ulupna: Maximum 8. Galiamble: Maximum 16.	Winja Ulupna: Minimum 3 months. Galiamble: Minimum 15 weeks.	18‐year‐olds and older	Winja Ulupna: Female. Galiamble: Male.	Culture: Family; shared experience; communication norms; shame. Holistic and strength‐based approach: Support.
Fitts and Palk [38], 2016	Original research	NR	Focus groups and semi‐structured interviews with a series of open‐ended questions, thematic analysis	Two Far North Qld communities: one is located 70 km from Cairns (outer regional) and another is located 800 km from Cairns (very remote)	25	2013	Alcohol	Drink driving program	The outer regional program was delivered in an outdoor area within the rainforest, within walking distance to the local Indigenous community	Two Far North Qld communities: one is located 70 km from Cairns (outer regional) and another is located 800 km from Cairns (very remote)	Eight	Four 2‐hour sessions	18 years old and over	Male	Culture: Family. Organisational components: Location; strategies and materials
Nichols [39], 2010	Original research	Yes	Qualitative, semi‐structured interviews	Derby area of the West Kimberley region of north WA	170	2010	Alcohol	Residential	Residential facility	Two locations in West Kimberley, WA	Maximum 16	Expected to average 4–6 months' stay, although residents could stay for up to a year	Focus on young people, although people of all ages would be eligible	NR	Culture: Family. Holistic and strength‐based approach: Managing change; support. Organisational components: Location; self‐determination.
Conigrave et al. [40], 2012	Original research	NR	Quantitative questionnaire	SSWAHS region	58	2009	Alcohol	Community‐based education and brief intervention	Community‐based groups	SSWAHS region	One	Eight sessions conducted over 12 months	18 years old and over	Male and female in separate groups	Holistic and strength‐based approach: Learning skills.
Chenhall and Senior [41], 2013	Original research	NR	Ethnographic observations, informal conversational discussions, semi‐structured interview	NT, WA and NSW	38	2008–2009	Alcohol, cannabis, amphetamines	Residential	Residential facility	NT, WA, and NSW	NR	Varying from two weeks to over 24 weeks	The majority of residents were young, with 45% aged between 26 and 39 years old	NR	Culture: Shared experience. Organisational components: Staff; self‐determination.
Norgate [42], 2011	Perspective	No	Ethnographic observations	NR	NR	NR	Alcohol and other drugs	Residential	Residential facility	Adelaide, SA	NR	NR	NR	Female	Culture: Family.
Clifford and Shakeshaft [43], 2011	Original research	NR	Pre‐ and post‐surveys, group interviews, phenomenological approach	Two ACCHSs in NSW: one rural and one metropolitan centre	36 health staff, 24 Indigenous patients	2007–2008	Alcohol	Alcohol screening and brief intervention	Community health services	Two ACCHSs in NSW: one rural and one metropolitan centre	One	One session	NR	NR	Organisational components: Staff; strategies and materials.
Hegarty et al. [44], 2010	Case study	NR	Ethnographic observations	St Kilda, VIC	8–12	NR	Alcohol and other drugs	Residential	Residential facility	St Kilda, VIC	8–12	16 weeks	18 years old and older	Male	Culture: Family; shared experience; storytelling; communication norms; shame. Holistic and strength‐based approach: Managing change; learning skills; support. Organisational components: Self‐determination.
Calabria et al. [45], 2013	Original research	Yes	Descriptive survey	NSW ACCHS	116	2010–2011	Alcohol	Cognitive‐behavioural intervention	Community health services	NSW ACCHS and rural NSW community‐based drug and alcohol treatment agency in rural NSW	One	NR	18 years old and older	NR	Holistic and strength‐based approach: Support. Organisational components: Trust.
Munro [46], 2018	Thesis	NR	Mixed methods, semi‐structured interviews (research yarning)	Orana, NSW	21 participants: 12 clients and 9 staff	2014–2017	Alcohol and other drugs	Residential	Residential facility	Orana Haven Residential Rehabilitation Centre in NSW	12	3‐months, average of 48 days	18 years old and older		Culture: Cultural connection and cultural safety; storytelling; communication norms Holistic and strength‐based approach: Learning skills; barriers to treatment; support Organisational component: Location; staff; trust; strategies
Bovill [47], 2018	Thesis	Yes	Yarning	Newcastle, NSW	24 Aboriginal women: 1 pregnant woman, 15 mothers, and 8 elders	2018	Tobacco	NRT and non‐pharmacological approaches	NR	NR	NR	NR	NR	Female	Organisational component: Strategies.
