Remote Australia Online

Collaboration is held to be an essential element of addressing complex problems. However, it is difficult to achieve, as it is often in tension with bureaucratic mindsets and traditions. Recently, Williams (2013) has suggested that all policy bureaucrats and program managers required to be involved with collaboration need to ‘span boundaries’ – to develop the capacity to build effective relationships, be able to engage ‘deeply’ with different parties, and understand and value multiple perspectives. A recent government initiative to improve Indigenous wellbeing in remote Australia had a strong emphasis on collaboration and partnership. However, policy actors involved in implementation resisted attempts to make them work differently, resulting in reversion to the status quo. Consistent with social practice literature, I contend that openness to changed ways of working is a critical element for success. Drawing on interviews with elite policy actors involved in the development and implementation of the initiative, the analysis finds that career public servants appear to be less open to collaboration than those who have worked outside. While I agree that boundary spanning capability is important for overcoming the pull of the status quo, the analysis suggests that diversifying the public sector workforce should supplement training efforts.

Introduction: CheckUP, in partnership with the Queensland Aboriginal & Islander Health Council is the jurisdictional fund holder of the Commonwealth Government’s Outreach program funds that are used to provide a range of medical, allied health and nursing services to rural and remote communities and Aboriginal and Torres Strait Islander peoples. Currently, these services are provided by face-to-face outreach clinics. Telehealth is the delivery of health care at a distance using information and communication technologies. Many health care providers use telehealth as an alternative method of delivering health care services which traditionally may have only ever been available face-to-face. It is considered “best practice” to provide healthcare using a combination of face-to-face and telehealth as opposed to a complete replacement of face-to-face services. The suitability and proportion of telehealth substitution varies by specialty, complexity, and case mix. Telehealth may reduce the cost of health care provision when avoided travel costs associated with outreach services are considered. The aim of this study was to identify how CheckUP provided outreach services and costs may be affected through the substitution of these services with telehealth. Methods: We performed a cost comparison study where the actual costs of providing face-to-face outreach clinics were compared to a modelled cost of providing the same service using a blended face-to-face and telehealth service delivery model. We modelled seven clinician reimbursement models and three rates of telehealth substitution (25%, 50% and 75%). Models were stratified by health discipline. We modelled the 16 health disciplines that accounted for the top 50% of CheckUP services for both activity (number of visits) and cost of providing the service. Costs were reported from the perspective of CheckUP. Results: Thirteen of the sixteen health discipline services were less expensive to provide using a blended face-to-face / telehealth service model in at least one of the reimbursement models and telehealth substitution rate permutations. The resultant cost savings were observed to increase as the rate of telehealth substitution increased. The telehealth substitution rate at which costs savings were realised varied by discipline − some disciplines (e.g. GP, podiatry) realised savings at a 25% substitution rate whereas, other disciplines (e.g. physiotherapy, dermatology) only realised saving at a 75% substitution rate. Three disciplines never resulted in cost savings using telehealth substitution. Conclusion: Degree of substitutability of face-to-face services with telehealth, travel savings and cost of telecommunications required for a telehealth service need to be considered on a case-by-case basis to determine if telehealth will result in cost savings.

Aims: Cervical cancer is the second most common cancer in women and the sixth leading cause of death worldwide. The incidence of cervical cancer in Aboriginal women is more than twice that of non-Aboriginal women and their mortality rate is fourfold higher. Despite this, Aboriginal women are significantly under screened with respect to cervical cancer screening due to complex cultural and socio-economic factors. The recent discovery of HPV as the primary causative agent in most cervical cancers has opened the door to HPV testing as an alternative to the traditional Pap test as a means of detecting cervical cancer. HPV testing as a primary screening test allows for self-sampling which may overcome some of the barriers to Pap testing, including being less-obtrusive, and this may make in a more acceptable screening practice for Aboriginal women. This study is exploring the feasibility and acceptability of HPV self-sampling as a cervical screening approach for Aboriginal women using a nurse-led community engagement approach. Methods: Following a comprehensive collaboration and co-creation process, eight rural centres in Western NSW were selected. Primary Healthcare Nurses (PHCNs), are working alongside Local Aboriginal Land Council Community Engagement Workers to identify, engage with, and provide culturally appropriate education to, Aboriginal women around the value of cervical cancer screening. Women are firstly offered assistance in procuring a regular Pap test and if they refuse, consenting women are assessed for eligibility for the study via an interview. Eligible participants can then conduct the self-sampling. HPV testing is being conducted by the Victorian Cytology Service with results forwarded to the participant, their nominated GP and the PHCN. Follow-up by the PHCN includes a discussion of the results, including referral information if required, along with an Evaluation Questionnaire. Results: Within the first month of the pilot, 6 of the 8 sites have commenced the trial. Of the expected 266 sample size, a total of 11 participants have been recruited and their swabs sent for cytology. Early results suggest a general interest and acceptance of the HPV self-sampling concept within the local Aboriginal communities. Conclusions: At the completion of the pilot, we will have developed a model created with and for Aboriginal women. It is anticipated that the results of this study will contribute to the work of others who are trialling the use of self-sampling and will inform the National Cervical Screening Program (May 2017), specifically in relation to Aboriginal women.

