Remote Australia Online

INTRODUCTION: This study investigated whether increased numbers of primary healthcare clinical consultations in Indigenous communities in some remote areas of Australia are associated with the reduced need for urgent medical evacuations and remote telephone consultations. METHODS: A retrospective comparison study of routinely collected data utilising correlation analysis was conducted. Statistical associations have been measured using Pearson product-moment correlation coefficients. The setting was 20 primary healthcare centres in the Northern Territory servicing >/=5900 residents between July 2008 and June 2010; data were collected from Central Australia Remote Health and the Royal Flying Doctor Service-Central Operations, Alice Springs base. Main outcome measures included number of acute medical evacuations and number of remote telephone consultations relative to number of face-to-face consultations with Aboriginal health workers, remote area nurses and general practitioners. RESULTS: Statistically significant positive correlations were found between numbers of acute medical evacuations and numbers of face-to-face consultations (r = 0.659; 95% confidence interval (CI): 0.305-0.855), remote area nurse consultations (r = 0.481; 95% CI: 0.055-0.765) and general practitioner consultations (r = 0.798; 95% CI: 0.555-0.920). Significant positive correlations were also found between numbers of remote telephone consultations and numbers of face-to-face consultations (r = 0.546; 95% CI: 0.135-0.795) and general practitioner consultations (r = 0.563; 95% CI: 0.163-0.805). CONCLUSIONS: The provision of more frequent healthcare centre face-to-face consultations, including general practitioner consultations, is associated with an increased burden of acute medical evacuations and remote telephone consultation services in this remote setting.

Aboriginal and Torres Strait Islander Community Controlled Health Services (ACCHSs) around Australia have been asked to standardise screening for unhealthy drinking. Accordingly, screening with the 3-item AUDIT-C (Alcohol Use Disorders Identification Test—Consumption) tool has become a national key performance indicator. Here we provide an overview of suitability of AUDIT-C and other brief alcohol screening tools for use in ACCHSs.

Significant investment has been undertaken by many countries into ‘Rural Clinical Training Placement Schemes’ for medical students in order to deal with shortages of trained health care professionals in rural and remote locations. This systematic review examines the evidence base of rural educational programs within medical education and focusses on workforce intentions and employment outcomes. The study provides a detailed description of the methodological characteristics of the literature, thematic workforce outcomes and key related factors are identified, study quality is assessed, and the findings are compared within an international context.

The uptake of small screen technology by adolescents is widespread, particularly in industrial nations. Whether the same is true for Australian Aboriginal youth is less clear as there is a dearth of research in this regard. Therefore, in this exploratory study the use of small screen technology by Indigenous students was examined. Twenty-four Indigenous adolescents (mean age 16.4 years) attending a boarding school in a remote region of Western Australia participated in individual and in-depth structured interviews that queried their use of: (1) television, (2) video games, (3) computers, (4) the internet, and (5) mobile phones. The results showed that mobile phones were the most frequently used and the most popular (i.e., they were nominated as first choice in a hypothetical scenario), followed by the internet, whereas television, video games and computers were used less often. It did appear that mobile phones were used by participating Aboriginal adolescents in ways similar to non-Indigenous adolescents (e.g., not only to make phone calls, but also to send text messages and access the internet). However, their mobile phone use did reflect differences based on their cultural values and identity, and also reflected their physical distance from their family (i.e., because of their enrolment at a boarding school). This study supports anecdotal evidence of a rapid uptake of mobile phones by Indigenous adolescents. It also suggests that as the small screen technology of choice, they have the potential to be utilised for educational opportunities.

