Remote Australia Online

Objective To assess the median urine iodine concentration (UIC) of young adults in the Top End of Northern Territory, before and after fortification of bread with iodised salt became mandatory. Design, setting Analysis of cross-sectional data from two longitudinal studies, the Aboriginal Birth Cohort and the non-Indigenous Top End Cohort, pre- (Indigenous participants: 2006–2007; non-Indigenous participants: 2007–2009) and post-fortification (2013–15). Participants Indigenous and non-Indigenous Australian young adults (mean age: pre-fortification, 17.9 years (standard deviation [SD], 1.20 years); post-fortification, 24.9 years (SD, 1.34 years). Main outcome measure Median UIC (spot urine samples analysed by a reference laboratory), by Indigenous status, remoteness of residence, and sex. Results Among the 368 participants assessed both pre- and post-fortification, the median UIC increased from 58 μg/L (interquartile range [IQR], 35–83 μg/L) pre-fortification to 101 μg/L (IQR, 66–163 μg/L) post-fortification (P < 0.001). Urban Indigenous (median IUC, 127 μg/L; IQR, 94–203 μg/L) and non-Indigenous adults (117 μg/L; IQR, 65–160 μg/L) were both iodine-replete post-fortification. The median UIC of remote Indigenous residents increased from 53 μg/L (IQR, 28–75 μg/L) to 94 μg/L (IQR, 63–152 μg/L; p < 0.001); that is, still mildly iodine-deficient. The pre-fortification median UIC for 22 pregnant women was 48 μg/L (IQR, 36–67 μg/L), the post-fortification median UIC for 24 pregnant women 93 μg/L (IQR, 62–171 μg/L); both values were considerably lower than the recommended minimum of 150 μg/L for pregnant women. Conclusions The median UIC of young NT adults increased following mandatory fortification of bread with iodised salt. The median UIC of pregnant Indigenous women in remote locations, however, remains low, and targeted interventions are needed to ensure healthy fetal development.

Maintaining connections to family, culture and community is essential for strengthening an Aboriginal child?s educational achievements. The Australian Bureau of Statistics collects self-reported information on a range of factors that can assist in understanding what influences Aboriginal children to complete school. The 2014?2015 National Aboriginal and Torres Strait Islander Social Survey (NATSISS) provides a national snapshot about how various characteristics influence the educational experience of Aboriginal children in remote Australia. In this article, findings from NATSISS have been used to interrogate qualitative data from the Whole of Community Engagement initiative led by Charles Darwin University. This is a multi-site participatory action research project working across six remote communities in the Northern Territory, Australia. We use Indigenous community perspectives to describe why maintaining connection to family, culture and community is important for both Aboriginal high school completions in remote Australia, and the subsequent impact this has on pathways into higher education.

Summary Human T-lymphotropic virus type 1 (HTLV-1) is hyperendemic amongst Indigenous Australians living in Central Australia. The epidemiology of the disease is poorly defined in other parts of Australia, despite a high prevalence of classically associated conditions. All HTLV-1 serology tests requested through public health facilities in Far North Queensland (FNQ) from January 1999 to December 2016 were reviewed. The person's age, sex, ethnicity, location, rationale for testing and result were recorded. There were 444 tests performed in 409 people; 217 (53%) were male; 171 (42%) identified as Indigenous Australians. Testing increased over time and was performed throughout the region, suggesting increasing awareness of the disease. Testing occurred in patients with haematological, neurological, dermatological and respiratory complaints, but only four (1%) had proven infection. Three of these individuals were in the same family and two were asymptomatic. One of the two symptomatic seropostive individuals had recurrent scabies infection, the other T-cell lymphoma. HTLV-1 infection is extremely uncommon in FNQ. The high rates of bronchiectasis and other associated conditions that are seen in the region are more likely to be addressed by public health policies focusing on the socioeconomic determinants of health.

In Australia, in the last decade, there have been significant policy changes to income support payments for people with a disability and Indigenous people. These policy reforms intersect in the experience of Indigenous people with a partial capacity to work in the Northern Territory who are subject to compulsory income management if classified as long-term welfare payment recipients. This intersection is overlooked in existing research and government policy. In this article, we apply intersectionality and Southern disability theory as frameworks to analyse how Indigenous people with a partial capacity to work (PCW) in the Northern Territory are governed under compulsory income management. Whilst the program is theoretically race and ability neutral, in practice it targets specific categories of people because it fails to address the structural and cultural barriers experienced by Indigenous people with a disability and reinscribes disabling and colonising technologies of population control.