Background: People living in rural and remote Australia experience increased mental health problems compared with metropolitan Australians. Moreover, Indigenous Australians are twice as likely as non Indigenous Australians to report high or very high levels of mental health problems. It is imperative, therefore, that effective and sustainable social and emotional wellbeing services (Indigenous Australians prefer the term “social and emotional wellbeing” to “mental health”) are developed for Indigenous Australians living in remote communities. In response to significant and serious events such as suicides and relationship violence in a remote Indigenous community, a social and emotional wellbeing service (SEWBS) was developed. After the service had been running for over three years, an independent evaluation was initiated by the local health board. The aim of the evaluation was to explore the impact of SEWBS, including issues of effectiveness and sustainability, from the experiences of people involved in the development and delivery of the service. Methods: Purposive sampling was used to recruit 21 people with different involvement in the service such as service providers, service participants, and referrers. These people were interviewed and their interviews were transcribed. Interpretative Phenomenological Analysis (IPA) was used to analyse the interview transcripts to identify superordinate themes and subthemes in the data. Results: Two superordinate themes and nine subthemes were developed from the interview transcripts. The first superordinate theme was called “The Big Picture” and it had the sub themes: getting started; organizational factors; funding; the future, and; operational problems. The second superordinate theme was called “On the Ground” and it had the subthemes: personal struggles; program activities; measuring outcomes, and; results. Conclusions: While the evaluation indicated that the service had been experienced as an effective local response to serious problems, recommendations and directions for future research and development emerged that were more broadly applicable. Issues such as appropriate staffing, localising decision making, identifying priorities and how they will be evaluated, and developing flexibility in terms of job descriptions and qualifications are highlighted.

Background: In the Northern Territory (NT) there is a lack of respite services available to palliative care patients and their families. Indigenous people in the NT suffer substantially higher rates of poorly controlled chronic disease and premature mortality associated with poor heath than the Australian population as a whole. The need for a flexible, community based, culturally appropriate respite service in Alice Springs was identified and, after the service had been operating for 10 months, a qualitative evaluation was conducted to investigate the experiences of people involved in the use and operation of the service. Methods: Semi-structured interviews were conducted with patients, carers, referrers, and stakeholders. A total of 20 people were interviewed. Interpretative Phenomenological Analysis was used inductively to analyse the transcripts. Two case studies are also described which illustrate in greater detail the impact the respite service has had on people’s lives. Results: From the semi-structured interviews, two superordinate themes along with a number of sub themes were developed. The two superordinate themes described both “The Big Picture” considerations as well as the pragmatics of “Making the Service Work”. The sub themes highlighted issues such as being stuck at home and the relief that respite provided. The case studies poignantly illustrate the difference the respite service made to the quality of life of two patients. Discussion: The findings clearly indicate an improvement in quality of life for respite patients and their carers. The respite service enabled improved care coordination of chronic and complex patients as well as improved medication compliance and symptom management. As a result of this evaluation a number of recommendations to continue and improve the service are provided.

Patient-led appointment scheduling is a form of responsive regulation in which patients schedule their own psychotherapy appointments within the constraints of available resources. Of 92 patients referred to a clinical psychology clinic in the public mental health service of a remote country town in Australia, 51 attended more than 1 appointment (M = 3.6; median = 3; range = 2–11). The average number of missed and cancelled appointments was between 0 and 1.1. As compared with reported results of other practice-based studies, this approach to treatment scheduling was equivalently effective (in terms of effect size) and substantially more efficient (in terms of effect size achieved per session attended). Patient-led regulation of treatment parameters holds promise in a context of heavy demands and limited resources in mental health services.

The Beagle Bay Immersion Program is a Christian Service-Learning experience, which facilitates opportunities for secondary school students to experience unique expressions of cultural diversity found in remote Aboriginal communities of Western Australia. Through engagement in the program, students undergo a process of experiential learning, identifying core social justice issues present in a broader Australian social context, and helping to address identified community needs. This immersion program is conducted as part of the Christian Service-Learning Program at a Perth-based Catholic Secondary College in Western Australia. The Beagle Bay Immersion Program serves as an opportunity for students to engage in acts of discipleship, modeling values of social and cultural inclusivity as a means of enriching their own communities. Underpinned by core Gospel values, the program aims to actively promote a “spirit of solidarity and service to others” (Prendiville, 2016, p. 42) both among the immediate participants and the wider school community. Presented in this chapter is an examination of the values which guide the College’s Service-Learning Program and the ways in which the Beagle Bay Immersion Program facilitates attitudes of inclusivity by exposing students to diverse populations. Christian Service-Learning can serve as a means through which students can circumvent barriers that preclude exposure to diversity. The Beagle Bay Immersion Program seeks to build relationships through service, which benefit both the College and Beagle Bay Communities, providing students opportunities for personal, spiritual, and academic growth while fostering a culture of inclusion.

