Remote Australia Online

INTRODUCTION: Australian remote area nurses (RANs) are specialist advanced practice nurses. They work in unique, challenging and sometimes dangerous environments to provide a diverse range of healthcare services to remote and predominantly Aboriginal communities. There is an emerging skills gap in the remote nursing workforce as experienced and qualified RANs leave this demanding practice. There is a shortage of new nurses interested in working in these areas, and many of those who enter remote practice leave after a short time. Distance management was examined in order to gain a better understanding of its effects on the retention of RANs in the Australian states of Northern Territory (NT), Western Australia (WA) and South Australia (SA). Distance management in this context occurs when the health service's line management team is located geographically distant from the workplace they are managing. METHODS: The study used a mixed method design, with a combination of anonymous surveys and interviews conducted by telephone and face to face. Qualitative and quantitative data were collected. The data were thematically analysed and basic descriptive statistics were also used. All RANs who worked in government and other non-Aboriginal controlled remote health services in NT, SA and WA were included in the sample. Sixty-one RANs (anonymous survey, 55% response rate) and 26 ex-RANs (telephone interview) participated in the research. The ex-RANs were sampled using a snowball technique where interviewees recommended former colleagues for interview. Nine nursing executives with expertise in distance management of remote health services also contributed (face-to-face interview), and they are referred to as 'the experts'. RESULTS: Respondents expressed a dichotomy in their reactions to remote area nursing. On one hand, they expressed a strong sense of pleasure and satisfaction in the nature of their work; while, on the other, they expressed dissatisfaction with aspects of infrastructure, support and management practices. Positive aspects included autonomy of practice, working in a small team, cross-cultural practice, and the beauty and isolation of the setting. Negative aspects included poor orientation, high stress, inadequate resources, poor systems, unrealistic expectations from communities and managers leading to excessive workload, and perceived lack of support from management. The greatest negative issue raised was poor handling of leave replacement, where RANs on leave were not replaced with appropriately qualified and skilled nurses. Respondents noted a frequent change in managers, and reported that the lack of stability in management contributed to lack of support for both RANs and their managers. Lack of support from managers was frequently cited as a main cause for ex-RANs leaving their employment. Despite this, almost all respondents indicated a willingness to remain in the remote workforce if possible. Experts noted that where management was dysfunctional, RAN retention rates fell. They also acknowledged the need for good communication, interpersonal skills, availability of staff development, leave, relief staff, feedback, debriefing, professional support and working conditions. Experts believed managers should make use of available and emerging technology to communicate with RANs, and work to improve RANs' understanding of the role of the management team. CONCLUSIONS: Remote Australian Aboriginal communities are mainly served by RANs in a health system that is sometimes ill-equipped and at times poorly managed. The theme of a second-class health system being serviced by RANs who felt they were treated as second-class health practitioners appeared throughout the data. Poor distance management practices may contribute to the high turnover of staff in remote Australia. Retention of RANs may increase with better managerial practices, such as effective communication and leadership, staffing replacement and leave, prompt attention to infrastructure issues, and staff development and appraisal. These are the keys to ensuring that RANs feel supported and valued. Remote area nursing is a rewarding career and, with systemic support, RANs may stay longer in remote practice.

INTRODUCTION: Access to appropriate continuing medical education (CME) opportunities has been identified by many researchers as a key factor in retaining medical practitioners in rural and remote communities. There has, however, been very little research that has measured the actual effectiveness of CME programs on retention. The purpose of this article is to provide some evidence as to the efficacy of rurally relevant CME programs in retaining medical practitioners in rural and remote communities. METHODS: Evaluation data provided by 426 to 429 CME workshop attendees over a 3 year period has been aggregated to explore participants' perceptions as to whether access to CME has been effective in increasing their confidence in practising in rural and remote communities, reducing professional isolation and increasing commitment to remain in rural practice. RESULTS: Data from 429 respondents suggest that 94% agree or strongly agree that access to CME contributes to confidence in practising in rural and/or remote locations. Similarly, data suggest that 93% of respondents (n = 427) agree or strongly agree that access to CME alleviates professional isolation. When asked whether they were less likely to remain in rural practice without access to CME, 80% of respondents (n = 426) agreed or strongly agreed that they were less likely to remain without access. CONCLUSION: The provision of CME based on the expressed needs of rural and remote medical practitioners tends to be well received and highly valued by workshop respondents. We suggest that professional support through the provision of rurally relevant workshop-delivered CME is an effective strategy in retaining doctors in rural and remote communities.

