Remote Australia Online

This special issue is being published at a time where our nation is waiting for the interim report of the Royal Commission into Aged Care Quality and Safety. In addition, the COTA (formerly known as Council on the Ageing) Australia recently held a Public Policy Forum on the need to challenge ageism, which is defined as prejudice or discrimination on the grounds of a person's age. And often the assumption is that age discrimination increases with advancing age. Thus, this focus on older persons’ health is timely, particularly given that this special issue is focused on the needs of rural, regional and remote seniors. Ageing undeniably comes with frail health, increased care needs and approaching death. And it is reassuring to know that good quality and safe aged care facilities are considered to be important enough to warrant a Royal Commission. But as this special issue demonstrates, ageing is not just about institutionalised care, illness and death. There is more to ageing, and there is more to seniors. And this is especially true in rural and remote areas, where there is limited availability of aged care facilities to begin with. We have a rapidly ageing population, that is also wealthier, better educated, better housed and contributes more to both paid and volunteer work. With this growing ageing population, it is the challenge for our rural health care system to relate to this population and to align our system of health care with their needs, which might be more diverse and not fitted to a “one size fits all seniors” approach.

Cultural loss has been neglected in the study of Aboriginal Australia. This neglect reflects the impact of changes in Australian society involving the recognition and celebration of Indigenous culture. Yet new jurisprudence relating to compensation under Australian land rights legislation has refocused attention on cultural loss. This article draws on ethnography from North West Queensland's Gulf Country to examine how the concept of loss relates to change. Reflecting on the rise of the juridical notion of a 'compensable act,' I ask, When does 'loss' occur and to whom, and what solace may be found for cultural loss? I argue that these questions focus attention on the fraught relationship between Indigenous people, anthropology, and the law in Australia, while also offering an opportunity to reformulate those relations.

Purpose: This study explores citizen activism in the articulation of a politicised counter-account of Aboriginal rights. It aims to uncover the enabling factors for a successful challenge to established political norms and the obstacles to the fullest expression of a radical imagining. Design/methodology/approach: Laclau and Mouffe's theory of hegemony and discourse is used to frame the movement's success in challenging the prevailing system of urbanised healthcare delivery. Empirical materials were collected through extensive ethnographic fieldwork. Findings: The findings from this longitudinal study identify the factors that predominantly influence the transformational success of an Yaṉangu social movement, such as the institutionalisation of group identity, articulation of a discourse connected to Aboriginal rights to self-determination, demonstration of an alternative imaginary and creation of strong external alliances. Originality/value: This study offers a rich empirical analysis of counter-accounting in action, drawing on Aboriginal governance traditions of non-confrontational discourse and collective accountability to conceptualise agonistic engagement. These findings contribute to the practical and theoretical construction of democratic accounting and successful citizen activism.

Objective: To undertake an economic evaluation of community water fluoridation (CWF) in remote communities of the Northern Territory (NT). Design: Dental caries experiences were compared between CWF and non-CWF communities before and after intervention. Costs and benefits of CWF are ascertained from the health sector perspective using water quality, accounting, oral health, dental care and hospitalisation datasets. Setting and participants: Remote Aboriginal population in the NT between 1 January 2008 and 31 December 2020. Intervention: CWF. Main outcome measures: Potential economic benefits were estimated by changes in caries scores valued at the NT average dental service costs. Results: Given the total 20-year life span of a fluoridation plant ($1.77 million), the net present benefit of introducing CWF in a typical community of 300-499 population was $3.79 million. For each $1 invested in CWF by government, the estimated long-term economic value of savings to health services ranged from $1.1 (population ≤300) to $16 (population ≥2000) due to reductions in treating dental caries and associated hospitalisations. The payback period ranged from 15 years (population ≤300) to 2.2 years (population ≥2000). Conclusions: The economic benefits of expanding CWF in remote Aboriginal communities of NT outweigh the costs of installation, operation and maintenance of fluoridation plants over the lifespan of CWF infrastructure for population of 300 or more.

