Remote Australia Online

This Literature Review was undertaken to inform and support the Independent Review of Regional, Rural and Remote Education (IRRRRE) announced by the Australian Government in March 2017, and principally the development of a Discussion Paper to facilitate a call for submissions and a national program of consultations. As such, the literature review is more of a working document than a piece of polished writing. For example, there is brief commentary from time to time which functions as an aide-memoire to the writer of the Discussion Paper. The IRRRRE was tasked with considering the key issues, challenges and barriers that impact on the learning outcomes of regional, rural and remote students and provide recommendations on innovative and fresh approaches to support improved access and achievement of these students in school and their transition to further study, training and employment.

Schools in rural South Australia are remote from opportunities for students and teachers to engage in music learning and professional development. This aim of this research project was to investigate the degree to which partnerships between rural schools and non-government organisations (NGOs) can be effective and meet this need. Anderson and White (2011) note that partnerships in education, both in Australia and elsewhere, continue to be a prominent policy feature, as a preferred way of working to deal with key challenges for schools. This project employed a participant-observation methodology that incorporated methods of survey and invitational semi-structured interviews. It explored the ways in which schools benefited from partnering with a non-for-profit organisation in music education. Project results indicate that the quality of partnerships between an NGO (Musica Viva) and rural schools (government and nongovernment) have a positive impact on: student and teacher learning of music; the advancement of teachers’ music pedagogy and; student, teacher and community wellbeing. Importantly, this positive impact occurred in rural and remote schools with significant numbers of vulnerable, disadvantaged and disengaged students. Conclusions may be used to inform the development and strengthening of school-NGO partnerships to improve the quality of music education in rural schools. The project also offers itself as an example of how future investigations of school-NGO partnerships more generally might be pursued.

Objective To determine the impact of an integrated diabetes service involving specialist outreach and primary health care teams on risk factors for micro- and macrovascular diabetes complications in three remote Indigenous Australian communities over a 12-month period. Design Quantitative, retrospective evaluation. Setting Primary health care clinics in remote Indigenous communities in Australia. Participants One-hundred-and-twenty-four adults (including 123 Indigenous Australians; 76.6% female) with diabetes living in remote communities. Main outcome measures Glycosylated haemoglobin, lipid profile, estimated glomerular filtration rate, urinary albumin : creatinine ratio and blood pressure. Results Diabetes prevalence in the three communities was high, at 32.8%. A total of 124 patients reviewed by the outreach service had a median consultation rate of 1.0 by an endocrinologist and 0.9 by a diabetes nurse educator over the 12-month period. Diabetes care plans were made in collaboration with local primary health care services, which also provided patients with diabetes care between outreach team visits. A significant reduction was seen in median (interquartile range) glycosylated haemoglobin from baseline to 12 months. Median (interquartile range) total cholesterol was also reduced. The number of patients prescribed glucagon-like peptide-1 analogues and dipeptidyl peptidase-4 inhibitors increased over the 12 months and an increase in the number of patients prescribed insulin trended towards statistical significance. Conclusion A collaborative health care approach to deliver diabetes care to remote Indigenous Australian communities was associated with an improvement in glycosylated haemoglobin and total cholesterol, both important risk factors, respectively, for micro- and macrovascular diabetes complications.

Morbidities and deaths from noncommunicable chronic diseases are greatly increased in remote Australian Aboriginal communities, but little is known of the underlying community-based health profiles. We describe chronic-disease profiles and their risk factors in 3 remote communities in the Northern Territory. Consenting adults (18+ years of age) in 3 communities participated in a brief history and examination between 2000 and mid-2003 as part of a systematic program to improve chronic-disease awareness and management. Participation was 67%, 128%, and 62% in communities A, B, and C, respectively with a total of 1070 people examined. Current smokers included 41% of females and 72% of males. Most men were current drinkers, but most women were not. Parameters of body weight differed markedly by community, with mean body mass index (BMI) varying from 21.4 to 27.9 kg/m2. Rates of chronic diseases were excessive but differed markedly; an almost threefold difference in the likelihood of any morbidity existed between communities A and C. Rates increased with age, but the greatest numbers of people with morbidities were in the middle-aged group. Most people had multiple morbidities with tremendous overlap. Hypertension and kidney disease appear to be early manifestations of the integrated chronic-disease syndrome, while diabetes is a late manifestation or complication. Substantial numbers of new cases of disease were identified by testing, and blood pressure improved in treated people with hypertension. Wide variations occur in body habitus, risk factors, and chronic-disease rates among communities, but an overwhelming need for effective smoking interventions exists in all. Systematic screening is useful in identifying high-risk individuals, most at early treatable stages there. Findings are very important for estimating current treatment needs, future burdens of disease, and for needs-based health services planning. Resources required will vary according to the burden of disease.