Network of Alcohol and other Drugs Agencies [48], 2016	Magazine	No	NR	NR	NR	NR	Alcohol and other drugs	Residential	Residential facility	Orana Haven Residential Rehabilitation Centre in NSW	NR	NR	NR	NR	Holistic and strength‐based approach: Barriers to treatment. Organisational component: Trust.
Victorian Aboriginal Health Service [49], 2017	Annual Report	Yes	NR	NR	NR	NR	Tobacco	Community‐based education and brief intervention	Local gym	VIC	67	1 Year	NR	NR	Culture: Cultural connection and cultural safety; family and community.
Marrin Weejali [50], 2019	Annual Report	Yes	NR	NR	NR	NR	Alcohol and other drugs	Community‐based education and brief intervention	Community‐controlled healing centre	Blackett, NSW	NR	NR	NR	NR	Culture: Shared experience. Holistic and strength‐based approach: Learning skills; support. Organisational components: Staff; strategies.
Network of Alcohol and other Drugs Agencies [51], 2016	Magazine	No	NR	NR	NR	NR	Alcohol and other drugs	Residential	Residential facility	Cowra, NSW	NR	NR	NR	Male	Culture: Family and community.
McCuaig and Nelson [52], 2012	Government document	No	NR	NR	NR	NR	Alcohol, other drugs and tobacco	Community‐based education and brief intervention	Educational setting (high school) and youth detention centre	South‐East Qld	NR	8‐session program	13 years old and older	NR	Organisational components: Strategies.
Pienaar et al. [53], 2017	Original research	No	In‐depth qualitative interviews	VIC & NSW	60	2014–2016	Alcohol and other drugs	Self‐help group and rehab	NR	NR	NR	NR	NR	NR	Culture: Cultural connection and cultural safety; shared experience. Organisational components: Strategies.
Halacas et al. [54], 2015	Evaluation report	Yes	Ethnographic observations	VIC	150	2013–2014	Alcohol and other drugs	Community‐based education and brief intervention	NR	VIC	30 (1/3 being Aboriginal)	Single session	NR	NR	Holistic and strength‐based approach: Managing change; barriers to treatment. Organisational components: Location; trust.
Senior et al. [55], 2009	Evaluation report	NR	Mixed methods	Alice Springs, NT	8	2008	Alcohol	NR	NR	Alice Springs, NT	NR	NR	NR	NR	Holistic and strength‐based approach: Managing change; barriers to treatment. Organisational components: Location.
Berry et al. [56], 2022	Original research	NR	Semi‐structured interviews and questionnaire	NSW	101	NR	Alcohol and other drugs	Residential	Residential facility	NSW	NR	4–20 weeks	18 years old and older	Male	Culture: Cultural connection and cultural safety. Organisational components: Location; staff.
PricewaterhouseCoopers Indigenous Consulting Pty Limited [57], 2017	Evaluation report	No	Semi‐structured interviews and review of records	NT	NR	2015	Alcohol and tobacco	Alcohol mandatory treatment and NRT	Residential facilities, community‐based alcohol treatment providers, other health services	Darwin & Alice Springs, NT	NR	NR	NR	NR	Culture: Family and community. Holistic and strength‐based approach: Managing change; learning skills; support. Organisational components: Location.
Sindicich et al. [58], 2016	Original research	No	Qualitative, semi‐structured interviews	NSW	59 participants, 47 interviewed	2012–2013	Drug (opioid)	Opioid substitution therapy	Correctional centre	NSW	NR	NR	18 years old and over	Male and Female	Holistic and strength‐based approach: Managing change; barriers to treatment. Organisational components: Strategies.
Lee et al. [59], 2013	Original research	NR	Structured interviews	Sydney, NSW	24 clients, 21 staff	2013	Alcohol and other drugs	Outpatient AOD treatment	Hospital	Sydney, NSW	NR	NR	NR	Female	Culture: Shared experience; storytelling. Holistic and strength‐based approach: Managing change; support. Organisational components: Strategies
Langton et al. [60], 2020	Original research	Yes	Semi‐structured interviews, focus groups, participant observation, audit of legal framework	Mildura and Wodonga, VIC and Albury, NSW	97	2020	Alcohol and other drugs	Rehabilitation and counselling	NR	VIC and NSW	NR	NR	NR	NR	Holistic and strength‐based approach: Barriers to treatment.
EACH [61], 2019	Evaluation report	No	Document review, focus group, interviews	Eastern Metropolitan Region of Melbourne, VIC	13	NR	Alcohol, tobacco, and other drugs	Collaborative care	Community health services	VIC	NR	NR	NR	NR	Culture: Family and community. Holistic and strength‐based approach: Barriers to treatment; support. Organisational components: Trust; strategies.

