Remote Australia Online

Purpose: To illustrate the utility of a newly developed culturally safe and clinically relevant subjective daytime sleepiness assessment tool “Top End Sleepiness Scale” (TESS) for use among Indigenous Australians. Patients and Methods: The TESS questionnaire consists of pictorial representations of 6 items representing daily activities that would induce daytime sleepiness specific for Indigenous Australians living in the regional and remote Australia. Consecutive adult Indigenous patients who consented to pilot the TESS questionnaire prior to undergoing a diagnostic polysomnography (PSG) at the Top End Health Service region, Northern Territory of Australia were assessed. The TESS questionnaire was evaluated for its correlation in predicting obstructive sleep apnea (OSA) according to apnea-hypopnea index. Results: Eighty-two patients were included. The majority (70%) had moderate to severe OSA (AHI ≥ 15). Patients were aged in their mid-40’s (45.47 95% CI (42.9, 48.05)) with a tendency to obesity (median BMI 33.67 IQR 30.86, 38.95) and a high prevalence of chronic conditions (72%) (hypertension, diabetes or heart disease). The TESS showed high internal consistency (Split half Spearman correlation=0.71, Cronbach’s α =0.81), and a cut-off value ≥ 3 resulted in sensitivity 84%, specificity 38%. Comparison of area under the curve for TESS to Epworth Sleepiness Scale (ESS) in this sample showed the TESS to have greater sensitivity and specificity overall, which approached significance (p=0.072) when cut-off values of ≥ 3 and ≥ 8 (TESS & ESS respectively) were used. The sensitivity and specificity for TESS was also comparable to the other currently used questionnaires, such as the Berlin Questionnaire, STOP-BANG and OSA 50. Conclusion: Currently, there are no subjective daytime sleepiness assessment toll available specifically for Indigenous population. The proposed TESS sleepiness screening tool represented in this study can potentially complement or adopted alongside other existing questionnaire, which may offer greater utility in the assessment of sleep disorders among Indigenous people.

Background Aboriginal children in Northern Australia have a high burden of otitis media, driven by early and persistent nasopharyngeal carriage of otopathogens, including non-typeable Haemophilus influenzae (NTHi) and Streptococcus pneumoniae (Spn). In this context, does a combined mixed primary series of Synflorix and Prevenar13 provide better protection against nasopharyngeal carriage of NTHi and Spn serotypes 3, 6A and 19A than either vaccine alone? Methods Aboriginal infants (n = 425) were randomised to receive Synflorix™ (S, PHiD-CV10) or Prevenar13™ (P, PCV13) at 2, 4 and 6 months (_SSS or _PPP, respectively), or a 4-dose early mixed primary series of PHiD-CV10 at 1, 2 and 4 months and PCV13 at 6 months of age (SSSP). Nasopharyngeal swabs were collected at 1, 2, 4, 6 and 7 months of age. Swabs of ear discharge were collected from tympanic membrane perforations. Findings At the primary endpoint at 7 months of age, the proportion of nasopharyngeal (Np) swabs positive for PCV13-only serotypes 3, 6A, or 19A was 0%, 0.8%, and 1.5% in the _PPP, _SSS, and SSSP groups respectively, and NTHi 55%, 52%, and 52% respectively, and no statistically significant vaccine group differences in other otopathogens at any age. The most common serotypes (in order) were 16F, 11A, 10A, 7B, 15A, 6C, 35B, 23B, 13, and 15B, accounting for 65% of carriage. Ear discharge swabs (n = 108) were culture positive for NTHi (52%), S. aureus (32%), and pneumococcus (20%). Conclusions Aboriginal infants experience nasopharyngeal colonisation and tympanic membrane perforations associated with NTHi, non-PCV13 pneumococcal serotypes and S. aureus in the first months of life. Nasopharyngeal carriage of pneumococcus or NTHi was not significantly reduced in the early 4-dose combined SSSP group compared to standard _PPP or _SSS schedules at any time point. Current pneumococcal conjugate vaccine formulations do not offer protection from early onset NTHi and pneumococcal colonisation in this high-risk population.

This study examines the incidence of Indigenous driving offending in the Northern Territory since 2006 and assesses the effectiveness of law enforcement in addressing this crime. It seeks to ascertain alternative forms of regulating driver safety and whether they are better suited to Indigenous communities. In doing so, it identifies some of the major reasons for offending. It is particularly concerned with driving offences that have increased dramatically since 2006, including driving unlicensed and driving unregistered and uninsured cars.

This article analyses the recent closure of the Uluru climb in the settler colonial context of Australia and reflects on (im)possibilities for doing tourism otherwise to practices and logics of coloniality. Tourism at Uluru is embedded within settler colonial map-making, privileging supply side models of consumption at the expense of the Anangu Traditional Custodians. We contribute to the emerging body of research in tourism that argues for a dismantling of colonial logics in practice and theory and discuss the possibilities inherent in forms of tourism led by the Aboriginal custodians. In this context, tourism can promote deeper engagement to place that is ‘more-than-human’, beyond the Eurocentric dualisms of nature and culture, human/non-human/spirit. Unlearning coloniality is key for promoting transformative tourism.