Few studies have explored mental health treatment programs for Aboriginal Australian children under the age of 12 years old. Isolated locations, coupled with therapy modalities that are not developmentally and culturally suitable for children who have experienced adversities, exacerbate the typical challenges in providing health services needed for optimum child development. Therapeutic services offered in Aboriginal communities typically follow a traditional delivery of therapy, meeting no more than once a week, or less, as remoteness increases. The purpose of this pilot study was to determine the effectiveness of an intensive child-centered play therapy (iCCPT) program in a remote Aboriginal community with children who have experienced adversity. Pre- and postmeasures, utilizing Goodman’s (1997) Strengths and Difficulties Questionnaire, were collected from parents and teachers. Semistructured interviews were conducted with parents who participated in the program after the intervention ended. Nine child participants attended an average of 15 sessions in a 10-day format. Total difficulties, as reported by both parents and teachers, diminished after the program. In particular, emotional problems, as rated by teachers, decreased over time. If replicated in a randomized control trial, these findings would suggest that an iCCPT program may be feasible and effective in remote Australian Aboriginal communities. (PsycINFO Database Record (c) 2018 APA, all rights reserved)

This article outlines an innovative narrative therapy project in the remote Aboriginal community of Kalumburu, in the Kimberley region of Western Australia. The project was a collaboration between the Tramalla Strong Women's group from Kalumburu community, and a narrative and community practitioner. The project incorporated digital storytelling in combination with narrative therapy practices to document and reclaim stories of survival and resilience to enable people to speak of future hopes and dreams. Narrative therapy practices such as re-authoring, rememembering, outsider witness process and definitional ceremonies provided the framework to unearth these stories. This article explores the ethical position underpinning the collaborative partnerships and how narrative therapy practices and digital storytelling practices were adapted in a rural and remote context. The project also outlines an experiment with an online outsider witnesses practice.

Introduction: This article describes factors predicting James Cook University (JCU) medical graduates undertaking at least 1 year of remote practice. The cross-sectional design involved point-in-time (2015) analysis of the JCU medical school's ongoing longitudinal graduate tracking database. Participants were the first seven cohorts of graduates from the JCU medical school who had completed at least their postgraduate year (PGY) 4 in Australia (n=529); that is, PGY 4 to PGY 10 graduates. Methods: Multiple logistic regression and Classification and Regression Tree (CART) analysis of medical graduate application data (age, gender, hometown, interview score, ethnicity), undergraduate data (scholarships awarded, clinical school location) and postgraduation data (internship location, specialty training) was performed. Analysis identified independent predictors of having practised for at least 1 year in a 'remote' Australian town (Australian Standard Geographic Classification Remoteness Area 4-5). Results: Forty-seven (9%) of JCU Bachelor of Medicine and Bachelor of Surgery graduates in the first seven cohorts had practised for at least 1 year in a remote location between PGY 4 and 10. Practice in a 'remote' town was predicted by undertaking rural generalist training (p<0.001; prevalence odds ratio (POR)=17.0), being awarded an 'above average' interview score at medical school selection (p=0.006; POR=5.1), attending the Darwin clinical school in years 5-6 (p=0.005; POR=4.7), being female (p=0.016, POR=3.6) and undertaking an outer-regional or remotely based internship (p=0.006; POR=3.5). CART analysis identified Indigenous graduates as another key subgroup of remote practice graduates. Conclusions: This study provides the first Australian evidence that likelihood of remote medical practice is enhanced by investment in a 'remote pipeline' - medical education via clinical schools and internships in rural/remote locations, with a later option of a rural generalist pathway. The proportion of medical graduates working in remote practice may also be increased by preferentially selecting Indigenous Australian applicants and applicants who score highly for communication, teamwork, self-reliance and motivation for rural and remote practice

