Values in health and health care for Indigenous people globally: an umbrella review

Before the disruption of settler colonialism, Indigenous health models were tried and perfected, establishing a 65 000‐year‐old ecosystem that sustained an intrinsic relationship of health and wellbeing between people and place. Fundamental to this is Indigenous ways of knowing, being and doing, which is grounded in a holistic conceptualisation of health.1 The devastating impact of colonisation amounted in the suppression of Indigenous models and perceptions of health, leading to the inequity and disparity prevalent in Indigenous communities today.2,3

Western conceptualisations of health are often used to design policies, service delivery models, and systems of health care.4,5 This limits their appropriateness for Indigenous populations, resulting in low engagement, which affects health outcomes.6 Historically, government‐funded programs and services developed and delivered by Indigenous people have been de‐funded due to traditional cost–benefit evaluations used to assess their effectiveness.7 Such evaluations neglect the perceived value by Indigenous communities and the tremendous efforts of Indigenous organisations to improve the health and wellbeing of their own communities.8

Globally, however, greater emphasis is being placed on value‐based health care and embedding Indigenous worldviews in the planning, delivery and evaluation of health care policies and services.9 Nevertheless, genuine engagement with Indigenous populations to understand what they value in health and health care, which could increase the effectiveness and cultural safety of health services for Indigenous people, is still lacking.4,8 Therefore, the aim of this umbrella review was to understand: what do Indigenous people value in health and health care globally?

Methods

Positionality statement

LJC and DB are Indigenous Australian researchers. LJC is a traditional custodian of the Galari Bila people of the Wiradjuri Nation. DB is a Sydney‐based Wiradjuri person. YD, KM and CM are non‐Indigenous Australian researchers.

Collaborative yarning

Collaborative yarning is an Indigenous research method that allows researchers to engage meaningfully and respectfully to exchange and share perspectives and ideas through reflecting, storytelling, speaking and deep listening.10 This method was used to facilitate decision making between Indigenous and non‐Indigenous researchers in this umbrella review. Collaborative yarning took place at each stage of this review between LJC and YD, from conception and formulation of the research question to study selection and the meta‐synthesis, via online and face‐to‐face discussions.

Protocol

The Joanna Briggs Institute protocol for umbrella reviews (https://jbi.global/critical‐appraisal‐tools), which endorses the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA),11 was used to guide the development of this review. Our PRISMA reporting checklist is in Appendix A of the Supporting Information.

Search strategy

A Macquarie University librarian was consulted to develop the search strategy and search terms. Search terms were based on the Population, Intervention, Context, Outcome (PICO) search strategy for systematic reviews. Search terms included: “Indigenous populations globally” (Population); “assessment of value in healthcare”, “social and cultural determinants of health”, “accessibility in healthcare”, “health knowledge”, “attitudes”, “evidence‐based practice”, “best practice recommendations for healthcare”, “socio‐economic outcomes for healthcare programs”, “system level changes in healthcare” (Intervention/Outcome); and “healthcare” (Context). Databases searched included MEDLINE, Embase, CINAHL, Scopus and the Cochrane Database of Systematic Reviews. Appendix B of the Supporting Information demonstrates the search strategy for MEDLINE, which was adjusted accordingly for the remaining databases. Reference lists of included reviews were also searched.

Eligibility criteria

Inclusion criteria included: systematic, scoping or narrative review, written in English, and published between 1 January 2000 and 1 May 2024. Eligible reviews were those that included studies that directly included the perspectives of Indigenous people describing the value of health and/or health care.

Study selection

Following the initial search, all references were imported into Covidence (https://www.covidence.org) for screening and duplicates were removed. Titles and abstracts were screened independently by LJC and YD, with half of the imported references allocated to each screener. Following this, full texts were reviewed together by LJC and YD through collaborative yarning to determine if reviews met the inclusion criteria. Disagreements were resolved by consensus or discussion with a third reviewer (CM).

Data extraction

Data extraction was completed by LJC and YD and included the name of the first author, year of publication, author positioning, type of review conducted, number and type of studies included in the review, type of analysis conducted, and a summary of key findings. Author positioning reflected the depth of Indigenous leadership of the included reviews and the overall interpretation of the reported findings which were ultimately considered in this umbrella review.