Note: Indigenous‐led status: Yes—Literature published by Aboriginal Community‐Controlled Organisations or Aboriginal and/or Torres Strait Islander authors (where reported within the article). No—Government literature (unless led by an Indigenous author). NR—Literature that did not mention the author's Indigenous status.

Abbreviations: ACCHS, Aboriginal Community‐Controlled Health Service; AOD, alcohol and other drugs; NR, not reported; NRT, nicotine replacement therapy; NSW, New South Wales; NT, Northern Territory; Qld, Queensland; SA, South Australia; SSWAHS, Sydney South West Area Health Service; VIC, Victoria; WA, Western Australia.

3.3. Synthesis of results

Results of the thematic analysis of data reported within the included studies were organised along three major themes: the essential role of culture, the value of holistic, and strength‐based approaches in facilitating recovery and the influence of organisational components. A graphical representation of the results is presented in Figure 2.

FIGURE 2.

Diagram of results. AOD, alcohol and other drugs; AMT, alcohol mandatory treatment; NRT, nicotine replacement therapy; OST, opioid substitution therapy; SBI, screening and brief intervention

3.3.1. The essential role of culture

Culture, including practices, beliefs, values, attitudes, behaviours and norms shared by a group of people [62], appeared prominently in the reviewed literature containing data about Indigenous people's lived experiences of accessing and undergoing AOD treatment. It is important to note that the cultures of Indigenous Australians vary throughout the various First Nations communities, where there is significant linguistic and cultural diversity [34]. Cultural connection, which respected and promoted a strong sense of Indigenous identity throughout Indigenous people's engagement with AOD services, was an important element evident in our secondary analysis of Indigenous people's experiences of AOD treatment [46, 49, 53, 56]. Cultural connection is an individual feeling that can be embodied through cultural practices and upholding cultural values, yet is considered important to overall health and wellbeing [63, 64, 65]. In this review, the literature contained data about cultural connection, including opportunities to engage in cultural activities [46, 53, 56] and with Indigenous peoples, such as elders and Indigenous workers in programs [46, 56]. Reviewed literature also highlighted the ways in which cultural connection provided participants with opportunities to be themselves [49], to feel a sense of pride and self‐worth [46], and enable a sense of healing and hope [56].