Objective: This qualitative review aims to identify and list the barriers and facilitators to accessing medical services for rural and remote Australians, within the current literature to inform policy development and highlight the need for further research. Methods: The review was guided by the PRISMA method. Boolean search strings identified relevant articles using the Griffith University Library electronic catalogue. The study included only English language research articles published between August 31st, 2018 and August 31st, 2021, focusing on facilitators and barriers within the Australian context considering both access and rurality/remoteness. Results: Thematic analysis of six articles identified ten barriers: communication, confidentiality, fear and shame, funding, geography, health behaviours, reliance on others, service provision, staffing, transport; and eight facilitators: collaboration/partnerships, communication, cultural safety funding, service provision, staffing, and telehealth, to accessing medical services in rural and remote Australia. Conclusion: Ten barriers and eight facilitators to accessing medical services in rural and remote Australia were identified and listed from six articles identified through a qualitative review. This review identified a research gap regarding understanding the underlying challenges behind these barriers and facilitators and the implications for policy implementation to improve access to medical services.

PERSPECTIVE: For tens of thousands of years, Aboriginal and Torres Strait Islander people have operated and thrived within sovereign societies. The sustained and systematic effects of colonisation — which enabled the combined denial of Aboriginal and Torres Strait Islander people's self-determination, autonomy, leadership, and capability to mobilise health-benefiting resources — have created the situation in which we find ourselves today of poor health and systemic differences in health care access and outcomes. For kidney health in Aboriginal and Torres Strait Islander people, this situation is illustrated through the persistent inequities in kidney failure incidence rates, health system access, and treatment outcomes.

Background Tuberculosis (TB) incidence is decreasing in the Northern Territory (NT) but still exceeds rates elsewhere in Australia. Deaths and morbidity from advanced TB continue, with delay in diagnosis a contributor to adverse outcomes. Aims We aimed to describe the delay in diagnosis of TB, identify risk factors for delay and examine the associations between delay and clinical outcomes. Methods We conducted a historical cohort analysis which included adult inpatients diagnosed with TB at the Royal Darwin Hospital from 2010 to 2020. Patient delay was measured as time from symptom onset to first seeking care, and health system delay was quantified as time from first relevant clinical contact to diagnosis. The sum of these two periods was the total delay. Ethics approval was granted by NT HREC (2020-3852). Results Eighty-four cases were included; the median total delay was 90 days (interquartile range (IQR): 60–121), patient delay was 53 days (IQR: 30–90), and health system delay was 21 days (IQR: 12–45). Patient delay was longer among patients with extrapulmonary (median: 100 days (IQR: 90–105) compared with pulmonary TB patients (39 days (IQR: 27–54), P < 0.0001). Health system delay was longer in those aged ≥45 years (30 days (IQR: 16–51) vs younger patients (14 days (IQR: 8–30), P = 0.007) and among non-smokers (31 days (IQR: 21–55) vs 21 days (IQR: 10–40), P = 0.048). Median delay was longer among patients with non-drug-related complications of disease (P < 0.0001), those admitted to critical care (P < 0.0001), and those with respiratory failure (P = 0.001). Conclusion The patient delays we report are longer than reported elsewhere in Australia. The next steps will require concerted efforts to improve community awareness of TB and strategies to strengthen health systems through better resourcing and healthcare provider support.

Chronic Kidney disease (CKD) is over-represented amongst First Nation people with more than triple the rate of CKD in those aged 15 years and over. The impact of colonisation, including harmful experiences of health practices and research, has contributed to these health inequities. Cape York Kidney Care (CYKC) has been created as an unique service which provides specialist care that aims to centre the client within a multidisciplinary team that is integrated within the primary care setting of the remote health clinics in six communities in western Cape York, Australia. This research aims to describe the Cape York Kidney Care service delivery model, and baseline service data, including aggregated client health measures.