This paper presents a comic-strip to tell the story of an experience where we, the researchers, struggled to reconcile our institution’s ethical requirements with the need to build respectful and reciprocal relationships with research participants, the essence of ethical practice. The core images of our comic-strip derive from Wallace and Lovell’s monoprint, “Monstrous Breaches” (Lovell & Wallace, in press). We respond to the artists’ invitation to re-work their monoprint in order to better understand the “monsters” or dangers of our research world. We contend that traversing the spaces between institutional and relational ethics is itself a process that is often fraught with ethical dangers, “monsters” that researchers and institutions often overlook at our peril.

Information communication technologies have permeated new consumer markets at remarkable speeds, diffusing to even the most remote and economically marginalised populations. In remote Aboriginal communities in the Northern Territory of Australia, residents have until recently been isolated from these symbols and facilitators of globalisation. But the rapid diffusion of Internet based technologies in recent years raises important questions about future residential migration aspirations as residents engage with the global order. In this paper we critically review these ?technologies of change? for their propensity to alter remote Indigenous spatiality. We propose a theoretical reconstruction of transitional migration theory, as it has been previously applied, and denote the implications for policy makers, researchers and service providers.

Since 2013, northern Australia has experienced a large downturn in its population growth rate, and negative growth in some areas. This followed the highs of the mining boom and was due to net losses of residents to southern regions. Under these circumstances, positive contributions of migrants to population, jobs, and communities have become increasingly important. Existing studies show that northern and remote regions of Australia fare poorly at attracting and retaining international migrants. However, an important consideration in evaluating the success of policies and initiatives for attracting and retaining migrants to these regions is how these are assessed and measured. For many communities across the north, permanent retention of a handful of skilled migrants and their families can significantly improve demographic and economic trajectories. Evaluations on the success of schemes at macro-region levels may miss nuanced and significant population impacts at the local level. This working paper presents three case examples from the Northern Territory demonstrating the potential for overseas migration to alter demographic, economic, and social pathways for northern and remote communities, and thus the broader region.

In Australia, the numbers and rates of Indigenous incarcerations continue their long-term increase, particularly in the Northern Territory where a third of the population are Indigenous. In this paper, we provide theoretical discourse on incarceration as a form of mobility and demonstrate the demographic scale of impacts for small and remote communities using indirect estimation methods. Results reveal significant proportions, especially those aged 20?39 years, may be missing and mobile through incarceration. Overlaid onto pre-existing high population churn, effects on immobile community members contribute to intergenerational demographic, social and economic dysfunction and point to the need for innovative solutions.

The ABS 2006 Post-Enumeration Survey was extended to include a sample of localities from the whole of Australia, thereby providing an estimate of census net undercount reflective of the enumeration in remote Indigenous settlements for the first time. The results revealed substantial undercounting of the Indigenous population in certain jurisdictions. At the same time, census counts in many locations were substantially higher than demographic factors could account for. The analytical and policy issues that arise from this revolve around a simple question: what credence can we give to observed spatial patterns of Indigenous population change? This paper seeks to provide an answer by establishing the spatial relationship between population change and net migration at the small area level. This reveals the detailed geography of census undercount and ?overcount? with the former common in remote areas and the latter most evident in regional towns and cities. The findings raise important policy issues about the proper interpretation of Indigenous population change data and the nature of estimates used to determine fiscal resourcing for Indigenous policies and programs.

Aboriginal suicidal behaviours in remote Australia present as very different phenomena to suicidal behaviours in mainstream Australian society. Multiple suicide threats and behaviours often appear to express ways of executing violence or retaliation, rather than the immediate wish to die. This may be a response to the lack of choices in the face of an historical context of intergenerational trauma, grief and loss. Aboriginal youth are grasping the possibility of death, and the threat of dying, as a violent means to gain control over their lives. This enactment of agency can give instant ?power? to those violent and vulnerable enough to use it. Using examples of such a suicidal crisis common within these communities, this paper argues that those who work within Australian Aboriginal communities need to better understand the continuing impacts of colonialism and inter-generational trauma and ?decolonisation?. Further, the approach taken in providing services to communities may need to be adapted from the more orthodox approach of linear referral pathways. Understanding the importance of cultural context and place allows for a more dynamic and beneficial therapeutic relationship to be formed. It may also help to more effectively facilitate support for healthcare workers.

