Remote Australia Online

The virtues of rubbish research: A novel way of measuring the impact of crime prevention interventions in public spaces

In this chapter we want to problematise the notion that closing the gap in education will improve socioeconomic outcomes. In short, we question whether human capital theory that is so uncritically accepted as an elixir to socioeconomic disadvantage is applicable in all cross- or inter-cultural contexts, or in all territorial spaces.

The burden of type 2 diabetes mellitus (T2DM) among Indigenous children and adolescents is much greater than in non-Indigenous young people and appears to be rising, although data on epidemiology and complications are limited. Young Indigenous people living in remote areas appear to be at excess risk of T2DM. Most young Indigenous people with T2DM are asymptomatic at diagnosis and typically have a family history of T2DM, are overweight or obese and may have signs of hyperinsulinism such as acanthosis nigricans. Onset is usually during early adolescence. Barriers to addressing T2DM in young Indigenous people living in rural and remote settings relate to health service access, demographics, socioeconomic factors, cultural factors, and limited resources at individual and health service levels. We recommend screening for T2DM for any Aboriginal or Torres Strait Islander person aged > 10 years (or past the onset of puberty) who is overweight or obese, has a positive family history of diabetes, has signs of insulin resistance, has dyslipidaemia, has received psychotropic therapy, or has been exposed to diabetes in utero. Individualised management plans should include identification of risk factors, complications, behavioural factors and treatment targets, and should take into account psychosocial factors which may influence health care interaction, treatment success and clinical outcomes. Preventive strategies, including lifestyle modification, need to play a dominant role in tackling T2DM in young Indigenous people.

Background: This paper identifies the latent opportunities and challenges inherent in the formative stages of a project that was resumed after partial completion by other on-the-ground research teams. Methods: Grounded theory methods were used to analyse project documentation from previous research teams and to generate new process-oriented data. Results: The intention of all research teams was moving towards Engaging in Community-Based Participatory Research; this was conceptually identified as the core category. The social process involved in achieving community engagement practice was named Coming to an Ethics of Practice. Four different facets comprised the core category: Developing meaningful relationships; being reflective; recognising difference; and making research relevant. Conclusions: To achieve mutually beneficial outcomes, researchers conducting community-based research with Aboriginal people must implement strengths-based approaches to realise ethically sound research; prioritise the relevance of the research to the daily lives, needs and aspirations of those with whom they work; and in doing so, remain cognisant of their own philosophical position and context in which the research is located.

This article describes two strategies that have strengthened the capacity and effectiveness of rural health advocacy in Australia over the past nearly three decades. The first is the development of the National Rural Health Alliance, an organisation that grew from strategic efforts to develop relationships between rural and remote health practitioners and organisations. The second is the development, organisation and use of data and evidence to highlight rural health needs. There has been important synergy between these two streams of activity, with research and evidence providing the tools and the National Rural Health Alliance providing the strategy and techniques to influence the rural and remote health care agenda.