This Discussion Paper aims to outline some of the key issues surrounding alcohol availability and consumption in remote Aboriginal communities, focusing on those in Cape York. The legislative and policy background to the contemporary alcohol situation is outlined. Sales data from the Council-run alcohol outlets are presented for four sample Aboriginal communities, which indicate extraordinarily high alcohol consumption levels. The data suggest that virtually all drinkers in these communities, on average, are drinking at extremely hazardous or harmful levels. Such drinking levels underlie the very poor health and morbidity statistics for Cape York's Indigenous peoples. The Paper examines various explanatory models in the literature for Aboriginal drinking, and suggests that the policies developed to deal with the issue tend to be dependent upon the theoretical model adopted. A syncretic model is proposed which has at its core the argument that Aboriginal drinking practices and understandings have to be seen as arising over time from the conjunction of factors located essentially in the dominant society, together with those whose origins lie basically within Aboriginal societies themselves. This suggests that actions at both levels are requiredÐthat of the institutions and structures of the wider society on the one hand, and that of the internal dynamics, values and practices of the particular Aboriginal group on the other. It is argued that this model provides a useful framework for the development of policies in the alcohol area, and four case studies are examined.

The diffusion of digital technologies around the globe is progressing at various rates. This chapter explores initiatives that are attempting to bridge the digital divide in remote Indigenous Australian communities. It looks at the social context of the use of ICTs and draws attention to the generational divides, linguistic divides, and literacy divides in remote Indigenous Australia generated by the rapid diffusion of digital technologies. A digital divide is still evident in many remote Indigenous communities in Australia, yet as will be argued here, where there is access, there is uptake, if the devices and infrastructure can be shaped by the context, values, and practices of the user community. That is, where there is access to technologies that are meaningful to Indigenous people’s social and cultural life, there has been rapid uptake, often leading to productive learning (Kral & Schwab, 2012) and innovative applications (Carew, Green, Kral, Nordlinger, & Singer, 2015; Christen, 2008; Ormond Parker, Fforde, Corn, O’Sullivan, & Obata, 2013; Thorner & Dallwitz, 2015). Indigenous people have also been quick to realize the communicative potential embedded in the digital environment through Facebook and to harness the potential for the multimodal expression of ideas through digital music and media production, thereby suggesting that rather than consider the ‘digital divide’ solely in terms of infrastructure, hardware, and training, the digital divide also needs to be understood in terms of social and cultural practice.

5G is described as a step change in mobile delivery. While it has the potential to provide significant benefits to remote First Nations communities and homelands in Australia, the current market-driven model of 5G deployment building outward from urban and regional centres risks increasing existing digital inequalities. A new Closing the Gap target aimed at digital equity for First Nations people by 2026 provides a critical lens to assess the impact of new technologies on digital inclusion for vulnerable populations. This article draws on findings and case studies from the Mapping the Digital Gap research to analyse the potential benefits, risks and limitations of 5G in closing the digital gap across remote Australia. Alternative communications solutions combined with co-design principles may be more effective in addressing remote First Nations communities’ needs. The authors call for more holistic policy and targeted programs to improve digital inclusion for remote First Nations people.

This chapter reviews the emergence from the 1980s of community-based initiatives aimed at reducing alcohol-related harm by curtailing the availability of alcohol. We distinguish three types of local restrictions on supply: voluntary agreements negotiated between liquor outlets and neighbouring communities; restrictions negotiated between outlets and communities and then incorporated into the licence conditions of the outlets concerned, and restrictions imposed by state/territory licensing authorities. Local restrictions on supply are usually based on a public health approach to alcohol problems which focuses on reducing alcohol-related harms at a local population level rather than focusing on individual drinkers. Historically, and particularly in central Australia, campaigns to impose restrictions were often led by women, who experienced at first hand the violence associated with excessive drinking. We discuss evidence from local restrictions in remote communities and regions, and in regional towns with large Aboriginal populations. Evidence suggests that, where restrictions are a product of genuine community input, they are effective in reducing alcohol-related harms and enjoy strong support. Where they are imposed with little regard to community input—as in the case of some Alcohol Management Plans introduced by the Queensland Government in the early 2000s—they are often perceived by those affected as discriminatory and disempowering. Community-based restrictions are also often politically contentious, largely as a result of opposition by the liquor and hospitality industries. The chapter also discusses the relationship between alcohol restrictions and anti-discrimination legislation and summarises factors associated with effective community-based restrictions on supply.

