Remote Australia Online

Many teachers working in remote and regional areas have limited access to collegial support networks. This research aimed to examine the existing strategies that were being undertaken by the Department of Education in Western Australia, to provide professional learning to teachers in regional and remote areas. It was important to establish the perceptions of teachers’ access to professional learning from those working at the coalface in geographically dispersed areas. Consequently, the possible opportunity for improving the amount and variety of professional learning, through the application of both synchronous and asynchronous technologies was proposed. The study was guided by the primary research question: “In what ways might technology be used to support professional development of regional and remote teachers in Western Australia?” Generating descriptions of current practice of professional learning along with the teacher perceptions were central to this research endeavour. The study relied on a mixed method research approach in order to attend to the research question. The data were collected in phases, referred to as an explanatory mixed methods design. Quantitative data were collected from 104 participants to provide a general picture of the research problem. To further refine this general picture, qualitative data were collected through interviews and e-interviews of 10 teachers. Participants in the study included graduate teachers, teachers who had taught more than two years, senior teachers and Level Three teachers from seven teaching districts within Western Australia. An investigation into current practice was included in this phase and technologies available to support a professional learning community over distance were documented. The final phase incorporated the formulation of a conceptual framework where a model was developed to facilitate the successful implementation of a professional learning community through the application of synchronous and asynchronous technologies. The study has identified that travel time in order to access professional development is significant and impacts on teachers’ personal time. There are limited relief teachers available in these isolated areas which impacts on the opportunities to access professional development. Teachers face inequities, in terms of promotion, because professional development is explicitly linked to promotional opportunities. Importantly, it was found that professional learning communities are valued, but are often limited by small staff numbers at the geographic locality of the school. Teachers preferred to undertake professional learning in the local context of their district, school or classroom and this professional learning must be established at the need of the individual teacher in line with the school priorities. Teachers reported they were confident in using technology and accessing professional development online if required, however, much uncertainty surrounded the use of web 2.0 technologies for this purpose. The recommendations made from the study are intended to identify how a professional learning community might be enhanced through synchronous and asynchronous technologies.

Around one third of all Australians live in rural and remote areas. People living in rural and remote areas tend to experience poorer health status than their metropolitan counterparts. Differences in health status are likely to be attributed, in part, to poorer access to health services. Many areas of rural and remote Australia experience a shortage and maldistribution of health care providers, high levels of health workforce turnover, and major problems with accessibility to services. These difficulties are inextricably linked to the recruitment and retention of health service providers. A number of factors have been identified in the literature as influencing the retention of rural and remote health service providers. Prominent amongst these are the possession of a rural background, and education and training, particularly access to continuing professional education. To date, retention has been less researched than recruitment, and most of the research has utilised quantitative methods, usually in the form of questionnaires. In addition, there is little research into factors which influence the retention of allied health professionals. An interpretive research approach was chosen for the current study, in order to explore the experiences and thoughts which led to allied health professionals either staying in or leaving rural and remote areas. Allied health professionals were asked what experiences influence their decision to stay or to leave, when living and working in rural and remote areas of South Australia. This approach allowed the issues being explored to be described in depth and detail. A descriptive study was utilised, influenced by the interpretive paradigm. In-depth interviews were conducted with allied health professionals about their experience of living and working in a rural or remote area, and the experiences which they saw as having an influence upon their decision to stay or to leave. Allied health professionals from two groups were interviewed; those who were living and working in a rural or remote area, and those who had lived and worked in a rural or remote area and had subsequently left. The interviews were audio taped and then transcribed verbatim. The interview transcripts were coded, and thematic analysis conducted in order to extract main themes. Member checks were used to check the accuracy and credibility of the findings and interpretations made. Twelve allied health professionals were interviewed. From the analysis of the interview data, five main themes emerged; Really a City Girl; Support Makes All the Difference; Feeling Cut Off; Being a Jill of All Trades; and If I Had It My Way. These themes suggest that socio-cultural adaptation, support, isolation, work variety and self-efficacy are important experiences influencing the decision of allied health professionals either to stay or to leave, when living and working in a rural or remote area. These findings have implications for local rural and remote services, universities, government bodies and professional associations.

There are limited respite services for palliative care patients and their families in the Northern Territory (NT). The high prevalence of complex chronic diseases, limited access to primary care services, and the poor living situations of many Aboriginal and Torres Strait Islander Australians result in high hospitalisation rates and pressure on tertiary health services. Palliative Care NT identified a need for a flexible, community based, culturally appropriate respite service in Alice Springs. It was of particular interest to assess the impact of the respite service on the extent to which hospital resources were accessed by this population of patients.

This thesis investigated the work lives of principals of central schools situated in remote inland areas of the state of New South Wales (NSW), Australia. This research considered how the situational contexts of central school leadership in remote NSW have affected the work lives of principals of central schools in remote NSW. These contexts included the education policy context of devolution of government school systems, the community context of remoteness and low socio-economic status (SES) and the specific school context of leading a small school and leading both secondary and primary departments. Research literature such as Ballet and Kelchtermans (2008), Gronn and Rawlings-Sanaei (2003) and Southwell (2008) on the factor of the education policies of devolution in the work lives of principals described characteristics which match the attributes of work intensification including longer hours of work, more tasks to be completed in a day, and diversification of skills. However, current literature has much less data about the particular contexts of the work lives of principals living in, and working with the issues of, remote and low SES communities. There is even less data about the implications for principals attempting to provide secondary education in such communities. This research study used a mixed methods design beginning with a survey questionnaire of all principals of central schools in NSW. Nearly half of the survey respondents then participated in a longitudinal program of interviews conducted in the schools of the principals. The rapport with principals developed by the researcher as an „insider‟ facilitated the collection of rich data on the work lives of the principals. Many of the issues raised had not been fully researched in broader studies. The study confirmed the research of Starr and White (2008) and Hatton (1995, 1996), who reported “massive intensification” in the work lives of principals in remote Australian schools. In addition, the study provided a more nuanced understanding of the work intensification of these principals as it reported on the many aspects and consequences of the personal, family, social and professional isolation of principals in remote schools as they responded to issues related to high welfare needs of students and of the community in general.. Principals were threatened with violence and, in several cases, were required to respond to high levels of child sexual abuse in their communities. Participant principals in this study were professionally isolated and faced limited career prospects. The data in this study provided a greater understanding with respect to the issue of low numbers of applications for the principalship, particularly in remote areas. Much of the literature on school leadership is generic in nature with considerable reliance on theories of leadership and management which have been developed in non-school contexts. This study suggested that there needs to be more research on the variety of educational and social contexts in which principals work in order to provide a more nuanced understanding of the work lives of principals of remote, low SES schools and the high stakes in the career prospects of these principals. For policy makers, a removal or amelioration of the disincentives in remote school principalship identified in this study would appear to be more urgent and more effective than the current policy of provision of incentives to work in such schools.

This PhD research examines what influence women and men in Central Western Queensland (CWQ) have on natural resource management policy that significantly impacts on their lives and livelihoods. It uses the Lake Eyre Basin Wild Rivers (LEB WR) policy development and deliberations as a case study focusing in particular on the period from 2009–2011. Sociological research in remote Australia is rare, especially research conducted by a long-term community based insider researcher. Some organisations and individuals expend a substantial amount of time and money to influence government policy from remote areas, with varied success. This case study provides evidence of policy being shaped by remote citizens despite widely disparate views being held by participants and a perception that Wild Rivers policy was imposed on them. The topic is explored using a critical theory approach drawing on Lukes structural theories of power. Gender and intersectionality are also used to frame the research as are the concepts of Deliberative Democracy and Ecological Sustainable Development (ESD). Geographic remoteness, gender and indigeneity are specifically examined as potential sites of marginalisation. Methods included the use of semi-structured interviews with activists and a media content analysis. While resistance was evident, many of those trying to influence policy were engaged in activism. The terms ‘remote’ and ‘activist’ have almost been mutually exclusive. However while some dominant sectors had the power to influence policy this was not the domain of any one organisation throughout the policy development period. While it was largely urban based conservation advocacy groups that ensured that the Wild Rivers policy was on the government agenda initially, of necessity their representatives collaborated with diverse stakeholders in remote based deliberative forums to shape the policy. Through this process, other sectors also had influence (in particular agriculture and local government). Some sectors such as mining lobbied government more actively outside regional deliberative forums. The Remote Area Planning and Development Board (RAPAD) were influential in the process, using a power-to mechanism to bring together a diverse range of stakeholders, to deliberate on policy before official regional government consultation. This strategy, as well as negotiation between forums and meetings, proved useful to shape the emerging policy despite the fact that some sectors were more dominant at times and others such as women and Indigenous people were marginalised. There are major barriers for remote area activists which need to be recognised by governments. First and foremost is the cost of travel across vast distances. Other significant barriers include volunteer burnout, cultural barriers, seasonal climatic and geographic constraints and limits on internet connectivity. The marginalisation of female voices was very evident in the lack of women participating in regional deliberative forums and commenting on the policy via the media. Indigenous participants in this research, while initially excluded, felt they had been relatively well included in government and other consultative forums. Despite the considerable barriers and power imbalances remote citizens had influence as they re-shaped the existing Wild Rivers policy to fit the Lake Eyre Basin through collaboration, negotiation and the use of other activist tactics.