Introduction: The health care needs of underserved rural and remote communities are often not addressed due to a lack of clinicians. In some rural communities’ preschool and primary school children are showing signs of mental health disorders including emotional, social and behavioural problems. These children often have lower levels of literacy compared to state levels. Short description of practice change implemented: Occupational therapy (OT) and speech pathology (SP) students from various Australian universities are placed in preschool and primary schools throughout the year. Each of the students are given a case load of up to 20 children. The students provide ongoing support and feedback to teachers and parents. The practice changes are: 1) provision of continuous early intervention and therapy 2) traditionally these children would not have had access to allied health (AH) services 3) low intensity supervision 4) student immersion into disadvantaged rural populations 5) interprofessional placement 6) placement is outside of the traditional acute care setting 7) students are encouraged to consider where changes in policy and practice are appropriate. Aim and theory of change: The primary aim of the placements are for students to experience: an authentic rural placement in a primary care environment with diverse patient populations; a real-life application of knowledge in a real community context, that cannot be replicated in a hospital or university setting; a student led, continuous, interprofessional, low intensity supervised placement. The diffusion of innovation theory is applied. Targeted population and stakeholders: Schools in small rural towns with a higher rate than the state average of Indigenous people, families experiencing poverty, and higher rates of trauma and domestic violence. Stakeholder are clinical supervisors, teachers, parents and principles. Timeline: The program has been in place for 18 months across 12 schools. Highlights (innovation, Impact and outcomes): The innovation aspects are 1) Continuous service provision 2) meeting rural healthcare needs 3) low intensity supervision 4) rural community immersion 6) non-traditional settings 7) students implementing policy and practice changes. These non-traditional placements lead to students reporting: increased autonomy and confidence to work unsupported in a rural environment; increased social accountability and a positive attitude towards working with disadvantaged rural populations; feeling workforce ready; Sustainability: The model delivers allied health services to rural communities. The stakeholders have expressed a commitment for the program to continue as they recognise improved health outcomes. Transferability: The model could be rolled out to other small rural towns and applied in other disciplines and services. The model is already applied in residential aged care demonstrating the transferability of the model. Conclusions: Students get to experience a real-life application of knowledge in a real community context, that cannot be replicated in a hospital or university setting. Discussions: Low intensity supervision. Workforce readiness. At-risk populations’ needs. Lessons learned: These placements can provide an opportunity to increase students’ capability to work in rural settings and provide a solution to addressing: the lack of AH services in small rural communities and a low supply of rural AH clinicians.

The Federal Government recently announced the formation of a new taskforce consisting of relevant health care providers, researchers, clinicians, and all levels of government to combat HTLV-1 in remote Indigenous communities.

CONTEXT: This article describes a unique, remote, water safety-training program delivered to 11 remote Australian communities during 2006-2007. The program, known as 'Water Safety in the Bush', was developed by Combined Universities Centre for Rural Health in Geraldton Western Australia in consultation with the Commonwealth Government Department of Health and Ageing, and the Royal Life Saving Society of Australia. ISSUE: PROGRAM DESCRIPTION: Drowning and near drowning are major causes of childhood death and injury in rural and remote Australia, making improved water safety awareness and skills a public health priority. Water Safety in the Bush employed a flexible, community development model to meet the special requirements of remote and isolated communities. The model had three elements: coordination by a local organisation; a water safety instruction program based on a Royal Life Saving Society of Australia curriculum adapted to meet local priorities; and strategies for sustainability. PROGRAM EVALUATION: In the delivery of the program a total of 873 children and 219 adults received swimming and water safety instruction; 47 adults and older children received first-aid training; and 38 community members became AUSTAWIM (the Australian Council for the Teaching of Swimming and Water Safety) accredited instructors. Project evaluation showed parents and community organisations were very satisfied with the program which met a real need. Parents and instructors gave evidence of children's increased skills in water safety, swimming ability, life-saving and water confidence. Training programs with greater contact hours showed greater skill gains. Sustainability strategies included accreditation of local AUSTSWIM instructors, the erection of water safety signs, sourcing of continuing funding, and the introduction of water safety theory into the school curriculum. LESSONS LEARNED: Flexibility was the major success factor. Within the parameters of minimum guidelines, communities were encouraged to choose the timing, venue and delivery mode of the training to ensure the program was best suited to the local community. Community ownership was achieved by requiring that local organisations design and implement the projects. Designing programs that addressed local constraints ensured high participation rates. A number of challenges were also identified. Not all community organisations had the capacity to take on the coordinating role, and struggled to effectively deliver a sustainable program. Other models may be needed for these communities. Accessing appropriately qualified water safety instructors in local areas also proved difficult at several of the sites. Further, designing standardised outcome evaluation strategies that could be implemented across all participating sites was problematic. IMPLICATIONS: Remote and isolated communities have a pressing need to gain the knowledge and skills necessary for water safety and survival. Standard training programs, which in the case of swimming and water safety instruction are generally run in two-week blocks, are often not feasible. Models for delivering training, which give resources and power to local organisations to find innovative ways to meet their priorities, build capacity and ensure high participation rates.