Issues addressed: To explore the perceptions of remote Indigenous community members and health staff regarding the acceptability and effectiveness of different tobacco control health promotion interventions. Methods: Qualitative methods were used for this exploratory study, including interviews with remote Indigenous community members and health staff, as well as observations of the delivery of different tobacco control activities in three remote communities in the Northern Territory (NT). Results: Several tobacco control interventions for which there is strong evidence in other settings were generally perceived as acceptable and efficacious in the remote Indigenous setting. Primary care interventions, such as brief advice and pharmaceutical quitting aids, when available and accessible, were perceived as important and effective strategies to help people quit, as were the promotion of smokefree areas. By contrast unmodified Quit programs were perceived to have questionable application in this context and there were conflicting findings regarding taxation increases on tobacco and social marketing campaigns. Conclusions: Several evidence-based ?mainstream? activities are perceived to be acceptable to this population, but we may also need to address the concerns raised by health staff and community members about the acceptability of some unmodified activities. Additionally, organisational barriers within the health system may be contributing to the reduced effectiveness of tobacco control in this setting. Key words: smoking, tobacco, Indigenous, intervention, remote, qualitative.

The Central Australian Remote Practitioners Association Standard Treatment Manual (CARPA) contains protocols for primary health care in remote Central Australia. This context stands in stark contrast to the mainstream settings in Australia and features an Aboriginal population with very poor health status, powerful social determinants of health, geographical isolation and high turnover of health practitioners. The manual consolidates the core elements of national guidelines, particularly as they pertain to Aboriginal health care, into a single document. The aim of this study is to explore factors that promote or impede the use of CARPA by general practitioners (GPs) in Central Australia, with a particular focus on chronic disease management.

This report presents an overview of homelessness in Western Australia: its nature, composition, antecedents and consequences, and the policy and practice responses that we believe should be considered address it. We review and consolidate evidence and extant knowledge from various statistical sources, academic research, evaluation reports, the lived experience of those who experience homelessness, and recent guiding frameworks provided by the Western Australian and Commonwealth Governments, as well as The Western Australian Strategy to End Homelessness published recently by the Western Australian Alliance to End Homelessness (Western Australian Alliance to End Homelessness [WAAEH], 2018). The report has the following five objectives: 1. To synthesise the evidence base on the scale, scope and profile of homelessness in Western Australia; 2. To outline the key drivers and causes of homelessness; 3. To analyse the current approaches to addressing homelessness in Western Australia and their effectiveness; 4. To identify system level gaps in responses to homelessness and key research and evidence gaps; and, 5. To provide guidance in terms of a way forward towards addressing homelessness in a Western Australian context.

While the literature on women and educational leadership has been addressed in substantive ways in recent years, the experiences that reflect female Australian educational leaders are rare. This article reports findings from a study of five female Indigenous principals in the Northern Territory utilising biographic narratives and foregrounds their experiences as female educational leaders in Indigenous communities. I share the views of Ribbins, P. and Gronn, P. (2013. Researching principals: context and culture in the study of leadership in schools. Asia Pacific journal of education, 20 (2), 34?45) and Dimmock, C. and Walker, A. (2005. Educational leadership: culture and diversity. London: Sage) that research and theory into educational leadership must move towards the inclusion of localised unique cultural contexts since the practice of leadership is a socially bounded process. The study reveals the daily complex roles and challenges of being a female Indigenous principal in communities that are grounded in broader Indigenous epistemologies, beliefs, and value systems yet to be fully embraced by mainstream educational leadership perspectives.

INTRODUCTION: This paper will discuss health issues among Filipinas (women born in the Philippines) living in remote and rural environments in Queensland in comparison to Filipinas living in other parts of the state. The sample was recruited as part of the University of Queensland component of the Australian Longitudinal Study of Women's Health. Access to health services will be discussed in terms of the framework outlined by McKinley et al: (i) Knowledge (Availability) is measured in terms of consumers' knowledge about the services and consumers' confidence in being able to use the medical care they require; (ii) Accessibility is considered in terms of their location to the consumers in relation to the services (distance) and being able to physically get to them (transport); (iii) Affordability is measured in terms of the extent to which cost is seen as a barrier to service use; (iv) Accommodation is measured in terms of the extent to which service delivery arrangements are able to accommodate consumers' needs and the extent to which doctors' attitudes are seen to be accommodating of those needs. It would be expected that cultural and linguistic issues would primarily affect Knowledge and Accommodation. Differences in Accessibility and Affordability would be expected to be affected by location. Access to services in rural areas may be more difficult and dependent on personal transport. METHODS: The sample, consisting of women born in the Philippines, was recruited though community organizations as part of the University of Queensland component of the Australian Longitudinal Study of Women's Health. Most of the women lived in urban or semi-urban areas (391) and 90 lived in areas designated as rural or remote areas by Queensland Health. The overall response rate was 87% and 83%. RESULTS: There were no differences between urban and rural and remote women in terms of knowledge. However women living in rural and remote areas had greater difficulty getting their information needs met. Consequently problems caused by structural limitations of health service delivery were often exacerbated by differences in expectations of health services and lack of understanding of methods to optimise access to care. CONCLUSION: Many of the barriers experienced by migrant women in rural/ remote areas mirror those of other Australian women. However the results suggest that better information about health services and self-management may improve the interface between service providers and their clients.

