Remote Australia Online

Speech technology is transforming language documentation; acoustic models trained on “small” languages are now technically feasible. At the same time, forced alignment built for major world languages has matured and now offers ease of use through web interfaces requiring low technical expertise. This paper provides an updated and detailed evaluation of cross-linguistic forced alignment, the approach of using forced aligners untrained on the target language. We compare two options within MAUS (Munich Automatic Segmentation System): language-independent mode vs major world language system (here, Italian) on the one dataset, a comparison that has not previously been reported. The dataset comes from a corpus of adult conversational speech in Kriol, an English-based creole of northern Australia. The results of using MAUS Italian were better than those of using the language-independent mode and those in previous studies: the agreement rate at 20 ms was 72.1% at vowel onset and 57.2% at vowel offset. With completely misaligned tokens excluded, the overall agreement rate rose to 69.2% at 20 ms and over 90% at 50 ms. Most errors in the output SAMPA (Speech Assessment Methods Phonetic Alphabet) labels were resolvable with simple text replacements. These results offer updated benchmark data for an untrained, late-model forced alignment system.

Developing pedagogies that enhance learning for Aboriginal students is a priority given their poor learning outcomes. Remote teachers recognise the strengths in the arts and sport as interest areas to build bridges between the home and school, and increasingly the strong interest in ICTs and a range of digital media is being recognised. This chapter reports on strategies used by teachers to enhance learning through the use of ICTs, by employing a culturally responsive pedagogy to build a program for remote Indigenous learners. In this chapter the tensions and affordances of such an approach are highlighted, and third generation activity theory is used to frame the learnings from this intervention.

Northern Territory (NT) government policy acknowledges the “need for active participation by all people, including Indigenous people, for the north to achieve ongoing prosperity.” However the majority of Aboriginal adults cannot engage due to low levels of English language, literacy and numeracy (LLN). Aboriginal people constitute 30% of the NT population and more than half speak English a second language (54%). Reading, writing, oral communication in English and numeracy skills remain a persistent challenge and the issue continues to be treated as peripheral, complex and “too hard”. English LLN is central to social capacity building, engaging with the economy, society and systems. Recent consolidation of an NT wide sample of 670 assessments points to very low levels across the NT, with the majority of people falling well below the level required to participate in education and work. The monetary cost of low literacy and the benefits of improvement have never been calculated for the NT. A Strategic Project has been underway to raise awareness, build the evidence base and catalyse change - much remains to be done. Excellent models in service provision exist, with high levels of Indigenous aspiration identified, and there is real momentum for change - but where is the commitment to collective and sustained action by Government, and who has responsibility for adult LLN in the NT?

Objectives To determine whether socio-economic status at birth is associated with differences in risk factors for cardiovascular disease — body mass index (BMI), blood pressure, blood lipid levels — during the first 25 years of life. Design Analysis of prospectively collected data. Setting, participants 570 of 686 children born to Aboriginal mothers at the Royal Darwin Hospital during 1987–1990 and recruited for the Aboriginal Birth Cohort Study in the Northern Territory. Participants resided in 46 urban and remote communities across the NT. The analysed data were collected at three follow-ups: Wave 2 in 1998–2001 (570 participants; mean age, 11 years), Wave 3 in 2006–2008 (442 participants; mean age, 18 years), and Wave 4 in 2014–2016 (423 participants; mean age, 25 years). Main outcome measures Cardiovascular disease risk factors by study wave and three socio-economic measures at the time of birth: area-level Indigenous Relative Socioeconomic Outcomes (IRSEO) index score and location (urban, remote) of residence, and parity of mother. Results Area-level IRSEO of residence at birth influenced BMI (P < 0.001), systolic blood pressure (P = 0.024), LDL-cholesterol (P = 0.010), and HDL-cholesterol levels (P < 0.001). Remoteness of residence at birth influenced BMI (P < 0.001), HDL-cholesterol (P < 0.001), and triglyceride levels (P = 0.043). Mother's parity at birth influenced BMI (P = 0.039). Conclusions Our longitudinal life course analyses indicate that area-level socio-economic factors at birth influence the prevalence of major cardiovascular disease risk factors among Indigenous Australians during childhood and early adulthood.