Over the last seven years the recruitment of overseas trained doctors (OTDs) has formed a significant part of Australia’s policy to address the medical workforce issue of geographic maldistribution to ensure that communities in rural and remote Australia have access to adequate general practice (GP) services. This policy has not been without problems, particularly in the areas of assessment of skills and qualifications, appropriate orientation and integration into Australian communities, and retention of these doctors within rural and remote communities. To date there has been little evidence-based research on the role of OTDs in the medical workforce in Australia. This study explores the service provision and quality of care provided by OTDs using the 5 Year OTD Scheme as the case study. In doing so, it assesses the adequacy of this strategy and discusses the implications for future workforce policies and programs. A mixed method design was used in the study. The quantitative component involved secondary analysis of Medicare Australia data for all OTDs participating in the 5 Year OTD Scheme in 2002 and all Australian trained doctors (ATDs) practising in rural and remote Australia in the same year. A log Poisson regression model was used to assess the interactive effect of the various GP characteristics, such as age, sex, experience and practice location with OTD/ATD status on the rate of a particular service item per patient, adjusted for patient age and sex. The qualitative component involved two focus groups with OTDs which were used to help explain the relationships between variables found in the quantitative component of the study. Template analysis was used to identify themes from the focus group. Significantly different rates per patient between OTDs and ATDS were found across most service items and GP characteristics examined. The greatest variation was found among items relating to in-surgery consultations and non-surgery consultations such as nursing home visits. Fewer differences were found between groups relating to pathology, imaging or procedural services. Analysis of surrogate quality items identified few differences between OTDs and ATDs. The focus group identified a number of other factors that influenced their patterns of service and accounted for some of the differences identified in the quantitative analysis. These factors included knowledge of the health care system in Australia, cultural and communication influences, health conditions of patients, patient and community attitudes, remuneration influences and training influences. These had varying degrees of influence on their patterns of service. The reasons for the differences found between OTDs and ATDs are partially explained by the characteristics of the GPs examined and partially explained by other external influences that relate to the particular circumstances of the OTDs, such as knowledge of the Australian health care system and cultural and communication issues. Understanding the nature of practice is central to ensuring appropriate professional support measures. The study findings highlight the need for a targeted training program for OTDs that address the areas that have the greatest influence on patterns of service to ensure that rural and remote communities receive the same quality of service from OTDs as provided by ATDs.

Occupational stress among remote area nurses is an emerging concept in the nursing literature. Consistent with general nursing stress research, remote area nurses (RANs) also suffer from high levels of occupational stress, exacerbated by geographical, social and professional isolation. The structure of the very remote health workforce requires RANs to be the constant frontline workers, performing frequently in the absence of medical practitioners and allied health professionals. They are consequently required to practice an extended clinical role. This thesis explores the nature of the occupational stress experience for nurses working in very remote Australia and identifies the specific stressors inherent in the remote area nursing workplace. Levels of stress in this context have been measured and comparisons drawn between nurses working remotely and nurses working in hospital-based settings. Levels of stress were also compared to that of other professional samples. Data were obtained through two waves of survey administration, completed by 349 nurses working in very remote Australia and 277 nurses working in major Australian hospitals (2008), and later, 433 nurses working in very remote Australia and 177 nurses working in a major Australian hospital (2010). Analyses examined both cross-sectional and longitudinal data. Initial findings provided support for the expectation that, relative to other professional samples, remote area nurses experience higher levels of occupational stress. Contrary to expectation, however, remote area nurses reported lower levels of occupational stress than nurses working in major Australian hospitals. Importantly, resilience was found to mediate the relationship between job demands and psychological distress for the remote area nursing sample but not the hospital-based nursing sample. In addition to these findings, a review of nursing stress measures demonstrated that no existing psychometric instrument could be suitably applied to assess occupational stress in the remote area nursing workforce. This thesis consequently describes the development and validation of the Remote Area Nursing Stress Scale (RANSS) – a new self-report instrument designed specifically to measure occupational stress in this context. Finally, an ecological, macro-level framework is presented for the occupational stress experience of remote area nurses, proposing that worker well-being is impacted by the environmental context, organisation-environment adaptation, and the influence of these factors on task-level job demands and resources.

The attraction and retention of statutory child protection workers in regional, rural and remote Australia has been identified at the national and state/​territory level as a priority challenge for the child protection sector. This research emerged from the recognition of and response to this problem by the Government of Western Australia’s Department for Child Protection (the Department), Murchison District, and the Department’s search for evidence-based responses under the umbrella of the Australian Research Council Linkage Project ‘Pathways to Better Practice’ (LP0082806). The size and distribution of the Australian population, and the extreme nature of the physical environment, means that geographic and demographic characteristics of place are central to the challenges of service delivery in regional and remote Australia. Maintaining the supply of a skilled and professional workforce to these places is largely dependent on ‘migration’ employment models, particularly for professional workforces such as that of the Department. The significant over-representation of Aboriginal and Torres Strait Islander children in the child protection system is identified as presenting particular challenges. In Western Australia, the employment of Aboriginal people is integral to strategies across the sector to improve services and outcomes for Aboriginal children and families. The geographic distribution and demographic characteristics of the Aboriginal population in remote Western Australia suggest additional challenges for the delivery of child protection services in locations such as the Murchison District. This is due to a combination of factors, including the level of disadvantage and the complex needs of this client population, the limited resources in place, and the cultural dimension to practice. In seeking to develop an evidence-based response to the problem of attraction and retention of child protection workers in the Murchison an ecological model has served as both the conceptual and methodological framework for the research. This approach to the study of the problem has meant attending to the multiple settings in which the research is embedded, and the interplay between variables acting on attraction and retention. These variables range from the individual work and lifestyle choices to the organisational responses and local characteristics of place to the effects of the global labour market, and are consistent with reflexive theories in sociology. In exploring the dimensions of place, work and individual life choices to attraction and retention, the research has embraced a combination of methods: analysis of secondary statistical data to examine the characteristics of the Murchison and Department’s workforce; interviews; and surveys of the individual subjects of the Department’s interventions, the Murchison District workforce. The research reveals the complex web of both actual and potential factors that shape attraction and retention. These include changing preferences and life trajectories both in the work and non-work environment that demonstrate the limits of unilateral, organisational responses. The research reveals a number of paradoxical effects in relation to the Department’s strategies to attract and retain. These include the constraining effect of the introduction of changed qualifications requirements for child protection roles on supply, and the disconnect between the Department’s idealised representations and the realities of the places to which the Department seeks to attract and retain. The changing nature of place, work and the ‘life’ in late-modernity which reveal the heterogeneity of preferences presents both opportunities and challenges for future interventions.

Introduction: Most Australians take at least one prescription medication during their final 30 years and multiple medications during their final 10 years for one or more chronic condition. Chronic disease is increasingly affecting Australians’ quality of life and health expenditure. Medication and healthy lifestyle change are major health interventions, but patient adherence to prescribed therapy is reported to be less than 33%. Patients with chronic disease must collect prescription repeats regularly every month, creating an opportunity for intervention by community pharmacists. Aim: To investigate if a collaborative community pharmacist and GP model of care in chronic disease management in rural Australia could improve patients’ outcomes through better monitoring of disease markers, increased self-management skills and greater medication adherence. Design and Methods: This project was a pilot, pre- and post-intervention study designed to support future definitive studies. The clinical intervention phase was designed to support the existing advice patients had been given, was minimally invasive (lancet finger pricks for point of care testing) and did not involve any active medication administration. The study used three tools: a modified Health Education Impact Questionnaire (heiQ™) for patients pre- and post-intervention, mid-study survey for pharmacists and end of study feedback statements from pharmacists and patients. The study was conducted in community pharmacies located in rural and remote Australia in areas with a Pharmacy Access/Remoteness Index of Australia of code 2 to 6. The intervention took place over 12 months, of which three months were promotion, three months enrolment and baseline data collection, and six months patient monthly monitoring. Data were analysed in ASReml -R™ using linear mixed models and generalised linear mixed models. Results: The patients’ mean modified -heiQ™ score after the intervention was 29.65% higher than at baseline, a statistically significant improvement. The number of medications they took also significantly changed by using alternative medication with fewer side effects, removing duplications and adding medications for previously untreated conditions. During the period of the intervention, all parameters monitored became and remained stable within the patient best target level. Improvement in patients’ body mass index and blood cholesterol were difficult to determine due to the short period of the intervention. Conclusion: Early detection and early intervention improve quality of life and reduce disease burden and medication-related problems. Blood pressure, total cholesterol, blood glucose level and international normalised ratio parameters are possible to monitor in the community pharmacy setting in Australia, but the cost needs to be covered by either Medicare or the community pharmacy and government agreement. Sub-optimal communication between pharmacists and doctors leads to fragmentation in the provision of health services. A national two-way, balanced, collaborative primary care model for chronic disease between general practitioners and other health professionals that includes pharmacists would address disconnections in the continuity of care and improve patients’ outcomes.