BACKGROUND: The individual and contextual factors influencing current mental health and well-being within rural communities are poorly understood. METHODS: A stratified random sample of adults was drawn from non-metropolitan regions of NSW, Australia. One-quarter (27.7%) of the 2,639 respondents were from remote/very remote regions. An aggregate measure of current well-being was derived from levels of distress and related impairment (Kessler-10 LM), self-reported overall physical and mental health, functioning, satisfaction with relationships, and satisfaction with life. Multivariate methods investigated the contributions to current well-being of demographic/dispositional factors, recent events and social support, individual exposure to rural adversity, and district/neighbourhood level characteristics. RESULTS: Respondents from very remote regions tended to be younger and have lower education. Univariate associations were detected between well being and exposure to rural adversity (greater drought-related worry, lower perceived service and support availability, greater number of years living in the current district). Multivariate analysis (n = 2,462) accounted for 41% of the variance in well-being scores. The major contributing variables were dispositional factors (trait neuroticism, marital status), recent adverse events and indices of social support. However, no additional effects were detected for district-level variables (drought severity, regional socioeconomic categorisation, population change). Similar associations were detected using the K-10 alone as the outcome measure. CONCLUSIONS: The chief determinants of current well being were those reflecting individual level attributes and perceptions, rather than district-level rural characteristics. This has implications for strategies to promote well being within rural communities through enhancing community connectedness and combating social isolation in the face of major adversities such as drought.

This article examines the issues surrounding the mapping of the oral language development of Standard Australian English (SAE) in the early school years of remote and very remote Aboriginal education in the Northern Territory (NT). Currently, teachers in this context have 2 mandated documents as guides that chart the development of SAE oracy. However, a close inspection of both documents demonstrates an incomplete view of English oracy for this unique education and linguistic context within the broader Australian social milieu. A detailed profile of emerging English oracy is not captured by current profiles that do not recognise the influences of homeland Aboriginal language groups on the acquisition of SAE. A more detailed emergent SAE oral profile can be constructed from existing oral SAE language samples. These samples have been collected by the NT Department of Education and Training (NT DET) from 6-year-old children participating in the Indigenous Language Speaking Student (ILSS) program. The development of an emergent oral SAE profile will be an extremely useful adjunct for the 2 existing documents. This article is a preliminary mapping of the issues with current SAE oral language profiles for remote and very remote Aboriginal school children.

A rural and remote international clinical exchange permits the senior nursing student to experience another culture and to develop a feel for daily life and nursing practice abroad. In a student exchange between Australia and Canada, similarities exist with regard to life and work for nurses who live in these developed countries. Similarities extend to a growing population base of original inhabitants or indigenous peoples with complex health challenges. Differences, however, are also apparent in rural and remote health care delivery due to the uniqueness of each country's demographics, nursing programs, nursing culture, and health care systems. In the rural hospitals of the Riverland region, South Australia, the Australian public and private health care systems are witnessed working side by side. Aboriginal health care with its unique cultural care practices was experienced in the remote Aboriginal community of Hermannsburg in the Northern Territory, and in the district hospital in Alice Springs. The international exchange provided the opportunity to reflect on the impact of the social determinants of health, and the similarities and differences between developed countries in nursing practice and nursing culture. The sense of community and autonomy gained in rural and remote placements in Australia provided incentive for nursing students to consider this area of practice on their return to Canada.