Introduction: While the majority of births in Australia occur in hospitals with maternity services, it is inevitable that some women will present in established labour to health facilities without midwives or other appropriately qualified staff. These unexpected presentations pose challenges for the woman, her family and the health workforce. In 2016, 69 women gave birth in 32 Queensland Health facilities without maternity services; approximately 90% of these births occurred in rural and remote settings. Methods: The development, implementation and evaluation of the Imminent Birth Education Program for non-midwives practising in rural and remote non-birthing facilities in Queensland employed a participatory action approach. A state-wide steering group was established and consulted on all stages of the project. The project consisted of three distinct phases: Development of an online, evidence based component of the education program; Pilot testing the online component and development and pilot testing of the face-to-face workshop and facilitator’s guide; Promotion, implementation, monitoring and evaluation of the Imminent Birth Education program throughout Queensland. Results: The Imminent Birth Education Program for non-midwives practising in rural and remote non-birthing facilities in Queensland was developed, piloted and evaluated. The education package comprises an online component, 3.6-hour Imminent Birth workshop and a facilitator guide for a midwife to facilitate the course. By July 2018, 639 health professionals completed the online course, 54 health professionals were trained to facilitate the face-to-face workshop and 114 non-midwives completed an onsite workshop. The Imminent Birth Education Program was accessed by health professionals in all 16 Queensland Hospital and Health Services. Conclusion: The education program resulted in improved knowledge of the non-midwifery workforce to assist and support women who present when birth is imminent. It has decreased levels of anxiety about providing clinical care to women who present at non-birthing facilities when birth is imminent and improved ability to provide women who present when birth is imminent with safe, evidence-based clinical care.

Objectives To report on changes in dental caries experience in children of a remote Indigenous community following 6 years of passive preventive intervention (PPI) and 2 years of active preventive intervention (API). Methods Five consecutive cross-sectional surveys were conducted on 4- to 15-year-old school going children between 2004 and 2017 following phases of Community Water Fluoridation (CWF), post-cessation of CWF and API. Following treatment of any cavities present, API included selective placement of fissure sealants (FS) and an annual application of povidone-iodine (PI) and fluoride varnish (FV). The World Health Organization's (WHO) “Oral Health Surveys – Basic Methods (4th Edition)” methodology was used in the first two and the International Caries Detection and Assessment System (ICDAS-II) in the latter three surveys. ICDAS-II codes of 3-6, representing advanced caries, were combined to allow comparison to the decayed component of the DMF caries index. Results Age-weighted mean dmft decreased by 37.7% in the deciduous (DD) and DMFT by 35% in the permanent (PD) dentitions between the pre- and post-CWF surveys, followed by increases of 25% and 7.7%, respectively, between the 1-year and 4-year post-CWF surveys. After 2 years of API, mean dmft decreased by 14.3% and DMFT by 7.1%. Untreated dental caries however remained a concern in the DD and PD during both phases of PPI and of API. The decline in caries experience for both dentitions following 2 years of API exceeded that for the 6-year period of PPI. Conclusions The annual reductions in caries experience of 7.2% (DD) and 8% (PD) during the phase of API exceeded annual decreases of 4.7% (DD) and 4.6% (PD) during the phase of PPI. Due to remoteness, cost and logistics in ensuring long-term viability of API programmes, CWF remains necessary in this type of community.

A dearth of research has utilized spatial research methods to clarify the dispersion of disability specific services in relation to people with disability in priority areas, and urban and remote settings. Consequently, this study sought to investigate the dispersion of disability support services for people in localities within Queensland, Australia. Four datasets from two sources were used to establish (i) the geographic dispersion of disability support services in relation to localities within three regional disability level classifications (areas having high, low, or intermediate levels of disability), and (ii) the level of remoteness of localities within the three regional disability level classifications. Two separate hotspot analyses were conducted to ascertain regions with high, low, or intermediate numbers and percentages of people with disability in Queensland. Furthermore, network analyses were conducted to ascertain the travel time among localities within these settings. Finally, inferential analyses using the Kruskal-Wallis test were conducted to ascertain the difference in travel times to disability support services across localities within the three regional disability level classifications, and simple linear regressions were conducted to clarify the association between locality regional disability level classification and remoteness. The findings confirm that localities within areas classified as having low numbers or percentages of people with disability experience significantly higher travel times to all disability support service types: support and advocacy, aids and equipment, and information and referral. The findings also confirm that these localities are associated with having a higher level of remoteness. The study findings suggest that areas with low numbers and percentages of people with disability in Queensland may be lacking proximately available disability support services. Furthermore, the study adds evidence to the notion that people with disability in rural and remote areas may be moving to urban centres to be closer to services.