Since 1990, the School of Education at James Cook University has produced and delivered a successful offcampus Bachelor of Education for Aboriginal and Torres Strait Islander people in their home communities through the Remote Area Teacher Education Program (RATEP):A community-based teacher education program for Indigenous peoples. This paper examines five key areas. One is the intersystemic management structure that has majority representation from Indigenous communities and peak education bodies as well as representation from the other three stakeholders: Education Queensland, the School of Education at James Cook University and the Tropical North Queensland Institute of Technical and Further Education (TAFE). A second area is RATEP’s innovative use of information and communication technologies in teaching and learning. A third theme is its dynamic evolution from (a) two dedicated RATEP sites in the Torres Strait to 12 sites throughout Queensland; (b) geographically remote sites to a combination of remote, rural, and urban sites; (c) a principle where students gather at a dedicated site with its own teachercoordinator to clusters where a number of students are living in different locations and the coordinator travels between these; (d) movement of sites from location to location depending on need and demand; and (e) a fixed program to a highly flexible one that allows multiple entry and exit points, including honours. A fourth area is the critical insights generated from research into the program by Indigenous and non-Indigenous researchers. The final theme is the retention of graduates from RATEP within the classroom and their promotion into the administrative and advisory teaching sectors.

This is an observational study in remote Indigenous communities, examining relations between primary and hospital care for diabetes management. The level of hospitalisation for diabetes patients was minimised when the frequency of primary care visits was around 7.9 times per person per year. Females, those aged over 40 years and those with ischaemic heart disease and renal diseases required more frequent primary care visits. The relations between primary and hospital care seem U-shaped functions with optimal levels of primary care, after adjusting for confounders. A lack of balance between primary, secondary and tertiary care in management of diabetes has pervasive cost consequences.

Objectives The aim of this study was to estimate the costs of providing primary care and quantify the cost impact of high staff turnover in Northern Territory (NT) remote communities.Methods This cost impact assessment used administrative data from NT Department of Health datasets, including the government accounting system and personnel information and payroll systems between 2004 and 2015, and the primary care information system from 2007 to 2015. Data related to 54 government-managed clinics providing primary care for approximately 27 200 Aboriginal and non-Aboriginal people. Main outcome measures were average costs per consultation and per capita, cost differentials by clinic, year and levels of staff turnover. Linear regression and dominance analysis were used to assess the effect of staff turnover on primary care costs, after adjusting for remoteness and weighting analysis by service population. Both current and constant prices were used.Results On average, in constant prices, there was a nearly 10% annual increase in remote clinic expenditure between 2004 and 2015 and an almost 15% annual increase in consultation numbers since 2007. In real terms, the average costs per consultation decreased markedly from A$273 in 2007 to A$197 in 2015, a figure still well above the Medicare bulk-billing rate. The cost differentials between clinics were proportional to staff turnover and remoteness (both P < 0.001). A 10% higher annual turnover rate pertains to an A$6.12 increase in costs per consultation.Conclusions High staff turnover exacerbates the already high costs of providing primary care in remote areas, costing approximately A$50 extra per consultation. This equates to an extra A$400 000 per clinic per year on average, or A$21 million annually for the NT government. Over time, sustained investments in developing a more stable primary care workforce should not only improve primary care in remote areas, but also reduce the costs of excessive turnover and overall service delivery costs.What is known about the topic? Population size and geographical remoteness are important cost drivers in remote clinics, whereas elsewhere in Australia the high use of short-term staff to fill positions has been identified as a major contributor to higher nurse turnover costs and to overall health service costs. Nursing staff expenditure accounts for a large proportion (46%) of total expenditure in NT remote health services, whereas expenditure on Aboriginal Health Practitioners (AHPs) comprises only 6%. Annual nurse turnover rates in remote NT clinics average approximately 150%, whereas levels of 40% in other contexts are considered high.What does this paper add? Annual expenditure for NT remote clinics has increased, on average, by 10% per annum between 2004 and 2015, but small declines in real expenditure have been observed from a maximum in 2012. Expenditure on nursing staff comprises 40% of overall expenditure in remote clinics, whereas expenditure on AHPs comprises less than 5%. The cost impact of every 10% increase in remote nurse and AHP annual turnover has been quantified as an extra A$6.12 per primary care consultation, which equates, on average, to an extra A$400 000 per remote clinic, and an extra A$21 million overall for the NT Department of Health each year. The average real expenditure per primary care consultation has decreased from A$273 in 2007 to A$197 in 2015, representing a statistically significant linear trend reduction of A$7.71 per consultation annually.What are the implications for practitioners (and other decision-makers)? Adjusting policy settings away from the high use of short-term staff to investment in appropriate training ‘pipelines’ for the remote primary care workforce may, in the medium and longer term, result in reduced turnover of resident staff and associated cost savings. Targeted recruitment and retention strategies that ensure individual primary care workers are an optimal fit with the remote communities in which they work, together with improved professional and personal support for staff residing in remote communities, may also help reduce turnover, improve workforce stability and lead to stronger therapeutic relationships and better health outcomes.