Background: The disproportionate burden of noncommunicable disease among Indigenous Australians living in remote Indigenous communities (RICs) is a complex and persistent problem. Smartphones are increasingly being used by young Indigenous adults and therefore represent a promising method to engage them in programs seeking to improve nutritional intake. Objective: This study aimed to consult RIC members to inform the content of a smartphone app that can be used to monitor and reduce sugar-sweetened beverage intake in RICs. Methods: The study was conducted in two phases. The formative phase involved a simulated grocery selection activity with think aloud (“think aloud shop”), a semistructured interview, a questionnaire outlining current smartphone and app use, and a paper prototyping activity. A preliminary end-user testing phase involved a think aloud prototype test and a semistructured interview regarding user satisfaction. Convenience sampling was used to recruit 20 18- to 35-year-old smartphone users for each phase from two RICs in the Northern Territory, Australia. Thematic analysis of transcribed audio recordings was used to identify determinants of food choice from the think aloud shop; themes related to the Theory of Planned Behavior (TPB) from the eating behaviors interview; and usability, comprehension, and satisfaction with the app from the preliminary end-user testing. Results: Smartphone use in RICs is currently different to that found in urban environments; in particular, extremely low use of Facebook, restricted variety of phone types, and limited Internet access. Findings regarding promoting app engagement indicate that utilizing an opt-in approach to social features such as leader boards and team challenges is essential. The inclusion of games was also shown to be important for satisfaction, as were the use of audio features, contextually embedded dissemination, and streamlined app design for comprehension in this target group. Conclusions: This research provides critical insights and concrete recommendations for the development of lifestyle improvement apps targeted toward disadvantaged young adults in nonurban settings, specifically RICs. It serves as a framework for future app development projects using a consultative user-centered design approach, supporting calls for the increased use of this strategy in app development.

In the Gibson Desert of Western Australia, the first physical encounters between Aboriginal and European Australians were often with military, mineral exploration or surveying personnel who came to that remote country by helicopter. This paper discusses stories of cross-cultural contact in the period 1957–1975, which continue to be publicly recalled; they include accounts that vary from hiding in great fear, nervous contact and goods exchange, to assertive action to drive these intruders away. Particular attention is given to the narratives of one man: Fred Kumpari Ward, Tjungarrayi, speaker of several desert languages and senior Law man for the country in which these contact encounters occurred. Fred Ward was also the senior Applicant of a native title compensation application that was discontinued in 2015. For over 20 years the political and legal processes engaged to provide secure title to their lands have proven, to the desert people, to be as alien and as difficult to comprehend as their first contacts with ‘white men’ less than 60 years ago.

Rural and remote students remain significantly underrepresented in higher education in Australia. At the same time, the workforce is rapidly transforming with the substantial growth and integration of digital and automated processes into everyday work and life. The digital economy requires workers who are digitally literate and competent. Rural students have lower digital lite racy competencies than urban based students. Queensland, which is a largely regionalised state, has a high percentage of rural students. Using Bourdieu’s cultural capital and habitus as a conceptual framework, this research identifies four influences on rural Queensland students’ decisions to pursue higher education and their perceptions of the value of digital media, and develops a model of influence. The influences include family, community, school and digital media. The thesis draws on 25 interviews conducted with rural Queensland high school students. Findings provide valuable new data around student influences towards higher education and digital media and suggest avenues to improve widening participation targeting students in rural areas. At the outset, this research suggests that widening participation efforts could be more effective if rural students’ families and communities were targeted in addition to schools by programs. The interactions discussed in interviews highlight the people and resources rural students draw on to make decisions, and which inputs hold the most value to students. It was found that family plays the most significant role in the decision making process, while the student’s school and community also play a role in the decision making process. The research also found interviewed students’ value of digital media and digital media learning at school depended somewhat on their intended career choice.

This essay concerns two experimental governmental interventions undertaken in Ceduna, far west South Australia. The first scenario involves a local council initiative, which I argue was designed to expunge public spaces of the presence of disturbing Indigenous bodies, which elicited local disgust. The second case involves a current federal government trial of stringent welfare reform measures. I argue that this case was framed primarily in terms of suffering, which arouses compassion and demands intervention. Thus the essay explores how disgust and respectability, suffering and compassion, as well as alterity, circulate and come to settle on different Indigenous bodies. Focussing on the governing of Indigenous people, I use these two policy experiments to track the state's penalization and abandonment of, interventions into, and concern for Indigenous lives in a single setting.