My country, mine country: indigenous people, mining and development contestation in remote Australia

Australian Aboriginal children experience disproportionate levels of health, educational and social disadvantage. Their significant disadvantage stands in stark contrast to the well-being of the majority of Australians. These poor outcomes are magnified in remote communities where Aboriginal children have been shown to have developmental vulnerability beyond the national average. A concerning and poorly understood determinant of development and well-being is the influence of prenatal alcohol exposure (PAE). National surveys show differences in the drinking patterns between Aboriginal and non-Aboriginal Australian women. Aboriginal women are less likely to drink than non-Aboriginal women but when they do consume alcohol, they do so at far more hazardous levels. As alcohol is a teratogen, PAE can have devastating effects on fetal and brain development leading to a spectrum of disorders termed Fetal Alcohol Spectrum Disorders (FASD). FASD are characterised by significant learning, behavioural, cognitive and motor deficits which disrupt education and development trajectories leading to severely limited occupational options and dependent living. These adverse life outcomes place enormous burden on families, their communities and social supports. The Fitzroy Valley in north Western Australia contains a unique, culturally rich population of 4,500 people (81% Australian Aboriginal), living in approximately 45 very remote communities with five distinct language groups. Over the last decade there has been growing anxiety amongst Aboriginal leaders in the Fitzroy Valley, that high-risk maternal drinking within many of their remote communities may be harming the development and future potential of children. This concern led to an invitation from Aboriginal leaders for researchers to collaborate with them on a project to evaluate the impact of in-utero alcohol exposure on child health and development. This project conducted in 2011 was named The Lililwan Project and is Australia’s first population-based study to determine FASD prevalence, using active case ascertainment, in remote Australian Aboriginal communities. Population-based data from this study indicate that high-risk alcohol use is common. Of the 127/​134 (95%) eligible mothers and caregivers who participated in this study, it was reported that more than half (55%) of mothers drank. Of mothers who did drink, 52% did so at “risky” or “high risk” levels with 88% drinking in the first trimester and 53% drinking in all three trimesters. FASD diagnoses were determined in 21/​108 (194.4 per 1000) children, one of the highest prevalence rates in the world. The FASD diagnostic process includes the assessment of neurodevelopmental functional outcomes in a number of central nervous system (CNS) domains known to be affected by PAE. Motor performance and its subset gross motor performance is one of several CNS domains recommended for assessment by four key international FASD guidelines. Despite this, data on motor function are rarely included in FASD prevalence or observational studies and therefore the association of motor performance and PAE or FASD is poorly understood. In the Fitzroy Valley, physical activity including football, basketball, netball, swimming and cultural activities such as hunting and traditional dance feature highly in recreational pursuits of children. Given concern that the motor skills needed to participate in these activities could be significantly affected by PAE, motor performance was included as a CNS domain for assessment in the Lililwan Project, with the results of this original research being reported in the following chapters. Chapter One provides an introduction to the context of this Thesis and a literature review of the existing evidence. The current Thesis contributes much needed evidence to support the neurodevelopmental needs of children with motor impairment associated with PAE or FASD who live in the Fitzroy Valley. This work is unique as cultural considerations and the very remote geographical location with extreme climate makes this population very difficult to assess. Not surprisingly, there is paucity of data related to motor performance of Aboriginal children living in very remote communities and currently no normative data or observational studies exist. The findings provide a significant evidence base to assist parents, clinicians, the education sector and policy makers, to make optimal decisions for management of children and their families living with FASD. The first aim of this Thesis was to characterize gross motor impairment in children with a diagnosis of fetal alcohol spectrum disorder (FASD) or “moderate” to “heavy” maternal alcohol intake. Chapter Two describes a systematic review where 2881 articles were identified of which 14 met the inclusion criteria. The subjects’ mean age ranged from 3 days to 13 years. Study limitations included failure to report cut-offs for impairment, non-standardised reporting of PAE, and small sample sizes. The meta-analysis pooled results (n=​10) revealed a significant association between a diagnosis of FASD or moderate to heavy PAE and gross motor impairment (Odds Ratio: 2.9; 95% Confidence Interval: 2.1–4.0). GM deficits were found in balance, coordination, and ball skills. There were insufficient data to determine the prevalence of gross motor dysfunction in the included cohorts. In conclusion, these results suggest that evaluation of gross motor proficiency should be a standard component of multidisciplinary FASD diagnostic services. The second aim of this Thesis was to identify a suitable standardised instrument to measure motor performance (including fine and gross motor skills) and determine its reliability for use in predominantly Australian Aboriginal children living in very remote communities and with risky levels of PAE. Chapter Three reports on this work. The Bruininks-Oseretsky Test of Motor Proficiency – Second Edition (BOT-2) Complete Form was identified after performing a literature review and consulting with national and international experts. Given the difficult logistical context in which the research was performed, it was decided to use the highly correlated short-form version of the BOT-2 for the reliability testing. A reliability study using the BOT-2 Short Form was then performed with a convenience sample (n=​30) of children aged 7-9 years from the Lililwan Project (n=​108). The inter-rater reliability for the BOT-2 Short Form score sheet outcomes ranged from 0.88 (95%CI, 0.77 – 0.94) to 0.92 (95%CI, 0.84 – 0.96) indicating excellent reliability. The test-retest reliability (median interval between tests being 45.5 days) for the BOT-2 Short Form score sheet outcomes ranged from 0.62 (95%CI, 0.34 – 0.80) to 0.73 (95%CI, 0.50 – 0.86) indicating fair to good reliability. The raw score Minimal Detectable Change was 6.12. In conclusion, the BOT-2 Short Form has acceptable reliability for use in remote Australian Aboriginal communities and will be useful in determining motor deficits in children prenatally exposed to alcohol. This is the first known study evaluating the reliability of the BOT-2 Short Form, either in the context of assessment for FASD or in Aboriginal children. The third aim of this Thesis was to describe motor performance in predominantly Australian Aboriginal children living in very remote communities (n=​108) and to compare motor performance in children with no PAE, PAE or FASD. Chapter Four describes this work. Motor performance of the cohort was assessed using the modified BOT-2 Complete Form, and the relationship between motor skills, PAE, and FASD was explored. FASD diagnoses were assigned using the Canadian guidelines. Motor impairment sufficient to contribute to a CNS domain of impairment was defined according to these guidelines as a score two or more standard deviations (SD) below the mean. A total of 108 children (Aboriginal: 98.1%; male: 53%) with a mean age of 8.7 years were assessed. The cohort’s mean total motor composite score (mean±SD: 47.2±7.6) approached the Bruininks–Oseretsky Test of Motor Proficiency - Second Edition normative mean (50±10) despite high levels of risky PAE, social disadvantage, and poor fine motor skills. There was no difference between children with PAE and those without PAE (mean difference ± standard error: -2.2±1.5; 95% CI: -5.1 to 0.80). Motor performance was lower in children with FASD diagnosis than those children without a diagnosis (Mean Difference±SD: -5.0±1.8; 95% CI:-8.6 to -1.5). The prevalence of motor impairment (≥ 2SD below the mean) was 1.9% in the entire cohort, 9.5% in children with FASD, 3.3% in children with PAE and 0.0% both in children without PAE or FASD. In conclusion, these results show that almost 10% of children with FASD have significant motor impairment. Evaluation of motor function should routinely be included in assessments for FASD, to document impairment and enable targeted early intervention. The fourth aim of this Thesis was to characterise gross motor performance, as distinct from total motor performance as discussed above. In children participating in the Lililwan Project (n=​108), a subset of the BOT-2 motor performance data that related to the gross motor performance of the cohort was extracted which enabled exploration of the relationship between gross motor skills, PAE, and FASD. Chapter Five describes this work. A total of 108 children (98.1% Aboriginal; 53% males, mean age: 8.7 years) were assessed. Half (52.2%) were exposed to at least “risky” levels of PAE and 21 (19%) were diagnosed with a FASD. The mean Gross Motor Composite score of the cohort (47.0±8.4) approached the BOT-2 normative mean (50.0±10) despite poor health and development indices, and was similar between children with and without PAE (MD±SD: -1.8±16.5; p=​0.27). This mean score however, was significantly lower in children with FASD than those without (MD±SD: -5.5±20.6; p=​0.006). Compared to children without FASD, children with FASD had (i) significant impairment in Subtests for Running Speed and Agility (MD±SD:-2.4±8.1; p=​0.003) and Strength (MD±SD:-2.8±9.9; p=​0.004) and (ii) a higher proportion than expected had overall gross motor impairment (≤2SD:9.5%; ≤1SD:23.8%). In groups with PAE, no PAE, and no FASD, gross motor function approached expected population norms and there were no significant difference in function between these groups. In conclusion, almost 10% of children with FASD had gross motor scores that indicated significant impairment whilst 25% of these children had scores which indicated a need for therapy. Evaluation of gross motor performance should routinely be included in FASD assessment to determine strategies to optimise child development. The fifth aim of this Thesis was to describe the presence of soft neurological signs (SNS) in predominantly Australian Aboriginal children (n=​108) living in very remote communities where children had no PAE, PAE and FASD. Chapter Six reports on this work. The presence of SNS in the cohort was assessed using the Quick Neurological Screening Test – Second Edition (QNST -2) and the relationship between SNS, PAE, and FASD was explored. “Severe discrepancy” was defined as scores equal or below the 5th percentile while “moderate discrepancy” represented scores from the 6-24th percentile. FASD diagnoses were assigned using the Canadian guidelines. International expert opinion recommended that a QNST-2 Total Score of equal to or greater than 30 be used to define SNS sufficiently significant to contribute to a CNS domain of impairment. A total of 108 of 134 (80.6%) eligible children (mean age 8y 9mo, SD=​6mo, 53% male) were assessed. The median QNST-2 Total Score for all participants was within the normal category (19.0, range 4–66) despite more than half (52.2%) of the cohort being exposed to at least risky levels of PAE. However, the median QNST-2 Total Score was higher in children with PAE than without PAE (r=​0.2, p=​0.045) and in children with FASD than without FASD (r=​0.3, p=​0.004). Half (8/​16) of children scoring ‘moderate discrepancy’ and all (2/​2) children scoring ‘severe discrepancy’ had at least three domains of CNS impairment. In conclusion, SNS were more common in children with PAE or FASD, consistent with the known neurotoxic effect of PAE. The QNST-2 is a useful screen for subtle neurological dysfunction and for indicating the need for more comprehensive assessment in children with PAE or FASD. The final aim of this Thesis was to systematically review the literature to investigate the efficacy of conservative interventions to improve gross motor performance in children with PAE or FASD or a range of similar neurodevelopment conditions. Chapter Seven describes this work. As no clinical trials for children with FASD were found, results from groups of children with similar neurodevelopmental disorders and mild to moderate gross motor impairment were considered. Of 2513 papers, 9 met inclusion criteria including children with cerebral palsy (CP) (n=​2) or Developmental Co-ordination Disorder (DCD) 98 (n=​7). There were 11 different interventions reported among the 9 included trials. Two of 9 trials showed an effect for treatment, and a meta-analysis was performed to determine the pooled effect of intervention on gross motor function. Using the least conservative trial outcomes a large beneficial effect of intervention was shown (standardised MD:-0.8; 95%CI:-1.1 to -0.5) with “very low quality” Grading of Recommendations, Assessment, Development and Evaluations (GRADE) ratings. Using the most conservative trial outcomes there was no treatment effect (SMD:-0.1; 95%CI:-0.3 to 0.2) with “low quality” GRADE ratings. Study limitations included the small number and poor quality of the available trials. In conclusion, although we found that some interventions such as Taekwondo can improve gross motor outcomes in children with DCD or CP, our confidence is limited by the very low quality of the available evidence. High quality intervention trials are urgently needed. Chapter Eight provides a summary of the principal findings of this Thesis, describes implications of these findings, proposes directions for future research and presents recommendations. In conclusion, the series of studies reported in this Thesis provide the first data on motor performance, gross motor performance and SNS in a population-based cohort of predominantly Aboriginal Australian children with PAE. They represent the only data of this kind. The findings provide new information regarding the motor performance skills of Aboriginal children living in remote communities, and demonstrate the significant impairments that children with a FASD suffer. This work has significant implications for future studies of FASD prevalence emphasising the importance of assessing motor performance as a component of CNS function. The findings also highlight the impact of alcohol on child development particularly motor performance and indicate the critical need for allied health services to ensure the health and well-being of these most vulnerable children.