Background Many regional and remote (‘regional’) hospitals are without the specialist services that support Antimicrobial Stewardship (AMS) programs in major-city hospitals. This can impact their ability to implement AMS activities. Aim To identify factors which impact on the delivery of AMS programs in regional hospitals. Methods Healthcare clinicians who have primary AMS responsibilities or provide AMS support to a health service or across health services with an Australian Statistical Geography Standard Remoteness classification of inner regional, outer regional, remote or very remote were recruited (purposively and via snowballing). A series of focus groups and interviews were held, and the discussions audiotaped and transcribed verbatim. The transcripts were coded by two researchers and thematic analysis undertaken using a framework method. Findings Four focus groups and one interview were conducted (22 participants). Six main themes that impacted on AMS program delivery were identified; culture of independence and self-reliance by local clinicians, personal relationships, the geographical location of the hospital influencing antimicrobial choice, the local context, inability to meaningfully benchmark performance and lack of resources. Possible strategies to support the delivery of AMS programs in regional hospitals proposed by participants were categorised into two main themes; those that may be best developed or managed centrally and those that should be a local responsibility. Conclusion AMS program delivery in regional hospitals is influenced by factors that are not present in major-city hospitals. These findings provide a strong basis for the development of specific strategies to support regional hospitals to implement sustainable AMS programs.

Social structure creates heterogeneity of interactions between individuals, thus influencing infectious disease spread. The objective of this study was to describe and characterise the social structure of free-roaming dog populations in three communities in the Torres Strait, Australia. Dogs in Kubin, Saibai, and Warraber communities were collared with GPS units that recorded locations at 15 s intervals for up to 1 week, and datasets were obtained from 24 (62% of the dog population), 23 (53%) and 21 (51%) dogs in each community, respectively. An association (potential contact) between dogs was defined as proximity within a spatio-temporal window of 5 m for 30 s. Networks were constructed for each dog population: 1. nodes were individual dogs, and 2. edges were weighted according to the duration of spatio-temporal association between pairs of dogs as a proportion of their simultaneous time monitored. Network statistics were calculated for each population and the robustness of networks to the duration of association between pairs of dogs was assessed in terms of efficiency, degree distribution and fragmentation (number of components). Dog social networks had ‘small-world’ structures, with characteristic clustering and low average shortest-path length between individuals. Overall, all three networks were highly connected in terms of degree distribution and global and local efficiency, but the median tie strength (2–13.5 min) was low. Centrality and the duration of association (tie-strength) between dogs were significantly different between communities. The Kubin network was least robust to fragmentation when ties of short duration were successively removed (14 components with minimum tie strength of 2 h). In contrast, the Warraber dog network was relatively robust with 7 components at minimum tie strength of 2 h as well as high local efficiency within components. We conclude that whilst infectious disease that requires a short duration of contact for transmission is likely to spread rapidly between and within clusters in all three networks in this study, fragmentation of networks ― once ties of short duration are removed ― is likely to limit spread of disease that requires a longer duration of direct contact. The network information in this study is useful as a foundation for disease spread modelling and to investigate control strategies such as movement restrictions in dog populations.

