Remote Australia Online

Objective: A model of intermittent psychiatric service provision to rural and remote New South Wales communities by metropolitan psychiatrists and mental health professionals has been evaluated. The services provided included peer support to lone mental health and generic health workers, direct psychiatric care to clients in their own environment and skills development education sessions to general health staff and other professionals affiliated with health care (e.g. police and ambulance officers). Method: There were 10 visits of teams made up of a psychiatrist and another mental health professional to six rural and remote locations. Outcomes of the services delivered were examined including clinical services and teaching skills training sessions. Indirect outcome measures included changes to Pharmaceutical Benefits Scheme prescription patterns in areas serviced and data regarding transfer of clients for psychiatric care in regional centres. Difficulties in evaluation are discussed. Results: The feasibility of intermittent service provision was demonstrated. Education packages were well received and a positive change in workers’ attitudes toward mental health practice was found. Conclusion: Intermittent psychiatric services in remote settings add value to health care delivery particularly when dovetailed with skills-based education sessions.

Objective: To critically review the evidence regarding barriers to implementing research findings in rural and remote settings, and the ways those barriers have been addressed. Design: A systematic review that included searching several electronic databases, Internet sites and reference lists of relevant articles, assessment of methodological quality of the studies, and data extraction and analysis where possible. Eligibility for the review was not limited by study design. Settings/Participants: Studies that reported on: (1) barriers to the implementation of evidence by health professionals in rural and remote areas, or (2) interventions for implementing evidence-based practice or an element of evidence-based practice in rural and remote areas. Results: There were no experimental data available on the implementation of research findings in rural and remote clinical settings. The small amounts of empirical research undertaken (surveys) showed that some of the problems experienced by general practitioners were exacerbated by rural and remote location, particularly with relation to isolation, lack of time and locum cover, and poor information technology infrastructure. Conclusion: There is a paucity of empirical literature on implementing evidence-based practice in rural and remote settings. This is in contrast to the large amount of literature available on implementing evidence in other clinical settings. A clear finding from the literature was that getting evidence into practice needs to be context-specific and yet very little research has been conducted into the rural and remote context. Research is needed into how evidence can be implemented in contextually specific ways in rural and remote areas. What is already known: There is a substantial body of literature about the barriers to implementing research findings into clinical practice and how to address these barriers. This literature includes many systematic reviews and even overviews of systematic reviews. One of the consistent findings of the literature is that the implementation of research findings needs to be context-specific to have any chance of making lasting and worthwhile changes to practice. There is little work, however, on the context of rural and remote clinical practice. What this study adds: This study aimed to review the literature on the implementation of evidence based practice in rural and remote settings. No experimental studies were found and the limited empirical evidence from surveys found that the rural and remote context exacerbated some of the problems experienced by health professionals in other settings, particularly those related to lack of time, inability to get locum cover and poor and unreliable information technology infrastructure. More research is required to isolate the aspects of rural and remote practice that influence the uptake of research findings.

Aim: The shortage of community and hospital pharmacists is particularly acute in rural and remote areas of Australia. Pharmacy students, in particular, as those who may be able to alleviate this shortage, need to be made more aware of the challenges and rewards of rural pharmacy practice. A marketing tool was developed to promote rural and remote pharmacy practice as a career option. A DVD was produced from interviews with health professionals working in rural and remote areas of Australia. This DVD will complement current rural practical placements, which have been incorporated into the curriculum of Australian schools of pharmacy. Methods: Interviews were conducted with healthcare professionals from areas in Tasmania, Northern Queensland and the Northern Territory. Interviewees included pharmacists, graduate pharmacists, pharmacy students, aboriginal health workers and a general practitioner. Each of the interviewees was able to provide personal accounts of experiences in rural and remote healthcare, and roles and opportunities for pharmacists. A final draft of the DVD was shown to University of Tasmania students to assess the impact and quality of the production. Results: A number of common themes arose from interviewing and these were subsequently converted into five key chapters of the DVD – Lifestyle, Belonging, Diversity, Indigenous Health and ‘Give it a go’. The final DVD, produced from over 15h of footage, runs for 35min. Students reported positive feedback on both the technical quality and the information contained within the DVD; 37% of students who viewed the DVD felt that it increased their awareness of what rural pharmacy has to offer. Conclusions: The rural pharmacy, ‘Enjoy the Lifestyle’ DVD can be used to increase awareness of rural and remote pharmacy practice to students and other pharmacists, and complements other pharmacy workforce strategies for rural and remote areas of Australia. It could also be a useful approach for adaptation in other countries.