Linking with community development: an outsider working in remote Aboriginal communities of central Australia

This thesis presents a policy framework for improving outcomes for remote Indigenous land tenure and housing policy in Australia. The framework is developed from an analysis of related policies and programs in several pioneer settler societies with similar historical characteristics to Australia. The number of pioneer settler societies in the world is small. Originating in the 16th through 18th centuries, these societies grew out of European colonization practices that displaced indigenous societies, and made indigenous people a minority in their own land. The four societies examined in this thesis are Australia, Canada, New Zealand, and The United States of America. This thesis is presented in three parts. Part 1 (Chapters 1-3) scopes the problem being addressed in this thesis: the gap(s) in well being between Indigenous and Non-Indigenous people as measured by indicators of wellbeing such as housing, health, education, and employment. These quality of life gaps can be seen as the result of two inadvertent and compounding impacts on indigenous people from colonial dispossession: 1) removal of livelihoods through a lack of access to land-based resources, and 2) loss of cultural identity I caused by being separated from the land Elements of successes in different pioneer settler societies are later used to formulate a framework for improved land tenure and housing policy outcomes for remote Indigenous Australia. Part 1 also presents an overview of the research design used in the case studies of ! the four pioneer settler societies. Part 2 (Chapters 4-7) presents the case studies of indigenous housing and land tenure in the four pioneer settler societies. The policy factors that are analyzed illustrate the various methods used by governments in an attempt improve Indigenous quality of life. Part 3 (Chapters 8-10) draws upon the data in the four case studies to develop a policy framework for use in Australia. Chapter 8 presents a meta-analysis of the four case studies, which identifies a wide range of lessons potentially relevant to Australian context from the other three nations. Similarities and differences in policy approaches and outcomes for pioneer settler societies are identified, compared, and contrasted. A synthesis of the lessons from the meta-analysis is used to identify two themes and eight 'building blocks' to frame policymaking. These themes are: 'Experiencing the Land and People', and The Policy Process These 'building blocks' and principles can make sure that the actors, activities and practices used in the policymaking process facilitate the exchange of relevant information, redress potential conflict and maximize opportunities for collaboration among stakeholders in policymaking. The framework for policymaking is an insightful tool for making sense of the complexities associated with particular policy decisions, thus expediting improved policy outcomes on land tenure and housing issues. As such, the policy 'building blocks' and supporting principles provide a road map for developing a policy framework that can bridge 'the gap' in well being between Indigenous and Non-Indigenous people.

It is widely acknowledged that rural and remote Australians have poorer levels of health than their major city counterparts. As nurses are the most widely and evenly distributed health professional across rural and remote areas of Australia, maintaining a nursing presence is imperative to ensure health care remains available and accessible. Maintaining the competence, health and wellbeing of nurses prepared to work in rural and remote areas is crucial. The presence of a locum workforce is one available strategy that can ensure the needs of the permanent nursing workforce, and the communities they serve, are met. This interpretive description study explores the phenomenon of the locum nurse in rural and remote areas of Australia. Findings from interviews with 19 participants who chose locum work in rural and remote areas aids understanding of the issues and challenges they experienced and how this impacted on their recruitment and retention. The description component brings elements of the locum nurse role and their experiences to the awareness of others, while the interpretation component provides a level of sense-making derived from the patterns and themes in the findings that may potentially change the way the phenomena of the locum nurse is normally considered. Findings highlighted participants’ belief that they had a significant role in supporting the permanent workforce, this was revisited many times throughout their interviews and supported their retention. Receiving support to stay in their locum role was an important aspect that impacted on their experience and their retention to individual locations. Participants revealed the complexity of decision-making when working across rural and remote areas resulting in concern around their scope of practice. Participants chose to pursue a locum lifestyle despite the challenges living away from home presented. The findings of this study provide an understanding of the factors that impact on the recruitment and retention of locum nurses. Whatever motivators supported the predominantly urban- based nurses to come to these areas needs to be fostered and, in some instances, improved so that the y find it easy to return. While participants had been retained to the workforce they cautioned that many aspects of their experience may negatively impact on the recruitment and retention of others. Time spent fostering the needs of the visiting locum workforce will ensure the permanent workforce receives the support it needs to maintain a health presence in the absence of sufficient numbers of other health professionals in rural and remote areas.

