Remote Australia Online

Objective: To improve the maternity emergency skills and knowledge of health service providers, without midwifery qualifications, in remote Australia. Design: A descriptive paper utilising data from a needs assessment and course evaluations used to develop and refine a short course in maternity emergencies. Subjects: Remote area health providers. Interventions: A multidisciplinary short course, targeting non-midwives in remote areas, aimed at improving knowledge and skills in detection, management and referral of maternity emergencies. Results: Ten courses have been delivered to 175 participants. Evaluations demonstrate a highly valued program, well received and supported by remote health staff. Conclusions: The course is an important strategy to improve the maternity services offered to women in remote Australia.

The discourse associated with adult literacy provision in remote Aboriginal Australia is now intertwined with the notion of training for employment outcomes. The all too common provision of ad hoc, short-term vocational training courses coupled with a ‘bolted-on’ (Bradley, Parker, Perisce, & Thatcher, 2000) approach to literacy reflects the shifting policy environment that typically underpins funding in the remote sector.

If young adults in remote Indigenous Australian communities are to acquire the knowledge and skills necessary to participate effectively in mature roles in their own and the wider community, then educators will need to pay attention not only to the provision of schooling and formal adult-literacy tuition, but also to how language, literacy, and technological know-how are acquired through socialization and learning as a lifelong process. In this article, Inge Kral and Jerry Schwab take a social practice approach to reading (and writing) by looking at how Indigenous youth use alphabetic and digital literacies in everyday life and in community settings beyond school. Their proposition is that, in addition to pedagogy, it is meaningful practice across the lifespan that determines competence. Drawing on ethnographic research, Kral and Schwab outline a “learning centre” model, suggesting that it provides a template not only for transformative practice but also for achieving an appropriate blend of formal and nonformal approaches to adult learning in the remote context.

In remote Australia there is an expanding emphasis on the employment and training of Indigenous people in the mining industry. Employment and training programs are presented as an effective strategy for breaking welfare dependence and empowering individuals and communities to take responsibility for their future. Using the case of programs targeting Warlpiri people's participation in the gold mining industry in the Tanami Region of the Northern Territory of Australia, this paper explores some of the different ways in which Warlpiri people are being governed. It investigates the endeavours, through various practices and discourses, to constitute Warlpiri people as particular kinds of neoliberal and ‘job ready’ subjects. Whilst the employment and training programs claim to respect the culture and liberties of Warlpiri people, there are clearly outlined attempts to construct self-reliant, autonomous and active individuals. Finally, the paper explores the potential links between rationalisations justifying the programs and the current concern, at the level of state and national governments, to direct various populations into work.

Type 2 diabetes (T2DM) contributes significantly to the mortality gap between Indigenous and non-Indigenous Australians, with the onset of diabetes occurring at a younger age among Indigenous Australians. We respectfully acknowledge the two Indigenous populations of Australia, the Aboriginal and Torres Strait Islander peoples, who are referred to as Indigenous people in this paper. Thus T2DM is increasingly reported in Indigenous children and youth, and also prior to pregnancy among Indigenous women. Indigenous women are 10 times more likely to have T2DM in pregnancy and 1.5 times more likely to have gestational diabetes (GDM) than non-Indigenous women.

This article examines the relationship between the sexuality and understandings of nature. Employing a case of ‘romance’ in ‘outback’ Australia, we dissolve the boundaries between ‘nature’ and ‘society’ to show some of the varied ways in which the construction and performance of heterosexuality is shaped by (and is integral to) dominant ways of knowing nature. In practical terms, we draw on a reality TV series in which single men in ‘outback’ Australia (‘bush bachelors’) advertise for potential partners (‘sheilas’) from the UK. The series charts the development of the relationships as they are played out in remote parts of Western Australia. In this article we critically read the series and draw out three key themes characterising the relationality of nature and heterosexuality. Initially, we look at how nature frames the expectation and reality of sexual relationships in the ‘outback’, particularly in terms of its power and hostility. We then explore the centrality of nature to constructions of ‘outback’ masculinity and the way such constructions dominate the heterosexual relationships that develop between the couples. Finally, we show how a further dynamic of the nature/sexuality relationship involves the expectation of a particular kind of femininity as appropriate to the physical, social and cultural nature of the ‘outback’.