Importance of community stakeholder participation in coastal freshwater and tidal wetland monitoring and restoration has become increasingly recognised. In Australia, Land and Sea Rangers (LSR) are appointed land and sea custodians from local indigenous communities and under guidance of experts learn a range of scientifically relevant and rigorous sampling techniques to protect and conserve Country. Scientific training to build LSR confidence to tackle restoration and conservation of sensitive and culturally important wetlands is shown here. Between May 2014 and May 2015 three training campaigns were completed where LSR on Boigu and Saibai Islands (the most northern islands in the Torres Straits, Australia), completed water quality and wetland flora/fauna surveys across both islands. Forty wetland fauna species were documented (with a similar wetland assemblage on each ANOSIM P > 0.4) comprising 35 fish species (including the invasive freshwater climbing perch, Anabas testudineus), two crustaceans, a freshwater turtle (Chelodina oblonga) (a relic freshwater species after the last sea level rise approximately 6,000 years ago in the region), and two mangrove snakes (Myron richardsoni and Fordonia leucobalia) (both snake records represent a range extension). This data was presented at community workshops with the purpose to build LSR confidence, and with the community, develop a plan to conserve wetland cultural and environmental values. Five thematic wetland conservation themes were identified which resulted in agreeing to management actions necessary on both islands. Since the inception of this program in 2014, additional LSR restoration and monitoring programs have extended to wetlands on other islands in the Torres Straits. We advocate the need for more remote area wetland monitoring and management programs facilitated through LSR programs.

Objective To describe the process of gaining consensus across regional organisations in formulating measures to improve coordination of care for people from remote Far North Queensland communities coming to town (Cairns) to access health care. Design This is a descriptive study that includes survey data from workshop participants. Setting Coming to town for health care poses great challenges, especially for Indigenous Australians from remote communities. Numerous organisations are involved, communications are fragmented and there is no central coordinating body. The system frequently fails to deliver necessary services. This generates preventable cost burdens through missed flights, missed appointments, missed treatment opportunities and extra administration. Workshop organisers invited key service providers from across Far North Queensland. Main outcome measures Using real-case scenarios, the task was to identify and prioritise the central issues and explore ways to address them. Participants jointly crafted the final recommendations and also posted suggestions on a ‘wish-list’ board. A participant assessment survey was conducted at the end of the workshop, followed by an online survey 6 weeks later. Results There were 32 participants. The concluding survey indicated the workshop was well received and people valued the collaboration. There were six primary recommendations plus numerous wish-list suggestions. The best-supported recommendation was establishment of a coming to town Hub with a local coordinating team and community-based representatives. Conclusion Implementation of the workshop recommendations and support of all key service providers should be culturally acceptable and resource-efficient with better health outcomes for travellers, their families and communities.

Elder abuse has been recognised as a significant social issue in recent years. Though the vast majority of reported elder abuse is perpetrated by family members, it is often not recognised as a form of family and domestic violence. In contrast to family and domestic violence, elder abuse tends to manifest as non-spousal violence, with the majority of reported cases perpetrated by adult children. Elder abuse is estimated to affect up to 15.7 per cent of community dwelling older people in high and middle income countries (Yon, Mikton, Gassoumis & Wilber, 2017). Though older people from rural and remote areas are potentially more vulnerable to abuse due to social and geographic isolation, and difficulties accessing support and legal services, there has been little research in this area. A systematic scoping literature review was undertaken to explore national and international evidence about prevention and service responses to elder abuse and family and domestic violence in rural and remote communities. The review identified 27 articles discussing overlapping prevention and service response issues for both sectors. Seven key responses were identified; advocacy, safety planning, community approaches, inter-agency collaboration, education, abuse screening, and crisis and transitional services. This paper outlines these responses and discusses the benefits and implications of collaboration between service providers from the Australian elder abuse and family and domestic violence sectors.