Objective: This study describes the extent to which general practitioners in the Kimberley region are available for doctor-provided primary care and relates primary care availability to need and standardised population. Design: Data collection and analysis was based on government statistics and interviews with general practitioners, local managers and regional employers and organisations. Results: A shortfall of 20.6 full time general practitioner positions was identified and this was aggravated by a significant number of unfilled positions in the areas of greatest need. Overall the region had only half the primary care general practitioners needed. The Shire of Halls Creek at the time of survey had less than a quarter of the doctors required based on this analysis. Conclusion: Steps to increase the Australian medical workforce have begun but resources to recruit, support and sustain this workforce are required. Aboriginal health workers and locally trained nurses competently provide much of the primary care but need greater resources to support the available medical care.

Australia has a universal health care system and a comprehensive safety net. Despite this, outcomes for Australians living in rural and remote areas are worse than those living in cities. This study will examine the current state of equity of access to birthing services for women living in small communities in rural and remote Australia from a population perspective and investigates whether services are distributed according to need.

In this paper I wish to contribute to an understanding of ‘Aboriginal resistance’ by a study of the politics of remote Aborigines' ‘employment’. I begin by highlighting some themes in recent discussions of the Community Development Employment Projects (cdep) policy, before looking back at some features of the welfare and pastoral economy in the Central Australian hinterland, c. 1950 to c. 1975. My aim is twofold: to show some of the cultural continuities in the relationships between remote Aborigines and government; and to criticise constructively the notion of ‘Aboriginal resistance’, to advocate a structural and processual notion of ‘resistance’ and to move away from one based on the clear identification of actors.

This article applies Schaffer's 1984 critique of the “sectoralism” of mainstream public policy practice and discourse to Aboriginal housing policy in Australia. It analyses the approaches and programs of the Aboriginal housing policy sector and the priority given to them over the years. It then identifies the dominant agenda of Aboriginal housing policy defined in terms of massive statistics of nationwide Aboriginal housing need. An alterative agenda defined in terms of appropriate non-conventional housing and facilities for remote areas is also identified and its struggle for recognition traced. The final sections of the article suggest reasons why this alternative agenda has remained on the margins of the Aboriginal housing policy sector and examine its prospects for becoming less marginal in the future.

Objective: To trial a measure of rural and remote GP access for small areas. Design: A cross-sectional study using geographical information systems software to calculate GP to population rates with a floating catchment of 100 km radius around census collection districts (CCDs). Setting: Non-metropolitan Western Australia. Participants: The locations and full-time equivalents of GPs and other primary-care doctors were identified through a GP workforce survey. Main outcome measures: GP to population ratios for each CCD were classified as being above or below a benchmark of adequate GP access. CCDs with no GP sessions reported within 100 km were identified separately. These categories were investigated by divisions of general practice and by indigenous status, age and employment characteristics of the population. Results: Small-area estimates detected greater variation in access than depicted by conventional methods. Sixty-four per cent of the non-metropolitan population live in CCDs with adequate GP access. Forty-five per cent of indigenous people and 52% of people working in rural industries live in CCDs with access below the benchmark. Conclusions: The floating catchment method is a powerful tool to identify small areas of inadequate service. It can be applied to measure access to other professionals, medical equipment or facilities.