Within the reviewed literature, our secondary analysis found that Indigenous peoples highly valued kin and kinship supports, both during treatment and post‐treatment, emphasising the importance of having kin accompanying them throughout stays at residential programs [39, 42] and during program activity participation [44]. In other studies, such as Anderson et al. [37], Indigenous men in a residential treatment facility in Melbourne used kinship supports, such as cousins, and cultural values, such as respect, as a bridge to support attitudinal change towards women. The wisdom and support of elders were also valued in other studies reviewed, with Indigenous peoples in a drink driving program in Far North Queensland receiving guidance from Elders on overcoming peer pressure to drink [38]. Services that were family‐centric were also valued by Indigenous peoples in one study [61]. Indigenous peoples looked forward to reconnecting with family after treatment in other studies [57], reporting the feeling of peace and contentment after re‐integration into community following residential treatment in one study in NSW [51]. In a Derby‐based study, Indigenous peoples felt that re‐engagement with family and community responsibilities should be a measure of success in treatment outcomes [35].

Other reviewed studies highlighted how shared experiences were valued by Indigenous peoples in treatment programs. Some Indigenous peoples highlighted the therapeutic power of yarning—that is, the telling and sharing of stories and information within Indigenous cultures (see Bessarab and Ng'andu [66] for further information)—and working together in studies based in Northern Territory, Western Australia, NSW and Victoria [41, 44, 59] as it facilitated interconnectedness between participants in the program, and improvements in their relationships with one another and their own families [36, 37, 44]. Three studies reviewed indicated how experiencing the program together with other Indigenous peoples also helped to enable a sense of feeling ‘normal’ and ‘not alone’ [50, 53, 59].

In two studies based in Melbourne and NSW, Indigenous peoples' preference for the use of storytelling was observable in two residential programs [44, 46] and an outpatient AOD treatment service [59]. In our review of Hegarty et al.'s [44] study, we found that some Indigenous peoples also preferred their reflections to be written into prose and reported that metaphors used helped them to visualise their journey and stay on the path to recovery. Sharing stories motivated and inspired Indigenous participants in outpatient AOD treatment in a Sydney‐based study [59], and enabled mutual learning in a residential program in Orana, NSW in Munro's [46] study.

Potentially influenced by cultural communication norms, some Indigenous men and women in AOD programs in two studies reviewed initially found it challenging at the beginning to talk openly about their thoughts and feelings [37, 46]. Through the programs however, Indigenous peoples reported in Anderson et al. [37] and Munro [46] gradually feeling safe communicating openly with each other. Some studies reviewed also showed that when sharing of experiences was unforced and supported in culturally safe spaces, trust and confidence within the group was built, facilitating the expression of thoughts and feelings among Indigenous peoples in treatment [44, 46].

In two studies reviewed, shame posed a significant barrier, influencing some Indigenous people's experiences in residential programs, while relapse was found to cause many Indigenous participants to feel shame and reluctance to re‐engage with services in Melbourne [37, 44].

3.3.2. Holistic and strength‐based approach to initiate and sustain change

Our review of included studies found that Indigenous peoples' lived experiences of accessing and undergoing AOD treatment also revolved around their capacity to initiate and sustain change pre‐, during‐ and post‐treatment. Four studies reviewed indicated several barriers to treatment for Indigenous peoples, including a lack of transportation to services, the absence of someone to care for children while seeking treatment, a lack of specialist AOD treatment targeting particular substances and long waitlists [40, 54, 55, 58]. Indigenous people's motivation and readiness were also factors highlighted as barriers and enablers to treatment access and sustained change in four included studies [48, 58, 60, 61].

Indigenous peoples in residential programs in studies based in Derby, Victoria, and the Northern Territory, challenges in sustaining change upon returning to community were highlighted [36, 54, 57] as new and old identities collided [44]. This was found to be pertinent where substance use was rife in one study [39] and transition to life post‐treatment was not supported in other studies [54, 55, 58]. Programs that increased knowledge of substance misuse management and effects were indicated in three studies as building Indigenous peoples' strengths in coping with challenging situations, which helped to sustain change [36, 58, 59].