Data analysis

Included studies were imported into NVivo 14 (Lumivero) qualitative data analysis software. Appendix C in the Supporting Information summarises key descriptive data, including the aim or study question, country of Indigenous population, type of review, number of studies included in the review, type of analysis conducted and a summary of the results. A thematic meta‐synthesis, which aims to develop and understand complex themes through interpreting and synthesising findings from qualitative studies,12 was conducted to generate concepts of value in health and health care.

The thematic meta‐synthesis was conducted through five steps:

• initial familiarisation of included reviews through reading;
• coding values of health and health care identified from the results of included reviews using NVivo;
• collaborative yarning to sort and refine codes into overarching themes of value in health and health care;
• defining and reviewing the themes through collaborative yarning; and
• preparing the final report.

LJC and YD coded a sample of three reviews and met to ensure initial agreement of the coding structure through collaborative yarning. Following good agreement, LJC and YD independently coded half of the remaining articles and then met again to sort, refine and define the codes into themes through collaborative yarning.

Results

Characteristics of included reviews

This umbrella review identified 25 reviews that analysed what is valued in health and health care by Indigenous people globally13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37 (Supporting Information, appendix C) from 2477 identified references. A total of 1860 references were screened after removing 617 duplicates, 1815 were excluded as they did not meet the inclusion criteria, 45 were reviewed in full, and a further 20 were excluded as their outcomes or study designs did not align with the inclusion criteria (Box 1). Reviews primarily included qualitative studies with Indigenous people from Australia, New Zealand, the United States and Canada. Reviews reported seven studies in the fields of health care services, four for hospital services, three for health and wellbeing, two for cancer care, two for disability services, two for kidney health care services, and one study each for aged care, cardiovascular health care services, smoking cessation, palliative care services, and health care services recognising and responding to family violence.

Six studies reported on author positioning or the use of Indigenous methods or theories to guide their studies. Examples of author positioning or Indigenous methods and/or theories included Indigenous researchers,29,36 researchers with experience in Indigenous health,20 collaborative yarning,36 Kaupapa Māori positioning,27,37 two‐eyed seeing,13 and an Indigenous standpoint theory33 developed by Gilroy and colleagues.38

Culture

The literature demonstrated a clear distinction between Indigenous and Western paradigms of health and health care with Indigenous paradigms of health and health care grounded in culture. Box 2 provides a synthesis of the findings, which depicts culture at the centre of both cultural determinants of health and values in health care. Articles included in this review described culture as vital to the continuum of traditional knowledges and Indigenous ways of knowing, being and doing while being able to navigate the complexities and impacts of colonisation in contemporary settings, including health care.13,19,30,31,35

Cultural determinants of health

Indigenous cultural determinants of health included: identity; land, Country and community; and spirituality and traditional healing (Box 2). The value of identity was integral to an individual's sense of belonging to family, community, culture, land and spirituality, which is central to Indigenous worldviews and perceptions of positive health.13,19,29,30,31,35 Indigenous relationality and interconnections with land, Country and community were fundamental factors to ensure positive health and wellbeing outcomes for Indigenous people.19,30,33 Moreover, Country, land, family and community are interconnected and mutually reinforce an individual's cultural identity and belonging to the broader community. Spirituality and traditional healing methods produced positive perceptions of health and wellbeing for Indigenous people globally. Indigenous culture, spirituality and traditional healing practices are viewed as methods of resistance to colonial assimilation and dislocation by retaining knowledge transmission, cultural connectedness, ceremonies and relationships with Elders.13,17,29,30,31

Values in health care

Our meta‐synthesis identified five core values in health care for Indigenous people globally: decolonised and holistic systems of care; culturally safe health services and care; Indigenous and culturally aware non‐Indigenous workforce; accessibility; and communication, trust and rapport building (Box 2; Supporting Information, appendix D).

Decolonised and holistic systems of care

Decolonised health systems embed culture into health service delivery. They are often Indigenous‐led and managed; they are developed in partnership with Indigenous communities; they are welcoming14,34 and Indigenous‐centred, and incorporate an Indigenous worldview;25,31 and they challenge traditional power differentials.16 These types of health systems and services provide culturally safe care, increase patient engagement, positively impact health outcomes, and are preferred and valued by Indigenous people.23,24,36 Colonial‐led health systems are often not welcoming, and reduce patient engagement and the provision of culturally safe care.23,24,36 In Australia, Aboriginal community‐controlled health services are preferred to Western models of health care as they are led by and for local community, are considered culturally safe, and provide a range of holistic and comprehensive services.