Poverty alleviation in remote indigenous Australia

An accurate picture of mortality informs a society as to its social progress within each community, as mortality is a key indicator of effective public health policies and programs. Data on the causes of sudden infant and childhood mortality also reflect a broader set of social, economic, and political issues (1). As an example, sudden infant and child mortality is a key indicator of an important public health issue, given that some of the causes of infant and childhood mortality are potentially preventable. Effective prevention strategies and relevant health policy require a comprehensive and accurate profile of mortality, which, in turn, requires a better understanding of the epidemiology and mechanisms involved. This profile should include not only the patterns and trends of mortality over time, but also measurements of the indicators that have the potential to contribute to premature mortality among infants and children. These factors should include perinatal, maternal, and infant indicators; the specific causes of death; and the role of the geographical location as an indicator of excess sudden infant and child mortality (2). This chapter will outline the Australian perspective associated with sudden infant death syndrome (SIDS) and sudden infant and early childhood death. It will comment on the patterns and trends of sudden infant and early childhood mortality reported for all Australians and then focus on the First Peoples of Australia, the Aboriginal and Torres Strait Islander population, within the limitations of the availability of an accurate ascertainment of the Indigenous population. With respect to Aboriginal and Torres Strait Islander peoples, in this chapter the authors follow the Australian Institute of Health and Welfare (AIHW) principal that “[t]o acknowledge the separate Indigenous peoples of Australia, the term ‘Aboriginal and Torres Strait Islander people’ is preferred ... [H]owever, the term ‘Indigenous’ is used interchangeably when referring to Indigenous status or when assists readability” (3). The chapter will conclude with a case study that describes a health promotion project that was introduced in Western Australia (WA) in 2005: Reducing the Risks of SIDS in Aboriginal Communities (RROSIAC). This project addresses the high rates of sudden unexpected death in infants (SUDI) in WA Aboriginal and Torres Strait Islander people in rural and remote communities, which have continued despite decreasing rates among non-Indigenous communities following the Red Nose SUDI risk reduction campaigns. It also provides an example of the use of linked population data to more accurately ascertain the impact of public health interventions among minority populations.

On Australia day in 2016, artist Elizabeth Close was at an Adelaide shopping centre speaking to her young daughter in Pitjantjatjara, when a woman approached and said to her: 'It's Australia Day. We speak English.' Close was shocked, and replied, 'Pardon?' The woman slowed down her speech and repeated herself. Close retorted that as she was speaking a native Australian language, she 'could not get more Australian'. The woman walked off without another word.

Background Medical workforce problems still dominate headlines despite considerable investment in education, training and other initiatives. There is little consensus about what Australia’s general practice workforce should look like or what training outcomes should be reported. Objective The aim of this paper was to explore a number of issues relevant to outcomes of workforce programs and offer suggestions for identifying and overcoming these issues. Discussion Social accountability literature highlights the importance of outcomes focusing on community needs. We suggest that evaluations should ‘count what counts’ and be careful what is counted. Numbers are only part of the story; not everything that counts is counted, and synergies and cooperation are key. Australia has many general practice workforce programs that are generally heading in the right direction. We believe that closer attention to appropriate outcome measures is important if we are to maximise return on investment and get the best outcomes for the community.