Background: We analysed hospital admissions of a predominantly Aboriginal cohort of children in the remote Fitzroy Valley in Western Australia during the first 7 years of life. Methods: All children born between January 1, 2002 and December 31, 2003 and living in the Fitzroy Valley in 2009–2010 were eligible to participate in the Lililwan Project. Of 134 eligible children, 127 (95%) completed Stage 1 (interviews of caregivers and medical record review) in 2011 and comprised our cohort. Lifetime (0–7 years) hospital admission data were available and included the dates, and reasons for admission, and comorbidities. Conditions were coded using ICD-10-AM discharge codes. Results: Of the 127 children, 95.3% were Indigenous and 52.8% male. There were 314 admissions for 424 conditions in 89 (70.0%) of 127 children. The 89 children admitted had a median of five admissions (range 1–12). Hospitalization rates were similar for both genders (p = 0.4). Of the admissions, 108 (38.6%) were for 56 infants aged <12 months (median = 2.5, range = 1–8). Twelve of these admissions were in neonates (aged 0–28 days). Primary reasons for admission (0–7 years) were infections of the lower respiratory tract (27.4%), gastrointestinal system (22.7%), and upper respiratory tract (11.4%), injury (7.0%), and failure to thrive (5.4%). Comorbidities, particularly upper respiratory tract infections (18.1%), failure to thrive (13.6%), and anaemia (12.7%), were common. In infancy, primary cause for admission were infections of the lower respiratory tract (40.8%), gastrointestinal (25.9%) and upper respiratory tract (9.3%). Comorbidities included upper respiratory tract infections (33.3%), failure to thrive (18.5%) and anaemia (18.5%). Conclusion: In the Fitzroy Valley 70.0% of children were hospitalised at least once before age 7 years and over one third of admissions were in infants. Infections were the most common reason for admission in all age groups but comorbidities were common and may contribute to need for admission. Many hospitalizations were feasibly preventable. High admission rates reflect disadvantage, remote location and limited access to primary healthcare and outpatient services. Ongoing public health prevention initiatives including breast feeding, vaccination, healthy diet, hygiene and housing improvements are crucial, as is training of Aboriginal Health Workers to increase services in remote communities.

A remote, multi-site Aboriginal Medical Service in Western Australia has been using an electronic medical record as their primary health care clinical record for seven years. During this time a number of innovations have been developed which have improved the care delivery to patients in an incredibly remote part of Australia. In this presentation, a representative of the Aboriginal Medical Service will outline how the customer, together with the Vendor developed a software feature that has enhanced emergency patient care in this remote region. Due to the transient nature of the patient demographic, high rates of chronic disease/comorbidities and English being a second and sometimes third language among many of their patients, the customer needed something to assist in ensuring the continuity of care, for the many patients who end up at an acute care facility around the region. The software enhancement allows a pre-approved organisation, in this case, 6 remote hospitals, to be able to search for and access the patient’s primary health record if they present to the hospital requiring treatment. When the patient presents, the hospital searches for the patient in the organisations’ patient lists. They select the correct patient and after recording patient consent or inability to provide consent, the record is made visible to the hospital for a period of 24 hours. A secure and encrypted message is sent to clinical leaders at the AMS, advising them that the patient has presented to the hospital and that the patient clinical record has been accessed. Staff at the primary health care site are aware of the patient’s presentation, and are able to provide appropriate follow up that they otherwise would not if they did not know of the presentation. Since training was completed, there has been an average of 173 ED Access episodes per month. Following the patient encounter, staff at the hospital, record a progress note, advising the reason for presentation, findings, management and importantly whether the patient was admitted of discharged. The customer will talk about governance and training models implemented, and outline the impact that the ability to share the patient primary clinical record has had on the lives of those who live in this remote outback area, and how she monitors the program to ensure protocols are respected. The vendor will outline some of the technical challenges of developing this feature and how organisations using this feature address privacy concerns and will provide a live demonstration of the feature.

This presentation will cover the current national mental health reforms resulting from the National Mental Health Commission Report and special issues affecting rural and remote Australia will be the focus and the economic issues emphasised.