Objective: Early childhood anaemia affects health and neurodevelopment. This study describes anaemia among Aboriginal and Torres Strait Islander children of Far North Queensland. Methods: This retrospective cohort study used health information for children born between 2006 and 2010 and their mothers. We describe the incidence of early childhood anaemia and compare characteristics of children and mothers where the child had anaemia with characteristics of children and mothers where the child did not have anaemia using bivariate and multivariable analysis, by complete case (CC) and with multiple imputed (MI) data. Results: Among these (n=708) Aboriginal and Torres Strait Islander children of Far North Queensland, 61.3% (95%CI 57.7%, 64.9%) became anaemic between the ages of six and 23 months. Multivariable analysis showed a lower incidence of anaemia among girls (CC/MI p<0.001) and among children of Torres Strait Islander mothers or both Aboriginal and Torres Strait Islander mothers (CC/MI p<0.001) compared to children of Aboriginal mothers. A higher incidence of anaemia was seen among children of mothers with parity three or more (CC/MI p<0.001); children born by caesarean section (CC/MI p<0.001); and children with rapid early growth (CC/MI p<0.001). Conclusion: Early childhood anaemia is common among Aboriginal and Torres Strait Islander children of Far North Queensland. Poor nutrition, particularly iron deficiency, and frequent infections are likely causes. Implications for public health: Prevention of early childhood anaemia in ‘Close the Gap’ initiatives would benefit the Aboriginal and Torres Strait Islander children of Far North Queensland – and elsewhere in northern Australia.

Artificial Intelligence (AI) and telemedicine have the potential to play a significant role in dermatology given the visual nature of most dermatological conditions. This is particularly in rural or remote areas where access to specialists is limited. Clinical images or histopathological images of sufficient quality may be utilised in various platforms to obtain a diagnosis either via consultation with a dermatologist, dermatopathologist, or artificial intelligence algorithms. This perspective piece seeks to examine the implications and potential impact of AI and telemedicine, and to evaluate where these have been implemented around the world as shown in case studies.

Background: The morbidity and mortality due to acute coronary syndrome (ACS) in Australia is substantial. People living in rural and remote Australia and Indigenous Australians have poorer access to guideline recommended ACS treatment.

Background Pregnant women and infants <6 months old have a high baseline risk for pneumococcal disease compared to the general population, particularly among Indigenous populations living in poverty and low-resource settings. Efficacy trials of pneumococcal vaccination in pregnancy examining adverse birth outcomes are lacking. Aims We report adverse birth events as secondary outcomes from the ‘PneuMum’ randomised controlled trial of 23-valent pneumococcal polysaccharide vaccination (23vPPV) in pregnancy (August 2006–January 2011). Materials and methods Australian Aboriginal women aged 17–39 years with singleton uncomplicated pregnancies were randomised (1:2 ratio) to receive 23vPPV or no 23vPPV in pregnancy at 30–36 weeks gestation. We compared risks of stillbirth, preterm birth, low birthweight (LBW), and small for gestational age (SGA) between vaccinated and unvaccinated pregnant women. Cox proportional hazard ratios (HRs) were calculated on an intention-to-treat basis. Results Among 227 enrolled participants, 75 (33%) received 23vPPV in pregnancy. Risk differences in adverse birth outcomes between 23vPPV vaccinated and unvaccinated pregnant women were; preterm birth 9% vs 4% (HR 2.79; 95% CI 0.94–8.32) P = 0.07; LBW 9% vs 5% (HR 2.09; 95% CI 0.76–5.78) P = 0.15; and SGA 15% vs 17% (HR 1.02; 95% CI 0.50–2.06) P = 0.96. There were no stillbirths. Conclusions We found a numerically higher rate of preterm births among women who received 23vPPV in pregnancy compared to unvaccinated pregnant women. Although further investigation with larger participant numbers is needed to better evaluate this safety signal, the contribution of safety results from smaller studies using appropriate data analysis methodologies is critical, particularly as more clinical trials in pneumococcal vaccination in pregnancy are progressing.