Gurriny Yealamucka Health Service Aboriginal Corporation (GYHSAC) is an Indigenous community-controlled health organisation providing comprehensive primary care to the people of Yarrabah in far north Queensland, Australia. GYHSAC conducts an annual Young Person’s Health Check (YPC) for people aged 15–25 years based on the Medical Benefits Schedule Item 715. However, the YPC is constantly evolving to meet the needs of the community, and in 2016, in response to concerns about psychological risk among Indigenous youth, GYHSAC teamed up with James Cook University to trial an adapted PHQ-9 depression screening tool (aPHQ-9) as part of the YPC. This study describes the 2016 YPC event, reports the prevalence of depressive symptoms, examines local issues related to the use of the screening tool and proposes recommendations for future health screening. Experienced health professionals conducted the aPHQ-9 assessment in a private area of the clinic. One-in-five young people were found to have moderate–severe symptoms or self-harm ideation in the previous 2 weeks; they were referred to the mental health service. The aPHQ-9 screening process was found to be straightforward and well accepted by staff and youth. Importantly, it provided valuable ‘space’ to facilitate communication on sensitive issues and was a conduit for speedy referral and follow up by trained staff. Based on our experience, we recommend dedicated depression screening in future routine community health checks for young people and adults.

Background Australia continues to develop as a multicultural nation, with a population that is ageing and developing complex health needs. The world around us is changing, and the pace of change is increasing. These contextual changes pose challenges for general practice training. Objective This paper explores the potential impact of these changes on the general practice workforce. Discussion General practitioners (GPs) will continue to have a central role in coordinating continuous, comprehensive care but are more likely to act as managers of multi-source, continuous monitoring data that facilitate personalised medical care. GPs will need to adapt rapidly to change, seizing opportunities offered by disruptive technology in a globalised world affected by climate change. The nature and impact of change is difficult to predict, and more research is needed to explore how change will affect healthcare and healthcare professionals. Ideally, training for general practice should include preparation for managing continuous change.

The report will provide an overview of the literature and outcomes of a recent study by the Queensland University of Technology examining the requirements for a state-wide approach to trauma-aware schooling in Queensland. It is hoped that the content of this report will have state, national, and international implications, providing impetus for a new vision for schooling systems across Australia and overseas.

The way Australian federal governments have approached Aboriginal and Torres Strait Islander employment and welfare policy over the last two decades has been a paradigmatic example of what not to do in policymaking. In the absence of effective engagement or consultation, a series of decisions under Coalition and Australian Labor Party governments have had a range of negative consequences for Aboriginal and Torres Strait Islander peoples. These changes – centred around the closure of the Community Development Employment Projects (CDEP) scheme and implementation of the Community Development Programme (CDP) – have resulted in increased unemployment, inadequate support for job creation, a dramatic over-application of income penalties to social security recipients and reduced capacity in many community organisations. This article argues that these outcomes constitute policy failure, especially given that genuine engagement with Aboriginal and Torres Strait Islander people could have prevented many of these consequences. It then turns to an exploration of three ways in which Aboriginal and Torres Strait Islander people are responding to such policy failure: through promotion of new narratives, new alliances, and new institutions. The study concludes that while we should avoid “specious hope”, there is room for optimism in a renewed push for Aboriginal and Torres Strait Islander sovereignty.