Introduction: The number of children with medical complexity CMC residing in rural areas is growing as the life span of CMC increases, placing an increased, unsustainable load on tertiary health services. Families of children with CMC also experience significant challenges relating to regular, long distance travel to receive health care treatment. A review of how we deliver care to CMC living in rural and remote locations identified opportunities to deliver care closer to home, avoiding frequent visits for routine care to teritary hospitals. There remains a knowledge gap about how best to structure a model of care for such children and the specific health care needs of the children and families have nor been adequately described. We aim to address this gap. Method: We conducted semi structured interviews with eighteen parents of CMC. The interview schedule included questions based on themes from the Agency for Clinical Innovation ACI Patient-Centred Dimensions of Care. Patients were provided flexible interview method options, including face-to face, phone and email. In addition two carers were interviewed using a patient story format. Detailed field notes were taken by the interviewer. Using an inductive approach we conducted qualitative thematic analysis of the field notes. Results: There were several key issues/themes which emerged related to barriers experienced when accessing health care locally, including limited services available, financial constraints and out-of-pocket costs, difficulties navigating systems, poor communication across services, and the impact these barriers had on the child’s health and the family unit as a whole. Although these issues were not dissimilar to those experienced by families living in metropolitan locations, geographical isolation heightened the level of complexity and negative impact on providing necessary health care for their child. This was particularly related to the need to travel long distances to receive specialist treatment and review, and the fragmentation between local and tertiary services. Discussion: Results indicated the need for increased collaboration, better linkage of cross-sector care, coordination of health care and community support services. Patients identified opportunities for building local capacity enabling service delivery closer to home and indicated that this would alleviate the burdens that families currently experienced while up-skilling local services. Conclusions comprising key findings: Engaging with families of CMC provides an added level of understanding of the effect geographical isolation has on care delivery. Inclusion of the views of patients/parents in the co-design of services is crucial to the success of any new service. Lessons learned: Engaging directly with families can provide a wealth of unique knowledge important in driving successful integration of care. Limitations: The families who took part in the interviews were from a sample area of the district, which excluded children and families located in the most isolated/remote areas. Suggestions for future research: A larger sample group which distinguishes CMC by condition, facility, and those involved with additional clinical supports such as Clinical Nurse Consultant’s CNCs would provide a greater understanding of gaps specific to subgroups within this paediatric population.

In this paper we attempt to understand at least some of the complex and interacting forces – cultural, biological, developmental and historical – that influence adolescents’ sexual behaviour in three remote Australian Aboriginal communities. We use the concept of ‘agency’ only as a foil for our interpretation. Drawing upon ethnographic material, we focus on: ‘walkin’ around at night’, avoidance of arranged marriages and the exchange of sexual favours for drugs and money. Cognitive, evolutionary, and neuroscience enable us to illustrate the interpenetration of sociocultural and psychobiological factors in adolescent girls’ behaviour: expectations about marriage, a desire for love, sexual urges, a brain that is highly responsive to peers and rewards, a disadvantaged and uncertain environment, and challenges to effective adult control.

The release of the United Nations Sustainable Development Goals and the Paris Climate Change agreement highlighted the importance of global sustainability internationally. Here, we outline a vision and strategies for developing northern Australia that demonstrate how a focus on sustainable prosperity can both expand historical approaches and current government plans and integrate the biophysical realities with the social, political, and cultural characteristics of the region. We highlight examples of the significant horizontal and vertical integration opportunities that this expanded vision and related strategies provide for (a) land (carbon farming, targeted food production systems, and native title arrangements); (b) water (water resources management); (c) energy (renewable energy production, storage, and distribution); (d) workforce (culturally appropriate ecotourism, Indigenous ranger programs, and protected area management); (e) knowledge services (health care and innovative employment opportunities); and (f) governance (greater participatory governance). We found that realisation of even 10% of these emerging opportunities over the next 10 years alone could result in economic growth worth over AUD 15 billion and 15,000+ jobs for northern Australia as well as the further ecological and social benefits derived from a sustainable prosperity strategy.