Background: The increasing prevalence of diabetes and obesity represents a significant disease burden in Australia. Practice nurses (PNs) play an important role in diabetes education and management. Aim: To explore PNs' roles, knowledge and beliefs about diabetes education and management in rural and remote general practice in Australia. Method: Exploratory study undertaken in three phases: 1) Pilot study to test the performance of the questionnaire; 2) One-shot cross-sectional survey using self-complete questionnaires; 3) Individual interviews. Results: Ten PNs completed the pilot test; the draft questionnaire was deemed appropriate to the study purpose. Then, 65 questionnaires were distributed to PNs and 21 responded. Fourteen respondents had worked in the role <5 years, and most PNs attended diabetes education programmes in their workplace. A minority (40%) used diabetes management guidelines regularly. Most knew obesity to be the most common risk factor for diabetes but only 50% knew that glycosylated haemoglobin indicates blood glucose levels over the preceding three months. Self-reported competency to assess patients' self-care practices and medication management practices varied. Conclusion: PNs' diabetes management was self-reported; their knowledge varied and their perceived benefits of diabetes education differed from those of patients.

Objective: To assess an important part of Australia's National Mental Health Strategy by examining the collaboration and referral practices between general practitioners and community mental health workers in rural and remote areas. Design: Semistructured interviews. Setting: Rural and remote health service region in Australia. Participants: In total, 31 general practitioners and 14 mental health workers. Results: Meaningful collaboration and referral practices between general practitioners and mental health workers are prevented by contradictory and ambiguous definitions involving professional roles and mental health. A pattern of negative collaboration was further magnified by the rural and remote context. Conclusion: The implementation of Australia's National Mental Health Strategy faces serious problems in rural and remote area due to the negative collaboration and referral practices between general practitioners and mental health workers.

Background: Antenatal screening for, and prompt management of, sexually transmitted infections (STI) can prevent adverse maternal, fetal and perinatal outcomes. This is particularly important in areas of high STI endemicity. Aims: To assess adherence with antenatal STI screening guidelines in a large remote region, and whether completeness of antenatal syphilis screening improved after the onset of a regional syphilis outbreak in April 2001. Methods: Data from the regional antenatal syphilis screening database from 1997 to 2002 were analysed to identify time trends in the completeness of antenatal syphilis screening. Adherence to antenatal screening guidelines was assessed by examining pathology request forms of women undergoing antenatal syphilis screening to determine whether screening for gonorrhoea, chlamydia, hepatitis B and HIV had also been carried out. Logistic regression was used to analyse associations between adherence to the guidelines and patient's age and race, and health service characteristics. Results: Adherence to syphilis screening guidelines improved from 44.6% in 1997 to 68.9% in 2001 and 81.4% in 2002. After controlling for the time interval between the first antenatal syphilis test and date of delivery, being younger and Aboriginal, and delivering after the syphilis outbreak had been identified were positively associated with adherence to syphilis screening guidelines. Proportions of antenates screened for gonorrhoea/chlamydia, hepatitis B and HIV at booking and for gonorrhoea/chlamydia in the third trimester were 69%, 91%, 68% and 77%, respectively. Aboriginal women were more likely to have been screened for gonorrhoea and chlamydia. Women seen by a doctor were more likely to have undergone HIV screening than those who saw a nurse. Conclusions: Significant improvement in adherence to antenatal syphilis screening guidelines occurred after identification of a syphilis outbreak. This achievement is reason for optimism regarding the potential to achieve more complete antenatal screening of other STI.

Objectives: To describe the development and implementation of a prevocational medical training program in public health medicine and primary health care in remote Australia and to evaluate the program's adherence to adult learning principles. Methods: Reports, funding applications and other relevant material relating to the program were reviewed to document learning objectives, and teaching and program implementation strategies. Results: The 24-week program employs two prevocational medical practitioners each year and comprises four weeks at Fremantle Hospital's sexual health clinic followed by 20 weeks in the Kimberley. Curriculum objectives include clinical and public health aspects of sexually transmitted infection management, immunisation, clinical audit and quality improvement, primary health care in remote Aboriginal communities, oral and written presentation skills and working as part of an interdisciplinary team. Teaching strategies used were in accordance with adult learning principles. Conclusions: Prevocational medical training in public health medicine and primary health care in remote Australia is achievable and reduces current gaps in prevocational medical education.

Objectives: The objectives of this study were to assess health professionals’ adherence to Western Australian sexually transmitted infection (STI) management guidelines and to document the outcomes of contact tracing in a remote Indigenous setting. Methods: This article comprises 2 parts: a retrospective clinical audit of quality of clinical STI management and outcomes of contact tracing and an analysis of completeness of relevant laboratory investigations. Results: Documented clinical STI management of index cases varied from 94% receiving treatment in accordance with the Guidelines, whereas only 48% underwent a clinical examination. Sexual contacts who underwent STI consultation had concordant (30%) and discordant (17%) STI(s). The proportion of patients with STI(s) in whom all appropriate laboratory investigations had been requested increased from 25% in 1998 to 9% to 49% in 2001–2002. Conclusions: This study demonstrates that quality of clinical STI management comparable to that observed overseas is possible despite the challenges of healthcare delivery in a remote setting.