A chronic disease outreach program for Aboriginal communities. Background Our objective is to describe a program to improve awareness and management of hypertension, renal disease, and diabetes in 3 remote Australian Aboriginal communities. Methods The program espouses that regular integrated checks for chronic disease and their risk factors are essential elements of regular adult health care. Programs should be run by local health workers, following algorithms for testing and treatment, with backup, usually from a distance, from nurse coordinators. Constant evaluation is essential to develop community health profiles and adapt program structure. Results Participation ranged from 65% to 100% of adults. Forty-one percent of women and 72% of men were current smokers. Body weight varied markedly by community. Although excessive in all, rates of chronic diseases also differed markedly among communities. Rates increased with age, but the greatest numbers of people with morbidities were middle age and young adults. Multiple morbidities were common by middle age. Hypertension and renal disease were early features, whereas diabetes was a variable and later manifestation of this integrated chronic disease syndrome. Adherence to testing and treatment protocols improved markedly over time. Substantial numbers of new diagnoses were made. Blood pressure improved in people in whom antihypertensive agents were started or increased. Components of a systematic activity plan became more clearly defined with time. Treatment of people in the community with the greatest disease burden posed a large additional workload. Lack of health workers and absenteeism were major impediments to productivity. Conclusion We cannot generalize about body habitus, and chronic disease rates among Aboriginal adults. Pilot data are needed to plan resources based on the chronic disease burden in each community. Systematic screening is useful in identifying high-risk individuals, most at an early treatable stage. Community-based health profiles provide critical information for the development of rational health policy and needs-based health services.

Reduction in natural death and renal failure from a systematic screening and treatment program in an Australian Aboriginal community. Background Australian Aborigines in remote areas are experiencing an epidemic of renal and cardiovascular disease. In November 1995, we introduced a renal and cardiovascular treatment program into the Tiwi community, which has a three- to fivefold increase in death rates and a recent annual incidence of treated end-stage renal disease (ESRD) of 2760 per million. Our previous study described an estimated 50% reduction in renal failure and all-cause natural deaths in the treatment group through December 31, 1998. We now describe a reduction in these events through mid 2000. Methods People eligible for treatment were those with confirmed hypertension, diabetics with microalbuminuria or overt albuminuria, and people with overt albuminuria, regardless of blood pressure and diabetes. Treatment centered around the use of perindopril (Coversyl, Servier), with additional agents as needed to reach defined blood pressure goals, attempts at control of glucose and lipid levels, and health education. Two hundred and sixty-seven people, or 30% of the adult population, have been enrolled, with mean follow up of 3.39 years. Rates of terminal endpoints were compared on an intention-to-treat basis with those of 327 historical controls matched for baseline disease severity, who were followed for a mean of 3.18 years in the pre-treatment program era, against a background of no treatment or inconsistent changing treatment. Results Terminal events occurred in 38 controls and 23 people in the treatment group. The estimated rate of natural deaths in the treatment group was 50% that of the controls, (P = 0.012); the rate of renal deaths was 47% (P = 0.038) and the rate of non-renal deaths was 54% that of controls (P = 0.085). Survival benefit in the treatment group was observed at all levels of overt albuminuria, in non-diabetics and diabetics, in normotensive as well as hypertensive people, and in people who had been taking angiotensin converting enzyme-inhibitors (ACEi) in the pre-program era, as well as those who had not. Benefit was absent among the low death rates of people without overt albuminuria, and questionable among people with glomerular filtration rates (GFRs) <60 mL/min. The number of people needed to treat (NNT) to avoid one terminal event of natural causes was calculated at only 11.6. Conclusions Falling rates of deaths and renal failure in the whole community support marked benefit of the program. Millions of dollars have been saved, based on avoidance of dialysis alone, but the reduction in premature death is the greater benefit. Chronic disease programs like this are enormously effective, and should be introduced into to all high-risk communities as a matter of urgency.