INTRODUCTION: Remote communities across Australia lack the ready access to medical care generally afforded to metropolitan populations. The Royal Flying Doctor Service (RFDS) medical chest program provides medical resources to these communities allowing medications to be dispensed in conjunction with a telehealth consulting service. More than 3000 medical chests are located throughout Australia and each year the Queensland RFDS conducts approximately 20 000 telehealth consultations. The aim of this study was to review the use of the medical chest model within the state of Queensland and to analyse changes in the medical chest program from 10 years earlier to evaluate the changing healthcare needs of remote Australian populations. METHODS: All telehealth consultations and items dispensed from the medical chests were reviewed over a 1-year period from 1 July 2013 and 30 June 2014. Items dispensed were categorised and compared to those in 2005-06 in absolute terms by one-way ANOVA and proportionately by chi2 with Fisher's exact test. Consultations using the medical chest were categorised and compared to those in 2005-06 by chi2 with Fisher's exact test. RESULTS: The number of telehealth consultations conducted in 2013-14 (N=20 707) was not different to the number conducted in 2005-06 (N=21 470). Fewer items were dispensed from the medical chests in 2013-14 (3936 total items) than in 2005-06 (8607 total items; p<0.0001). In the specific categories of 'burns and other dressings' and 'antihistamines', the number of individual items dispensed increased. Resources from the medical chest were used more for genitourinary system consultations and less for consultations involving specific infectious diseases; the circulation, respiratory and abdominal systems; skin diseases; injury; symptoms without a diagnosis; and following other contact with a health service. CONCLUSIONS: The medical chests remain a vital tool for medical care of remote populations and the need for telehealth medical advice remains unchanged, although fewer items are being dispensed. The use of the medical chest for each diagnostic category of consultation has shown some variation over the past 10 years, reflective of changing patterns of accident, injury and disease.

Objective: A considerable health disparity exists between Aboriginal and non-Aboriginal Australians, including a higher incidence and severity of cardiovascular and respiratory diseases. The burden of these diseases appears to be greatest in communities located in the remote regions of Australia. Unique environmental challenges in these regions may be a contributing factor; however these are yet to be adequately investigated. We aimed to develop a case to improve our understanding of environmental risk factors in remote Aboriginal communities. Methods: We comprehensively reviewed the literature regarding physical environmental challenges that are likely to be highly prevalent in remote Aboriginal communities, and have been linked with adverse health. We focused on exposure to inhaled geogenic (earth-derived) dust and biomass smoke, bacterial and heavy metal contamination of drinking water and overcrowding. Results: These environmental factors are anecdotally high in remote Aboriginal communities and have been linked, mostly epidemiologically, to cardiovascular, respiratory and other infectious diseases. These challenges are an under-recognised problem and are likely to have a significant impact on Aboriginal community health; increased research focus in this area would be of great benefit. Implications: It is crucial to identify and quantify these physical environmental factors, and to determine the mechanisms through which they impact on health, particularly as these factors are modifiable and may be suppressed using relatively simple, cost-effective changes in community infrastructure. Protection against these exposures is likely to reduce their cumulative negative effects on individuals across the life course and result in significantly improved health in remote Aboriginal Australian communities.

Legal restrictions on alcohol availability have been used to address violence and injury in the world’s remote Indigenous communities. In Australia, alcohol management plans (AMPs) were implemented by the Queensland Government in 2002. This study reports changes in indicators of alcohol-related violence and injury in selected communities. Methods: Design and setting: A longitudinal observational study was conducted in four Aboriginal and Torres Strait Islander (Indigenous) communities in Cape York, far north Queensland. All communities are similarly-isolated from population centres where alcohol is available. Data: For 2000 to 2015 inclusive: 1019 Royal Flying Doctor Service aeromedical trauma retrievals; 5641 Queensland Police Service records of unique assault occurrences, including 2936 involving alcohol; and records for 2741 unique assault victims were examined. Data analysis: Rates (per 1000 population) of trauma retrievals, assault occurrences and assault victims (per 1000 population) were compared across three policy phases. Phase 1: 2000 to 2008. Initial restrictions on possession and consumption of alcohol in ‘restricted areas’ were implemented during 2002–2003. Phase 2: 2009 to 2012. All alcohol was prohibited in three study communities and its legal availability limited in the fourth from 2009. Phase 3: 2013 to 2015. Government reviews of AMP policies in light of legal challenges and community responses characterise this phase. Results: Compared with Phase 1, in Phase 2 retrieval rates declined by − 29.4%, assault occurrences by − 34.1% with less than one-third involving alcohol, and assault victims by − 21.1%, reaching historically low levels in 2010–2012. These reductions did not continue consistently. Compared with Phase 1, in Phase 3 retrieval rates, assault occurrence rates and assault victim rates declined by somewhat lesser amounts, − 13.9%, − 15.0% and − 13.4%, respectively. In Phase 3, the proportion of assault occurrences involving alcohol in communities 2, 3 and 4 rose towards pre-2008 levels. Conclusions: Early successes of these controversial alcohol restrictions are jeopardised. Indicators of violence and injury appear to be rising once more in some AMP communities. Importantly, rates have not generally exceeded the highest levels seen in Phase 1. Fresh policy action is required with rigorous monitoring to prevent erosion of initial important successes.