Aboriginal and Torres Strait Islander people face complex challenges in gaining consistent access to the range of services required to live successfully in remote Australia. Geographical distance from urban centres, environmental extremes, high costs and cross-cultural considerations are factors in people being able to choose and use services that best meet their needs. For people with disabilities, accompanying ill-health, limited transport and low levels of community understanding of their situation are additional obstacles. The purpose of this paper is to share the findings of research on ways to improve the positive impact of services on the lives of Aboriginal and Torres Strait Islander people with disabilities in remote Australia. It presents six key insights that have emerged from the activities of our organisation over the last decade, with special reference to our research with Aboriginal people with disabilities in four communities in the Northern Territory and South Australia in 2015-16. Notable observations arising from the research are that people tend to be passive in their responses to service providers, that community knowledge and education levels on disability are very low, benchmarks and standards relevant to remote communities are applied unevenly and that competencies to work cross-culturally are under-developed among service providers. We find that groups that support empowerment and advocacy for people with disabilities are largely absent from remote communities. A significant theme is that the design of services for Aboriginal people with disabilities in remote locations tends to be transactional in character rather than transformative, a point developed further in the paper. Through case studies and examples, we offer greater depth and human insight to the subject, as well as bringing out the voices and perspectives of people with disabilities. The paper proceeds to make recommendations orientated towards improving services, an aim best accomplished by integrating what has been learned from research into augmented national strategies, standards and approaches. We argue that for disability in remote communities to be better understood, greater knowledge should be generated in ways that empower people with disabilities themselves. The fundamental challenge for people with disabilities in remote Australia is how best to gain access to care and support services within a community environment that encourages social and economic inclusion. We recommend that further strategic, design and operational work is conducted to tackle the challenges and problems we describe in the paper.

Significant challenges exist for Indigenous people in identifying suitable economic and commercial development opportunities directed at enhancing economic and human development within their communities. Ecotourism is seen as one sector that could provide such opportunities. Don Fuller and his colleagues examine the importance and implications of Indigenous culture for ecotourism developments in remote Australian Indigenous communities, in order to evaluate the potential of ecotourism ventures as a possible contributor to economic and human development within remote Indigenous communities. In addition to examining the influence of culture, the paper suggests important strategies for Indigenous success in operating ecotourism enterprises. These include the importance of consultation and planning processes, the availability of suitable education and training to Indigenous business owner-operators and the availability of joint-venture partnerships with actors in the mainstream economy.

Introduction: Trachoma is an important eye infection, which affects an estimated 84 million people, and is responsible for 8 million cases of preventable blindness worldwide. The international Alliance for Global Elimination of Trachoma by the year 2020 (GET2020) is a WHO-led initiative which unites countries, including Australia, in a commitment to eliminate trachoma as a public health problem by 2020. Australia has several areas in which endemic trachoma persists, including rural and remote Aboriginal Communities in Western Australia (WA). The WA Trachoma Program formed in 2006, and applied evidence based guidelines, and a coordinated strategic approach to reducing trachoma across WA. We review program data and discuss their implications for trachoma elimination in Australia, identifying key lessons learned. Methods: Reported trachoma screening data from more than 50 Aboriginal Communities across WA were analysed to provide an understanding of program progress. Key challenges and barriers to effective implementation have been documented, as well as reflections from key stakeholders. The impact of identified program milestones and key program decisions are analysed with respect to the changing rates of trachoma prevalence. Results: The trachoma prevalence in WA has dropped from 24% in 2006, to 2.6% in 2015. Program KPIs improved over this time, with the number of ‘at risk’ communities screened increasing from 75% to 100%, and the number of children in the target group screened increasing from 39% to 89%. Program milestones that facilitated these successes included: increased funding; clearly identified KPIs; a coordinated approach to screening; innovative workforce solutions; formation of a Program Reference Group; and excellent relationships with key stakeholders and Aboriginal Communities. Discussion: As Australia nears its target of eliminating trachoma as a public health problem by 2020, significant challenges to this goal remain. New programmatic issues threaten elimination in some areas, including the limitations of the screening tool, the highly mobile Aboriginal population and issues of program fatigue. New strategies are required that address these issues: greater coordination between jurisdictional programs; renewed Community engagement with the use of more generic health promotion messaging; and a sharp focus on key social determinants, particularly environmental health conditions. Conclusion: Trachoma is a worldwide problem and Australia is the only developed country with endemic trachoma. The WA Trachoma Program has demonstrated that a flexible and responsive approach can greatly reduce trachoma prevalence as we near our target of elimination by 2020.

Burns are a leading cause of child morbidity and mortality in Australia.1,2 Previous studies have shown that Indigenous children and children living in rural and remote areas are disproportionally affected by burn injuries.3,4 A much larger proportion of Indigenous (5.1%) compared with non-Indigenous (0.5%) children live in remote areas.5 However, to our knowledge, it has not yet been explored if living in remote areas impacts differently on the risk of burn injury in Indigenous compared with non-Indigenous children. This level of information is important to inform if burn injury prevention measures specifically targeted at Indigenous children in remote areas are needed.