My contribution to the discussion around the 2008 shires reform will attempt to move beyond both an instrumental evaluation of policy and a simple critical understanding of policy as a reflection of social power structures. Instead I apply a cultural-ethnographic focus on minor events, and a conceptualisation of the shires reform as a layer in a larger policy “assemblage”. This allows for a more open-ended analysis of the complexities of a policy reform process in an intercultural setting, with blurred boundaries between intrinsic and extrinsic forces. My thesis thus assembles some minor stories of other agential forces in policy: the hostile Indigenous community resident, a pastoral property map, rebellious cyborgs, cows, rivers, distance, dirt.

Objective Explore how older adults’ talk about accessing rural community health services. Methods A qualitative narrative gerontological approach explored issues related to accessing health services in their community. Semi-structured digitally recorded individual interviews were undertaken with 32 community-dwelling older people aged between 75 and 93 years. A narrative data analytic process was undertaken. The COnsolidated criteria for REporting Qualitative research guidelines were followed to ensure rigour in this study. Results Three collective narratives resulted from the data analytic process: (a) “accessing local health services”; (b) “accessing specialist services”; and (c) “accessing emergency services.” Conclusions Narrators identified a number of issues related to accessing rural health services. These included long waiting times, lack of continuity in care provision by doctors and difficulties accessing specialist and emergency services. Nurses were frequently cited as a reliable point of contact for these older people. Expansion of nursing roles would enhance the provision of rural health-care services.

Objectives To investigate the prevalence of polypharmacy, under-prescribing and potentially inappropriate medicine use among Aboriginal Australians living in remote Western Australia. Design Cross-sectional study. Setting Six remote communities and the town of Derby in the Kimberley, Western Australia. Participants Aboriginal people aged 45 years or more with complete medication histories. Main outcome measures Proportions of patients with medicine histories indicating polypharmacy, potential under-prescribing of indicated medicines, or potentially inappropriate prescribing (including potential prescribing cascades or drug interactions). Results Complete medicine histories were available for 273 participants. The mean number of prescribed medicines was 5.1 (SD, 3.6). At least one form of suboptimal prescribing was identified for 166 participants (61%), including polypharmacy for 145 (53%), potential under-prescribing of at least one indicated medicine for 33 (12%), and potentially inappropriate prescribing for 54 participants (20%). Potential prescribing cascades or drug interactions were identified for 12 participants (4%). Conclusions Potentially suboptimal prescribing affected more than half the participating older Aboriginal Australians from the Kimberley. If generalisable to other remote Indigenous Australians, the prevalence of polypharmacy, potentially inappropriate prescribing, and under-prescribing of indicated medicines is problematic, and suggests that older Indigenous people in remote areas are at risk of medicine-related harm.

A contemporary Australian health system must be characterised by partnerships with consumers. Partnering with consumers is about healthcare organisations, healthcare providers and policy makers actively working with consumers to ensure that health policy, information, systems and services meet their needs. Recognition of the need for a more active role for consumers in healthcare is gaining momentum. Currently in Australia, emphasis is being given to the role consumers and communities can play in the governance of PHNs and local hospital networks, with some accompanying investment in recent years to provide governance training. However, there is a considerable way to go in harnessing the role consumers can play as agents of change in the health system. According to Alison Trimble, 2018 (King’s Fund, UK)“Consumers are renewable energy and the secret ingredient to transformational change within the health and care system”. Collaborative practice underpins co-design and is essential to implementing current health reforms in Australia. The King’s Fund,(an independent charity in the UK) have developed a program Collaborative Pairs which is designed to support the development of the mindset and practices that underpin the culture of shared leadership and partnership and, specifically, joint clinician-consumer approaches to program and service development. The program consists of five one day sessions undertaken over a five month period to enable pairs to work on a shared work challenge in between sessions. The Consumers Health Forum of Australia in collaboration with Western NSW Primary Health Network (PHN)and three other PHNS and the Australian Commission on Safety and Quality in Health Care (ACSQHC)are implementing Collaborative Pairs as part of a National Demonstration Trial in Australia. As one of the largest rural and remote PHNs in Australia, Western NSW PHN is well placed to test the program in a rural and remote context. This paper will provide an overview of the Collaborative Pairs Program, the model being implemented in the National Demonstration Trial with a specific focus on Western NSW. The challenges and opportunities of delivering a world class innovative program in a remote location will be discussed as well as the need to build capacity of both consumer and clinical leaders to work together in rural and remote Australia. The importance of collaborative practice and the ways that it is being practiced, supported and integrated in Western NSW as compared to other more urban sites will also be discussed.