I would like first to acknowledge the Aranda people as the traditional owners of the land on which this conference is being held. Thank you for the opportunity to address the 8th National Rural Health Alliance Conference. This biennial conference has become a landmark on the rural health calendar because of its importance in bringing together such a diverse group of people united by their common concern to improve the health and well-being of rural and remote Australians and its role in informing the policy agenda of governments and rural health stakeholder organisations. I feel privileged to be invited to address this auspicious gathering of friends and colleagues. My talk this evening will be brief as I do not want to limit the time available for you to network with colleagues and friends who have gathered together here from all parts of Australia. I shall take my cue on how long to talk not from the chair but the expressions of delegates sitting furthest away from me. As our church Minister says to the congregation “You have to be early the get a good seat at the back”!! This evening I would like to focus on two issues. First I want to take the opportunity to celebrate some of the achievements that have resulted since the first National Rural Health Alliance Conference was held in Toowoomba in 1991. Secondly, I would like to use the occasion to reflect on what more is needed in our quest to ensure optimal health and well-being for residents of the many rural and remote communities throughout Australia.

Successful, “innovative” primary health care (PHC) models exist that have adapted to the specific circumstances of their rural and remote context. A typology of discrete, integrated, comprehensive and outreach rural and remote services exists rather than a “one coat fits all” PHC health service model. Successful models are characterised by macro-scale environmental enablers (supportive health policy, federal–state relations, and community readiness) and five essential service requirements (workforce organisation and supply; funding; governance, management and leadership; linkages; and infrastructure). Service sustainability depends on ensuring that key systemic service requirements are met at the local level in ways that accord with, and are supported by, the broader macro-scale environmental enablers. Based on these principles, these model types are amenable to generalisation and evaluation in other regions.

Forty years after the 1967 Referendum and 10 years after the Bringing Them Home inquiry published its report into the Stolen Generations, in June 2007 the Howard Federal Government launched an Emergency Response intervention in the Northern Territory, having recognised the urgent need to reduce the incidence of child maltreatment in remote Aboriginal communities. This intervention was developed in response to the Northern Territory Government report on child sexual abuse in Indigenous children that described the urgency of the situation. In the present review of the literature, the complexity of the issue of child maltreatment, in particular child sexual abuse, in Indigenous Australia is explored. The Northern Territory Emergency Response is examined in the light of research evidence, detailed in numerous government reports, that reducing child maltreatment in Aboriginal communities necessitates both Aboriginal self-determination and extensive consultation between Indigenous and non-Indigenous people working in the field. The extent to which the Emergency Response is evidence based and the complexity of making a report about child maltreatment, in particular child sexual abuse, in a remote Aboriginal communities are explored. Implications for policy and practice are also discussed. The current Rudd Federal Government has adopted most of the policies involved in the Northern Territory Emergency Response and has called for a comprehensive and independent review to be completed by 30 September 2008.

Background and aim Maternity care in remote areas of the Australian Northern Territory is restricted to antenatal and postnatal care only, with women routinely evacuated to give birth in hospital. Using one remote Aboriginal community as a case study, our aim with this research was to document and explore the major changes to the provision of remote maternity care over the period spanning pre-European colonisation to 1996. Methods Our research methods included historical ethnographic fieldwork (2007–2013); interviews with Aboriginal women, Aboriginal health workers, religious and non-religious non-Aboriginal health workers and past residents; and archival review of historical documents. Findings We identified four distinct eras of maternity care. Maternity care staffed by nuns who were trained in nursing and midwifery serviced childbirth in the local community. Support for community childbirth was incrementally withdrawn over a period, until the government eventually assumed responsibility for all health care. Conclusions The introduction of Western maternity care colonised Aboriginal birth practices and midwifery practice. Historical population statistics suggest that access to local Western maternity care may have contributed to a significant population increase. Despite population growth and higher demand for maternity services, local maternity services declined significantly. The rationale for removing childbirth services from the community was never explicitly addressed in any known written policy directive. Declining maternity services led to the de-skilling of many Aboriginal health workers and the significant community loss of future career pathways for Aboriginal midwives. This has contributed to the current status quo, with very few female Aboriginal health workers actively providing remote maternity care.