Working in a remote Indigenous community has many challenges in delivering an effective drug and alcohol harm minimisation and treatment program. We live and work in the community and have firsthand experience of the cost of drug and alcohol misuse, this behaviour now normalised is not consistent with Aboriginal culture. Ferdy’s Haven is an Aboriginal Community Controlled Health Organisation which provides a residential recovery program for people who self-identify as having a substance misuse problem and self-refer on Palm Island. Services were initially established in early 1980 on the Alcoholics Anonymous (AA) program. However, the AA program does not meet everybody’s needs and is not consistent with the harm minimisation strategies within the current Australian National Drug Strategy. Now, times have changed since the early 1980s, and community social issues have evolved and escalated with the introduction of other forms of drugs and substances resulting in high levels of drug and alcohol consumption that is now affecting young people and their families in the community. Tackling the issues has meant that we need to evaluate how we provide our service and we recognise that our programs need to change to meet the needs of the community today. The Australian National Drug Strategy is developed on evidence based research and we realised that this was needed at Ferdy’s Haven and became research partners with James Cook University though the Townsville Aboriginal and Islander Health Service in 2015. This is the first time that Ferdy’s Haven has been involved with a formal research process in the last decade. This is an important process which included Ferdy’s from the beginning, the youth workers were trained as research assistants and were involved in developing the survey tool through to data analysis in the project. Young people doing research with young people and finding out the issues is really important for our service delivery and building Ferdy’s to meet the community’s need. Our experience has been positive, the interim findings of the research has provided more insight into the lives of the young people and their needs for us. The research process has been a steep learning curb for Ferdy’s but we see this as having potential to building a better service for our remote community. We would like to share our story with you.

Australia produces over 90 per cent of its domestic food requirements. Compared with many other nations, it is in a global sense ‘food secure’. However, within the Australian population there are some people who regularly experience food insecurity and a greater number for whom it is an occasional issue. In a country as generally affluent as Australia, this situation is perhaps surprising. It is certainly a situation we should do something about. Fundamentally, food security and insecurity are determined by economic means. Food insecurity can be a consequence of a range of disadvantages, given their simplest expression in the word 'poverty'. Most frequently and most simply, it is low income that is the issue: financial poverty. However it might also be 'mobility poverty' that is involved: an inability to access food due to the absence of means of transport, or physical immobility. Or it might be 'communications poverty': the inability of a consumer to express their wishes and needs due to language, physiology or technical barriers. Or it might be the absence of the knowledge and skills needed to know what a healthy diet is and how to manage food appropriately. Frequently these various types of vulnerability go hand-in-hand, with some individuals and families experiencing challenges on several fronts simultaneously. The population groups at greatest risk of food insecurity include some Aboriginal and Torres Strait Islander people, families with no employment or low income, welfare recipients, single parent families, and some others in more remote areas of the nation. This Report describes the human health effects of food insecurity, and explores the policy and program settings currently in place to try to address it nationally and in the various jurisdictions. It then considers the means by which the challenges might be better managed. One of the particular interests of the NRHA is the extent to which 'rurality' (or distance from major centres) affects the incidence of food insecurity. Unfortunately most of the data sources relevant to the issue of food insecurity are poor at distinguishing populations in remote locations from other areas. In exploring the effect on human health, the report takes a whole of life approach, examining the health impact of food insecurity prior to birth, at birth to age 4, 5 to 12 years of age, 13 to 18 years of age, into adulthood and into old age. Finally, based on the evidence presented, the report proposes options for dealing with food insecurity in Australia. The purpose of the Report is to bring these issues to the attention of policy makers and researchers, and to promote their discussion. Working collaboratively, governments, communities, researchers, non-government organisations and the private sector can reduce the incidence of food insecurity and its adverse human effects.

This thesis examines issues of development, Indigeneity and environmental conservation byconsidering how the controversial Wild Rivers Act 2005 (Qld) was debated, reported on,celebrated and condemned in Cape York Peninsula, northern Australia between 2004 and 2012.The Peninsula has long been constructed as a ‘wild’ space, whether as terra nullius, a zoneexcepted from settler law or a biodiverse wilderness region in need of conservation. The past twodecades, however, have seen two major changes in the political and social composition of theregion, the first being the legal recognition of geographically extensive Indigenous land rights andthe creation of a corporate infrastructure to govern them. Second, the Peninsula has been thecentre of national debates regarding the market integration and social normalisation ofIndigenous people and the site of substantial investment in Indigenous policy reform. Ironically,the Queensland state government’s own attempts to ‘settle’ land use through the Wild Rivers Act2005 (Qld) brought out the immanent tensions within the region’s present political formation.This thesis adopts an interdisciplinary approach to examine how and why the controversy overthe legislation occurred and what it indicates about present imaginaries of the governance andpotentiality of Indigenous lands and waters in northern Australia. The thesis shows thathistorically embedded forms of ‘wildness’ continue to shape debates about Cape York Peninsula’sfuture, debates in which economic and social development are often conflated and conceptualisedas beneficent transformations. Ultimately, the thesis contends that close consideration of thisevent provides insights into the future dilemmas of development, conservation and Indigenouspolitics in remote Australia.