Summary Background In 2007–08, a genotype J mumps outbreak occurred among Aboriginal people in northern Western Australia, despite high vaccine coverage. In March, 2015, a second protracted mumps outbreak occurred in northern Western Australia and spread widely across rural areas of the state. This time the outbreak was caused by a genotype G virus and again primarily affected Aboriginal people. We aimed to describe the epidemiology of this outbreak. Methods In this population-based surveillance study, we analysed statutory notifications and public health case follow-up data from the Western Australia Notifiable Infectious Diseases Database and vaccination information from the Australian Childhood Immunisation Register. An outbreak case of mumps was notified if the affected person was living in or visiting a community in Western Australia where there was active mumps transmission, and if mumps infection was confirmed by laboratory diagnosis or by an epidemiological link. We analysed case demographics, vaccination status, and age-standardised attack rates in Aboriginal and non-Aboriginal people by region of notification. Laboratory diagnoses were made by real-time RT-PCR, serology, or both, and carried out by the sole public pathology provider in Western Australia. Findings Between March 1, 2015, and December 31, 2016, 893 outbreak cases were notified. 798 (89%) of 893 outbreak cases were reported in Aboriginal people. 40 (4%) of 893 people were admitted to hospital, and 33 (7%) of 462 men reported orchitis. Mumps attack rates increased sharply with age, peaking in the 15–19 age group. 371 (89%) of 419 people aged 1–19 years were fully vaccinated and 29 (7%) were partly vaccinated. Of the 240 people who tested positive by real-time RT-PCR and had also been tested for mumps-specific IgG and IgM, 165 (69%) were positive for IgG but negative for IgM, indicating the importance of RT-PCR testing for diagnosis in vaccinated populations. None of the cases from the 2007–08 genotype J outbreak were re-notified. Interpretation The number of mumps outbreaks reported in recent years among highly vaccinated populations, including Indigenous populations, has been growing. More widespread and pre-emptive use of the third dose of measles, mumps, and rubella vaccine might be required to control and prevent future outbreaks in high-risk populations. Research should explore the benefit of increasing the intervals between vaccine doses to strengthen the durability of vaccine protection. Funding None.

This study compared flocked (nylon) swabs and (non-flocked) rayon swabs for the detection of Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis in nasopharyngeal samples from 20 enrolled Indigenous children under the age of 6 years living in remote Australian Aboriginal communities, and determined which swab the child or parent perceived to be more comfortable. There was no evidence of a significant difference between flocked and rayon swabs in the recovery of common respiratory bacteria. Rayon swabs detected presence of S. pneumoniae (90% cf. 74%, p = 0.375), H. influenzae (79% cf. 74%, p = 1.00) and M. catarrhalis (79% cf. 74%, p = 1.00) at higher rates than the flocked swabs. Analysis of semi-quantitative growth scores also showed no significant differences in either the ranked distributions or medians. Rayon swabs median semi-quantitative growth scores were higher for S. pneumoniae (4 [IQR 1–5] cf. 3 [IQR 0–6], p = 0.699), and H. influenzae (2 [IQR1–5] cf. 1 [IQR0–5], p = 0.946). Sixty percent of participants preferred samples to be taken with flocked swabs. This study demonstrates that microbiological outcomes are not compromised when using flocked or rayon swabs in respiratory bacterial carriage studies in this population. Therefore, cost, methodological consistency across studies, and participant preference can be considered when choosing swab type.

This research addresses the overarching question: What impact has the Literacy for Life Foundation (LFLF) ‘Yes, I Can!’ adult literacy campaign had on Aboriginal members’ encounters with the criminal justice system in the NSW towns of Bourke and Enngonia? ‘Yes, I Can!’ uses a campaign model to raise the adult literacy rate within a community. It was introduced in Wilcannia in 2012, and extended to Bourke and Enngonia Aboriginal communities in 2013-14, running four different times in Bourke and once in Enngonia. The team identified the following research questions: 1. Has the campaign facilitated improved interactions with officials in the justice system? 2. Has participation in the campaign influenced how community members access legal resources and advocacy? 3. Do informants see any change in the frequency of encounters with the justice system following participation in the campaign? 4. Does participation influence how criminal justice officials respond to individual community members? Overall, the interview results indicate that the ‘Yes, I Can!’ campaign has impacted positively on the communities of Bourke and Enngonia. Interview participants cited a range of social benefits for individuals in the campaign, such as empowerment, increased self-esteem, greater engagement and interaction with both the wider community and also within family units in terms of engaging and promoting the importance of literacy. Greater opportunities for employment and access to services such as health services were also cited as benefits of the campaign.