Background: Aboriginal children in the Kimberley/Pilbara region of Western Australia (WA) experience dental decay at more than 3 times the rate of non-Aboriginal children, the majority of which remains untreated. A simple alternative, Atraumatic Restorative Treatment (ART), approach to manage dental decay using principally hand instruments to prepare the cavity and without local anaesthesia in children has been shown to be successful. The approach reduced the need for specialist care, and was clinically successful, acceptable by children and parents, and cost-effective. This approach has implications for dental services delivery in rural and remote communities where access to dental care is poor. The aim of the study was to test the feasibility of the ART model of care in rural and remote communities of the Kimberley in WA. Methods: The study design was a pragmatic two-armed, delayed intervention, cluster RCT. Communities with the expected number of children (n=15) in the target age (0-6-year-old) were invited to participate. Participating communities were randomised into the early intervention (test) or delayed intervention (control) arm of the study. Participating parents completed a questionnaire and the children provided with a baseline dental health assessment. Early intervention children were offered dental treatment. Delayed intervention children were advised to seek care through the standard care options available to the community and will be offered dental treatment as part of the study at the 12-month follow-up. The primary outcome was the number of children provided with the needed dental treatment and/or referred for specialist dental care. Results: Twenty-six communities were selected and the majority of communities (n=25) have agreed to participate. Wide ranging community consultation and presentation of the study proposal was undertaken which included face-to-face meetings with the CEOs of the Aboriginal Controlled Health Organisations in the Kimberley as well as Chief Executive Officers (CEO) of the selected communities and Chairpersons of the community councils. An Aboriginal study reference group was formed with representation from the local Aboriginal Health Organisations. As at the end of June 2018 recruitment has occurred in 12 communities (n=150) with participation ranging from 6-24 children. Challenges: Consultations with the community representatives and the CEOs and the community councils was well-received and the study proposal was supported, however, engagement at the individual level remains challenging. High mobility of the families also presented challenges in the provision of treatment and for follow-up.

Purpose The focus of this paper is to centre the lived experiences and perceptions of western education held by Aboriginal people who lived at Moola Bulla Native Cattle Station (Moola Bulla) in Western Australia, between 1910 and 1955. Of interest is an investigation into how government legislations and policies influenced these experiences and perceptions. The purpose of this paper is to promote the powerful narrative that simultaneously acknowledges injustice and honours Aboriginal agency.Design/methodology/approach The research from which this paper is drawn moves away from colonial, paternalistic and racist interpretations of history; it is designed to decolonise the narrative of Aboriginal education in remote Western Australia. The research uses the wide and deep angle lens of qualitative historical research, filtered by decolonising methodologies and standpoint theory. Simultaneously, the paper valorises the contributions Indigenous academics are making to the decolonisation of historical research.Findings Preliminary findings suggest the narrative told by the residents who were educated at Moola Bulla support a reframing of previous deficit misrepresentations of indigeneity into strength-based narratives. These narratives, or “counter stories”, articulate resistance to colonial master narratives.Social implications This paper argues that listening to Aboriginal lived experiences and perceptions of western education from the past will better inform our engagement with the delivery of equitable educational opportunities for Aboriginal students in remote contexts in the future.Originality/value This paper will contribute to the wider academic community by addressing accountability in Aboriginal education. Most important to the study is the honouring of the participants and families of those who once lived on Moola Bulla, many who are speaking back through the telling of their story.

A high proportion of Aboriginal Australians residing in remote communities are mobile-only internet users. This chapter examines how infrastructures and social norms are informing digital choices in these communities, and how this in turn influences the utility of location technologies. Within this setting, device sharing practices are undermining location technologies insofar as they are assumed to be associated with ongoing, individual use.

Introduction: Studies show Aboriginal and Torres Strait Islander people are at increased risk of dementia. Whilst there have been several studies evaluating the use of telehealth for improving Aboriginal and Torres Strait Islander health outcomes, and studies validating telehealth dementia screening tools for the wider community, none have addressed the pressing need for culturally appropriate telehealth dementia screening for this at-risk population. The aim of the study was to examine the utility of using a culturally appropriate dementia screening tool (KICA-screen) in a telehealth setting. Methods: A prospective field trial was used to compare administration of the short version of the Kimberley Indigenous Cognitive Assessment (KICA-screen) face-to-face and via telehealth. A total of 33 medically stable Aboriginal and Torres Strait Islander inpatients/outpatients participated. The stability of the KICA-screen scores, administered face-to-face and via telehealth, for each participant was measured. Results: The two test delivery methods showed not only good correlation (Pearson’s r = 0.851; p < 0.01) but good agreement (intraclass correlation coefficient = 0.85; p < 0.01). Discussion: Results of the assessment showed that KICA-screen can be reliably administered via videoconference and resulted in comparable scores to face-to-face testing in the majority of cases. The telehealth process was acceptable to participants, who were able to understand the process and complete the full screen via telehealth conditions.