Problem: Inhabitants of Torres Strait Islands have the highest prevalence of diabetes in Australia and many preventable complications. In 1999, a one year randomised cluster trial showed improved diabetes care processes and reduced admissions to hospital when local indigenous health workers used registers, recall and reminder systems, and basic diabetes care plans, supported by a specialist outreach service. This study looked at whether those improvements were sustained two years after the end of the trial. Design: Three year follow up clinical audit of 21 primary healthcare centres, and review of admissions to hospital in the previous 12 months. Background and Setting: Remote indigenous communities in far north east Australia, population about 9600, including 921 people with diabetes. Key Measures for Improvement: Number of people on registers, care processes (regular measures of weight, blood pressure, haemoglobin A1c, urinary protein concentration, and concentrations of serum lipids and creatinine), appropriate clinical interventions (drug treatment and vaccinations), and intermediate patient outcome measures (weight, blood pressure, and glycaemic control). Admissions to hospital. Strategies for Change: Audit and feedback to clinicians and managers; provision of clinical guidelines and a clear management structure; workshops and training. Effects of Change: The number of people on registers increased from 555 in 1999 to 921 in 2002. Most care processes and clinical interventions improved. The proportion of people with good glycaemic control (haemoglobin A1c 7%) increased from 18% to 25% in line with increased use of insulin (from 7% to 16%). The proportion of those with well controlled hypertension (< 140/90) increased from 40% to 64%. The proportion admitted to hospital with a diabetes related condition fell from 25% to 20%. Mean weight increased from 87 kg to 91 kg. Lessons Learnt: In remote settings, appropriate management structures and clinical support for people with diabetes can lead to improvements in care processes, control of blood pressure, and preventable complications that result in admission to hospital. Control of weight and glycaemia are more difficult and requires more active community engagement. Priorities now include increasing the availability and affordability of good food, achieving weight loss, and increasing appropriate use of hypoglycaemic agents, including insulin.

On 28 July 2016, a new adult guardianship scheme commenced in the Northern Territory, adopting the tribunal model common to the rest of the country and establishing an independent guardian of last resort. However, the overall impact of the changes has taken the Territory further from compliance with international norms, deprived vulnerable persons of the right to representation and weakened the structural independence of the responsible tribunal. Aboriginal Territorians, disproportionately represented in the guardianship system, have been especially disadvantaged by the ‘streamlined’ process and removal of access to legal representation. Urgent reforms are needed to bring the Territory closer into line with international law and domestic best practice.

Integration of public health and primary healthcare (PHC) is a hallmark of comprehensive PHC to reduce inequitable rates of preventable diseases in communities at risk. In the context of a syphilis outbreak among Indigenous people in Northern Australia, the association between PHC clinic factors and syphilis testing performance (STP) was examined to produce empirical insights for service managers. Data from the Audit and Best Practice for Chronic Disease National Program (2012–14) were analysed to examine associations between clinic factors and STP (proportion of clients ≥15 years who were tested for or offered a test for syphilis in the prior 24 months). Univariate analyses were conducted for 77 clinics and a subset of 67 remote clinics. Multivariate linear regression models were used to determine independent predictors of STP. Syphilis testing performance across PHC clinics ranged from 0 to 93.8% (median 46.5%). In univariate analysis, Delivery system design, which refers to clinic infrastructure, staffing profile and allocation of roles and responsibilities, was significantly associated with higher STP in all clinics (P = 0.004) and in the subset of remote clinics (P = 0.008). Syphilis testing performance was higher in the Northern Territory compared to other states, in remote clinics and clinics serving smaller populations. In multivariate analysis, Delivery system design and jurisdiction remained associated with STP. To better realise the potential of comprehensive PHC, service managers should focus on PHC delivery system design to enhance the current syphilis outbreak response.

The Australian Nurse-Family-Partnership Program, an adaption of the Olds’ Nurse-Family-Partnership (NFP), commenced in Alice Springs in 2009 (Central Australia FPP), aiming to improve the health and social outcomes of Aboriginal mothers and infants. This study explores the feasibility of NFP implementation in a remote Australian Aboriginal community. Feasibility was defined by programme uptake by eligible women, retention in the programme, actual vs. scheduled visits and extent of programme content delivery. Programme uptake was established from pregnancy data in the patient Clinical Information System and programme referrals to December 31, 2015. Rates of withdrawal, retention and content delivery were derived from FPP data and compared with published NFP data. Modified Poisson regression was used to identify client characteristics associated with retention beyond the child’s first birthday. There were 469 valid referrals (43% of eligible pregnancies) and 299 women with at least one completed home visit by December 31, 2015. Of these, 41% completed the programme to the child’s second birthday and 53% beyond the child’s first birthday. Dominant reasons for leaving were “moved out of service area” (35%) and “declined further participation” (35%). There was a statistically significant positive association for programme retention with later gestational age at referral (RR = 1.27, p value = 0.03). A high proportion (75%) of scheduled visits was achieved and high delivery of programme content (80%). Central Australia FPP is the first implementation of the NFP model in a remote Aboriginal community. This study found that it can be implemented successfully in this setting. Outcome evaluation is needed to test achievement of hypothesised benefits.