Valued service provision is proactive, comprehensive and holistic,13,14,20,25,33 is community‐wide, provides outreach to remote communities, includes health promotion, and engages with Indigenous communities.24 This type of health care provides mainstream health services, supports social and emotional wellbeing,14 and includes traditional practices such as ceremonies, dancing and arts and craft.24,31,37

Continuity of care with the same practitioner was highly valued among Indigenous people, particularly within primary health care and hospitals.31 This provided a familiar face, enabled time to build rapport, and provided an ongoing relationship between the patient and clinician.31 However, locums, particularly in rural and remote communities, and high staff turnover prevented continuity of care, creating unsettled feelings of frustration, and forced Indigenous patients to build relationships with new clinicians or health workers and retell their clinical history and impacts.37 Interagency collaboration within health systems was highly valued, particularly for the management of complex, chronic diseases, as health systems that are difficult to navigate limit patient engagement.31

Culturally safe health services and care

Culturally safe services were described as those that enable Indigenous people to make their own decisions about their health,17,19,28,29,30,31,34 promote self‐determination,28,29,30 question the health service provider or feel comfortable to make a complaint.27 Services that are culturally safe consider and act on the diverse needs of different Indigenous communities, are provided on Country and are viewed as meeting places for community, echoing the importance of holistic services, not simply places for medical treatment.27 Good communication between the clinician and patient, and building trust,17,29,33,35 rapport and connection, contribute to the provision of culturally safe care; clinicians providing non‐judgemental care, and making people feel valued, respected, reassured and heard, also help to make health care culturally safe.14,17

Indigenous people value health care providers who have flexible appointment schedules and allow family to attend appointments.17,35,37 Consideration of gender is important and the opportunity for male patients to see a male doctor, for example, is valued.24 Indigenous staff, artwork, flags and celebrating significant Indigenous events were viewed as important for culturally safe care.19,24 Value was found in services that were provided in different Indigenous languages and included interpreters to facilitate access.15,24,29,32,36 Moreover, value was perceived in providing or supporting traditional healing practices or traditional medicine,24,25,31,37 and supporting spirituality and spiritual healing. Indigenous‐led and run services were more likely to support and provide traditional healing.13,17,29,37

Indigenous and culturally aware non‐Indigenous health workforce

The value of the Indigenous health workforce was seen as critical to good outcomes. Indigenous health workers facilitated a connection to culture, language and traditional practices.31,32 They increased engagement26,27 and acted as a “conduit”32 between Indigenous patients and primary health care providers.17,18,20,21,29

Indigenous people highly valued non‐Indigenous clinicians who were caring, kind, trustworthy and open‐minded. Clinicians who are culturally aware and understand Indigenous history and the impacts of colonisation, including enduring intergenerational trauma, are preferred.17,29,31 Racist clinicians and those who lack Indigenous knowledge provide culturally unsafe care, leading to disengagement in health services such as early discharge from hospital.33,34,36

Accessibility

Local services, especially in rural and remote areas, significantly improve access to care, reducing geographical barriers of travel and accommodation. However, a paucity of services in rural and remote areas and for geographically isolated communities means that many services are inaccessible for Indigenous people,17,29 with barriers including long wait times, costs of travel and managing children.23,27,37 The provision of transport and accommodation to access services was highly valued.14

Communication, trust and rapport building

Consistently good communication between Indigenous people and health service providers was highly valued. Moreover, trust, trustworthiness and rapport in the provision of culturally safe health care for Indigenous people were considered important.14,16,17,18,23,24,26,27,29,31,32,36,37 Good communication was characterised by mutual respect, taking the time for introductions and building rapport. Further, taking the time to explain health conditions and services in a culturally acceptable and relatable manner and minimising the use of medical jargon were highly valued.16,23,24,27,32,36,37 Good communication increased engagement with and positive experiences of health care services.