OBJECTIVE: In this study an analysis was undertaken to determine: (i) the major factors that influence oral health professionals to practise in rural areas and determine practice location; (ii) what assists the professional oral health workforce to remain in rural practice; and (iii) what the main reasons are for leaving rural practice. DESIGN: A postal survey was undertaken among all registered oral health professionals in Western Australia. SETTING: Rural and remote Western Australia. PARTICIPANTS: Registered dental therapists, dental hygienists and dentists in rural and remote Western Australia. RESULTS: Results indicated that there are various factors that attract people to rural and remote areas, other than financial incentives. Incentives to remain in rural practice include the need for professional development. The most common reason for leaving rural practice was to access children's educational facilities. CONCLUSIONS: This study emphasises that many factors contribute to recruitment and retention of dental professionals in rural practice. A broad integrated retention strategy is needed to address oral health workforce shortage issues in rural and remote Western Australia.

Importance Diabetes mellitus (DM) is highly prevalent among Indigenous Australians and contributes greatly to premature death. The association of diabetic retinopathy (DR) with early mortality however, has not previously been reported among Indigenous Australians. Background To investigate associations between 10 year mortality and the presence of DR among Indigenous Australians living in central Australia. Design Prospective cohort study. Participants 1,257 individuals aged 40 years or older, living in one of 30 remote communities within central Australia were recruited through outreach clinics. Methods Fundus examination was performed on all patients at recruitment. The presence of any DR was recorded. Main Outcome Measures Mortality rate and cause were obtained at 10 years, and their association with any DR was determined. Results Ten year all-cause mortality was found to be 29.3%. Of those with DM but no DR, 24.0% died during the 10 years after recruitment, compared with 40.1% for those with any DR (P<0.0001). Those who had any DR were 75% more likely to die (HR 1.75; P<0.0001) and were more likely to die from renal failure (HR 2.71; P=0.004) or stroke (HR 5.91; P=0.026). Conclusion and Relevance The presence of any DR among those with DM, was associated with a 75% greater 10 year all-cause mortality rate and were more likely to die from renal failure or stroke. We recommend that whenever DR is noted among Indigenous Australians with DM, that they be immediately referred for investigation and management of risk factors which might predispose to renal failure and stroke. This article is protected by copyright. All rights reserved.

Through this paper we hope to stress the importance and value of this kind of research and believe there are similarities between the data we have gathered on GPs and their partners and the Australian RHW. There are complexities but we suggest while there may be some barriers to applying this kind of research for the Australian Rural Health Workforce, they could be overcome.

Objective: Data collection ‘silos’ can be linked for health research. Anaemia in early childhood is a long-recognised health issue in remote Aboriginal communities of the Northern Territory and Western Australia, but information is lacking for Queensland. The objective of this work was to compile existing information from health and education data collections to investigate anaemia among Aboriginal and Torres Strait Islander mothers and their children in Far North Queensland. Methods: Data mapping identified four health data collections and one education data collection holding relevant information. Data Custodians’ approval was secured for release of linked de-identified information. Results: Approval processes and preparation of the dataset for release took 23 months. Birth information was obtained for 2,205 mother–child pairs where the Aboriginal and/or Torres Strait Islander child was born in Far North Queensland between 2006 and 2010. Pathology information from before/during pregnancy was obtained for 2,126 mothers (96.4%), growth and haemoglobin information for 982 children (44.5%), and childhood development indicators at school entry for 963 children (43.7%). Conclusion: Linking existing information ‘silos’ enables research into key public health issues. Implications for public health: Information linkage is particularly valuable in respect of vulnerable populations including rural and remote Aboriginal and Torres Strait Islander peoples.