This research examines the sustainability of small water and wastewater systems for remote settlements in Central Australia, and develops a multi-criteria assessment framework to compare the performance of technologies for use in such systems. The sustainability of water and wastewater systems has been the subject of considerable research, for both centralised and decentralised systems in developed and developing countries. The use of Multi Criteria Assessment (MCA) to solve sustainability-oriented water and wastewater problems has also been the subject of prior research in a variety of settings. Both these fields have emphasised the need for locally determined definitions of sustainability and MCA processes which reflect the reality of the stakeholders who will be influenced by project outcomes. Such research has only been carried out to a limited extent in relation to the small, self-managed water and wastewater systems which are typical of remote settlements in Central Australia. The work undertaken as part of this project aims to fill that gap. The research had two aims. The first was to develop a picture of water and wastewater systems sustainability that was relevant and applicable to remote Central Australian settings. The second was to use that vision of sustainable systems to design a multicriteria assessment framework which could be used to compare and evaluate water and wastewater treatment technologies for use in those settings. Both qualitative and quantitative methods were used to achieve these aims. Firstly, a qualitative pre-scoping study was carried out to gain an understanding of the conditions and settings at remote Central Australian sites. This involved site visits and discussions with the person responsible for the water system at each site. The outcomes informed the full scoping study into systems sustainability, in which interviews and focus groups with experts and different types of users in Central Australia were undertaken to discuss systems, technologies and the issues faced in water and wastewater provision. Analysis of these results led to the development of the overall sustainability framework for water and wastewater systems. Further analysis relating to what respondents were saying specifically about technologies contributed to the development of the sustainability oriented multi-criteria assessment process for assessment of technologies. A telephone survey of users was then carried out to determine the weightings for different criteria in the MCA process. Technology manufacturers were also surveyed to obtain data on technology performance against the criteria, which was then input to the analysis. Different weighting and scoring methods were used to examine the sensitivity of the model and the analysis itself was carried out in Microsoft Excel. It was found that systems sustainability is made up of five dimensions for remote settlements in Central Australia – economic, social, environmental, technical and institutional. Principles, criteria and indicators of sustainability were developed for each of these dimensions. The MCA framework consisted of 13 criteria relating to the economic, social, environmental, technical & institutional performance of technologies. The commercially available technologies considered for water purification were all small reverse osmosis units with a permeate production capacity of up to 2,000L/day. The reason these units were chosen is that the primary reliable source of water for most sites in remote locations is groundwater, and salinity of groundwater often represents a barrier to its use as a potable source. The technologies assessed for wastewater treatment are all commercially available units designed for sites not connected to a centralised sewerage system. They represent a range of treatment methods, namely aerobic treatment, membrane bioreactors and packed bed treatment. Chlorination and ultraviolet tertiary treatment options are considered in combination with these where they were available as part of the unit. The assessment of water technologies found two units which out-performed the others. The results varied depending on the weighting and scoring method used, and there were some differences between user groups. The assessment of wastewater technologies showed that one unit was the best performer across every combination of weighting and scoring bar one. Areas in which further technology development should be undertaken for improved performance have included modularity of technologies; robustness in harsh conditions; simplicity of operation and maintenance and regulatory compliance. The sustainability model developed for water and wastewater treatment in remote settings could be used to: • Assess the sustainability of existing water and wastewater systems, by examining their performance against the indicators • Assist in planning new systems to ensure that they will be sustainable, by making sure that steps are in place to fulfil each of the indicators • Examine policy or funding decisions related to service provision which may impact on any of the criteria or indicators either positively or negatively. The multi-criteria assessment framework can be used to compare technologies and assess relative sustainability performance. The adoption and use of these two tools should lead to more sustainable water and wastewater systems for remote Central Australian sites in the future.

Gender equity has been recognized as a guiding principle for conservation management globally. Yet little attention is paid to gender in the design and implementation of many conservation programs including those in the vibrant and expanding arena of Australian Indigenous conservation partnerships. We examined the impact of gender in management of the Northern Tanami Indigenous Protected Area (IPA) in arid central Australia through qualitative research (interviews and participant observation) with senior Warlpiri women and men and members of the all-male Wulaign community-based ranger group. Senior men and women had many similar perspectives including that customary knowledge, skills and activities were important in managing country and were occurring less through the IPA's management partnerships than they would like. Additional challenges reported by women included lack of vehicles to access country. Senior men specifically called for greater gender equity in allocation of resources including establishment of a women's ranger group. These perspectives indicate that gender equity is a Warlpiri cultural norm for management of country. Differences between Indigenous women's and men's management of country elsewhere in arid Australia suggest that opportunities also exist for gender equity to enhance conservation outcomes. Prevalent belief systems in Australia, and many other developed countries, are gender blind in that they fail to recognize differences between men's and women's needs, interests, knowledges, behaviors and power. Monitoring of Australian Indigenous conservation programs shows that an increasing proportion of Indigenous community-based rangers are women. However factors that might explain and support this trend cannot be readily identified because little or no attention to gender is apparent in program design and project planning. Gender-aware design of conservation management policies, programs and projects is important for challenging and changing gender blindness. Brokers and bridging institutions, or ‘two-way’ approaches, have been important in progressing cross-cultural equity in the implementation of Australian Indigenous conservation partnerships and can be expected to be also valuable for promoting gender equity.