Objectives: To describe the diabetic retinopathy screening program operating in the Kimberley and evaluate recruitment into and the quality and timeliness of, the screening procedure. Method: Review of the documents relating to the Kimberley diabetic retinopathy screening program and analysis of Kimberley diabetic retinopathy screening database. Results: The Kimberley Public Health Unit developed and maintains a program of training, credentialing and ongoing professional development for retinal camera practitioners and a Kimberley-wide database of retinal photographs taken for diabetic retinopathy screening. As a result of this program, diabetic retinopathy screening is available in or close to most diabetics’ home towns/communities and 58% had undergone retinopathy screening in the preceding 2 years. Over 90% of sets of photographs were of excellent or adequate quality. There was a positive relationship between credentialing and photograph quality and timeliness of photographs being sent away for reporting. Conclusions: Quality diabetic retinopathy screening, at prevalences comparable to, or higher than, other urban and rural populations, can be achieved in a remote area. What is already known: Screening and early treatment of diabetic retinopathy can prevent visual loss associated with diabetes. However, there is little published literature about the operational aspects of diabetic retinopathy screening programs in remote area settings. What this study adds: Diabetic retinopathy screening in remote areas can be successfully implemented using non-mydriatic retinal photography performed by credentialed local health professionals, such as Aboriginal health workers and nurses.

Summary Objective Indigenous Australians have rates of cardiovascular (CVD) mortality some seven to 10-fold higher than non-Indigenous Australians aged 25–64 years. We aimed to evaluate the impact of type 2 diabetes and components of the metabolic syndrome on carotid intima-media thickness (CIMT) as a marker of cardiovascular risk in Indigenous Australians living in remote and urban environments and in Australians of European ancestry. Design, patients and measurements: CIMT was measured by high-resolution B-mode ultrasound imaging of the common carotid artery in 119 remote Indigenous, 144 urban Indigenous and 122 urban European Australians with and without diabetes. Results: In nondiabetic participants, CIMT was lowest in Europeans (mean (SD) 0·64 mm (0·10)), higher in urban Indigenous Australians (0·67 mm (0·12)) and highest in remote Indigenous Australians (0·73 mm (0·15), P < 0·001). CIMT was higher with diabetes with the same pattern observed between populations: 0·73 mm, 0·79 mm and 0·82 mm, respectively (P < 0·001). Traditional risk factors (age, male gender, blood pressure and HbA1c) explained 35–45% of the variance of CIMT within each population group. However, differences in CIMT between population groups were maintained after adjustment for these cardiovascular risks plus cholesterol and smoking (P < 0·001). Factor analysis revealed that variables of the metabolic syndrome, together with smoking and elevated C-reactive protein (CRP) and urinary albumin-creatinine ratio (ACR), are likely to explain the higher CIMT in Indigenous Australians (and the urban-remote gradient). Unmeasured variables (genetic, psychosocial and socioeconomic) may also contribute to higher CIMT in these populations. Conclusion: Glycaemic control and metabolic syndrome components contribute significantly to premature atherogenesis in Indigenous Australians and we recommend that therapy should be targeted accordingly.

In Australia national concerns about climate change, biodiversity loss, water quantity and quality and land degradation have high priority on the government's environment agenda. With this comes the opportunity to strategically integrate Indigenous land and sea management into plans for tackling these challenges, not least because the Indigenous estate—which includes some of the most biodiverse lands in Australia—continues to increase as a result of successful land and native title claims and the declaration of more Indigenous Protected Areas. This paper explores government support for Indigenous land and sea management focusing on the Commonwealth government's Working on Country program. The paper outlines the development of formalised Indigenous cultural and natural resource management, and the emergence of the Working on Country program is discussed in the past and current policy context. The opportunities and challenges for the future of the program, and formalised Indigenous land and sea management in Australia more broadly, are outlined. To finish, a note of cautious optimism: while an expanded Working on Country program underpinned by community-led priorities and aspirations has the potential to simultaneously ameliorate Indigenous poverty and ensure natural resource management occurs, this will require targeted investment and a more holistic and less sectoral approach from government.

Health outcomes for Indigenous Australians with diabetes in remote areas remain poor, including high rates of avoidable complications which could be reduced with better primary level care. We aimed to evaluate the effectiveness of a community-based health-worker led case management approach to the care of Indigenous adults with poorly controlled type 2 diabetes in primary care services in remote northern Australia.