The national Quality Assurance for Aboriginal Medical Services (QAAMS) Program, in which point-of-care testing (POCT) for haemoglobin A(1c) (HbA(1c)) and urine albumin: creatinine ratio (ACR) is performed for diabetes management in 65 Australian Aboriginal medical services, is now embedded in the practice of diabetes care across Indigenous Australia. This paper documents the results of a detailed survey to assess levels of satisfaction with the QAAMS HbA(1c) Program among three key stakeholder groups–doctors, POCT operators and patients with diabetes. Both doctors and patients with diabetes agreed that the immediacy of POCT results contributed positively to patient care, improved the doctor-patient relationship, and made the patient more likely to be both compliant and self-motivated to improve their diabetes control. Both POCT operators and patients with diabetes reported improved satisfaction with their diabetes services after the introduction of POCT. The paper also provides evidence from two participating medical services that POCT has been an effective tool in improving the delivery of pathology services and clinical outcomes for both individuals and groups of patients with diabetes. A statistically significant reduction in HbA(1c) from 9.3% (± 2.0) to 8.6% (± 2.0) was observed in 74 diabetes patients 12 months after commencing POCT (p = 0.003, paired t-test). An improvement in the percentage of patients achieving glycaemic targets and a reduction in the percentage of patients with poor control was also observed in this group. These data provide evidence that the QAAMS POCT model delivers a culturally and clinically effective service for diabetes management in Aboriginal Australia.

Physiotherapists in rural and remote areas face challenges in their service delivery. The challenge is to provide accessible and comprehensive services to rural and remote Australians. Research was undertaken regarding the work practices of physiotherapists and the availability of other health professionals in rural and remote South Australia and Northern Territory. Rural and remote area physiotherapists in this study are likely to be sole practitioners with a generalist practice. The high number who have practising rights at public hospitals gives rise to service delivery with a wide range of clients and reduced opportunity for specialisation. In addition, the demand for physiotherapists to be multiskilled is increased with the lower number of resident medical specialists and allied health professionals in rural areas. Greater access to other professionals for rural and remote Australians may come from the development of resource networks supported by regional organisation of resources and infrastructure.

There has been much discussion and debate in the Western world, regarding the idea that some nurses, who are practising in certain contexts, should be recognised as nurse practitioners. The nursing profession and the New South Wales Department of Health have officially been involved in the debate since 1990. They have undertaken a two stage process in ascertaining the current status of the nurse practitioner in New South Wales and Australia. A recommendation from the 2nd Stage of the process was that a number of pilot projects be funded by the Department to look at the role of the nurse practitioner in New South Wales in three contexts: Area/District Health Services, General Practice Services and Remote Area Services. The implementation of these projects constitutes Stage 3 of the Project and is being jointly funded by the New South Wales and Commonwealth Health Departments. This paper describes one of these projects that has been operational since 1 September 1994. The Nurse Practitioner Pilot Project, Wilcannia will be continuing for 12 months. This paper outlines the steps taken to analyse the work undertaken by nurses working in one of New South Wales' remote hospital emergency locations. The expected outcomes will be acknowledgment, recognition, and appropriate policy and legislative change that will validate the role of nurse practitioners working in rural/remote Australia.

The case studies presented in this Support Document are a compilation of learnings derived from the research project, "Enhancing training advantage for remote Aboriginal and Torres Strait Islander learners." The project, funded by the National Centre for Vocational Education Research (NCVER), was conducted by a consortium of researchers from five institutions: TAFE SA, Batchelor Institute of Indigenous Tertiary Education, University of New England, James Cook University and the University of Notre Dame Australia. The research was conducted during 2016 with participants from five locations: the Anangu Pitjantjatjara Yankunytjatjara Lands of South Australia, the Northern Territory, western New South Wales, the Kimberley region of Western Australia, and the Cape York and Torres Strait Island regions of Queensland. Based on training programs considered to be successful, the project was designed in order to gain an understanding of the dynamics of retention and completion towards employability. Nationally, for very remote Aboriginal and Torres Strait Islander trainees, completion rates for VET courses are on average 16.6%, with an even lower figure for certificate I courses. [This document was produced by the author(s) based on their research for the report "Enhancing Training Advantage for Remote Aboriginal and Torres Strait Islander Learners" (ED574708).]