The Mental Health Emergency Care-Rural Access Program (MHEC-RAP) aims to improve access, safety, and service coordination of specialist emergency mental health care via telehealth technologies. The program was planned and developed in response to the population needs and unique geographic conditions to provide specialist care while maintaining and supporting the role of existing local services. It is the first to provide 24-hour access to a regionally-based team of specialists offering relevant and responsive information, support, and clinical services for all providers, patients, and residents needing emergency care from the rural and remote communities across western New South Wales (NSW), Australia. This evaluation of MHEC-RAP applied a case study methodology and the theory of access to determine whether the program provides accessible specialist emergency mental health care. The five individual studies reported here contribute to the evaluation aims of describing program activity, assessing the provision and experience of emergency mental health care through MHEC-RAP, examining program impact on access, and informing further program development, adaptation, and transferability. This evaluation is the first to examine emergency telepsychiatry use in EDs, to apply the time and motion study method to assess program efficiency, and to present a telepsychiatry model structure that may be adapted or implemented elsewhere. This evaluation offers evidence of a practical telepsychiatry program that is providing accessible emergency mental health care for consumers in communities across western NSW and is changing local practice and perspective. It also enhances the theory of access proposing a modification to the theory with the inclusion of a sixth concept - awareness. The individual study results can be used to guide the continuing development of MHEC-RAP as well as provide insights for program transferability or the development, delivery, and evaluation of other new and existing telepsychiatry services across Australia and abroad.

Unsettling country: the sensation of painting in remote northern Australia

Using theoretical and case studies, this dissertation explores how remoteness, tourism and sustainability relate to the planning of infrastructure for National Parks in remote Australia. Remote Australia is attractive to tourist activity because of its qualities of difference, uniqueness, naturalness, vastness, emptiness, ancient culture and 'reality'. Irregular and extreme natural disturbances, lack of formal knowledge, a sparse and often unstable population, however, combine with a reliance on distant markets to constrain how any enterprise proceeds here, including tourism. The characteristics of remoteness influence the type of planning required to ensure that tourist activity conserves environments as it interprets them, and suggest that modes of travel based on the experiences of discovery, exploration and education are the most appropriate. This thesis presents an evaluative model for sustainable tourist activity. This model links the major criteria constituting (1) care of the natural and cultural environment, and (2) use for environmental experience, with (3) the processes controlling them, especially physical planning and infrastructure provision. It is used to evaluate three cases, Bedarra Island, Lizard Island and Uluru/Yulara, over the period of their use and development. Lack of interpretation, possibilities for exploration or reflection, and a restricted choice of on-site experiences were the major weaknesses identified from the cases. Accommodation isolated from major attractions exacerbated these problems. These issues, combined with an evolving knowledge base and the administrative division between care and use, indicate the need for a significant investment in the processes of resource assessment, coordinated management planning and the clarification of experiential goals, along with a more consistent application of those strategies which successfully contributed towards sustainability on the case sites.

Persistent under-achievement by Indigenous students in national literacy and numeracy tests remains a complex problem in education in Australia. This problem is most sharply defined in the contexts of remotely located schools situated in Indigenous communities which over time have been subjected to a range of government policies and interventions. Since 2009, policy reform in Australian Indigenous education has focused attention on accelerating Indigenous students’ achievement in NAPLAN: the National Assessment Program: Literacy and Numeracy. Applied annually, NAPLAN is a key priority embedded into each school’s site improvement plans. This research study investigates the influence of NAPLAN-as-policy across remote schools in three states of Australia. NAPLAN as a test object is not the primary focus for investigation. Rather its use as a policy device to measure and report school performance is examined. In particular, the study aims to understand the complex relationship between NAPLAN-as-policy and its enactment by educators into practice. The study investigates respondent’s lived experience of NAPLAN-as-policy drawing data from 124 respondents represented by school leaders, teachers and education support assistants. The study explores reasons why the NAPLAN results from remote schools with significant Indigenous populations have remained relatively unchanged since 2009 and why, compared with their mainstream counterparts, the aggregated NAPLAN result of Indigenous students is significantly lower.