This article reports on a pilot vocational study programme for provision of antenatal services in the general practice environment. The concurrent evaluation study assessed practice nurses' experiences of undertaking the pilot programme, the level and applicability of the content, and the mode of delivery. General practitioners' understanding of the role of the nurse in providing antenatal services, and the actual and potential impact of this new role on models of service delivery and care were also investigated. Women receiving care from practice nurses within this new model of service delivery and care were also of interest in this study. Findings showed that the current role of the general practice nurse in caring for pregnant women is restricted to assisting the general practitioner to complete their assessment of clients. Organizing clinical placement with a midwife was a major barrier to completing the pilot programme.

Background: Remote general practice can be a highly rewarding career, but poses many personal and professional challenges. It is characterised by significant geographical, professional and social isolation and a requirement for practitioners with public health, emergency and extended clinical skills. The remote practitioner faces further challenges in the remote Aboriginal community setting, including language and cultural barriers. Objectives: This paper discusses the specific components of a remote Aboriginal community general practice registrar orientation program in the Northern Territory, and their particular importance and relevance to remote training and practice in this context. Discussion: Northern Territory General Practice Education, the regional general practice training provider in the Northern Territory, has developed a model for a comprehensive orientation program for general practice registrars planning to work in remote Aboriginal community locations. This comprises a number of core components, including communication and cultural safety training; clinical and procedural skill development; population health; self-care and personal/professional role delineation; and organisational issues. We believe it is a program that is applicable to other disciplines undertaking work in remote Aboriginal communities.

The current policy debate about the future of small Indigenous homelands communities in remote Australia is being framed in terms of a narrow economic definition of ‘viability’, with little attention to factors such as the social characteristics of such communities and the health, well-being, and aspirations of those who choose to live there. The debate is taking place in the absence of comparative socio-demographic data on these communities as opposed to other kinds of settlements in remote Australia. This paper argues for a broader conceptualisation of viability. It outlines some reasons why governments might consider helping homelands communities to become more economically self-sufficient rather than starving them of support so that their inhabitants increasingly face a ‘choice’ between a marginalized and impoverished existence on the homelands and recentralisation in larger settlements. The argument is based on an analysis of ethnographic data from north-east Arnhem Land that demonstrate the social cohesiveness and functionality of homelands communities as compared to larger hub settlements.

A nuclear family, that is the social unit comprising a husband, wife(s) and their children, is one of the significant core elements around which the great majority of societies are built. An individual's most immediate social and emotional relationships, those between children and parents, between husband and wife, and between siblings are encapsulated within it. How these relationships are realised in actual practice is partly dependent upon the form marriage takes. In this paper, I analyse Warlpiri marriage as practice and institution by drawing on and comparing material by Mervyn Meggitt (from his work at Lajamanu in the 1950s), Diane Bell (based on her work at Alekarenge in the 1970s) and my own data from my fieldwork at Yuendumu (from the mid 1990s and onward). My aim is to explore the following questions: What constitutes a marriage in Warlpiri eyes today? Are there continuities with the past? What has changed since the 1950s? And, what do these continuities and changes mean in regard to the way Warlpiri people live their lives today?

Objective: Australians are more likely to die in a hospital than anywhere else, and most of these deaths are ‘expected’. The aims of this survey were to identify if specific end-of-life issues were documented in clinical records of a regional hospital serving remote Australia. Design: A retrospective consecutive case-note audit covering 18 months from 1 January 2006. Setting: Alice Springs Hospital. Participants: Adult deaths in Alice Springs Hospital. During this period there were 128 deaths. Outcome measures: Demographic, process (diagnosis of dying documented, ‘not for resuscitation’ documentation, intensive care unit (ICU) admission, social worker referral and specialised palliative care service referral) and outcome data (‘comfort at end of life’) were surveyed. Results: Of the 128 admissions, 55 cases were excluded: 10 were children under 18, 33 died in <48 hours, nine were coroner's cases and three files could not be found. Of the 73 deaths surveyed (33 men), 47 (64%) were Aboriginal. A diagnosis of dying was made in 84%, 88% had an ‘not for resuscitation’ order, 48% were admitted to ICU during their last admission, 66% were referred to social workers, 68% were referred to palliative care and 85% of people were documented to be ‘comfortable’ during the dying process with no differential outcomes for Aboriginal and non-Aboriginal decedents except age (P < 0.0001). Conclusion: This survey highlights the continuing need to diagnose dying, understand optimal use of intensive care and improve comfort care at the end of life.