Background Nurse-led models of care are important for populations residing in regional, rural, and remote settings, who experience barriers to accessing health care. A previous review examining a subset of research undertaken in the Australian context through the Rural Health Multidisciplinary Training program identified a paucity of literature around nurse-led models of care implemented in these settings. Given the maldistribution of the medical workforce in non-metropolitan settings, scoping the broader literature for evidence around nurse-led models of care in these settings is imperative for informing the future directions of the nursing workforce. Aim To identify available literature for evaluated nurse-led modes of care implemented in regional, rural, and remote geographical settings of Australia. Methods A scoping review was undertaken using the Joanna Briggs Institutes’ scoping review methodology. A protocol was developed in advance, which documented the objectives, inclusion criteria, and methods. The search involved a comprehensive review of peer-reviewed and grey literature published between 2010 and 2022, to map the evidence examining evaluated nurse-led models of care implemented in regional, rural, and remote settings of Australia. A descriptive approach aligning with the review question and objectives, was used to synthesise findings. Findings The search retrieved 1807 unique citations, of which 53 were included with an additional 4 studies identified through review of reference lists. In total, 57 studies examining 49 unique nurse-led models of care were included. Studies were heterogenous in the models of care implemented, settings, and research evaluation designs. Most models of care were implemented in the community-health setting. The majority of first authors were affiliated with a university, with the highest proportion based in a metropolitan setting. The benefits of implementing nurse-led models of care included improving hospital indicators, the prevention and management of chronic disease, healthcare access, and health outcomes. Barriers for implementation were widely cited and were attributed to the non-metropolitan setting of implementation and organisational factors. Specific barriers were also cited for the implementation of nurse practitioner (NP) models of care, such as the constraints of the Medicare Benefits Schedule and role ambiguity. Discussion Nurse-led models of care included in this review were diverse, implemented across the lifespan, mostly led by registered nurses rather than nurses who were also NPs or transitional NPs, and implemented in the community-health setting. The findings expand on the international literature around nurse-led models of care and identify the need for greater support around implementation and evaluation, particularly in non-metropolitan geographical settings. Conclusion A greater focus on the implementation and evaluation of nurse-led models of care, including NP-led models of care, in regional, rural, and remote settings of Australia, is required. This is important given the maldistribution of the health workforce and inequity experienced by populations residing in these settings when accessing health services. Greater support is required for place-based evaluations of nurse-led models of care, which builds organisational capability and nursing workforce capacity for research.

This review paper examines the drinking water quality issues in remote and Indigenous communities, with a specific emphasis on Australia. Access to clean and safe drinking water is vital for the well-being of Indigenous communities worldwide, yet numerous challenges hinder their ability to obtain and maintain water security. This review focuses on the drinking water-related issues faced by Indigenous populations in countries such as the United States, Canada, New Zealand, and Australia. In the Australian context, remote and Indigenous communities encounter complex challenges related to water quality, including microbial and chemical contamination, exacerbated by climate change effects. Analysis of water quality trends in Queensland, New South Wales, Western Australia, and the Northern Territory reveals concerns regarding various pollutants with very high concentrations in the source water leading to levels exceeding recommended drinking water limits such as hardness, turbidity, fluoride, iron, and manganese levels after limited treatment facilities available in these communities. Inadequate water quality and quantity contribute to adverse health effects, particularly among Indigenous populations who may resort to sugary beverages. Addressing these challenges requires comprehensive approaches encompassing testing, funding, governance, appropriate and sustainable treatment technologies, and cultural considerations. Collaborative efforts, risk-based approaches, and improved infrastructure are essential to ensure equitable access to clean and safe drinking water for remote and Indigenous communities, ultimately improving health outcomes and promoting social equity.

This study explored the barriers and facilitators to hepatitis C virus (HCV) treatment for Aboriginal and Torres Strait Islander peoples in rural South Australia as viewed from a healthcare provider perspective in the era of direct acting antivirals (DAAs). Phase 1 was a qualitative systematic review examining the barriers and enablers to diagnosis and treatment amongst Indigenous peoples living with HCV worldwide. Phase 2 was a qualitative descriptive study with healthcare workers from six de-identified rural and regional Aboriginal Community-Controlled Health Services in South Australia. The results from both methods were integrated at the analysis phase to understand how HCV treatment could be improved for rural Aboriginal and Torres Strait Islander peoples. Five main themes emerged: the importance of HCV education, recognizing competing social and cultural demands, the impact of holistic care delivery and client experience, the effect of internal barriers, and overlapping stigma, discrimination, and shame determine how Indigenous peoples navigate the healthcare system and their decision to engage in HCV care. Continued efforts to facilitate the uptake of DAA medications by Aboriginal and Torres Strait peoples in rural areas should utilize a multifaceted approach incorporating education to community and cultural awareness to reduce stigma and discrimination.