Impetigo is prevalent among Australian Indigenous children living in the&​nbsp;Northern Territory. The cause of this endemic skin infection is multifactorial&​nbsp;including household overcrowding, poverty, endemic scabies and fungal skin&​nbsp;infections, tropical climate, insect bites and minor trauma. Although impetigo is&​nbsp;widespread, affecting up to 50% of children in a community at one time, care&​nbsp;seeking for treatment of impetigo does not reflect this burden accurately,&​nbsp;possibly due to awareness of the painful injection prescribed. A better treatment&​nbsp;is needed.This thesis presents the first randomised controlled trial conducted amongst&​nbsp;remote living Indigenous Australian children on the treatment of extensive&​nbsp;impetigo, and one of the largest impetigo trials worldwide. Methodological gaps&​nbsp;were addressed, with studies published on the susceptibility of Streptococcus&​nbsp;pyogenes to trimethoprim-sulphamethoxazole (SXT), the transport of impetigo&​nbsp;swabs in remote settings and photography protocols for capturing and scoring&​nbsp;sores. The principal findings are:1. Either of two short courses of SXT are non-inferior to standard treatment of&​nbsp;impetigo with intramuscular benzathine penicillin G (BPG) – published in The&​nbsp;Lancet;2. S. pyogenes remains the key driver of impetigo in our region; and3. S. pyogenes is susceptible in vitro to SXT, and SXT is effective in vivo for the&​nbsp;treatment of skin infections caused by S. pyogenes.These findings will inform the management of children with impetigo in remote&​nbsp;Indigenous communities and have already been incorporated into treatment&​nbsp;algorithms and guidelines regionally and nationally. This provides a simple,&​nbsp;short-course antibiotic regimen that is palatable, inexpensive and has a low side effect&​nbsp;profile, as an alternative to an injection of intramuscular penicillin, which&​nbsp;has been the standard of care for more than 20 years. Ongoing surveillance will be needed to understand how this new regimen is utilised and whether&​nbsp;widespread use for a common condition will alter antibiotic resistance profiles.

Rural and remote Australia suffers a severe, chronic shortage of a diverse range of health professionals. This is of major concern, because the people living in rural and remote Australia have worse health in several health outcome areas than their metropolitan peers. Australian and overseas studies have reported that health professionals who grew up in a rural or remote area are more likely than those from urban environments to return to work in a rural area after graduation. Career development theories indicate that children begin to shape ideas about careers in early childhood, and emphasise the importance of career exposure, including occupational role models, in shaping career choice. However, the severe chronic shortage of health professionals in rural and remote Australia means there is also a severe chronic shortage of health professional role models to which children in these areas can aspire. According to career development theories, career education should start long before high school if it is to make up for the absence of visible occupational role models. Any health career information in rural and remote Australia has focused on mid to late high school students. Career information provided to mid to late high school students is also too late for many students and their families to overcome the educational, cultural, social, family and financial barriers between them and participation in tertiary education for a health professional career at a distant university. This project explored the health professional careers with a small number of predominantly primary students living in rural and remote Australia and studying by distance education, as well as their teachers, parents and governesses. Issues around the knowledge, perceptions and aspirations of students in relation to these careers, before and after health professional career education, were central to this research. The aims were to contribute to long-term solutions to the severe health professional shortage in rural and remote areas, and to widen the career choices of these students. No previous documented research in Australia had explored the health professional careers with primary students or with distance education students living remotely. This project drew broadly on an action research framework, fundamental to which was a suite of activities aimed at informing the students about health professional careers. The research component involved initial qualitative interviews with parent, teacher, governess and student volunteers from two schools of distance education. The action component occurred over one school year and involved only one school, which serviced an area greater than 500,000 square kilometres. The action component was negotiated with the school community, and explored a diverse range of health careers. Follow-up interviews with volunteers from this school occurred at the end of the year. Observations, informal communications and curriculum review completed the data collection. These students had little opportunity to learn about professional careers, including the health professional careers, either in their daily lives or from the school. In contrast, they had rich opportunities to learn about working on the land. With few exceptions, students on initial interview showed very limited knowledge and few positive perceptions of, or aspirations towards, health professional careers. This contrasted with their knowledge, perceptions and aspirations in relation to these careers on follow-up by year's end. Interviews with parents, teachers and governesses unveiled factors contributing to the initial limited knowledge, perceptions and aspirations of these students in relation to health professional careers which suggested a recursive nature to the health professional shortage. This generation's students may have greater difficulty imagining themselves as health professionals than previous generations. These students, in general, have far less opportunity to become health professionals than to work on the land in the beef cattle industry. They also have far less opportunity to participate in tertiary education than many students living in university cities. This study explored how health professional career information can be disseminated to rural and remote students—in this case, students living in highly inaccessible areas, and serviced by distance education—as part of their education. The study also reports on participants' overall positive response to the program to which they were exposed. The data tentatively suggests that programs to address the shortage of health professionals in rural and remote Australia should include carefully planned integration of health professional career information in the school curriculum from an early age. The data also recognises the complexity of the shortage of health professionals in rural and remote Australia reported in previous studies. Finally, this research highlights the self perpetuating nature of the shortage of health professionals in rural and remote Australia, and the need for wide, sweeping changes to achieve a long-term stable health workforce in these areas.