Providing rural and remote clinical experiences for undergraduate nursing students could help address future recruitment in these areas, but adequate financial support for students during clinical placements is also necessary. Strategies to address nursing shortages to date have emphasised funding for rural re-entry programs, or supporting students from rural backgrounds to attend university courses. Assisting current undergraduate nursing students, especially those from urban backgrounds, to experience living and working in rural areas has been overlooked as a potential recruitment strategy. Ongoing qualitative evaluation of a clinical placement program shows students respond positively and with increased interest in returning to rural nursing after graduation. Unfortunately, many are disadvantaged financially by the added expense of their rural clinical rotation. Finding ways to support students from both urban and non-urban backgrounds to undertake rural and remote clinical placements should be an important strategic and funding priority.

The Access to Allied Psychological Services (ATAPS) Suicide Prevention Services initiative is an Australian Government-funded primary mental healthcare initiative providing free intensive psychological intervention for consumers at moderate risk of self-harm or suicide. Findings from a multi-method evaluation aimed at identifying whether the initiative is being implemented as stipulated within the operational guidelines, barriers and facilitators to implementation, and preliminary outcomes suggest that the Suicide Prevention Services are largely being implemented as stipulated in the Guidelines, but with some exceptions. In particular, service delivery barriers unique to rural and remote areas place limitations on implementation. Uptake of the ATAPS Suicide Prevention Services is high (10,428 consumers were referred to the Suicide Prevention Services between October 2008 and April 2013, and 86% of those attended at least one session), as is acceptance from organizations involved in its implementation.

Objective: To define characteristics of all-terrain vehicle (ATV) crashes occurring in north Queensland from March 2004 till June 2007 with the exploration of associated risk factors. Design: Descriptive analysis of ATV crash data collected by the Rural and Remote Road Safety Study. Setting: Rural and remote north Queensland. Participants: Forty-two ATV drivers and passengers aged 16 years or over hospitalised at Atherton, Cairns, Mount Isa or Townsville for at least 24 hours as a result of a vehicle crash. Main outcome measures: Demographics of participants, reason for travel, nature of crash, injuries sustained and risk factors associated with ATV crash. Results: The majority of casualties were men aged 16–64. Forty-one per cent of accidents occurred while performing agricultural tasks. Furthermore, 39% of casualties had less than one year's experience riding ATVs. Over half the casualties were not wearing a helmet at the time of the crash. Common injuries were head and neck and upper limb injuries. Rollovers tended to occur while performing agricultural tasks and most commonly resulted in multiple injuries. Conclusions: Considerable trauma results from ATV crashes in rural and remote north Queensland. These crashes are not included in most general vehicle crash data sets, as they are usually limited to events occurring on public roads. Minimal legislation and regulation currently applies to ATV use in agricultural, recreational and commercial settings. Legislation on safer design of ATVs and mandatory courses for riders is an essential part of addressing the burden of ATV crashes on rural and remote communities.

Objective: To develop a transparent, needs-based mental health resource allocation framework to guide area level service planning in rural and remote settings. Methods: Using the Central Australian mental health service region as a case study, a five-step approach was used to analyse and gather relevant data as follows: (i) mapping a regional sociodemographic profile; (ii) estimating the expected level of mental illness within the regional population; (iii) estimating the expected level of specialist mental health service usage; (iv) estimating the expected categories of specialist mental health care required for the regional population; (v) making adjustments to the costs of providing specialist mental health care on the basis of demographic features of the region. These data were then matched with the availability, access and cost of specialist mental health care currently provided at the regional level. Results: The capacity of specialist mental health care in Central Australia was below the expected benchmark for the population residing in this region. The region required approximately double the existing funding allocation to provide an adequate and equitable level of care that meets the needs of the diverse population groups. Children and adolescents were the group most in need, as were adult Aboriginal people living in remote settings. Conclusion: The framework described provides the beginnings of more open and transparent evidence-based decision-making regarding mental health resource allocation and service development for rural and remote residents.

The provision of specialist-level care for patients with chronic kidney disease in rural and remote areas is a significant challenge. There are well-recognized barriers to care in these areas but in addition there is a widely held view that the responsibility for chronic kidney disease falls to nephrologists, despite the lack of nephrologists in remote regions and the high burden of disease. This article describes how in Central Australia specialists and remote-based primary carers have adapted their usual roles and found new ways of working together to provide high-quality specialist-level care for remote chronic kidney disease patients. We are evolving a model where chronic kidney disease is no longer nephrologists’ business but is everybody's business, with primary carers providing much of the routine specialist-level care.