Objectives: To determine the clinical and environmental variables associated with frequent presentations by adult patients to a remote Australian hospital emergency department (ED) for reasons other than chronic health conditions. Design: Unmatched case?control study of all adult patients attending Katherine Hospital ED between 1 January and 31 December 2012. Participants: Cases were defined as frequent attenders (FAs) without a chronic health condition who presented to the ED six or more times during the 12-month period. A single presentation was randomly selected for data collection. Controls were patients who presented on only one occasion. Outcome measures: Basic demographic data were collected, including clinical outcomes, Indigenous status, living arrangements, and whether alcohol and violence contributed to the presentation. Environmental variables were extracted from the Bureau of Meteorology database and mapped to each presentation. Results: FAs were much more likely to be homeless (odds ratio [OR], 16.4; P < 0.001) and to be Aboriginal (OR, 2.16; P < 0.001); alcohol as a contributing factor was also more likely (OR, 2.77; P = 0.001). FAs were more likely to present in hotter, wetter weather, although the association was statistically weak. Clinical presentations by cases and controls were similar; the annual death rates for both groups were high (3.6% and 1.5%, respectively). Conclusions: There was a strong association between FA and Aboriginal status, homelessness and the involvement of alcohol, but alcohol was more likely to contribute to presentation by non-Aboriginal FAs who had stable living conditions. FAs and non-FAs had similar needs for emergency medical care, with strikingly higher death rates than the national average in both groups. As a result of this study, Katherine Hospital has initiated a Frequent Attender Pathway that automatically triggers a dedicated ED service for those at greatest clinical risk. Homelessness is a serious problem in the Northern Territory, and is associated with poor health outcomes.

Objectives: Aboriginal and Torres Strait Islander communities in remote parts of Australia are some of the most underserviced communities in regard to oral health care. These communities rely on volunteer dental programmes such as the Kimberley Dental Team to fill the gaps in care, however, there are no known continuous quality improvement (CQI) frameworks to guide such organizations to ensure that they are delivering high-quality, community-centred, culturally appropriate care. This study proposes a CQI framework model for voluntary dental programmes providing care to remote Aboriginal communities. Methods: Relevant CQI models wherein the (i) behaviour of interest was quality improvement, and (ii) the health context was volunteer services in Aboriginal communities were identified from the literature. The conceptual models were subsequently augmented using a 'best fit' framework and the existing evidence synthesized to develop a CQI framework that aims to guide volunteer dental services to develop local priorities and enhance current dental practice. Results: A cyclical five-phase model is proposed starting with consultation and moving through the phases of data collection, consideration, collaboration and celebration. Conclusions: This is the first proposed CQI framework for volunteer dental services working with Aboriginal communities. The framework enables volunteers to ensure that the quality of care provided is commensurate with the community needs and informed by community consultation. It is anticipated that future mixed methods research will enable formal evaluation of the 5C model and CQI strategies focusing on oral health among Aboriginal communities.

Introduction: Kowanyama is a very remote Aboriginal community. It is ranked amongst the top five most disadvantaged communities in Australia and has a very high burden of disease. Currently, the community has access to GP-led Primary Health Care (PHC) 2.5 days a week for a population of 1200 people. This audit aims to assess whether GP access correlates with retrievals and/or hospital admissions for potentially preventable conditions and whether it is cost effective and improves outcomes to provide the benchmarked staffing of GPs. Methods: A clinical audit was undertaken of aeromedical retrievals for the year 2019 to assess whether access to a rural GP would have prevented the need for retrieval and whether the condition for retrieval was 'preventable’ or 'not preventable'. A cost-analysis was undertaken to compare the cost of providing accepted benchmark levels of GPs in community with the cost of potentially preventable retrievals. Results: There were 89 retrievals of 73 patients in 2019. 61% of all retrievals were potentially preventable. Most (67%) of the preventable retrievals occurred with no doctor on site. For preventable condition retrievals, the mean number of visits to the clinic compared with non-preventable condition retrievals was higher for registered nurse or health worker visits (1.24 vs 0.93) and lower for GP visits (0.22 vs 0.37). The conservatively calculated costs of retrievals for 2019 matched the maximum cost of providing benchmark numbers (2.6 FTE) of rural generalist (RG) GPs in a rotating model for the audited community. Conclusion: Greater access to GP-led PHC appears to lead to fewer retrievals and hospital admissions for potentially preventable conditions. It is likely that some preventable condition retrievals would be avoided if a GP was always on site. Providing benchmarked numbers of RG GPs in a rotating model in remote communities is cost-effective and would improve patient outcomes.