Trusting relationships between Indigenous people and health service providers were valued and built on rapport and positive experiences.24,26,27,32 This reduced anxiety about health conditions, facilitated the provision of culturally safe care and increased engagement with health services.24,26,27,32 Experiences of friends, family and the wider community with health service providers also influenced perceived trust.23,27

Indigenous patients valued unhurried care,17,29,31 where clinicians took the time to build rapport and trust, rather than focusing solely on the provision of services. Further, scheduling time to establish and build rapport helped providers understand the often complex family dynamics of Indigenous people.31

Barriers to health and health care

The impact and harm of colonisation and racism were identified as structural drivers that directly affect the health and wellbeing of Indigenous people, and which contribute to health disparities between Indigenous and non‐Indigenous people.17,28,34 Institutional and systemic racism as well as intergenerational trauma of colonisation were barriers to accessing care for Indigenous people. These factors create negative experiences of health care and contribute to health inequities for Indigenous people, perpetuating mistrust of the health care system for Indigenous people.29,32,35

Discussion

This umbrella review explored values in health and health care perceived by Indigenous people globally from published literature. The main finding was the value of culture in positive perceptions of health and health care for Indigenous people. In addition to culture, strong cultural identity, connection to land and Country, and spirit and spirituality were identified as important values in health for Indigenous people. Just as there is a broad conceptualisation of the values in health for Indigenous people, centred around culture, there is equally a broad conceptualisation of health care beyond the provision of medical care alone to treat a disease, which is more reflective of a Western biomedical view. These values highly influenced engagement in health services and directly affected health outcomes, and are echoed by Indigenous health plans and action plans in Australia, New Zealand39 and Canada40 as well as those of the World Health Organization41 and the United Nations.42 Consistently, the importance of Indigenous‐led and run services was highlighted. These services provide holistic, comprehensive, culturally safe care for Indigenous people and their families, are places of employment for local community and are places for connection to culture.6

However, holistic care with the provision of social and wellbeing services and safe places for community to meet and practice traditions, language, ceremonies, arts and craft are in direct conflict with a biomedical definition of health that dictates health sector policy and funding. In Australia, for example, health sector funding is typically siloed for a specific purpose (field of health care) and makes assumptions about those affected by these policies or services (for example, everyone has equal access or has the same needs).43 This directly contributes to the inequitable access to health services and health inequalities experienced by Indigenous people. Indigenous‐led and run health services and programs co‐designed with Indigenous communities provide accessible and culturally safe services and are more likely to lead to positive outcomes for Indigenous patients.6 Problematically, Western evaluation methods, including cost–benefit analyses and arbitrary key performance indicators are used to measure the effectiveness of these services, neglecting the perceived value and benefit of these programs to Indigenous communities.43 Historically, and particularly in the Australian context, this Western lens has led to the cessation of valuable and beneficial health services provided for and by Indigenous people. Arbitrary key performance indicators and metrics fail to recognise and reflect the important, beneficial and, more importantly, valuable services that Indigenous‐led and delivered services provide.8 This demonstrates the critical need for evaluations to include perspectives of value as perceived by Indigenous people who access these services.44

Globally, Indigenous peoples and lifeways share commonalities due to the impact of colonisation and dispossession.2 The differences between Indigenous peoples are the myriad ways in which they have responded to and resisted this in historical and contemporary contexts.45 This variation of experience, however, does not obscure the health status of Indigenous peoples globally as a direct result of colonisation and ongoing forms of racism.4,41 Therefore, while these results provide a synthesis of reported experiences across different Indigenous cultures, the perceptions and experiences are likely to share greater similarities than differences.

Limitations

Included reviews and the quality of primary sources were not evaluated using an Indigenous quality appraisal tool.46 We included author positionality to determine the extent of Indigenous involvement. Moreover, while this study excluded reviews published before January 2000, the publication dates of primary sources in review articles were not considered, so primary materials might not be contemporary. Finally, Indigenous health knowledge, intelligence, perspectives and stories are situated and exist externally to the realm of academia. Therefore, limitations are inherent in the restrictions of Western scholarship databases and continuing knowledge hierarchy.

Conclusions

This umbrella review provided a comprehensive synthesis of published literature that described concepts of value by Indigenous people in health and health care globally. The findings will be used to inform a conceptual framework of values in health and health care that will be developed in partnership with Aboriginal community‐controlled health services in Australia and will guide genuine and meaningful engagement with Indigenous communities to co‐design and deliver effective, responsive and culturally safe care.

Received 23 December 2024; accepted 15 July 2025

Box 1 – Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) flow diagram demonstrating database searches and article selection

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Box 2 – Indigenous cultural determinants of health and values in health care

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