Background: Australia provides health care services for Indigenous peoples as part of its effort to enhance Indigenous peoples’ wellbeing. However, biomedical frameworks shape Australia’s health care system, often without reference to Indigenous wellbeing priorities. Under Indigenous leadership the Interplay research project explored wellbeing for Indigenous Australians in remote regions, through defining and quantifying Indigenous people’s values and priorities. This article aimed to quantify relationships between health care access, mental and physical health, and wellbeing to guide services to enhance wellbeing for Indigenous Australians in remote regions. Methods: Indigenous and non-Indigenous researchers worked with Indigenous people in remote Australia to create a framework of wellbeing priorities. Indigenous community priorities were community, culture and empowerment; these interplay with government priorities for Indigenous development of health, education and employment. The wellbeing framework was further explored in four Indigenous communities through a survey which measured aspects of the wellbeing priorities. Indigenous community researchers administered the survey in their home communities to 841 Indigenous people aged 15 to 34 years from June 2014. From the survey items, exploratory factor analysis was used to develop constructs for mental and physical health, barriers to health care access and wellbeing. Relationships between these constructs were quantified through structural equation modelling. Results: Participants reported high levels of health and physical health (mean scores (3.17/4 [SD 0.96]; and 3.76/4 [SD 0.73]) and wellbeing 8.07/10 [SD 1.94]. Transport and costs comprised the construct for barriers to health care access (mean access score 0.89/1 [SD 0.28]). Structural equation modelling showed that mental health, but not physical health was associated with wellbeing (β = 0.25, P < 0.001; β = − 0.038, P = 0.3). Health care access had an indirect positive relationship with wellbeing through mental health (β = 0.047, P = 0.007). Relationships differed significantly for participants in remote compared with those in very remote communities. Conclusions: Greater attention to mental health and recognition of the role of services outside the health care sector may have positive impacts on wellbeing for Indigenous people in remote/ very remote Australia. Aggregation of remote and very remote populations may obscure important differences between Indigenous communities.

Summary In Australia's Northern Territory (NT), acute infections are highly prevalent within Indigenous remote communities and difficulties in diagnosing the aetiology of infection are exacerbated by limited access to diagnostic tests. The objective of this study was to investigate the clinical effectiveness of point-of-care (POC) testing for total and 5-part differential white blood cell (WBC DIFF) counts for the triage of patients with possible acute infection. The HemoCue WBC DIFF POC device was introduced into 13 remote health clinics over a 6 month period. A retrospective clinical audit of patient cases meeting the selection criteria for three acute infections (sepsis, respiratory infection and appendicitis) were examined by four registrars in duplicate; one with POC test results available and the other with POC test results removed to determine if WBC DIFF results changed or assisted in patient triage. The number of changed outcomes provided a preliminary cost-benefit analysis. Sixty (23%) patient cases met the selection criteria for the clinical effectiveness analysis. POC test results changed the triage decision for 24 (41%) patients, of which 20 (34%) led to the prevention of an unnecessary medical retrieval and four (7%) indicated the patient had an acute infection which required a medical retrieval. POC test results assisted decision making for a further 13 (22%) patients. Cost savings related to avoiding unnecessary medical retrievals were estimated to be AU$481,440. Extrapolated NT-wide cost savings are projected to be AU$5.33 million per annum. POC testing for WBC DIFF counts aided clinical decision making for triaging patients with three common acute infections.