Pulmonary rehabilitation, consisting of exercise training and education, is one of the most effective strategies for improving the health outcomes of people with chronic obstructive pulmonary disease (COPD) and reducing associated healthcare costs. Prior to the work presented in this thesis a description of the structure and content of pulmonary rehabilitation programs in Australia had not been published. In addition, whether existing programs met Australian recommendations for practice such as those contained in the Pulmonary Rehabilitation Toolkit, was unknown. Despite the significant benefits for both individuals with COPD and the community, access to pulmonary rehabilitation is limited, particularly for those in rural and remote regions. A lack of adequately trained healthcare professionals may contribute to difficulties with establishing and maintaining pulmonary rehabilitation. However, the effect of healthcare professional training on the availability of pulmonary rehabilitation had not been previously investigated. There were no published reports documenting existing knowledge and skill levels, evaluating training strategies to up-skill rural/remote healthcare professionals or evaluating the impact of such training on the delivery of pulmonary rehabilitation. The aims of the studies presented in this thesis were to: describe the current provision of pulmonary rehabilitation in Australia and the alignment of these pulmonary rehabilitation programs with evidence-based recommendations; determine the level of knowledge and skills of rural and remote healthcare professionals in the management of people with chronic lung disease; investigate the ability of an educational training program for healthcare professionals to improve knowledge and confidence and improve the availability and delivery of pulmonary rehabilitation in rural and remote regions and explore the attitudes, opinions and concerns of healthcare professionals regarding the delivery of pulmonary rehabilitation. The first study (Chapter 2) was a cross sectional, observational study using a purpose designed anonymous paper-based survey. The national database of pulmonary rehabilitation programs, maintained by Lung Foundation Australia (LFA), was used to identify known programs in all states and territories of Australia. All pulmonary rehabilitation programs listed on the database at that time were included (n=193). Healthcare professionals who coordinated pulmonary rehabilitation were invited to participate. This study had a response rate of 83% (n=163) and all states and territories in Australia were represented. The responses enabled the structure and content of Australian pulmonary rehabilitation programs to be elucidated. Most Australian pulmonary rehabilitation programs broadly met recommendations for practice contained in the Pulmonary Rehabilitation Toolkit in terms of included components (exercise training and education), program length, patient assessment and exercise training (duration, frequency and mode). Many respondents were not aware of major evidence-based practice guidelines (including the Pulmonary Rehabilitation Toolkit). Interestingly, despite not being aware of guidelines, most respondents indicated that they perceived a gap between current evidence and their practice in terms of exercise prescription and training. The studies presented in Chapters 4-7 were undertaken as individual components of a mixed methods study to evaluate the impact of the Breathe Easy Walk Easy (BEWE) program on healthcare professional knowledge and confidence, service delivery and patient outcomes in rural and remote Australian regions. The BEWE program was an interactive education and training program related to providing components of assessment and management (in particular pulmonary rehabilitation) for people with chronic respiratory disease. The BEWE program consisted of a training workshop, access to online resources, provision of community awareness-raising materials and ongoing telephone/email support. Details of the development of the BEWE program are presented in Chapter 1. Further information regarding the content and structure of the BEWE program along with relevant methods for the studies contained in Chapters 4-7, are presented in Chapter 3. The evaluation process was conducted by a researcher (the PhD candidate) who was independent of the development and delivery of the BEWE program. The study presented in Chapter 4 was a descriptive cross-sectional, observational survey design using a written anonymous questionnaire. Participants were healthcare professionals (n=31) who registered to attend the BEWE program initial workshop in either one rural or one remote Australian region. The main outcomes were participant attitudes, objective knowledge (case vignette-based) and self-rated experience, training, and levels of confidence. Participants were from a variety of professional backgrounds (allied health, medical, nursing) but were predominantly nurses (n=13) or physiotherapists (n=9). The main findings of this study were that that rural and remote healthcare professionals had low levels of experience, training, knowledge and confidence in providing components of management for people with COPD. Most participants reported that they had minimal or no experience or training in this area of practice. The scores in the measured knowledge quiz were generally poor, with mean knowledge score (number of correct answers out of 19) being 8.5 (SD=4.5). There were higher numbers of correct responses for questions relating to COPD disease pathophysiology and diagnosis than for questions relating specifically to pulmonary rehabilitation. In addition, most participants reported particularly low confidence in the delivery of pulmonary rehabilitation. Based on the findings of the study, the need for an education and training program for rural and remote healthcare professionals in the evidence-based management of people with COPD with an emphasis on pulmonary rehabilitation was evident. The effects of the delivery of an education and training program on healthcare professional knowledge and confidence in the management of people with COPD and on the availability of pulmonary rehabilitation were investigated and are presented in Chapter 5. This study was a quasi-experimental, before and after repeated measures design. Healthcare professionals (n=33) from various backgrounds who participated in the BEWE program were eligible to participate. The BEWE program was delivered in one rural and one remote region. Participant knowledge, confidence and attitudes were assessed via anonymous written questionnaire before, immediately after and at three and 12 months following the BEWE workshop. Participation in the BEWE program resulted in significant improvements in participants’ self-rated knowledge and confidence immediately after the workshop, and at three and 12 month follow-up. Measured knowledge (case vignette score out of 19) improved significantly immediately after the workshop compared to before (mean difference 7.6 correct answers, 95% CI 5.8 to 9.3). At 12-month follow-up, three locally run pulmonary rehabilitation programs had been established in participating regions. The availability of pulmonary rehabilitation following delivery of the BEWE program, as well as patient outcomes and the factors contributing to the change in service delivery were further explored and results are presented in Chapter 6. Data were collected regarding the provision of pulmonary rehabilitation services before and after delivery of the BEWE program and patient outcomes (six-minute walk test and health related quality of life) before and after pulmonary rehabilitation. Pulmonary rehabilitation was not available in any of the participating sites before the BEWE program. At 12-month follow-up three sites had established locally-run pulmonary rehabilitation programs which had a structure and content broadly meeting Australian practice recommendations for pulmonary rehabilitation. Initial patient outcome data for the six-minute walk test and the St George’s Respiratory Questionnaire demonstrated evidence of the effectiveness of these pulmonary rehabilitation programs in improving functional exercise capacity and health related quality of life. Providing targeted specific training, the retention of key staff and strong local healthcare organisational support were important factors which contributed to the successful establishment of pulmonary rehabilitation. A study involving interviews with key healthcare professionals involved in the delivery of pulmonary rehabilitation in rural and remote regions was conducted and is presented in Chapter 7. Those healthcare professionals who participated in the BEWE program and who were identified as key informants, were invited to participate in semi-structured interviews. The purpose of the interviews was to gain a deeper understanding of the participants’ attitudes and opinions regarding developing, establishing and delivering pulmonary rehabilitation in rural and remote regions. This study was designed to add perspective to the quantitative data rather than to inform the design of the evaluation process. Interviews occurred at three and 12 months following the BEWE workshop in the remote region and at 12 months following the BEWE workshop in the rural region. Interviews were recorded and transcribed verbatim. A process of thematic analysis was used to analyse the transcripts. Healthcare professional staffing levels, time and case load constraints, knowledge and confidence, ensuring sustainability, individual and community attitudes, and practical issues related to the setting, structure and content of pulmonary rehabilitation were identified as the main concerns of informants. The results of this study indicate that dedicated funding to support additional healthcare professional staffing and to assist with providing specific education and training may facilitate the availability and delivery of pulmonary rehabilitation in rural and remote regions. The body of work contained in this thesis has contributed to a greater knowledge of the practice and availability of pulmonary rehabilitation in the Australian rural and remote context and has provided evidence that the provision of a training program for healthcare professionals can facilitate the delivery of effective pulmonary rehabilitation in rural and remote Australian regions.

Managing water demand in many remote Indigenous communities is critical yet often poorly implemented due in part to a lack of understanding of the volume and nature of water use. A combination of quantitative and qualitative data has enabled a deeper understanding of water consumption patterns and drivers in three remote Australian communities as part of Stage 1 of the Remote and Isolated Communities Essential Services (RICES) project. Total daily per person use averaged from 270 L/p/d to over 1,500 L/p/d and outdoor water use activities comprised up to 86% of total residential water consumed. Structured interviews with participants identified five main drivers for outdoor water use of which some are traditionally the role of local government service provision (e.g. dust control) and all are closely linked to day to day functioning (e.g. cleaning food, cooling). Traditional demand management strategies such as pricing are not yet appropriate, nor is a reliance on improving local government service provision, due partly to the resource challenges in remote communities. Community-based engagement and education, supported by local government role modelling, has been identified as a more suitable approach and will be tested in later stages of the RICES project.