Objective the aim of this research is to review the content, and describe the structural and contextual discourse around planned birthplace in six clinical practice manuals used to care for pregnant Aboriginal women in Australia׳s remote Northern Territory. The purpose is to better understand where, how and why planned birthplaces for Aboriginal women have changed over time. Methods content and discourse analysis was applied to the written texts pertaining to maternal health care and the results placed within a theoretical framework of Daviss׳s Logic. Findings the manuals demonstrate the use of predominantly scientific and clinical logic to sanction birthplace. Planned birthplace choices have declined over time, with hospital now represented as the only place to give birth. This is in opposition to Aboriginal women׳s longstanding requests and is not supported by robust scientific evidence. Conclusions despite scientific and clinical logics dominating the sanctioning of birthplace for Aboriginal women, conjecture is apparent between assumed logics and evidence. There needs to be further critical reflection on why Aboriginal women do not have planned birthplace choices, and these reasons, once identified, debated and addressed both in research agendas and policy re-development.

Congestive Heart Failure (CHF) is an ambulatory care sensitive condition, associated with significant morbidity and mortality, rarely with cure. Outpatient based pharmacological management represents the main and most important aspect of care, and is usually lifelong. This narrative styled opinion review looks at the pharmacological agents recommended in the guidelines in context of the Northern Territory (NT) of Australia. We explore the concept of validity, a term used to describe the basis of standardising a particular trial or study and the population to which it is applicable. We aim to highlight the problems of the current guidelines based approach. We also present alternatives that could utilise the core principles from major trials, while incorporating regional considerations, which could benefit clients living in the NT and remote Australia.

Gradual technical advancement and rapidly decreasing costs have led to widespread deployment of solar photovoltaic (PV) systems. In Australia, distributed PV systems make up the vast majority of installed PV capacity. In remote communities, distributed PV systems offer a supplementary solution to existing diesel-based electricity generation. However, remote electricity networks, being different from urban networks primarily due to their limited generation capacity and spinning reserve are likely to be critically affected by the variability characteristics of PV generation. The integration of distributed PV systems into conventional remote electricity networks has noteworthy impacts on their technical and non-technical operations that pose new challenges for PV deployment. Significant technical issues are observed in these networks as PV penetration levels increase, such as reduced power quality, inadequate diesel generator dispatch for spinning reserve, increased complexities in network operation and management, unintended islanding and even system blackouts. Utility adopted operational and control strategies significantly influence PV penetration levels in different remote networks around the world, including Australia. This paper reviews the current electrification scenarios in remote Australian networks and focuses on the impacts and technical challenges of distributed PV deployment and the control strategies adopted by remote area power utilities. Some suggestions and recommendations, such as the development of robust control mechanisms incorporating PV forecasting technology, modern network equipment, real-time measurements and network ancillary services provided by inverter coupled generation systems to enhance networks' operational stability and reliability are also presented. This review is of benefit to scientific researchers, investors and different stakeholders, who wish to have a better understanding of distributed PV systems' deployment scenarios into remote electricity networks. As the inherent characteristics of Australian remote electricity networks are similar to those in African and Asian rural electricity networks; the findings, reviews and recommendations presented are also relevant to those networks.

In Australia, tobacco smoking is more than twice as common among Indigenous people as non-Indigenous people. Some of the highest smoking rates in the country are in remote Indigenous communities in the Northern Territory of Australia. Owing to this high prevalence, tobacco use today is the single biggest contributing risk factor for excess morbidity and mortality among Indigenous Australians. Despite this, there is a lack of published research which qualitatively explores the social context of Indigenous smoking behaviour or of meanings and perceptions of smoking among Indigenous people. The aim of this study was to understand why Indigenous people start to smoke, the reasons why they persist in smoking and the obstacles and drivers of quitting. We conducted semi-structured interviews with a purposive sample of 25 Indigenous community members in two remote communities in the Northern Territory and 13 health staff. The results indicate that there is a complex interplay of historical, social, cultural, psychological and physiological factors which influence the smoking behaviours of Indigenous adults in these communities. In particular, the results signal the importance of the family and kin relations in determining smoking behaviours. While most community participants were influenced by family to initiate and continue to smoke, the health and well being of the family was also cited as a key driver of quit attempts. The results highlight the importance of attending to social and cultural context when designing tobacco control programs for this population. Specifically, this research supports the development of family-centred tobacco control interventions alongside wider policy initiatives to counter the normalisation of smoking and assist individuals to quit.