In Australia, ‘Alcohol Management Plans’ (AMPs) provide the policy infrastructure for State and Commonwealth Governments to address problematic alcohol use among Aboriginal and Torres Strait Islanders. We report community residents’ experiences of AMPs in 10 of Queensland’s 15 remote Indigenous communities.

The most important skin infections in Aboriginal communities in central and northern Australia are scabies and streptococcal pyoderma. Scabies is endemic in many remote Aboriginal communities, with prevalences in children up to 50%. The cycles of scabies transmission underlie much of the pyoderma. Up to 70% of children have skin sores, with group A streptococcus (GAS) the major pathogen. Group A streptococcus is responsible for the continuing outbreaks of post-streptococcal glomerulonephritis and acute rheumatic fever (ARF). The cycles of scabies transmission in dogs and humans do not appear to significantly overlap. Guidelines have been developed for community control of scabies and skin sores and successful community initiated coordinated programmes have occurred. The anthropophilic dermatophyte Trichophyton rubrum is ubiquitous in many communities, again reflecting living conditions. Other skin infections related to the tropical environment include melioidosis, nocardiosis, Chromobacterium violaceum and chromoblastomycosis. Sustainable and long-term improvements in scabies, skin sores and GAS-related disease and tinea require fundamental changes that address social and economic inequities and, in particular, living conditions and overcrowding.

Introduction: Improving chronic disease in Australia’s Indigenous populations is complex and new approaches are urgently required. Under the new Primary Health Networks PHNs, a contemporary commissioning approach in partnership with the Aboriginal Community Controlled Health Organisation ACCHO Sector is directly addressing health disparity in Indigenous chronic disease compared to other non-Indigenous Australians. Transformation: Cultural competence is embedded through an enterprising Alliance and Consortia arrangement that is shifting leadership and design of Indigenous health care delivery in Western NSW and Western Queensland. Aim and Theory of Change: The Marrabinya and Nukal Murra initiatives are health support services that aim to ensure eligible Indigenous clients of general practice have better access to more comprehensive care including medication and medical aids, transport, Specialist and allied health interventions. Using a service brokeragemodel, active chronic disease management is promoted across General Practice and ACCHO settings building health literacy and uptake of Medicare. A place-based commissioning approach, it allows knowledge of local behavioural, social and biomedical factors impacting on patient engagement and participation to be incorporated into culturally informed service delivery. Targeted Population: The Marrabinya consortium agreement Western NSW and Nukal Murra alliance agreement Western QLD targets Indigenous patients with chronic disease living across a combined landmass of 1,400,000km2. Timeline: Marrabinya commenced September 2016 and Nukal Murra July 2017. Both services have been funded through the Commonwealth PHN program till 2020. Highlights: Through direct commissioning with Australia’s ACCHO sector both services have pioneered innovative approaches to achieve program fidelity across vast regions of remote Australia: - supporting care-link workers who provide care coordination assisting patients to better navigate and understand their local healthcare system; - Increased enrolments; - decreased staffing and administration costs; - customised health intelligence and operating procedures; Sustainability: Centralised brokerage optimises quality, access and cost drivers of care. Increased active enrolments signify changes in attitudes of providers and patients. A quadruple aim locus is achieved through ‘whole of population’ coverage, leveraging regional ACCHO infrastructure to realise cost efficiency at scale, improving quality through cultural competence, and better differentiating clinical and non-clinical roles in care. Transferability: There is high transferability of this unique co-commissioning approach across the PHN national network. Commencing with the Marrabinya initiative, early sharing assisted the establishment of the Nukal Murra program. Conclusions: Partnering with ACCHOs can strengthen cultural competence in clinical practice resulting in significant innovation, efficiency and demonstrated patient and system benefits. Early indications highlight potential to reduce unwarranted acute presentations. Discussions: Cultural intelligence is an important element in commissioning and extremely difficult to dispense in practice. The cultural and social knowledge of Indigenous patients must be effectively integrated into systems supporting their care. Key Lessons Learned: Integrated approaches that engages Indigenous leadership in primary health care design can dramatically improve commissioning outcomes. Centralised brokerage and active health intelligence supports triage and assessment, as well as guiding greater efficiencies, clinical re-design and consumer and provider engagement. Combining short term commissioning pragmatism with longer term partnerships is an important development and a new feature of engagement with Indigenous people.