Aim: The aim of this study was to examine the social world of generalist nurses delivering mental healthcare in remote Australia. Background: Of Australia's population of approximately 25 million, one in five will experience a mental illness during their lifetime. People who live in remote Australia are significantly more likely than those in urban areas to experience a mental illness or substance use disorder, or to commit suicide. Commentators have suggested that the higher prevalence of mental health problems in remote communities is a reflection of socioeconomic disadvantage, a harsher natural and social environment, loneliness and isolation. The more remote from metropolitan centres, the less specialised mental health services, investment, funding and infrastructure are available to care for the mentally ill. Correspondingly, the specialised mental health workforce, across all disciplines and professions, rapidly declines with remoteness. This workforce maldistribution results in a situation where the largest permanent health workforce in remote Australia are generalist nurses. Remote nurses work in isolated communities and are regularly exposed to stressful and dangerous conditions. They are oldest cohort of Australian nurses and work the longest hours per week. Research has reported that remote nurses have low self-perceived levels of competency, confidence and skills when caring for mental health patients, particularly when confronted by violent and aggressive mental health presentations. Method: A single, explanatory, revelatory case study design, utilising a holistic approach, was employed in this study. Qualitative data were collected in semi-structured interviews conducted face-to-face or via telephone (n =​ 30). The data were subjected to interpretive thematic analysis. Findings from the thematic analysis were combined with secondary data sources relevant to the case and subjected to situational analysis (Clarke, 2005) using messy, ordered and relational maps to construct a social world/​arena map of the remote nurses' social world in delivering mental healthcare. Actor-network theory was employed to analyse the relationships between actors (human and non-human), which consisted of both individuals and groups within the remote nurses' social world. Findings: Three major findings arose from the study. First, under the actor-network analysis, when delivering mental healthcare, remote nurses assume the role of the obligatory passage point; second, remote nurses have low self-perceived levels of mental healthcare skills, abilities and confidence; and remote nurses possess unique characteristics that enable them to stay and function in the case environment. Conclusion: There exists substantial demand for mental health services in remote Australia. The delivery of such services must overcome many barriers. Central to the success of mental healthcare delivery are remote generalist nurses. This study revealed new insights into the complex and fluid social worlds of remote generalist nurses delivering mental healthcare. The study also found that remote nurses have unique characteristics, both individually and as a group, that enable them to remain in their social world and deliver front-line services.

This study explored how women living in remote areas of north-west Queensland, Australia, achieve health and wellbeing. The challenges that people living in rural and remote areas face in accessing services and achieving health contribute to poorer health outcomes compared to people living elsewhere in Australia. These challenges can be exacerbated by exposure to climatic extremes, the adverse effects of economic restructuring and distance from population and service centres. The negative impact on health is most pronounced in remote areas. There is evidence from national surveys of women that, despite the challenges, women living in remote areas consider themselves to be healthy and have equivalent or even better mental health than urban women. Speculation as to why this is so has focused on the characteristics of the women themselves and the nature of rural and remote communities. There is very little empirical research aimed at developing a deeper understanding of how rural and remote women achieve health. The study addresses this gap by exploring the meaning of health and wellbeing and the conditions which create it from the perspective of women living in remote north-west Queensland. The Australian National Women‘s Health Policy 2010 is based on the premise that women's health can only be understood within the broader context in which women live and work. The research demonstrates an approach to operationalising this approach to women‘s health by studying remote women in their social and geographical context. This was a woman-centred, grounded theory study based on a constructivist epistemology and a critical ecological theoretical lens. The thesis begins with my positioning as a health practitioner with a disciplinary background in social work and a practice in health promotion in remote north-west Queensland. The research process proceeded through three phases. In phase one, a synthesis of a sample of six qualitative studies related to remote women's health using meta-ethnographic methods was conducted instead of a conventional literature review. The studies selected for synthesis were analysed using reciprocal translation methods consistent with a grounded theory approach. This phase identified sensitising concepts: belonging, isolation, coping with adversity and rural identity, which were utilised for analysing the data gathered in phase two of the study and for discussing the emergent theory in relation to the literature in phase three. In the thesis, a detailed account of the methodological decision-making that led to the selection of the methodology for the study is presented. Phase two of the study involved field work in locations geographically classified as remote. A combination of quota sampling, convenience sampling and theoretical sampling was used to recruit women to the study. In-depth interviews were conducted with twenty-three women over a twelve month period. Data was analysed using rigorous, systematic grounded theory methods. Phase three involved theorising and authenticating the emergent theory with reference to women's narratives and the health and social science literature. The study findings are presented as a grounded theory of the capacity for flourishing. Flourishing describes an optimum achievable state of health and wellbeing as that is defined by each woman. The theory delineates a dynamic, multidimensional, integrated and contextualised process of adjustment and change arising from the interaction between women and their environment. The process integrates two axes: a being and doing axis and a person and environment axis, and four dimensions of flourishing: control, connecting, belonging and identity. Individual, contextual and structural factors which enable and constrain flourishing are described. The capacity for flourishing is embedded in these factors. The grounded theory is positioned in relation to Australian and international literature relating to rural and remote women's health and wellbeing. The study contributes to the literature by proposing a theory of how women achieve health and wellbeing that is relational and created through the interaction between women and their environment. The study extends the literature by conceptualising holistic health as flourishing. The study affirms the relevance of a sense of belonging to remote women's health and wellbeing. The study extends the literature in relation to the importance of connectedness to health by delineating a process for making connections. The study findings challenge current discourses in relation to rural women's identity. They also highlight the lack of attention to the concept of control in the rural and remote women's health literature. The findings suggest the need to move towards more holistic, contextual and health promoting approaches to understanding and supporting remote women's health and wellbeing. Future research utilising the concepts of flourishing and place in different remote geographical contexts is recommended.

Social work practice in rural Australia is influenced by high staff turnover, burnout and difficulties in recruitment and retention. The lack of professional social work supervision and lack of professional development opportunities have been identified in the literature as contributing to these recruitment and retention difficulties. Peer supervision is not a common model discussed in the available literature. In the current study, virtual peer supervision models were explored. It was envisaged that peer supervision could ameliorate the retention and supervision deficits in rural and remote Australia. The chosen methodology incorporated a qualitative, interpretive social science theoretical framework. Interpretive interactionism provided a framework to analyse the lived experiences of participants. Action research was chosen as the vehicle for this interpretive approach. A strengths-based approach was the philosophy that guided the action research activities. In this thesis, the processes involved in undertaking peer supervision with virtual teams in rural and remote Australia over a 12 month period is reported. Pre- and post-trial individual interviews; monthly group supervision sessions; online evaluations of the peer group supervision experiences and focus groups all provided a rich landscape of the experiences of participants. Three principles emerged from the thematic analysis process, which are not documented in the current literature. First, connection with like-minded professionals at a peer level within a safe (virtual) space was key to the success of these peer supervision groups. Second, structure and process were vital to the success of the groups. Third, supervision with peers in groups using teleconference technology works, and facilitates good quality supervision. Seven emerging themes further illuminating peer supervision emerged from the data analysis. These themes were: support; learning; reflection on practice; the value of diversity of social work contexts; the impact of structure or no structure; technology and the challenges of priority, preparation and time. The validity of social work peer supervision groups as a supervision option of choice is a key recommendation from this research, particularly for rural, regional and remote contexts.