Objective: The practice of rural and remote medicine in Australia entails many challenges, including a broad casemix and the remoteness of specialist support. Many rural practitioners employ advanced procedural skills in anaesthetics, surgery, obstetrics and emergency medicine, but the use of these skills has been declining over the last 20 years. This study explored the perceptions of rural general practitioners (GPs) on the current and future situation of procedural medicine. Design: The qualitative results of data from a mixed-method design are reported. Free-response survey comments and semistructured interview transcripts were analysed by a framework analysis for major themes. Setting: General practices in rural and remote Queensland. Participants: Rural GPs in Rural and Remote Metropolitan Classification 4–7 areas of Queensland. Main outcome measure: The perceptions of rural GPs on the current and future situation of rural procedural medicine. Results: Major concerns from the survey focused on closure of facilities and downgrading of services, cost and time to keep up skills, increasing litigation issues and changing attitudes of the public. Interviews designed to draw out solutions to help rectify the perceived circumstances highlighted two major themes: ‘synergy’ between the support from medical teams and community in ensuring ‘sustainability’ of services. Conclusions: This article presents a model of rural procedural practice where synergy between staff, resources and support networks represents the optimal way to deliver a non-metropolitan procedural service. The findings serve to remind educators and policy-makers that future planning for sustainability of rural procedural services must be broad-based and comprehensive.

The demographic and economic characteristics of Aboriginal people in Australia's remotest locations are examined from 1986 Census data. There are three objectives: first to argue the case for examining Aboriginal society in spatial context: second, to demonstrate how census data can be manipulated to isolate meaningful spatial sub-categories; third to consider the extent to which extreme remote location is associated with distinct social and economic characteristics. The conclusion is that on the whole, remote location is reflected in lower economic status but not in demographic structure.

In Australia, it is commonplace for tertiary mental health care to be provided in large regional centres or metropolitan cities. Rural and remote consumers must be transferred long distances, and this inevitably results in difficulties with the integration of their care between primary and tertiary settings. Because of the need to address these issues, and improve the transfer process, a research project was commissioned by a national government department to be conducted in South Australia. The aim of the project was to document the experiences of mental health consumers travelling from the country to the city for acute care and to make policy recommendations to improve transitions of care. Six purposively sampled case studies were conducted collecting data through semistructured interviews with consumers, country professional and occupational groups and tertiary providers. Data were analysed to produce themes for consumers, and country and tertiary mental healthcare providers. The study found that consumers saw transfer to the city for mental health care as beneficial in spite of the challenges of being transferred over long distances, while being very unwell, and of being separated from family and friends. Country care providers noted that the disjointed nature of the mental health system caused problems with key aspects of transfer of care including transport and information flow, and achieving integration between the primary and tertiary settings. Improving transfer of care involves overcoming the systemic barriers to integration and moving to a primary care-led model of care. The distance consultation and liaison model provided by the Rural and Remote Mental Health Services, the major tertiary provider of services for country consumers, uses a primary care-led approach and was highly regarded by research participants. Extending the use of this model to other primary mental healthcare providers and tertiary facilities will improve transfer of care.