Background: Diabetic foot disease (DFD) is one of the leading reasons why a person with diabetes is hospitalised. These complications are the result of significant patho-physiological changes from diabetes that includes peripheral neuropathy (foot numbness), peripheral arterial disease (poor circulation), and foot ulceration (foot sores) which are collectively known as diabetic foot disease. In some instances, DFD leads to diabetes-related lower extremity amputations (DRLEA) and death. Whilst clinical risk factors for DFD and DRLEA have been well researched, there is limited knowledge about non-clinical risk factors. Non-clinical risk factors in the form of wider social determinants of health and their effects on the distribution of DFD and DRLEA have not been extensively researched. From the perspective of Social Determinants of Health (SDoH), determinants such as socio-economic status, racial disparities and geographical remoteness are key factors in the disease process and mortality. Aim: The objective of this research was to investigate inequalities in DFD and DRLEA within a representative population of people hospitalised with DFD. The primary aim was to investigate the likelihood of acquiring a DRLEA based on socio-economic status, Aboriginal and Torres Strait Islander status and geographical remoteness. The secondary aim is to investigate the pattern of DFD hospitalisation and DRLEA by age, sex, socio-economic status, Aboriginal and Torres Strait Islander status and geographical remoteness. Method: This observational study obtained hospitalisation data for individuals who presented to a tertiary hospital and were diagnosed with a DFD-related complication in Queensland between 2005 and 2011. This study also captured individuals who were hospitalised and subsequently had a DRLEA procedure. The participant’s socio-demographic data included age, sex, Index of Relative Socio-economic Disadvantage score to assess area-level socio-economic status (SES), Access/Remoteness Index of Australia to measure geographical of remoteness (GR), and Aboriginal and Torres Strait Isl ander status. Univariate and bivariate statistics and logistic regression were undertaken to assess associations between DFD, DRLEA by age, sex, SES, GR and Aboriginal and Torres Strait Islander status. Results Between 2005 and 2011, 19,790 people in Queensland (65.9% male) were hospitalised for DFD. Compared with patients from socio-economically advantaged areas, those from more disadvantaged areas tended to be younger when admitted, were more likely to live in outer regional, remote, and very remote areas, and be of Aboriginal and Torres Strait Islander origin. Of those admitted for DFD, 22.4% (n=4,442) subsequently underwent a DRLEA. After simultaneously adjusting for all of the social variables, the odds of amputation were significantly higher for persons of Aboriginal and Torres Strait Islander status (OR 1.63, 95%CI 1.23-2.16) and significantly lower for those living in very remote areas (OR 0.70, 95%CI 0.53-0.94). There was no significant association between area-level socio-economic disadvantage and the odds of experiencing an amputation. Discussion: This study is unique as it examines the association between SES, GR and Aboriginal and Torres Strait Islander status independently and simultaneously in regards to DFD and DRLEA. Furthermore, it is the first time a study has investigated the pattern of DFD hospitalisation and subsequent DRLEA by age, sex, and SES, GR and Aboriginal and Torres Strait Islander status. This level of analysis has demonstrated gradients that have been reported in large population studies investigating other clinical outcomes and mortality. This study design has redressed certain selection biases found in other studies by acquiring a hospitalisation data set over a large population for seven years. The findings of this study demonstrate that, within the wider population, DFD and DRLEA are distributed unevenly across the SES spectrum, GR and Aboriginal and Torres Strait Islander status. Further research is required to understand what individual factors contributed to these findings. However, this study has demonstrated the need to plan and deliver targeted services to reduce hospitalisation for DFD and subsequent incidence of DRLEA.