Science is one of seven-mandated Key Learning Areas (KLAs) Foundation to Year 10 of the new Australian National Curriculum (ACARA, 2012). Not only, therefore, is science to be offered in every school as part of the curriculum, there is also the expectation that science is to be taught well to all students regardless of location, gender, cultural background or socio-economic status (ACARA, 2012). Studying science provides benefits to individuals by developing their scientific literacy skills (Goodrum, Hackling &​ Rennie, 2001; Hackling &​ Prain, 2008). Its study also benefits the national economy by equipping students with the innovative, inventive, and creative skills to generate and apply new ideas as knowledge workers in an interconnected and interdependent global economy (Marginson, Tytler, Freeman &​ Roberts, 2013; Productivity Commission, 2007). A study of recent literature, including the national and international data on the middle years of school (ACARA, 2012; ACER, 2011, 2013; Goodrum et al., 2001; Goodrum, Druhan, &​ Abbs, 2012; Hackling &​ Prain, 2007; Marginson et al., 2013; Office of the Chief Scientist, 2012; Productivity Commission, 2007), could reasonably be expected to show rural and remote students doing well in science if not at least as well as their metropolitan counterparts. Sadly, this is not the case. Science performance in national and international assessments overall is flat-lining (ACARA, 2011; ACER, 2011, 2013) and the gap between metropolitan, rural and remote students in some assessment data indicates as much as 18 months of difference in schooling in favour of metropolitan students and with the gap increasing with increasing remoteness. What are the causes of this inequity and how can it be addressed? Science teachers hold the key (Australian Council of Deans of Science, 2005; Dow, 2003a; Goodrum et al., 2001). Improving the effectiveness of science teachers helps improve science learning outcomes for students. One way to improve the effectiveness of science teachers is to improve their Pedagogical Content Knowledge (Kind, 2009b; Magnusson, Krajcik &​ Borko, 1999; Loughran, 2010; Loughran, Berry &​ Mulhall, 2006; Shulman, 1986) through professional learning experiences. However, improving teachers’ science PCK in the middle-school years in rural and remote settings through traditional face-to-face professional learning activities poses a number of challenges. These include lack of casual relief teachers, difficulties in attracting and retaining science teachers, the provision of experienced mentors and coaches and, the provision of fewer professional learning opportunities compared with metropolitan areas (Australian Council of Deans of Science, 2005; Australian Secondary Principal’s Association, 2006; National Centre of Science, Information and Communication Technology, and Mathematics Education for Rural and Regional Australia, 2006). Educative curricula designed to improve teachers’ science PCK as well as learning outcomes for students provide an alternative to traditional face-to-face professional learning for teachers in rural and remote locations (Davis &​ Krajcik, 2005). Can educative curricula help address the inequity in student science outcomes in rural and remote areas? The Middle Years Astronomy Project (the Project) is an example of one educative curriculum currently in use in the middle years of some rural and remote schools (McKinnon, 2005). This educative curriculum is aligned with the Australian Science Curriculum. It comprises access to telescopes and digital cameras located in NSW (Australia) and Wyoming (USA) that students can control remotely to take photographs of many astronomical phenomena, which can form the basis of further investigations. It also comprises a teachers’ guide designed to improve teachers’ science PCK by providing guidance on designing instructional strategies for science projects with knowledge of five factors in mind. These factors are knowledge of the science content, knowledge of students’ alternative conceptions, knowledge of instructional strategies and the most appropriate assessment strategies to employ, knowledge of the science curriculum, and knowledge of personal beliefs and orientations toward science teaching and learning. This thesis explores the potential for this educative curriculum to improve the PCK of teachers of science in the middle school years in rural and remote settings. It does this by employing a Type IV multiple-case, embedded mixed-methods design (Yin, 2014) over two phases in two states of Australia collecting a range of data from four remote sites in Western Australia and four rural sites in Victoria. Participants comprised 12 teachers, four principals, four teaching principals, one Science KLA Consultant, one Cluster Coordinator and over 200 students. Data were gathered from interviews; archival records; researcher direct observations; an astronomy diagnostic test; student artifacts; and school based documents. A framework, developed from the works of Davis &​ Krajcik (2005), Kind (2009b) and Magnusson et al. (1999), is used to analyse the data for evidence of changes in teachers’ science PCK. The results of this research indicate that the Project improved teachers’ science PCK for most teachers. Reasons for this are presented. An emerging phenomenon from the research was the ability of experienced science teachers to move holistically and fluidly between components of PCK to make in the moment pedagogical decisions to improve student learning. This has been referred to as ‘pinball pedagogical reasoning’ (Mitchell, Pannizon, Keast &​ Loughran, 2015). The findings of this research have implications for both current practice and future research, providing guidance to teachers and designers of professional learning experiences, including educative curriculum designers, on the areas to target when seeking to develop components of PCK for experienced teachers and on assisting less experienced teachers to acquire the ‘pinball pedagogical reasoning’ skills of experienced teachers. The findings also suggest that PCK development takes time and requires a planned and systematic approach to teacher career development with support from the employer. This thesis suggests further areas for research and concludes by arguing that a poor science education, which results in poorer scientific literacy skills and a reduced ability to contribute to, and thrive in, the national and international knowledge economies, adds to the education disadvantage students in rural and remote locations experience relative to their metropolitan peers. It advocates a moral imperative to ensure this does not happen. It also suggests that using educative curricula to improve the PCK of rural and remote science teacher, as well as science student learning outcomes, is a strategy worthy of pursuit.

Background: The gap between current and evidence-based management of type 2 diabetes is widely acknowledged in Australia. Therefore, there is a need to find effective strategies to encourage GP awareness and uptake of evidence-based diabetes guidelines. A well-developed and evaluated web-based education strategy is considered to be an appropriate method for practising GPs in rural and remote areas to undertake continuing medical education. This PhD research forms one part of an NHMRC project entitled “The effectiveness of continuing medical education and feedback in altering diabetes outcomes at a population level-A RCT”. Aims: 1) to examine the current knowledge, attitudes and practices of Australian rural and remote GPs regarding type 2 diabetes management, 2) to test the impact of an online education intervention on GPs’ learning outcomes, and 3) to identify barriers to GPs undertaking and completing the online educational intervention and online learning in general. Methods: The research design consisted of seven complementary studies: three systematic reviews of the literature; a cross-sectional national survey; a quasi-experimental study; and a mixed methods study comprising a short cross-sectional survey and semi-structured telephone interviews. The systematic literature reviews were conducted applying systematic approaches to the literature search, study selection and data extraction. The first systematic review (Study 1) aimed to assess evidence in the literature for the effectiveness of type 2 diabetes educational interventions specifically targeting practising GPs, and where possible, those practising in rural and remote locations. The second systematic review (Study 2) aimed to assess evidence in the literature for the effectiveness of online continuing medical education (CME) specifically targeting GPs. The third systematic review (Study 3) aimed to examine barriers to GPs undertaking and completing online CME. A national cross-sectional survey (Study 4) was conducted with 854 general practitioners (GPs) currently practising in rural and remote Australian communities with populations of between 10,000 and 30,000. A quasi-experimental design (Study 5) was used to compare the knowledge, attitudes and reported changes in practice of GPs who completed an online diabetes active learning module (ALM). The module has been offered by the main NHMRC project to 146 rural and remote GPs in the 11 intervention towns of NSW and QLD which have populations of 10,000 to 30,000. A mixed methods study, involving a short cross-sectional survey (Study 6) and semi-structured interviews (Study 7), were then used to identify enabling and inhibiting factors in undertaking and completing the online ALM. Findings: The national cross-sectional survey (Study 4) revealed that 209 completed surveys were returned, yielding an overall response rate of 24.5 %. GPs reported on their education preferences, knowledge, attitudes and practices relating to type 2 diabetes. GPs indicated a strong preference for face-to-face education options such as conferences and seminars (75.2 %). Whilst structured online education activities were less utilised than face-to-face options, GPs reported a desire to undertake more of their education online in the future. Survey findings revealed gaps in GP knowledge of the medical management of diabetes. The most prevalent self-reported learning needs related to pharmacological management (N =​ 87, (45.5 %)). Correspondingly, in the GP knowledge test, GPs received the lowest mean score for the section on medication management. GPs also reported having the least confidence in providing effective insulin treatment, compared with other aspects of diabetes management. GPs identified an array of difficulties encountered in providing best practice diabetes care, which were classified into three main categories: GP clinical management problems, patient-related challenges and health system-related difficulties. The quasi-experimental study (Study 5) failed to demonstrate the effect of the online ALM on learning outcomes due to inadequate responses to generate statistical inferences. Findings from the systematic review (Study 2) indicated that online CME has the capacity to improve GP satisfaction, knowledge and practice. However, there are very few well-designed studies that focus on this delivery method for GP education. A systematic review (Study 1) also showed that few studies have examined the effectiveness of GP type 2 diabetes education. Evidence to support their effectiveness in improving GP satisfaction, knowledge, practices and/​or patient outcomes is partial and weak. GPs reported reasons for non-participation in the online diabetes CME (Study 6) that correspond with the findings from the systematic reviews (Study 3). Barriers to GP online learning were grouped into four main domains: 1) structure, 2) learners, 3) facilitator and 4) the online program itself. However, GPs rarely reported difficulties inhibiting their completion of the online ALM (Study 6 and Study 7). Contribution of the research: This research adds new knowledge to the field of general practice education in Australia and internationally. The research addresses some of the widespread challenges of CME evaluation: there are currently few well-designed studies focusing on (1) GP CME in general; (2) GP diabetes CME (Study 1); (3) GP online CME (Study 2). The research also provides new insights into the current knowledge, attitudes and practices of Australian rural and remote GPs regarding their type 2 diabetes management. This may further assist CME providers and policy-makers in developing and providing education that addresses GPs’ needs. Conclusions and Recommendations: The national cross-sectional survey highlights a number of barriers to GP provision of best practice diabetes care in rural and remote Australia. Despite the availability of education programs and clinical practice guidelines, the GP respondents revealed deficits in knowledge and confidence in type 2 diabetes management. GPs identified numerous challenges to effective patient care, some but not all of which can be addressed through CME. Online CME has the capacity to improve GP satisfaction, knowledge and practices, but there are very few well-designed studies that focus on this delivery method for GP education. In order to overcome challenges identified in this research, improvements are needed in planning, developing and selecting the topics of education that are needed for GPs. Based on the doctoral research findings, the following recommendations are made: First, in order to provide CME programs for GPs or health care professionals, the learning needs should be clearly identified prior to program implementation. CME providers need to tailor education programs that specifically focus on and address current GP needs. Second, there is a noticeable absence of research focussing on diabetes CME, specifically for GPs practising in rural and remote areas. The use of multiple combined education techniques showed mixed effects. Future studies may need to examine specific combinations of educational techniques and delivery methods tailored to specific desired outcomes for rural and remote GPs. Third, in order to provide online learning activities for GPs, providers who develop the learning programs need to take into account barriers to undertaking and completing online CME. The number of studies examining GP online education is very limited. Therefore, further research is warranted specifically targeting GPs. In addition, future research should focus on clarifying when to use online CME for GP education and how online teaching technologies can be used most effectively. Fourth, future studies need to examine strategies to improve GPs’ participation in CME programs, and in research evaluating these programs.