This chapter discusses qualitative findings from doctoral research undertaken in Australia with Aboriginal and Torres Strait Islander pre-service teachers about integrating mobile devices within their tertiary studies and compares responses from those living in Very Remote communities and Inner Regional and Outer Regional locations. There are five categories of remoteness, used by the Australian Bureau of Statistics: Major Cities, Inner Regional, Outer Regional, Remote and Very Remote. These are based on road distance from five various sized centres of service delivery. Participants came from community-based Initial Teacher Education (ITE) programs in two states: Queensland and South Australia. The focus of this chapter is on the practice and preference of research participants about the use of mobile devices to provide elements of content material, administrative support, academic support and personal encouragement. The pedagogic implications for higher education institutions are explored, and technical ramifications are briefly mentioned, as are organisational policy issues. This research about the use of mobile devices is important in the context of a national initiative to increase the number of Aboriginal and Torres Strait Islander school teachers. Moreover, the research is significant as it addresses similar concerns of remote and marginalised communities throughout the Asia-Pacific Region. In addition, the research engages with global educational issues such as agency, collaboration, the supply of mobile devices and the cost of using them.

Background: This paper aims to describe models for service integration between ophthalmology and optometry when conducting outreach eye services. The effect of good coordination on clinical activity and cost-effectiveness is examined. Design: Cross-sectional case study based on remote outreach ophthalmology services in Australia. Participants: Key stake-holders from eye services in nine outreach regions participated in the study. Methods: Semistructured interviews were conducted to perform a qualitative assessment of outreach eye services' levels of coordination. Records of clinical activity were used to statistically compare the effects of good coordination. Main Outcome Measures: Clinical activity (surgery and clinic consultation rates), waiting times and costs per attendance. Surgical case rate being the proportion of surgery that results from a clinic. Results: Service integration between optometry and ophthalmology resulted in an increased surgical case rate for ophthalmology clinics (R2 = 0.57). There were trends towards increased clinical activity and reduced waiting times, and costs/attendance were stable. Conclusions: Coordination of eye services with better integration of ophthalmology and optometry roles may improve efficiency of services for patients. Coordination of eye services has multiple facets including facilitating engagement with the local community, eye professions and health facilities. The varied roles of eye health coordination require further definition and appropriate funding.

The Royal Perth Hospital provides access to dialysis treatment to Indigenous Australians living in remote areas of Western Australia who are suffering from end-stage renal disease (ESRD). The Remote Area Dialysis Programme (RADP), established in 1989, relocated traditional hospital services to remote communities and introduced home or community-based therapy. This unique state-wide programme was developed in cooperation with tribal elders in Aboriginal communities, and regional medical, nursing and community health staff. Prior to RADP's establishment, these patients faced the choice of permanent relocation to Perth for dialysis treatment or death from renal failure. Development of the RADP allowed Indigenous patients with ESRD to receive dialysis treatment in their own home/community. Requirements for home haemodialysis include establishing the suitability and capability of patients, the availability of carers and an appropriate home or community environment for dialysis machine installation. This has required novel strategies to address cultural and language impediments to home therapy. The remoteness of some isolated communities has been a technical challenge for the dialysis technicians due to the uncertainty of power supply, climatic extremes and inadequate supply or poor quality of water. A specific training program has been developed to adapt to the needs of Aboriginal patients. Patients undertaking home haemodialysis face many challenges and a number of initiatives will need to be implemented to ensure the ongoing success of the programme.

Issue addressed: This paper describes the Outreach School Garden Project, which was conducted in two remote Indigenous school communities in north-west Queensland. This project integrated nutrition into the key learning areas of the core school curriculum by using a school-based garden as a nutritional education tool. Methods: Evaluation was by a descriptive qualitative approach supplemented by some quantitative data consistent with Indigenous research methods. The objectives were linked to the Health Promoting Schools Framework, using concepts of community capacity building, action research, social capital and experiential learning. Results: Nutrition was extensively integrated into the core school curriculum by the teaching staff, who required no specific nutrition knowledge or gardening skills prior to the implementation. Students' knowledge and skills in nutrition and gardening were increased over the six-month period and positive improvements in the physical and social environment at the school were observed. Conclusion: A school-based nutrition garden enables the teaching and learning of basic nutrition through the core school curriculum. This concept was an innovative, practical nutritional education tool to engage and build the capacity of Indigenous students, school staff and the broader community in nutrition. So what? This method provided a stimulating and creative way to focus on nutrition in the school environment, positively influencing the students' knowledge of nutrition and future health practices. This concept is not limited to Indigenous students and can be used in all school environments.