Rural health has long been subject to less investment and often not prioritized in terms of resources (both human and financial) as well as investment, as stakeholders and decision-makers tend to focus their attention on urban areas and major cities. This has had negative consequences on the quality of service and patients outcome; for example, good roads can facilitate swift referrals and an effective supply chain; economic activities can create retention for health workers and avoid mass exodus from rural areas to urban areas. As the world is still wrestling with the consequences of Covid-19; rural health will be affected, and if no effective action is taken, most countries in Low and Middle-Income Countries will not reach the SDGs; and will continue to widen the gap and worsen the health conditions of those living in rural areas. Strengthening and improving the health system in general and specifically in rural areas is an effective tool for preventing the next epidemic and pandemic and addressing current pressing issues regarding coverage, access, and quality. The return on investment of robust rural health will be a lever for economic and social stability for many regions struggling to keep their citizens healthy and productive.

Despite long histories of traditional food security, Indigenous peoples globally are disproportionately exposed to food insecurity. Addressing this imbalance must be a partnership led by Indigenous peoples in accordance with the UN Declaration of the Rights of Indigenous Peoples. We report the co-design process and resulting design of a food security research project in remote Australia and examine how the co-design process considered Indigenous peoples’ ways of knowing, being, and doing using the CREATE Tool. Informed by the Research for Impact Tool, together Aboriginal Community Controlled Health Organisation staff, Indigenous and non-Indigenous public health researchers designed the project from 2018–2019, over a series of workshops and through the establishment of research advisory groups. The resulting Remote Food Security Project includes two phases. Phase 1 determines the impact of a healthy food price discount strategy on the diet quality of women and children, and the experience of food (in)security in remote communities in Australia. In Phase 2, community members propose solutions to improve food security and develop a translation plan. Examination with the CREATE Tool showed that employing a co-design process guided by a best practice tool has resulted in a research design that responds to calls for food security in remote Indigenous communities in Australia. The design takes a strengths-based approach consistent with a human rights, social justice, and broader empowerment agenda. Trial registration: The trial included in Phase 1 of this project has been registered with Australian New Zealand Clinical Trials Registry: ACTRN12621000640808.

This paper investigates the design of a hybrid renewable energy and diesel generator microgrid for a remote aboriginal community in Western Australia using two techno-economic design optimisation programs, HOMER and XENDEE. Each program approaches the design optimisation problem in a different way (evolutionary simulation algorithm vs linear programming) and this paper seeks to compare the results from the different approaches. The optimisation results from the two programs are very similar for the rural hybrid microgrid case study, although there are differences in how each program reached its conclusions. A key difference identified is how each program handles the time-sequential nature of the demand profile and renewable energy resource.

Conventional dietary assessment methods are based predominately on Western models which lack Aboriginal and Torres Strait Islander knowledges, methodologies, and social and cultural contextualisation. This review considered dietary assessment methods used with Aboriginal and Torres Strait Islander populations and assessed their applicability. Four electronic databases and grey literature were searched with no time limit applied to the results. Screening, data extraction and quality appraisal were undertaken independently by two reviewers. Out of 22 studies, 20 were conducted in rural/remote settings, one in an urban setting, and one at the national population level. The most frequently used and applicable dietary assessment method involved store data. Weighed food records and food frequency questionnaires had low applicability. Modifications of conventional methods were commonly used to adapt to Indigenous practices, but few studies incorporated Indigenous research methodologies such as yarning. This highlights an opportunity for further investigation to validate the accuracy of methods that incorporate qualitative yarning-based approaches, or other Indigenous research methodologies, into quantitative data collection. The importance of developing validated dietary assessment methods that are appropriate for this population cannot be understated considering the high susceptibility to nutrition-related health conditions such as malnutrition, overweight or obesity, diabetes, and cardiovascular disease.