Furthermore, some Indigenous peoples in a study in Derby highlighted that some residential programs focused on symptoms rather than causes, and that without the opportunity to learn new skills, returning unchanged to the same situations in their communities would occur [36]. Indigenous peoples' valued aspects of services and programs that provided holistic opportunities for change. Life‐skills education [36, 44, 57] and vocational courses [46, 50, 57] provided through residential and community‐based health programs were found to increase some Indigenous peoples' skills, confidence, sense of pride, and self‐esteem in some studies [36, 44, 57].

Indigenous peoples valued the support they received from workers and agencies in several studies [36, 46, 50, 57, 59, 61] and the other program participants [36, 37, 42] during treatment. Three studies highlighted that this also helped Indigenous peoples to feel that they were not alone in their recovery journey [37, 44, 61]. Indigenous peoples who participated in cognitive‐behavioural intervention and residential programs also expressed their needs for support post‐program in four studies [39, 44, 45, 46].

3.3.3. The influence of organisational components

Within the literature reviewed, we observed that Indigenous participants' experiences were significantly influenced by the organisational components of the services providing treatment, including location, staff skills, strategies, and materials used. In three studies, when residential programs were located at a distance away from cities, Indigenous peoples within these programs asserted that it provided them with peace and an opportunity to be on Country [36], away from those environments that lead them to drinking [39, 57]. Nevertheless, when program locations were too far from Indigenous participants' families, two studies indicated that it became impractical for families, caregivers and certain cultural protocols to be incorporated into programs [36, 54]. Program locations were important in two studies to facilitate cultural connection [46, 56].

Indigenous service users within studies based on various treatment types highlighted that staff skills and connections with participants impacted their experiences. With the preference for staff who have personal experiences of substance misuse, three studies highlighted that Indigenous peoples felt some staff were not sufficiently trained and lacked the authority to offer advice regarding substance misuse [36, 43, 46]. Two studies showed that Indigenous service users appreciated passionate, but firm [50] and approachable staff who were always available to talk [46]. Due to privacy issues, a few Indigenous peoples in one study preferred working with non‐Indigenous professionals, since they were less likely to be related to participants [41]. Furthermore, Indigenous peoples in one residential program in NSW valued culturally appropriate workers to facilitate cultural activities [56].

The development of trust between Indigenous peoples and workers was crucial in facilitating successful treatment in some studies reviewed. Several studies highlighted that Indigenous peoples expressed preference for staff with lived experience [61], who had experience working in their local community [45], who identified as Indigenous [46], and demonstrated empathy and understanding of their needs [54, 61] to facilitate rapport, cultural bonds and mutual respect. Programs that run for a longer duration [45], whose rules were strict, but fair [46], that facilitated a sense of safety [48], and were welcoming [61] were also found to promote the development of trust in some studies.

Strategies utilised by services within their programs influenced Indigenous peoples' experience of treatment, with behaviour‐changing strategies that were practical, relatable, holistic, and well‐implemented valued by Indigenous participants in several studies [38, 43, 46, 47, 53, 58]. Treatment strategies that were strength‐based and drew on the support of others were also preferred by Indigenous peoples in three studies reviewed [38, 43, 46]. Additionally, program structure influenced Indigenous peoples' experiences in two studies, with the availability of activities not related to substance abuse helping participants to take their minds off drugs [57] and keep busy [46]. Having a good balance between structured and unstructured activities as well as downtime was valued by Indigenous participants in treatment in NSW [46, 59]. Reported benefits of these program structures included changes in appearance, weight, eating, and sleeping habits [46], and better insight into addiction [50, 52]. Services that tailored treatment strategies to individual service users were valued by Indigenous peoples in one study [61].