Ischaemic heart disease (IHD) remains the leading cause of morbidity and mortality for both Aboriginal and non-Aboriginal Australians. Patterns of primary and specialist care in patients leading up to the first hospitalisation for IHD potentially impact on prevention and subsequent outcomes. We investigated the differences in general practice (GP), specialist and emergency department (ED) consultations, and associated resource use in Aboriginal and non-Aboriginal people in the two years preceding hospitalisation for IHD.

Economic futures on Aboriginal land in remote and very remote Australia: hybrid economies and joint ventures

Thank you very much to Race Mathews and Jacki Yowell for organizing this seminar and to Noni Sharp for commentating. It is always nice to be back in Melbourne to intellectually engage, for this is the city where I started my academic career in Australia in the economics department at the University of Melbourne nearly 30 years ago. It is also my third lecture in Melbourne this year: in April I presented a lecture on Brokering Aboriginal Art at the Museum of Melbourne and in June I gave a keynote address on Indigenous Issues to the Good Shepherd Microfinance Conference. Today I want to discuss the Indigenous hybrid economy. When this lecture was first mooted in April this year, I did not realize how timely and topical it would be, but the Howard Government has recently announced proposals for radical amendments to the Aboriginal Land Rights Act, and my unplanned consultancy for Oxfam Australia has resulted in one of the few research reports that offer vigorous dissent to these proposals. Debates in Indigenous affairs at the moment are becoming somewhat bifurcated and polarized. Last night, Noel Pearson from the Cape York Institute presented a lecture on development and welfare sponsored by the Centre for Independent Studies and delivered at the Sydney Stock Exchange; tonight I am addressing the Australian Fabian Society at the New Internationalist Bookshop on alternative Indigenous hybrid or diverse or community economies. The symbolism of this in terms of ideas and influence in Australian society today cannot be overstated. The ideas that I want to share with you tonight are not new, at least not for me: I want to discuss a form of economy that I term the hybrid economy that includes free market and customary and state components. I have been aware of this form of economy since 1979, when I left Melbourne to live and undertake research for a doctorate in anthropology at a remote outstation in Arnhem Land. There, the non-market or subsistence sector based on harvesting of wildlife was the dominant component of the economy. This late 20th century economy was not ‘traditional’, pristine, or precontact, even though colonization had come relatively late to Arnhem Land. This economy is contemporary and distinctly Indigenous. This economy is not single sector, it also has market and state sectors, and it does not exist in isolation (see page 2). While this hybrid economy has its own values, especially in the customary sector, it is also based on a series of conjunctions or articulations between all sectors. Diagrammatically, I have represented this economy as three overlapping circles, the market, the state and the customary, with four segments of articulation or overlap.

Objectives: To describe baseline growth and prevalence of anaemia in Aboriginal and Torres Strait Islander infants and young children enrolled in a nutrition promotion and anaemia prevention program in remote northern Australia. Design: Retrospective review of most recent growth parameters and haemoglobin records during the 3 months prior to and 1 month after recruitment into a prospective study conducted between 25 May 2010 and 6 May 2012. Setting: Primary health care clinics in six remote Aboriginal communities (east Kimberley, Western Australia (n = 1); Northern Territory (n = 4); Cape York, Queensland (n = 1)). Participants: Two hundred and sixty-two of the estimated 311 (84%) Aboriginal and Torres Strait Islander infants and young children aged 6–24 months residing in participating communities. Main outcome measures: Prevalence of anaemia, stunting, underweight and overweight at recruitment. Results: At recruitment, 42% of participants were anaemic, 18% stunted, 5% underweight and 5% overweight. Anaemia prevalence was higher than estimates (26–27%) in routine surveillance programs in remote communities and substantially higher than estimates (1.8–4.9%) in the general Australian population. One‐quarter of participants were anaemic prior to 6 months of age. Conclusions: The unexpectedly high prevalence of anaemia and stunting in these communities highlight the need for continued preventive health programs focused on ensuring adequate nutrition amongst infants, young children and their mothers. The early onset of anaemia and stunting suggests a comprehensive anaemia prevention approach is needed, including greater emphasis on maternal and pre‐pregnancy health and nutrition to increase infants’ iron stores at birth and sustain these to 6 months of age.