Objective to compare the quality of care before and after the introduction of the new Midwifery Group Practice. Design a cohort study. Setting the health centers (HCs) in two of the largest remote Aboriginal communities (population 2200–2600) in the Top End of the Northern Territory (NT), each located approximately 500km from Darwin. The third study site was the Royal Darwin Hospital (RDH) which provides tertiary care. Methods a 2004–06 retrospective cohort (n=412 maternity cases) provided baseline data. A clinical redesign of maternity services occurring from 2009 onwards focused on increasing Continuity of Carer, Communication, Choice, Collaboration and Co-ordination of Care (5Cs). Data from a 2009–11 prospective cohort (n=310 maternity cases) were collected to evaluate the service redesign. Outcome measures included indicators on the quality of care delivery, adherence to recommended antenatal guidelines and maternal and neonatal health outcomes. Findings statistically significant improvements were recorded in many areas reflecting improved access to, and quality of, care. For example: fewer women had <4 visits in pregnancy (14% versus 8%), a higher proportion of women had routine antenatal tests recorded (86% versus 97%) and improved screening rates for urine (82% versus 87%) and sexual tract infections (78% versus 93%). However, the treatment of conditions according to recommended guidelines worsened significantly in some areas; for example antibiotics prescribed for urine infections (86% versus 52%) and treatment for anaemia in pregnancy (77% versus 67%). High preterm (21% versus 20%), low birth weight (18% versus 20%) and PPH (29% versus 31%) rates did not change over time. The out of hospital birth rate remained high and unchanged in both cohorts (10% versus 10%). Conclusion this model addresses some of the disparities in care for remote-dwelling Aboriginal women. However, much work still needs to occur before maternity care and outcomes are equal to that of non-Aboriginal women. Targeted program interventions with stronger clinical governance frameworks to improve the quality of care are essential. A complete rethink of service delivery and engagement may deliver better results.

Background The Family Wellbeing (FWB) program applies culturally appropriate community led empowerment training to enhance the personal development of Aboriginal and Torres Strait Islander people in life skills. This study sought to estimate the economic cost required to deliver the FWB program to a child safety workforce in remote Australian communities. Method This study was designed as a retrospective cost description taken from the perspective of a non-government child safety agency. The target population were child protection residential care workers aged 24 or older, who worked in safe houses in five remote Indigenous communities and a regional office during the study year (2013). Resource utilization included direct costs (personnel and administrative) and indirect or opportunity costs of participants, regarded as absence from work. Results The total cost of delivering the FWB program for 66 participants was $182,588 ($2766 per participant), with 45% ($82,995) of costs classified as indirect (i.e., opportunity cost of participants time). Training cost could be further mitigated (~30%) if offered on-site, in the community. The costs for offering the FWB program to a remotely located workforce were high, but not substantial when compared to the recruitment cost required to substitute a worker in remote settings. Conclusion An investment of $2766 per participant created an opportunity to improve social and emotional wellbeing of remotely located workforce. This cost study provided policy relevant information by identifying the resources required to transfer the FWB program to other remote locations. It also can be used to support future comparative cost and outcome analyses and add to the evidence base around the cost-effectiveness of empowerment programs.

Background An increase in the number of Indigenous homeless persons in Cairns, Northern Australia, prompted the Queensland Police Service (QPS) to commence a pilot ‘Return to Country’ (R2C) program. The program was designed to assist homeless people who were voluntarily seeking to return to their home communities. This study assesses the costs of running the program and evaluates its net economic impact. Methods Retrospective uncontrolled cost, cost-effectiveness and cost-offset analyses were undertaken from a societal perspective. All costs were expressed in 2014 AU$. Results The R2C program successfully assisted 140 participants to return home, reducing the prevalence of homelessness in the regional center by 9.6%. The total program cost was estimated as AU$ 135,831 or AU$ 970 per participant. The economic analysis indicated that R2C was value for money, potentially saving AU$ 2,714,460. Limitations of the study included retrospective data collection and no established alternative comparison group. Conclusion R2C is a relatively simple, minimal cost program, which can be utilized by policy makers to offer one solution to homelessness. This economic evaluation informs the QPS of the effects of the R2C program in order to guide further program initiatives. The R2C model may be applied to assist temporarily stranded Indigenous people in other locations within Australia or internationally to return home. No funding was obtained for conducting this study.