Aim: To explore how clinical leadership is perceived by nurses in rural and remote areas of New South Wales, Australia. Background: There are few empirical studies aimed at understanding clinical leadership from a rural and remote perspective. Methods: A qualitative approach, based on interpretive phenomenology, used thematic analysis of recorded and transcribed interviews. Ethical approval was secured, 56 interviews were undertaken, across 14 different rural and remote health facilities, with nurses across the spectrum of practice. Results: Thematic analysis led to five themes and findings that support an understanding of clinical leadership from a rural and remote context. Clinical leaders were seen to considerably impact on the initiation of change and quality of care. They also faced barriers if the health facility was poorly staffed, lacked support and if the community were strongly co-dependent. Conclusion: In rural and remote areas, clinical leadership is evident to support change, innovation and care quality. Implications for Nursing Management Managers should be aware that staff shortages and challenges to staff retention or the initiation of change are affected by poor clinical leadership. This paper suggests that managers who facilitate clinical leadership are better able to support professional education and greater efficiencies in the delivery of quality health care.

Mental health service delivery to children in rural and remote areas faces many challenges including attracting and retaining staff, continuity of care, poor accessibility and limited consumer choice. Royal Far West has teamed with a number of different service partners in health and education seeking solutions to meeting the mental health needs of children in rural and remote areas With improvements in internet capacity across Australia, internet based therapy has become a viable mode of delivery for mental health services. Royal Far West has developed a number of innovations in telecare including mixed mode service delivery, gamification of therapy resources and introduced interactive, child friendly therapy packages to ensure children are offered engaging and stimulating interventions. A randomised controlled trial of telecare vs face to face demonstrated that the outcomes for internet based therapy are comparable to face to face delivery. Consumer satisfaction evaluations have demonstrated that the services are well received, and in some instances preferred. Further, our service partners have been able to provide mental health services to those children who would not otherwise be able to access services. To conclude, internet based service delivery models are safe, effective, consumer friendly, accessible and provide service choice to children in rural and remote regions of Australia.

Case series suggest that human T-cell leukaemia virus type 1 (HTLV-1) is associated with kidney disease; however, little is known about the impact of proviral load (PVL). The present study was commenced to determine whether higher HTLV-1 PVL is associated with end stage kidney disease (ESKD) in Indigenous Australians. A case-control study was conducted in Alice Springs Hospital (ASH), 1 July 2007 to 30 November 2015. Cases included all 80 Indigenous adults (>17 years) with HTLV-1c and ESKD, matched 1:1 by sex to controls with HTLV-1 who had no renal disease or other recognised disease associations of HTLV-1, and were recruited during the same period. The association between PVL and ESKD was assessed using logistic regression. Median (IQR) HTLV-1c PVL for subjects with ESKD (6.86, IQR (3.35, 8.23) log copies per 105 peripheral blood leukocytes (PBL) (ie, 0.95; IQR, 0.03; 3.70% PBL) was significantly higher than that of the asymptomatic group (3.47; IQR (−0.04, 6.61) log copies per 10 5 PBL (ie, 0.01; IQR, 0.00; 0.52% PBL) (asymptomatic vs ESKD, P (ranksum) < .001). Major factors associated with ESKD were diabetes (adjusted odds ratio [aOR], 21.80; 95% CI, 4.84, 98.22; P < .001), hypertension (aOR, 4.16; 1.11, 15.64; P = .03), remote residence (aOR, 5.34; 95% CI, 1.17, 27.29; P = .03) and HTLV-1c PVL greater than or equal to 100 copies per 10 5 PBL (aOR, 3.67; 95% CI, 1.36, 9.92; P = .01). Higher HTLV-1c PVL are strongly associated with inflammatory diseases. The high HTLV-1c PVL reported here may have clinical implications for people with HTLV-1 who require haemodialysis. Longitudinal studies are required to determine whether this association is causal.

This qualitative study examined smokefree leadership among the Yol?u people, Indigenous landowners of East Arnhem Land. Despite disproportionately high smoking prevalence, the study found that most people enacted smokefree leadership within families and communities. While there was broad concern about not impinging on the autonomy of others, Indigenous health workers regularly advised clients, family and community members to quit smoking. This followed a general belief that the issue of smoking was best raised by health workers, rather than traditional leaders. Protecting children from second-hand smoke and preventing smoking initiation was important to all participants irrespective of their smoking status. An enduring and highly valued cultural connection to ?arali? (tobacco) remains an essential part of the sacred practices of the funeral ceremony, an important and unique social utility. The study found consensus among participants that this would not change. Navigating traditional connections to ?arali? in a context where most people are still addicted to commercial tobacco is challenging and requires respectful and culturally compelling approaches. Tobacco control initiatives with the Yol?u should therefore utilise existing smokefree leaders within the social context in which ?arali? is valued and used, an approach that may resonate with other Indigenous Australian nations and communities.