The typically arid climates in the likely locations for renewable thermal power plants such as Concentrating Solar Thermal (CST) power plants provide the motivation for dry cooling technology applications. Natural draft dry cooling tower (NDDCT) with low maintenance cost and no parasitic power consumption offers a feasible and cost effective option for such applications. Compared with the conventional coal fired and nuclear power plants, the size of the CST power plant proposed for Australian regional communities is much smaller. However, the existing cooling tower design is optimised for large steam power plants, and is not optimal for these renewable power plants. To help address this issue, Queensland Geothermal Energy Centre of Excellence (QGECE) at The University of Queensland was developing the small NDDCT technology for renewable power plants. A 20 m high NDDCT was built on the Gatton campus of the University of Queensland as testing base for developing dry cooling technologies for future small scale (<10 MWe) CST power plants. Using both numerical simulations and full-scale experimental tests, this thesis investigated the cooling performance of this small NDDCT in different ambient conditions, discussed the feasibility of the small NDDCT in CST power plant, identified two specific potential cooling issues for the small NDDCT and proposed the mitigation solutions. The main findings of this thesis are summarized as following: (1) This research developed the 1D analytical model and the 3D CFD model of the 20 m high Gatton NDDCT. The cooling performance of this cooling tower is investigated under different ambient temperatures, different hot water inlet temperatures and different crosswind speeds. The results show that both ambient temperature and the crosswind have significant influence on the performance of the cooling tower. (2) The performance of the experimental tower was tested at two constant heat loads of 600 kW and 840 kW, respectively, with various ambient temperatures. The 1D numerical model was refined and validated with the experimental data. The thermodynamic model of a 1 MW CST power plant running with sCO2 cycle was developed and integrated with the updated cooling tower model. Significant differences were observed between the steam Rankine and sCO2 cycles in terms of the effect of the ambient temperature on power generation. The differences between steam Rankine and sCO2 Brayton cycle in this context were analysed and discussed. (3) Two potential cooling issues with small NDDCT, the crosswind and the cold inflow, were identified and the detail experimental data were presented. The crosswind effect on small cooling tower is different from the conventional big cooling towers. With the increase of the crosswind speed, the overall cooling performance of the small NDDCT first decreases and then increases. The mixed convection theory and the Richardson Number were proposed to explain this phenomenon. On the other hand, repeated cold inflow events were observed during the tests, which cause a significant decrease of the air temperature inside the cooling tower. The water outlet temperature can be increased up to 3°C as a result of the cold inflow effect. Further analysis of the mechanism shows that the cold air incursion at the top of the cooling tower could decrease the driving force and also form an extra flow resistance for the airflow through the heat exchanger. (4) Based on the working mechanism of the air-cooled heat exchanger and the crosswind effect on NDDCT, this study proposed a new method to increase the cooling performance of NDDCT under crosswind conditions by optimizing the water mass flow rate in the air-cooled heat exchangers. By optimising the water distribution, the water outlet temperature of each heat exchanger is more uniform and the adversely influence of the crosswind can be effectively relieved. The findings in this paper can lay an important foundation for future small cooling tower design and operation.

This study explored the experience of having a child educated away from home at boarding school for Aboriginal parents living in regional and remote communities in Western Australia (WA). In-depth interviews were conducted with 11 participants and thematic analysis found the following major themes emerged from the data: (1) Access, Standards and Quality, and the subthemes of Declining Local Schools, Opportunity, and Worldliness; (2) Parental Agency and the subthemes of Parent-School Connection, Parenting Style, Communication, and Milestones and Siblings and; (3) Cultural Heritage and the subtheme of Maintenance and Transmission. The findings are described and then discussed in terms of practice implications relevant to boarding schools in WA. Limitations of the current study are acknowledged and directions for future research are proposed.

This study explored the experiences of 32 male Aboriginal students from regional and remote towns and communities while they attended a metropolitan boarding school away from home and family in Perth, Western Australia. Using narrative interviews it specifically investigated how these Aboriginal students construct meaning around the transition experience to boarding school. Three major themes emerged from the data: (1) Decision Making and the subthemes of Choice-less Choice and Opportunity; (2) Organisational Climate and the subthemes of School Environment and Belonging, Culture Shock, Homesickness, Identity, Code Switching, Teachers, Academic Expectations, Residential Life, and Friendships and Peer Relations; and (3) Relational Change and the subthemes of Family Dynamics, Friendships at Home, and Cultural Connectedness. This study emphasises the importance of conceptualising and understanding social phenomena from the perspective of those who actually undertake the experience, and the findings are discussed in terms of policy and practice relevant to Australian boarding schools.