Background In Australia, Aboriginal women and babies experience higher maternal and perinatal morbidity and mortality rates than their non-Aboriginal counterparts. Whilst midwifery led continuity of care has been shown to be safe for women and their babies, with benefits including reducing the preterm birth rate, access to this model of care in remote areas remains limited. A Midwifery Group Practice was established in 2009 in a remote city of the Northern Territory, Australia, with the aim of improving outcomes and access to midwifery continuity of care. Aim The aim of this paper is to describe the maternal and newborn outcomes for women accessing midwifery continuity of care in a remote context in Australia. Methods A retrospective descriptive design using data from two existing electronic databases was undertaken and analysed descriptively. Findings In total, 763 women (40% of whom were Aboriginal) gave birth to 769 babies over a four year period. There were no maternal deaths and the rate of perinatal mortality was lower than that across the Northern Territory. Lower rates of preterm birth (6%) and low birth weight babies (5%) were found in comparison to population based data. Conclusion Continuity of Midwifery Care can be effectively provided to remote dwelling Aboriginal women and appears to improve outcomes for women and their infants.

A molecular phylogeny of all extant species (21) in two clades of phyllodinous acacias , including the Acacia victoriae, A. pyrifolia and A. murrayana groups, is the basis of a paralogy-free subtree analysis of historical relationships of geographic areas in arid and semi-arid Australia. These clades are in a relatively basal position within Acacia subgenus Phyllodineae. Sister taxa generally show vicariant (allopatric) patterns. The summary area cladogram indicates that the earliest regions to differentiate were Arnhem and the North-West semi-arid region (including Dampierland, Ord-Victoria Plains and Tanami), relative to the other regions occupied by these acacias. In arid central Australia, the Central and MacDonnell Ranges are most closely related to the South-West Interzone (Coolgardie bioregion). The Eastern Desert, Western Desert and Pilbara are related as a group, which does not support the idea that these two deserts have been colonized independently from different centres on the margin of the continent. The widespread and genetically variable A. victoriae species complex also showed regional differentiation, one pattern being the relationship of the Northern subtropical regions, from the southern Kimberley east to the Gulf Uplands and Cape York. It is argued for these acacias that the underlying differentiation of areas of endemism in the Eremean zone of Australia is relatively old, with increasing aridity during the Cenozoic, not withstanding that present-day species pairs and intra-specific variation might relate to more recent shifts in vegetation and arid cycles.

The aim of this study was to explore the potential of a service-learning immersion program to promote pre-service teachers' development of cultural competency in the area of Aboriginal education. That is, the research focused on ways the immersion program helped pre-service teachers (a) develop awareness of cultural implications in teaching in a remote school and (b) understand and respect Aboriginal people with a view to reconciliation. The program has operated since 2013 and occurs in a remote Aboriginal school and community in Western Australia. The duration of the immersion is eight days and is open to early childhood, primary and secondary pre-service teachers. The underlying epistemology of the research is constructivist, specifically interpretivist in nature, with a symbolic interactionist lens. That is, the research attempts to ‘give voice’ to the participants through their own language. Content analysis was the methodology used to explore the pre-service teachers’ experiences and perceptions while undertaking their service-learning immersion. Data collection methods included focus group interviews, participant journals and a questionnaire. These data were collected over a four-year span from 2014 to 2017. The findings indicate that the service-learning immersion has enabled pre-service teachers to explore their interests and passion to teach Aboriginal students in both rural and remote locations.

Objectives This study aims to monitor the prevalence of suppurative otitis media in remote Indigenous communities after introduction of 13-valent pneumococcal conjugate vaccine (PCV13) in October 2011. We previously reported a decline in suppurative OM following replacement of PCV7 by 10-valent pneumococcal Haemophilus influenzae protein D conjugate vaccine (PHiD-CV10) in October 2009. Methods We continued regular surveillance in remote Indigenous communities between February 2010 and August 2013. This analysis reports the general health, otitis media (OM), nasopharyngeal (NP) carriage and middle ear microbiology in children less than 36 months of age who received a primary course of at least two doses of PHiD-CV10 or PCV13, and not more than one dose of another pneumococcal vaccine. Results Mean ages of 511 PHiD-CV10- and 140 PCV13-vaccinated children were 19 and 13 months, respectively. Most children received 3-dose non-mixed PCV schedules. At the time of assessment, general health was poor and prevalence of risk factors was high in both groups: overall, around 14% of children had scabies, 20% had impetigo, 59% had runny nose and 39% had cough. Average household size was 8 persons, and 60% of the mothers smoked. Bilaterally normal middle ears were detected in 10% and 7%, respectively. OM with effusion (OME), almost all bilateral, was diagnosed in 52% and 50%, any suppurative OM (acute OM or any tympanic membrane perforation [TMP]) in 37% and 41%, and TMP in 14% and 12%, respectively. Children in the PCV13 group had significantly less NP carriage of combined Streptococcus pneumoniae (Spn) and non-typeable Haemophilus influenzae (NTHi) (62% versus 51%) but significantly more polymicrobial (Spn and NTHi) middle ear cultures (12% versus 43%), and significantly less Staphylococcus aureus-positive middle ears (40% versus 7%). Although NP carriage of pneumococcal serotype 19A was low in the PCV13 group, serotypes 19F and 23F persist. Conclusions The general health, particularly ear health, of little children in remote Australian Indigenous communities remains in crisis. In particular, transition to PCV13 did not show substantial further improvement in ear health. Possible vaccine-related differences in microbiology, including potential beneficial effects of PHiD-CV10 on NTHi infection, need to be further evaluated in randomised trials.