Opportunities to exercise self‐determination through residential programs that were operated and managed by Indigenous entities were valued by Indigenous peoples in Nichols' [39] study, where workers' respected Indigenous peoples' perspectives and feedback about the programs, and implemented them as concrete actions [41] Self‐determination for Indigenous participants to decide how to engage and contribute to activities was also highly valued in Hegarty et al.'s [44] study.

4. DISCUSSION

Understanding Indigenous peoples' lived experiences of accessing and undergoing AOD treatment may help to improve treatment design and delivery by tailoring treatment to the needs of consumers [67]. This secondary analysis of existing literature found that culture, holistic and strength‐based approaches, and organisational components influenced Indigenous peoples' experiences of AOD treatment in Australia.

Indigenous peoples' perception and experience of institutions and the services they engage with are influenced by culture [63]. Despite significant diversity and complexity within Indigenous cultures [68], studies have demonstrated a clear link between the importance of Indigenous cultures and improved health and wellbeing outcomes [65, 69, 70]. The importance of culture was evident within the lived experiences of Indigenous peoples undergoing AOD treatment within the literature reviewed. Similarly, the involvement of family and kin was paramount throughout AOD treatment and beyond. This is in line with Verbunt et al.'s [70] assertion that as part of a holistic view of health and wellbeing, family and kin play a crucial part in facilitating Indigenous peoples' health and wellbeing. Furthermore, within the domain of culture, feelings of shame associated with seeking treatment observable in the literature reviewed is in line with Brady's [71] assertion that shame is heavily influenced by cultural beliefs and attitudes regarding AOD use.

These findings highlighted the importance for policymakers and service providers to better integrate culture into AOD treatment for Indigenous service users, best tailored to the specific cultural needs of communities [72]. This is needed in a context where culturally inappropriate care for Indigenous peoples in AOD treatment has been previously highlighted [73]. Challenging non‐Indigenous peoples' assumptions and expectations about service provision is also needed [74].

To address the social determinants of health, such as poverty, racism and trauma that can influence harmful substance use [75, 76], it is important that services are tailored to meet the context‐specific needs of Indigenous peoples and communities with appropriate funding and support. Gray et al. [77] remarked on the current lack of ongoing care, outreach services and programs within AOD services that addresses issues interrelated with addiction and substance abuse, including violence, grief and trauma. This siloed approach to AOD treatment fails to address the social determinants of health associated with substance abuse [78]. Holistic, trauma‐informed and culturally appropriate policy and services are needed, driven by Indigenous self‐determination [79]. Our review highlights the importance for policymakers and service providers to improve the provision of holistic, strength‐based AOD programs for Indigenous peoples.

Recognising the importance of family and kin to Indigenous peoples' health and wellbeing [70], it is important to respect the strengths of Indigenous cultures, where family and kin are engaged in AOD treatment. This supports a relational approach to AOD treatment, focused on collective needs, as opposed to a culturally inappropriate focus solely on individual need since family, kin and community are fundamental to Indigenous cultures [63, 70].

Organisational components also significantly influenced Indigenous peoples' experience of treatment, with locations that are accessible, culturally appropriate, and providing space for recovery being valuable. Skilled staff who are relatable are needed, as are behaviour‐change strategies that are practical, relatable, strength‐based, holistic and well‐implemented [7, 77, 80]. Organisational components, including service location, staff skills and competency, strategies and program structure, are crucial elements for the effective delivery of treatment.

Trust is also important, in line with Terrell's [81] assertions, where developing trust between workers and service users are crucial for successful treatment. Influenced by traumatic experiences of injustice, experiences of systemic racism and concerns regarding confidentiality are crucial elements of trust especially relevant for Indigenous peoples [82].