There is limited evidence regarding the best approaches to helping Indigenous Australians to stop smoking. The composite analysis of the only two smoking cessation randomised controlled trials (RCTs) investigating this suggests that one-on-one extra support delivered by and provided to Indigenous Australians in a primary health care setting appears to be more effective than usual care in encouraging smoking cessation. This paper describes the lessons learnt from one of these studies, the Be Our Ally Beat Smoking (BOABS) Study, and how to develop and implement an integrated smoking cessation program.

Objective The aim of this study was to identify the factors contributing to high-quality clinical supervision of the allied health workforce in rural and remote settings.Methods This quantitative study was part of a broader project that used a mixed-methods sequential explanatory design. Participants were 159 allied health professionals from two Australian states. Quantitative data were collected using an online customised survey and the Manchester Clinical Supervision Scale (MCSS-26). Data were analysed using regression analyses.Results Supervisee’s work setting and choice of supervisor were found to have a positive and significant influence on clinical supervision quality. Supervisee profession and time in work role were found to have a negative and significant influence on the quality of clinical supervision.Conclusions High-quality clinical supervision is essential to achieve quality and safety of health care, as well as to support the health workforce. Information on high-quality clinical supervision identified in this study can be applied to clinical supervision practices in rural and remote settings, and to professional support policies and training to enhance the quality of supervision.What is known about the topic? There is mounting evidence on the benefits of clinical supervision to health professionals, organisations and patients. Clinical supervision enhances recruitment and retention of the health workforce. However, there are still gaps regarding the factors that contribute to high-quality clinical supervision, especially for rural and remote health professionals.What does this paper add? This study, the first of its kind, recruited rural and remote health professionals from seven allied health disciplines across two Australian states. It investigated the factors that influence high-quality clinical supervision in this under-resourced group. This paper outlines specific factors that contribute to clinical supervision quality for rural and remote allied health professionals.What are the implications for practitioners? Effective and high-quality clinical supervision of the rural and remote allied health workforce can enhance recruitment and retention in those areas. Healthcare organisations can facilitate effective clinical supervision delivery by using the evidence gathered in this study in clinical supervision policy, training and practice.

Background: Aboriginal and Torres Strait Islander Australians experience a greater burden of disease compared to non-Indigenous Australians. Around one-fifth of the health disparity is caused by cardiovascular disease (CVD). Despite the importance of absolute cardiovascular risk assessment (CVRA) as a screening and early intervention tool, few studies have reported its use within the Australian Indigenous primary health care (PHC) sector. This study utilises data from a large-scale quality improvement program to examine variation in documented CVRA as a primary prevention strategy for individuals without prior CVD across four Australian jurisdictions. We also examine the proportion with elevated risk and follow-up actions recorded. Methods: We undertook cross-sectional analysis of 2,052 client records from 97 PHC centres to assess CVRA in Indigenous adults aged ≥20 years with no recorded chronic disease diagnosis (2012–2014). Multilevel regression was used to quantify the variation in CVRA attributable to health centre and client level factors. The main outcome measure was the proportion of eligible adults who had CVRA recorded. Secondary outcomes were the proportion of clients with elevated risk that had follow-up actions recorded. Results: Approximately 23% (n=478) of eligible clients had documented CVRA. Almost all assessments (99%) were conducted in the Northern Territory. Within this jurisdiction, there was wide variation between centres in the proportion of clients with documented CVRA (median 38%; range 0-86%). Regression analysis showed health centre factors accounted for 48% of the variation. Centres with integrated clinical decision support systems were more likely to document CVRA (OR 21.1;95%CI 5.4-82.4;p<0.001). Eleven percent (n=53) of clients were found with moderate/high CVD risk, of which almost one third were under 35 years (n=16). Documentation of follow-up varied with respect to the targeted risk factor. Fewer than 30% with abnormal blood lipid or glucose levels had follow-up management plans recorded. Conclusion: There was wide variation in CVRA between jurisdictions and between PHC centres. Learnings from successful interventions to educate and support centres in CVRA provision should be shared with stakeholders more widely. Where risk has been identified, further improvement in follow-up management is required to prevent CVD onset and reduce future burden in Australia’s Indigenous population.