Evaluation of telepsychiatry (via videoconference) for older adults is mostly focussed on nursing homes or inpatients. We evaluated the role of a community based program for older adults in rural and remote regions of South Australia.

A community-led oral health service for Aboriginal people in Central Northern NSW identified the need for oral health promotion, as well as dental treatment; in three remote communities with limited access to dental services. A three-stage plan based on the Precede-Proceed model was used to develop a school-based preventive oral health program. The program will be piloted in three schools over 12 months aimed at improving the oral health of local Aboriginal children.

Indigenous governance in the context of suicide prevention activity is about Indigenous communities’ control of the design and implementation of suicide prevention activity taking place within them; or direction and leadership guiding external organisations to the same end. Suicide is a world-wide population health challenge. This includes among the Australian general population and, in particular, among Aboriginal and Torres Strait Islander peoples. For the latter, the suicide rate is about double that of the non-Indigenous population, and likely to be increasing; among adolescents and young adults, the rate is higher again. The 2017 Fifth National Mental Health and Suicide Prevention Plan (Fifth Plan) makes reducing Aboriginal and Torres Strait Islander suicide rates and improving mental health a national priority (Priority Area 4). The Fifth Plan also marks the adoption of integrated approaches to suicide prevention as the national approach to suicide prevention. However, while the evidence base for mainstream integrated approaches demonstrates they do reduce general population suicide rates, Aboriginal and Torres Strait Islander suicide is different. In part, it can be understood as a response to challenges affecting individuals (and such should be an important part of an overall approach to reducing Aboriginal and Torres Strait islander suicide). However, an exclusive focus on individual causes also runs the risk of overlooking underlying influences that operate collectively – at the population and community level. These are the culmination of a history of colonisation, and contemporary systemic social and economic disadvantages stemming from that history. Over 2016-17, the Aboriginal and Torres Strait Islander Suicide Prevention Evaluation Project (ATSISPEP) identified success factors in evaluated Aboriginal and Torres Strait Islander suicide prevention activity. The resulting Solutions That Work report is an invaluable resource for all those working in Aboriginal and Torres Strait Islander suicide prevention and is summarised in Appendix 1 of this Guide. Of particular relevance here, the non-negotiable success factor that underpinned successful suicide prevention activity was that the processes associated with design and implementation be empowering to Aboriginal and Torres Strait Islander communities.