We report a landscape-scale study investigating the responses of small mammals and lizards to fire in a central Australian hummock grassland. Vertebrates were surveyed on 26 study grids aged from 0 to >25 years post-fire. Analyses demonstrated that lizard and small mammal assemblages showed markedly different responses to each other with respect to post-fire vegetation succession. Lizard community composition could be arrayed along a single continuum of vegetation structure and conformed to a directional model for post-fire succession. In contrast, small mammal assemblages could not be arrayed along a continuum of post-fire vegetation succession. Geographical locality, rainfall, seedbank density and cattle grazing were prominent correlates of mammal assemblage structure. We propose a non-equilibrium state-and-transition model to describe small mammal community dynamics. This model has four temporal or geographical states that are characterized by different abundances of small mammals, and eight transitions that prompt shifts from one state to another. The model can be used to describe assemblage composition and identify areas or time periods when management activities should be implemented.

The transition to primary health care (PHC) is often described in an idealised manner, which either ignores or obscures the experiences associated with its implementation at the local level. By adopting an anthropological perspective, this article highlights some of these experiences and the context within which they occur for one health care organisation in remote Western Australia. It Specifically focuses on problems associated with economic rationalism, managerialism, and the inherently fragmented character of health service organisations. Such issues must be allowed to inform idealised PHC models in order to make them more applicable and attuned to local needs and realities.

Nasopharyngeal carriage of Streptococcus pneumoniae in unimmunised adults and older children in three remote Australian Aboriginal communities was compared in 2002 and 2004. Universal childhood pneumococcal vaccination with a catch-up program was introduced in late 2001. Carriage prevalence across all age groups of pneumococcal serotypes included in the 7-valent vaccine was 10% in both 2002 and 2004 (12 and 30 months after introduction of vaccination). This carriage prevalence was lower than anticipated. It is likely that indirect effects of childhood vaccination occurred before the 2002 survey. To further assess indirect effects on carriage of childhood pneumococcal vaccination, data prior to 2002 are required. Between 12 and 30 months following introduction of conjugate pneumococcal vaccination, indirect effects on carriage were unchanged.

Prevalence of complications of type 2 diabetes in a remote Australian Indigenous community was measured as part of a population survey of risk factors for diabetes and cardiovascular disease. Information was obtained from history, clinical examination, blood sample and medical records. Forty-three diabetic participants (six newly diagnosed) were assessed from a sample of 339 (12% diabetes prevalence); mean age 50 (range 31–67), duration of diabetes 5.6 (0–15) years, 40% male. Risk factors/complications: 70% with BMI≥25, 50% cigarette smokers, HbA1c 8.5 (S.D. 2.9)%, cholesterol 4.8 (0.8)mmol/l, triglycerides 2.7 (1.6)mmol/l, HDL 0.83 (0.2)mmol/l; 60% had albuminuria (micro 38%, macro 22%), 47% were hypertensive, 7% (n=2) had retinopathy, 24% had peripheral neuropathy, none had peripheral vascular disease, 14% had documented coronary vascular and one participant cerebrovascular disease. Of 37 with previously diagnosed diabetes: 43% were on aspirin, 65% on metformin, 80% with albuminuria on ACE inhibitors. Four additional diabetic participants (not studied) were receiving renal dialysis elsewhere. The results demonstrate on the one hand, very high indices of cardiovascular risk (smoking, hypertension, dyslipidaemia and albuminuria) and on the other, good quality primary health care providing good detection and follow up management of type 2 diabetic patients.