The objective of this study is to estimate the direct costs and downstream savings of improved quality of diabetes services, compared to usual care, in the primary care setting in a high-risk remote Indigenous Islander population. The study looked at cost impact analysis over six years (2000-2005) comparing costs of quality improvement with actual and projected savings in avoidable diabetes-related hospitalisations. Costs of service provision were derived from district financial reports, costs of diabetes-related complications requiring hospitalisations were estimated from actual admission data and costed using published Diagnosis-Related Group costings in Australian dollars (year 2000). Net present value cost of the quality improvement intervention was estimated using a 5% discount rate. A district health service in remote northern Australia, with 9,600 mainly Indigenous residents, including 1,000 adults with known diabetes served by 21 primary care centres and two hospitals, was the study population and setting. The main outcome measures are the costs of a quality primary level diabetes service and hospitalisations among people with diabetes for infections and other acute complications, lower limb amputations, end-stage renal disease and cardiovascular disease. Over the six years, a net present value cost of $570,000 is estimated for the new service. This is equivalent to A$1,800 for each major event avoided. After four years of initiation, annual cost savings exceed annual program delivery costs. It is concluded that, in this remote Indigenous population with high prevalence of diabetes and associated complications, investment in quality improvement in primary diabetes care using a chronic disease model will achieve cost savings through prevention of expensive diabetes-related hospitalisations.

Objective: To examine the relationship between self-reported tobacco smoking and urinary cotinine concentrations in the setting of a remote Aboriginal community. Methods: In a remote Northern Territory (NT) Aboriginal community the relationship between self-reported tobacco smoking and urinary cotinine concentrations was examined as part of a cross-sectional survey of cardiovascular risk factors. Current tobacco smoking was assessed as part of a questionnaire. The concentration of cotinine and cotinine/creatinine ratio (CCR) in a spot urine sample were used as a biochemical marker of nicotine exposure. Results: A total of 237 people took part in the survey, although completed questionnaires and urine results were available for 184 people. Current tobacco smoking was reported by 161 (69 [95% CI 63 to 75]%) people, with higher rates among males (84/104, 81 [95% CI 72 to 88]%) than females (77/129, 60 [95% CI 51 to 68]%, p<0.001). There was good agreement of self report with current tobacco smoking using categories based on urinary cotinine (agreement 94%, k=0.84) and urinary CCR (agreement 94%, k=0.86). Quantitative agreement between cotinine measures and self-reported number of cigarettes per day was better for CCR than cotinine, but the correlation was relatively weak for both. Conclusions: Self-reported cigarette smoking is a valid qualitative measure in this environment. The relatively weak correlation between the biomarker and number of reported cigarettes smoked illustrates problems both with questionnaire and urinary markers of nicotine exposure. Implications: As a qualitative measure of tobacco smoking in this setting, self-report appears adequate but the validity of quantitative self-report is unclear.

To identify mechanisms for the successful implementation of support strategies for health-care practitioners in rural and remote contexts. This is an integrative review and thematic synthesis of the empirical literature that examines support interventions for health-care practitioners in rural and remote contexts. This review includes 43 papers that evaluated support strategies for the rural and remote health workforce. Interventions were predominantly training and education programmes with limited evaluations of supervision and mentoring interventions. The mechanisms associated with successful outcomes included: access to appropriate and adequate training, skills and knowledge for the support intervention; accessible and adequate resources; active involvement of stakeholders in programme design, implementation and evaluation; a needs analysis prior to the intervention; external support, organisation, facilitation and/or coordination of the programme; marketing of the programme; organisational commitment; appropriate mode of delivery; leadership; and regular feedback and evaluation of the programme. Through a synthesis of the literature, this research has identified a number of mechanisms that are associated with successful support interventions for health-care practitioners in rural and remote contexts. This research utilised a methodology developed for studying complex interventions in response to the perceived limitations of traditional systematic reviews. This synthesis of the evidence will provide decision-makers at all levels with a collection of mechanisms that can assist the development and implementation of support strategies for staff in rural and remote contexts.