Indigenous people in Australia are vastly over-represented within the criminal justice system. While there has been fierce debate in academic circles regarding the nature of this overrepresentation, discriminatory policing practices and generally poor relations between Indigenous peoples and the police have been regularly highlighted. The dramatically higher rates of criminalisation and police intervention for Aboriginal people compared to non-Aboriginal people reinforce their exclusion from social and economic participation. Given the high proportion of Aboriginal people residing in rural and remote communities, such places are often viewed as sites of racial conflict and/or crime in the Australian context. This research examines police and Indigenous relations in rural and remote contexts in Australia. This research aimed to elicit insights from police officers in order to find further solutions to improve relationships between the two groups. It contributes to the body of knowledge seeking to identify ways to rectify the issue of Indigenous people being overrepresented in the criminal justice system. Whilst various themes surrounding drivers of police behaviour have been recorded in the literature, the perspectives of what influences individual police officers to choose certain police practices in the context of discrete Indigenous communities has not previously been explored in depth. Historically, the relationship between police and Indigenous people in Australia has been, for the most part, contentious. This dynamic between police and Indigenous people has been particularly evident in discrete Indigenous communities in Queensland, which were formed during the colonial period. Colonisation saw police responsible for forcing Indigenous people from their traditional lands and onto reserves, in order to control Indigenous people and manage their assimilation into white society. Ultimately, these discrete Indigenous communities set the scene for a history of ongoing tensions between police and Indigenous people. This research uses a grounded theory approach to gain insight into how social factors such as ecology, and organisational and occupational culture influence police in the course of their duties in the context of a discrete Indigenous community. In depth interviews were conducted with 15 police officers who work or have worked extensively in discrete Indigenous communities in Queensland. The research found that ecological factors, such as community dynamics and Indigenous culture, heavily influence how police respond to situations more than factors relating to organisational and occupational culture. It also found that ecological factors shape various policing practices directed at maintaining peaceful relationships and legitimacy. Overall the relationship between police and Indigenous people in Australia has been one of tension and conflict. However, in contemporary times the relationship between the two groups has been examined with a view to finding solutions to bring about better cooperation. The insights provided in this research contributes to that body of knowledge seeking to better understand what police do to manage tensions and improve relationships with Indigenous people; furthermore, it provides valuable insights for police organisations to consider to ensure future relationships are kept peaceful.

We come to this article as non-Indigenous teacher educators working as qualitative researchers in postcolonial/decolonial (Mignolo, 2000) times. We explore matters related to schooling in remote Australian Indigenous communities. In this article, we respond to Delamont’s invitation for qualitative researchers to revisit (Delamont and Hamilton, 1984) and think reflexively (Delamont, 2009) about our field work research methods. In doing so, attention is drawn to research processes involved with observing, narrating and writing lives and experiences. We highlight matters related to sequencing dilemmas (Delamont, 2009), the need to locate the self-as-researcher in the social (Delamont, 2007), and calling out ethical tensions associated with the ‘catch 22’ of confidentiality and acknowledgement (Delamont, 2007). Two separate researcher recounts of field notes are used to render visible our reflexive thinking as we attempt to negotiate Western educational research ethics policies and procedures and ways of knowing and being in Indigenous contexts.

Background: The cost of performing cardiac surgery in the public health system in Australia is unclear. This paper analyses the cost of cardiac surgery performed at Flinders Medical Centre (FMC), South Australia, comparing cost by procedure, rheumatic valvular heart disease status, Aboriginality and location. Methods: This study is a retrospective, population-based analysis of cardiac surgery data held in the Cardiac Surgery Registry cross-referenced to cost data provided by the FMC Department of Finance and Patient Travel, Accommodation and Transport Services at the Royal Darwin Hospital. 795 patients who underwent cardiac surgery at FMC from 1 July 2014 to 30 June 2016 were included. Results: Across all procedures, Northern Territory (NT) Aboriginal patients had a mean total cost of $78,506 which was $24,113 more than NT non-Aboriginal, $28,443 more than South Australian (SA) Aboriginal and $22,955 more than SA non-Aboriginal patients. The total cost of a patient undergoing a repeat sternotomy (reoperative procedure) was found to be significantly higher than a primary procedure ($85,797 versus $59,097). In patients undergoing valve surgery procedures, those identified with rheumatic heart disease had a higher mean total cost than those without (a difference of $25,094). Significantly, the rheumatic patient group showed a higher proportion of reoperative procedures (19% versus 5%). Conclusions: The cost of treating NT Aboriginal cardiac surgical patients remotely has a significant financial impact upon the health care delivery system, as does the impact of rheumatic heart disease. This study found that the cost for the NT Aboriginal patient group was substantially higher than the NT non-Aboriginal, SA Aboriginal and SA non-Aboriginal patient groups. The additional cost to family and dislocation of social structures is not able to be calculated, but would also clearly weigh heavily on both patient groups. These findings suggest that future health funding models should recognise Aboriginality, remoteness and rheumatic heart disease.