This article examines key socio-ecological interactions identified during a climate change vulnerability assessment in the Alinytjara Wilurara natural resources management (NRM) region of South Australia. The complex local socio-ecological interactions are highlighted to guide a response to the challenge of adapting to climate change within the region. Recognising several key desert drivers which perpetuate degraded socio-ecological systems, this article recommends that a range of strategies be employed simultaneously to enhance local environmental management in association with remote indigenous communities, including: linking people and NRM more closely; tracking funding but ensuring systems can withstand periods of limited financial support; developing cross-sectoral and cross-institutional links; empowering and engaging communities; communicating effectively; and actively supporting local and traditional environmental knowledge. Unless climate change adaptation responses within the region are conceptualised and enacted within the context of complex local socio-ecological systems, NRM will not improve and social vulnerability will increase.

Australia's medical education system is undergoing a socially motivated transformation focused on improving access to medical care for rural and remote communities. A rural and remote backbone of Rural Clinical Schools (RCS), University Departments of Rural Health, regional medical schools, and the postgraduate college, ACRRM, have enabled community responsive innovation and partnerships with rural health services that once would have been difficult to imagine. This article argues that this transformation is succeeding because of the passionate leadership of rural medical and community leaders, government seed funding to encourage rural medicine as an academic discipline, rigorous research and consultation that underpinned each step of the innovation pathway, and a political campaign to invest in rural medical education as a form of rural social capital.

Workplace violence affects health professionals globally, with up to eighty percent of nurses experiencing at least one violent incident through out their careers. The impact of this exposure can be felt at an individual, professional and organisational level. Nurses who work in geographically isolated parts of Australia have a reduced ability to access assistance during incidences of workplace violence, meaning that robust risk assessment systems are critical. This study aimed to identify the workplace violence risk profile for this cohort using industry tested tools to assess risk across the workplace characteristics of occupational, environmental and client. As well as identifying the workplace violence risk profile, the role of organisational culture and risk management practices in addressing workplace violence was also explored. Using a quantitative descriptive exploratory approach, we surveyed ninety-nine Remote Area Nurses from across Australia. A comprehensive risk profile for Remote Area Nurses was developed, with significant exposure identified across all three workplace characteristics. Significant links were also identified between organisational culture and risk management practices and the Remote Area Nurse’s ability to feel safe in the workplace. Identification of a risk profile is an important first step in developing a comprehensive risk mitigation plan and risk assessment system. When developing a comprehensive risk assessment system the role of organisational culture and systems cannot be understated in creating a safe working space.

Tobacco smoking during pregnancy contributes to a range of adverse perinatal outcomes; but is a potentially modifiable behavior. In Australia Aboriginal and Torres Strait Islander women face a range of barriers that hinder; rather than support smoking cessation. Few smoking cessation programs consider the broader social determinants of women’s lives; the gendered nature of these or the complexities which impinge on behavior change in the presence of social and economic disadvantage and substantial individual and intergenerational trauma. Drawing on the salient gender and trauma-informed literature this paper describes the rationale underpinning formative research which will inform the design of a localized, culturally meaningful smoking cessation program for Aboriginal women living in the Hedland and Western Desert communities of the remote Pilbara region of Western Australia. We contend that a women-centered, trauma-informed approach to smoking cessation has much to offer those seeking to address this critical public health issue.

BACKGROUND: Primary health care (PHC) is widely regarded as essential for preventing and treating ill health. However, the evidence on whether improved PHC reduces hospitalisations has been mixed. This study examines the relationship between PHC and hospital inpatient care in a population with high health need, high rates of hospitalisation and relatively poor PHC access. METHODS: The cross-sectional study used linked individual level PHC visit and hospitalisation data for 52 739 Indigenous residents from 54 remote communities in the Northern Territory of Australia between 1 July 2007 and 30 June 2011. The association between PHC visits and hospitalisations was modelled using simple and spline quadratic regression for key demographics and disease groups including potentially avoidable hospitalisations. RESULTS: At the aggregate level, the average annual number of PHC visits per person had a U-shaped association with hospitalisations. For all conditions combined, there was an inverse association between PHC visits and hospitalisations for people with less than four clinic visits per year, but a positive association for those visiting the clinic four times or more. For patients with diabetes, ischaemic heart disease or renal disease, the minimum level of hospitalisation was found when there was 20-30 PHC visits a year, and for children with otitis media and dental conditions, 5-8 visits a year. CONCLUSIONS: The results of this study demonstrate a U-shape relationship between PHC visits and hospitalisations. Under the conditions of remote Indigenous Australians, there may be an optimal level of PHC at which hospitalisations are at a minimum. The authors propose that the effectiveness of a health system may hinge on a refined balance, rather than a straight-line relationship between primary health care and tertiary care.