During the early 1980s the Warlpiri at Yuendemu, a remote Aboriginal community in Central Australia, began their own experiments in local television and radio production. This was prior to the launch of the AUSSAT satellite in 1985 which brought broadcast television and radio to remote Australia for the first time. There was concern amongst remote Aboriginal communities, as well as policy makers, that the imposition of mass media without consultation could result in permanent damage to Aboriginal culture and language. As a result, a policy review 'Out of the Silent Land' was published in 1985 and from that developed the Broadcasting in Remote Aboriginal Communities Scheme (BRACS) which allowed communities to receive radio and television from the satellite. BRACS also provided the option to turn off mainstream media and insert locally produced material. This study of the Warlpiri at Yuendemu has found that, since the original experiments, they have enthusiastically used modern communication technology including radio, video making, locally produced television, and, more recently, on-line services. The Warlpiri have adapted rather than adopted the new technology. That is they have used modern communications technology within existing cultural patterns to strengthen their language and culture rather than to replace traditional practices and social structures. The Warlpiri Media Association has inspired other remote broadcasters and is now one of eight remote media networks that link to form a national network via the National Indigenous Media Association of Australia. The Warlpiri have actively adapted modern communication technology because it is to their advantage. The new technology has been used to preserve culture and language, to restore, and possibly improve, traditional communications and to provide employment and other opportunities for earning income. It appeals to all age groups, especially the elders who have retained control over broadcasts and it also provides entertainment.

This thesis is an account of the role of contemporary Aboriginal women in subsistence. It refers to women living on remote outstations in the Sandover River region of arid, Central Australia. In this post-traditional situation, women's subsistence contribution combined foraging with the use of purchased foods. Their foraging contributed a small, but nutritionally important, component of the diet. However women devoted more time to foraging than to other subsistence activities. A sexual division of labour existed whereby men hunted regularly to provide fresh meat, while women were largely responsible for purchasing and preparing store foods. Substantial technological change was evident, but traditional values continued to shape contemporary subsistence practices. While women had abandoned the most onerous of their traditional tasks, they retained a central role in subsistence. Their contribution, though much changed, was essential to the maintenance of families and households. The subsistence work undertaken by women comprised one aspect of their productivity which also included child-care and household management. Anthropological models of subsistence that have emphasized the aspect of sexual separateness in the traditional division of labour have been influential in the analysis of women's role and social change in Central Australia. This modern ethnographic data, however, highlighted the inter-dependence of women and men. It suggests that subsistence is, and was traditionally, a sphere of domestic life within which the inter-relationship of women and men is a prominent and necessary feature.

Introduction: Includes a brief history of Patrol origins, and how they arose from the necessity to develop new forms of social regulation from a basis of extant cultural law after the colonisation of central Australia. Research Methodology: Delineates the field work methods and action research with remote settlement Patrols that informs this thesis. Some discussion of key reports and other publications that refer to, or are particularly relevant to Patrols. Local Knowledge: Describes some of the physical, cultural, and environmental factors that affect Patrols and their operations. Settlement Origins and Patrols: Describes how the differing origins of remote Aboriginal settlements (mission or pastoral) impacted on the functionality of settlements and their Patrols. Risk: Describes the most significant forms and sources of risks to health and safety in remote Aboriginal settlements in the region, with a particular focus on alcohol, substance misuse and violence. Culturally Specific Conflict: Investigates some forms of Aboriginal conflict such as 'jealousing' that have no non-Aboriginal equivalent. Functional Patrols, being cultural insiders, are particularly good at mediating and resolving these forms of conflict. Job Descriptions and Night Patrol Strategies: Descriptive chapter, using the picture reports developed by RANP and data generated from them, to describe in some detail some of the most common challenges for remote settlement Patrols, and the Patrol strategies and responses that are used to address them. These are all based in the primary cultural imperatives of Aboriginal cultural law. Lost Opportunities: The most significant threats to the functionality and sustainability of remote settlement Patrols are a result of the recent imposition of culturally alien operational modes and models, largely as a result of the Northern Territory Emergency Response (NTER, or the Intervention), and the simultaneously implemented new NT Shire system of local government. Conclusion is that the new operational Patrol regimes are not congruent with the essential basis in cultural law of remote Aboriginal settlement Patrols, and that this is the factor that represents the most significant threat to their ongoing effectiveness, functionality and existence.

Background Chronic Heart Failure (CHF) is defined as a complex clinical syndrome that is frequently, but not exclusively, characterised by objective evidence of an underlying structural abnormality or cardiac dysfunction. CHF affects up to 3% of the adult population and this rate is consistent throughout the developed world. In spite of the proven efficacy of treatments, there is a common theme of low implementation rates for recommended therapeutic guidelines. In Australia, where access to specialist CHF management is limited, the burden of care, for the 40% of CHF patients living outside capital cities falls predominantly onto community- based general practitioners (GPs). Unfortunately, there are diminishing numbers of GPs in rural and remote regions and this has created an apparent dual deficit in terms of equitable access to primary and specialist care for the CHF population living in these areas. Aims The purpose of this research was to determ ine, in a series of themed studies, the population distribution, management and potential information technology solutions for CHF in rural and remote Australia. Method Appropriate methods were utilised for each study and included epidemiological studies, a quantitative analysis of a large practice audit, geo-mapping, a systematic review, a case study review and a qualitative analysis of participant feedback and clinical notes. Results Using results from the Australian Bureau of Statistics population census of 2001, it was estimated that approximately 335,000 Australians (58% male) had symptomatic heart failure associated with bot h left ventricular systolic dysfunction (LVSD) and diastolic dysfunction and an additional 214,000 had asymptomatic LVSD. Of the total symptomatic population, 140,000 (40%) lived in rural and remote areas with a higher prevalence of CHF in rural Australia (19.8%) than in capital cities (16.9%) within the population over 45years. In 2004/05 only 5,000 of the total CH F patients discharged from hospital received specialist management. Ninety-six per cent of all CHF specialist services were located in Capital cities. The 4% that were located outside capital cities serviced a total of 80 patients. The mean distance from any Australian population centre to the nearest CHF management program was 332 km (median 163 km, range 0.15 – 3246 km). In rural areas where the burden of CHF management falls upon the GP, the mean distance to GP services was 37 km (median 20 km, range 0 km – 656 km). A practice audit of rural versus urban CHF management revealed that, CHF diagnosis using echocardiography was lower in rural and remote areas compared to urban (52% vs. 67.3%, p<0.001) areas. Rates of specialist referral were also significantly lower in rural and remote areas (69.6% vs. 59.1%, p<0.001) as were prescribing rates of angiotensin converting enzyme inhibitors (ACEI) (60.1% vs. 51.4%, p<0.001). There was no geographical variation in prescribing rates of beta- blockers across areas (11.8% vs. 12.6%, p< 0.32). Overall, only 3% of all Australians received gold-standard evidence based practice (Diagnosis by echocardiogram + ACEI + Beta Blocker) and there was statistically less prescription of recommended pharmacotherapy in rural areas. In rural Australia, the distances to CHF management programs or, where these are not available, to GP care, preclude CHF models of care such as home visiting. As a consequence, consideration needs to be given to alternate solutions of care, including GP-based multidisciplinary team approaches and/or the use of information technology to bridge the ga p between very remote communities and centres of care. Telemonitoring and structured telephone support have shown great potential in supporting CHF patients in their homes by reducing CHF hospitalisation rates by 22% (95% CI, 11% to 32%) and all-cause mortality by 21% (95% CI, 8% to 31%); However, the requirement of multistate licensure for all Australian health professionals to practice nationally has been identified as a barrier to telemonitoring practise. In spite of the bureaucratic hurdles, the Chronic Heart Failure Assistance by Telephone (CHAT) study has shown that elderly CHF patients can adapt quickly, find the use of telemonitoring an acceptable part of their healthcare routine, and are able to maintain good adherence for least 12 months. Conclusion The burden of CHF was significant in rural and remote Australia, due to a higher prevalence of the disease and issues in accessing appropriate healthcare. Overall this research has shown how disenfranchised these patients are and why we need solutions. With the likelihood of more cases of CHF within our ageing population and the release of the new 2006 Australian therapeutic guidelines, there is a clear need to better understand and support the rural health workforce, to promote best practice in accurately diagnosing and managing CHF and ultimately improving health outcomes at the individual and population levels.