Introduction While research highlights the benefits of early diagnosis and intervention for children with fetal alcohol spectrum disorders (FASD), there are limited data documenting effective interventions for Australian children living in remote communities.Methods and analysis This self-controlled cluster randomised trial is evaluating the effectiveness of an 8-week Alert Program school curriculum for improving self-regulation and executive function in children living in remote Australian Aboriginal communities. Children in grades 1–6 attending any of the eight participating schools across the Fitzroy Valley in remote North-West Australia (N ≈ 363) were invited to participate. Each school was assigned to one of four clusters with clusters randomly assigned to receive the intervention at one of four time points. Clusters two, three and four had extended control conditions where students received regular schooling before later receiving the intervention. Trained classroom teachers delivered the Alert Program to students in discrete, weekly, 1-hour lessons. Student outcomes were assessed at three time points. For the intervention condition, data collection occurred 2 weeks immediately before and after the intervention, with a follow-up 8 weeks later. For control conditions in clusters two to four, the control data collection matched that of the data collection for the intervention condition in the preceding cluster. The primary outcome is change in self-regulation. FASD diagnoses will be determined via medical record review after the completion of data collection. The results will be analysed using generalised linear mixed modelling and reported in accordance with Consolidated Standards of Reporting Trials (CONSORT) guidelines.Ethics and dissemination Ethical approval was obtained from the University of Western Australia (WA) (RA/4/1/7234), WA Aboriginal Health Ethics Committee (601) and WA Country Health Service (2015:04). The Kimberley Aboriginal Health Planning Forum Research Sub-Committee and WA Department of Education also provided approval. The results will be disseminated through peer-reviewed journals, conference presentations, the media and at forums.Trial registration number ACTRN12615000733572; Pre-results.

Objective: To highlight how evidence from studies of innovative rural and remote models of service provision can inform global health system reform in order to develop appropriate, accessible and sustainable primary health care (PHC) services to ‘difficult-to-service’ communities. Methods: The paper synthesises evidence from remote and rural PHC health service innovations in Australia. Results: There is a strong history of PHC innovation in Australia. Successful health service models are ‘contextualised’ to address diverse conditions. They also require systemic solutions, which address a range of interlinked factors such as governance, leadership and management, adequate funding, infrastructure, service linkages and workforce. An effective systemic approach relies on alignment of changes at the health service level with those in the external policy environment. Ideally, every level of government or health authority needs to agree on policy and funding arrangements for optimal service development. A systematic approach in addressing these health system requirements is also important. Service providers, funders and consumers need to know what type and level of services they can reasonably expect in different community contexts, but there are gaps in agreed indicators and benchmarks for PHC services. In order to be able to comprehensively monitor and evaluate services, as well as benchmarks, we need adequate national information systems. Conclusions: Despite the gaps in our knowledge, we do have a significant amount of information about what works, where and why. At a time of global PHC reform, applying this knowledge will contribute significantly to the development of appropriate, sustainable PHC services and improving access.

Background: Despite two decades of interventions, rates of sexually transmissible infections (STI) in remote Australian Aboriginal communities remain unacceptably high. Routine notifications data from 2011 indicate rates of chlamydia and gonorrhoea among Aboriginal people in remote settings were 8 and 61 times higher respectively than in the non-Indigenous population. Methods/design: STRIVE is a stepped-wedge cluster randomised trial designed to compare a sexual health quality improvement program (SHQIP) to usual STI clinical care delivered in remote primary health care services. The SHQIP is a multifaceted intervention comprising annual assessments of sexual health service delivery, implementation of a sexual health action plan, six-monthly clinical service activity data reports, regular feedback meetings with a regional coordinator, training and financial incentive payments. The trial clusters comprise either a single community or several communities grouped together based on geographic proximity and cultural ties. The primary outcomes are: prevalence of chlamydia, gonorrhoea and trichomonas in Aboriginal residents aged 16–34 years, and performance in clinical management of STIs based on best practice indicators. STRIVE will be conducted over five years comprising one and a half years of trial initiation and community consultation, three years of trial conditions, and a half year of data analysis. The trial was initiated in 68 remote Aboriginal health services in the Northern Territory, Queensland and Western Australia. Discussion: STRIVE is the first cluster randomised trial in STI care in remote Aboriginal health services. The trial will provide evidence to inform future culturally appropriate STI clinical care and control strategies in communities with high STI rates.