As a fundamental human right of Indigenous peoples, self‐determination is also paramount for Indigenous peoples in AOD treatment since it enables choice, agency and control of one's recovery journey [9, 10]. As Nakata [5, 8] highlights, self‐determination takes place at individual and collective levels where individuals and communities exercise control and management of their own affairs. In AOD treatment contexts, it is thus crucial at the individual level for Indigenous peoples to exercise their agency and self‐determination, without constraints or barriers, to initiating and sustaining change. At a community level, it is essential that Aboriginal Community‐Controlled Organisations exercise self‐determination by leading, driving and implementing solutions that are tailored to local contexts and compatible with Indigenous worldviews and perspectives on health [83] and AOD treatment [72]. Within this review, AOD treatment services that were culturally responsive, and tailored to meet the needs of both Indigenous peoples and communities, were highly valued, thus demonstrating the value of self‐determination to treatment design. Ensuring that Indigenous peoples have ownership of solutions, via self‐determination, is essential [7]. There is a crucial role for policymakers and service providers to ensure that Indigenous communities are involved in every stage of design, planning, and implementation of AOD treatment services, in ways that progress beyond tokenism or consultation.

4.1. Limitations

This review synthesised the lived experiences of Indigenous Australians that were reported in existing research. As such, this review did not analyse raw data, but instead, is limited by a secondary analysis of existing research that may be prone to bias. Findings from this review should thus be interpreted with caution, particularly given that 63% of included studies were either not, or not reported as, Indigenous‐led. Indigenous‐led research would potentially produce different research questions, aims and methodologies, and hence, a different set of findings for secondary review.

As this scoping review focused on the Indigenous Australian context, international literature that may have offered valuable insights were not reviewed. Furthermore, over one‐third of included studies related to residential program settings. As a consequence, three themes in our review of these secondary data (communication norms, shame, and self‐determination) related solely to residential settings. This indicates a need for future Indigenous‐led research that investigates the role of culture and self‐determination in non‐residential treatment settings.

5. CONCLUSION

This scoping review has highlighted the paucity of literature that solely focuses on Indigenous peoples' lived experience in accessing and undergoing AOD treatment. While there were variances in the experiences between different treatment types, three dominant themes emerged from this review. First, the importance of culture was evident within participants' experiences. Cultural connection, kinship, bonding, the use of storytelling, engagement in certain cultural practices, cultural communication norms and shame were elements that facilitated (or hindered) successful treatment for Indigenous peoples. Additionally, treatment services that were holistic and utilised strength‐based approaches facilitated Indigenous peoples' recovery. Lastly, organisational components had a significant influence on Indigenous peoples' experiences of treatment, where there is a need to ensure that services are both culturally appropriate and tailored to the local context.

The findings highlight the importance for policymakers, service providers, and practitioners to better integrate culture within AOD treatments for Indigenous peoples, driven by and within Indigenous communities. Self‐determination for Indigenous peoples is paramount, where power, control and leadership across every stage of AOD treatment planning and implementation is needed for holistic, appropriate and effective AOD treatment for Indigenous peoples.

AUTHOR CONTRIBUTIONS

Airin Heath led the scoping review, developed the scoping review question and the design of the study, including the development of the eligibility criteria and the search strategies, and the identification of data elements to be charted. Airin Heath and Mary Kristienne Martin performed the literature searches, screened the literature for eligibility, and charted and analysed the data. Airin Heath drafted the manuscript and Mary Kristienne Martin provided critical revisions. Jacynta Krakouer contributed to writing in revisions of drafts of the manuscripts and provided critical feedback, particularly in relation to the cultural context of the manuscript. All authors approved the final manuscript. Each author certifies that their contribution to this work meets the standards of the International Committee of Medical Journal Editors.

FUNDING INFORMATION

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

Supporting information

Appendix S1 Supporting Information.

Heath A, Martin MK, Krakouer J. Exploring the lived experiences of Indigenous Australians within the context of alcohol and other drugs treatment services: A scoping review. Drug Alcohol Rev. 2022;41(7):1664–1681. 10.1111/dar.13528