This study aimed to determine perceptions of the lived experience of food insecurity and suggestions to improve food security in four remote Aboriginal communities in the Northern Territory, and Queensland. Participants were Aboriginal and/or Torres Strait Islander pregnant and breastfeeding women, and parents/carers of children aged six months to five years. Semi-structured interviews (n=17) were conducted between June–July 2021 and the data thematically analysed using a four stage process. No specific term was used by participants to describe being either food secure or insecure. Descriptions of food security were centred in food sharing, food sufficiency, and family activities. Elements describing food insecurity were physical pain and emotional stress, adults going without food, seeking family help and managing without food until payday. Factors contributing to food insecurity were reported to be: (i) Low income and unemployment, (ii) Cost of living remotely, (iii) Resource sharing, and (iv) Impact of spending on harmful commodities and activities. Three themes were conceptualised: (1) Cultural practices buffer food insecurity, (2) Coping with food insecurity, (3) People accept a degree of food insecurity as normal. Findings suggest Aboriginal and Torres Strait Islander cultural practices such as sharing food buffer episodic food insecurity and constitute ‘cultural food security’. Despite use of cultural practices (e.g., procuring traditional food) and generic coping strategies, regular episodes of food insecurity often aligned with the off week of social assistance payments. Household energy (electricity) security was coupled to food security. Suggestions for improving food security included better transport and food access, extending electricity rebates, increases in the regularity of social assistance payments, and computer access and training in budgeting. Policies to advance food security should embody deeper Aboriginal and Torres Strait Islander descriptions and experiences. Community-derived policy suggestions which aim to increase access to adequate, regular, stable household income are likely to succeed.

This study aimed to understand the experiences, barriers, and facilitators of rural general practitioners’ involvement with high-acuity patients. Semi-structured interviews with rural general practitioners in South Australia who had experience delivering high-acuity care were audio-recorded, transcribed verbatim, and analyzed through content and thematic approaches incorporating Potter and Brough’s capacity-building framework. Eighteen interviews were conducted. Barriers identified include the inability to avoid high-acuity work in rural and remote areas, pressure to handle complex presentations, lack of appropriate resources, lack of mental health support for clinicians, and impacts on social life. Enablers included a commitment to community, comradery in rural medicine, training, and experience. We concluded that general practitioners are a vital pillar of rural health service delivery and are inevitably involved in disaster and emergency response. While the involvement of rural general practitioners with high-acuity patients is complex, this study suggested that with the appropriate system, structure and role supports, rural general practitioners could be better empowered to manage high-acuity caseloads locally.

We present the argument that medical recruitment to a previously under-recruited remote town was effected through what Social Network Analysis (SNA) measures as “brokerage” which operates amidst “structural holes”. We proposed that medical graduates being generated by the national Rural Health School movement in Australia were particularly affected by the combined effect of workforce lacks (structural holes) and strong social commitments (brokerage) – all key SNA concepts. We therefore chose SNA to assess whether the characteristics of RCS-related rural recruitment had feature that SNA might be able to identify, as operantly measured using the industry-standard UCINET's suite of statistical and graphical tools. The result was clear. Graphical output from the UCINET editor showed one individual as being central to all recently recruited doctors to one rural town with recruitment issues like all the others. The statistical outputs from UCINET characterised this person as the single point of most connections. The real-world engagements of this central doctor were in accord with the description of brokerage, a core SNA construct, relationship with reported the reason for these new graduates both coming and staying in town. SNA thus proved fruitful in this first quantification of the role of social networks in drawing new medical recruits to particular rural towns. It allowed description at the level of individual actors with a potent influence on recruitment to rural Australia. We propose these measures could be helpful as key performance indicators for the national Rural Clinical School programme that is generating and distributing a large workforce in Australia, which appears from this work to have a strong social basis. This redistribution of medical workforce from urban to rural is needed internationally.