Background: Aborigines in remote Australia are experiencing an epidemic of chronic disease. The “metabolic syndrome”, type 2 diabetes, hypertension cardiovascular, renal and chronic lung disease contribute to a 20-25 yr reduction in life expectancy, and vast increases in renal failure. Prevention depends on socioeconomic advancement, education and better primary health care. However, modification of disease in people already afflicted is critical to stabilise families and communities. The Tiwi program has shown how quickly lives can be saved and dialysis avoided by timely intervention. The Outreach Program. will extend to other communities principles of risk factor identification, early diagnosis and treatment, that are already included in most regional & national guidelines. The program is supported by Rio Tinto and OATSIH, through the Australian Kidney Foundation. Diabetes Australia and the National Heart Foundation are collaborating for a unified approach. Program elements include education, training, algorithms for testing and treatment that emphasise simplicity, on-site testing, familiarity with a limited number of medicines, ongoing medical support, help with recall & information systems and evaluation of process and outcomes. Participation of communities might be based on need (deaths and ESRD rates), unanimous request, and commitment of staff to participate in training, so that practices will be subsequently maintained in health care plans. Mechanisms of support will vary, based on the specific needs of each community: eg health worker training, local coordinators, facilitation of screening, refinement of medical management, and support of Aboriginal health promotion officers. A similar program, with a somewhat different approach, will operate from Flinders University. The program's reach and impact could be multiplied by establishing regional centres or reinforcing existing regional strategies nationwide, and asking local governments, NGOs and universities to bring additional support.

In Australia, Aboriginal and Torres Strait Islander people score poorly on national mainstream indicators of wellbeing, with the lowest outcomes recorded in remote communities. As part of a ‘shared space’ collaboration between remote Aboriginal communities, government and scientists, the holistic Interplay Wellbeing Framework and accompanying survey were designed bringing together Aboriginal priorities of culture, empowerment and community with government priorities of education, employment and health. Quantitative survey data were collected from a cohort of 841 Aboriginal people aged 15–34 years, from four different Aboriginal communities. Aboriginal community researchers designed and administered the survey. Structural equation modelling was used to identify the strongest interrelating pathways within the framework. Optimal pathways from education to employment were explored with the concept of empowerment playing a key role. Here, education was defined by self-reported English literacy and numeracy and empowerment was defined as identity, self-efficacy and resilience. Empowerment had a strong positive impact on education (β = 0.38, p < .001) and strong correlation with employment (β = 0.19, p < .001). Education has a strong direct effect on employment (β = 0.40, p < .001). This suggests that education and employment strategies that foster and build on a sense of empowerment are mostly likely to succeed, providing guidance for policy and programs.

The following reflections on the author’s management practice are based on the text of an address given by the author at the 1999 International Conference of the Royal Australasian College of Medical Administrators in Sydney. These reflections arise out of the author’s experience for the past 5 years as manager of Nganampa Health Council, an Aboriginal community-controlled health organisation located in the remote north-west of South Australia. Nganampa Health Council is a large regional service with a national reputation for clinical and administrative excellence. It has several leading-edge health programs, which provide an exemplar for other remote health services across Australia. The author discusses three generic key management issues that remote health services managers typically encounter and argues that services are likely to be most effective when resources are applied in a focused and strategic manner and when management practices that are pragmatic and culturally appropriate are adopted.