THERE ARE VARIOUS COMMUNITY-BASED literacy programs in Australian communities that aim to address educational disadvantage by fostering parental engagement with their young children in literacy activities. Despite the effort and goodwill of many community members, there is little evidence of the impact of these programs on children's literacy progress, school attendance or parental engagement. This paper reports on a pilot study of parents' engagement in their child's literacy development in one remote Indigenous community. Preliminary findings from parent reports indicate elevated progress in literacy by the children in the program. Similarly, parents involved in the program report being more engaged in community leadership and in their children's literacy learning than those who are not. The study suggests aspects of the interrelationship between parent engagement and children's literacy progress that require further investigation. Broader use of the instruments developed will help to establish an evidence base and inform such an investigation.

The World Health Organisation has identified ear disease to be a major public health problem in rural and remote communities, with access to services an identified barrier. (1) Rural community pharmacists are recognised as highly skilled, accessible and trusted health professionals. An innovative service “LISTEN UP” (Locally Integrated Screening and Testing Ear aNd aUral Program) has been implemented in two remote community pharmacies in Australia. The service involves patients with an ear complaint self-presenting to a participating pharmacy and receiving a clinical examination by a pharmacist, who has completed accredited training in ear health, otoscopy and tympanometry. “LISTEN UP” has been developed using the PRECEDE-PROCEED planning model.(2) The PRECEDE component of the model assesses social, epidemiological, behavioural, environmental, educational and ecological factors to inform the development of an intervention.(2) The PROCEED-component consists of pilot testing and evaluation.To describe an ecological approach to health promotion via the application of the PRECEDE-PROCEED planning model to develop a rural community pharmacy-based ear health intervention.PRECEDE (Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis) provided a framework to plan and develop a locally relevant and community focused program. This included research and engagement via meetings, surveys and interviews of consumers, pharmacists, health professionals and stakeholders. PROCEED (Policy, Regulatory, and Organisational Constructs in Educational and Environmental Development) outlined the structure for implementing and evaluating the intervention that was developed in the PRECEDE process. A pilot study has been included in PROCEED segment to allow improvement before implementing and evaluating the final model. Data will be collected in the pilot study via semi-structured interviews and surveys. This will be analysed using descriptive statistics and thematic analysis of qualitative data.As part of the PRECEDE segment a social assessment was undertaken via mixed method studies of rural consumers, pharmacists and health professionals. Hearing testing was ranked as the seventh (from twenty-six) most important expanded pharmacy service by both consumer and health professional groups. An epidemiological assessment found extensive ear disease in rural and remote locations resulting in complications and hearing loss. Behavioural and environment assessments identified eleven ear health interventions which include hearing screening [3], otoscopy pilot studies [2], audiometry services [1], specific education for undergraduate pharmacy students [2] and a pharmacy-based clinic [3]. However none of the interventions described a framework for continued service provision. Policy and regulation assessment was undertaken to align the intervention within the regulatory framework. The application of this model is partially complete with the study protocol for the intervention developed and the initial pilot study in progress. This study’s strengths include its applicability to rural populations and the limited evidence base that currently exists. It is however limited by the small size of the pilot study and application of this model to a national intervention would be useful for future.The application of the PRECEDE-PROCEED model demonstrates the applicability of this planning model for developing and evaluating an ear health intervention with a particular focus on community pharmacies in rural and remote locations.1. World Health Organisation. Deafness and hearing loss; 2020. Available from: https://www.who.int/health-topics/hearing-loss#tab=tab_1 [Accessed: 15/9/2020]2. Binkley CJ, Johnson KW. Application of the PRECEDE-PROCEED Planning Model in Designing an Oral Health Strategy. J Theory Pract Dent Public Health. 2013;1(3):http://www.sharmilachatterjee.com/ojs-2.3.8/index.php/JTPDPH/article/view/89

Around the world, women and girls experience inequities that have cascading socioeconomic and health repercussions (1). Menstruation is a healthy biological process that impacts approximately half of the global population throughout her lifetime (2). Despite its regularity and prevalence, many girls and women manage their monthly period with significant disruptions to their lives due to factors including access to resources, environmental challenges, and cultural taboos (2, 3). Initial research into the area of Menstrual Health and Hygiene (MHH) has primarily been conducted in developing countries and has not yet considered challenges experienced by underrepresented groups living in developed countries such as Australia (3, 4). Anecdotal findings from research conducted in Central Australia indicates that school-aged girls living in remote Australian communities may be experiencing similar menstrual challenges to those living in low-and middle-income countries, which may be influencing school attendance (5, 6). These findings initiated a local women’s group in the Western Cape, Queensland, to investigate the state of MHH for female students living in their own community. Following a yarning circle discussion gathering Indigenous Australian women leaders from across the country to discuss MHH (7), Minnie King (Indigenous Australian researcher) invited Nina Hall (non-Indigenous academic), to work together with Indigenous Australian and non-Indigenous students at Western Cape College in Western Cape, Queensland. The research project was developed to begin a discussion around female student-defined challenges and options for addressing menstrual health and hygiene (MHH), including how these challenges and options may relate to school attendance (Stage 1). In order to gather multiple perspectives, Stage 1 also included 15 interviews with school staff, health workers, and representatives from the community and other organisations. The results from Stage 1 informed a second visit (Stage 2), which involved engagement with both female and male students, and six (6) interviews with Western Cape College’s staff and key stakeholders.

Objectives. This study investigates the burden of cardiovascular risk markers in people with and without diabetes in a remote Indigenous Australian community, based on their HbA1c concentration. Methods. This study included health screening exams of 1187 remote Indigenous residents over 15 years old who represented 70% of the age-eligible community. The participants were stratified by HbA1c into 5 groups using cut-off points recommended by international organisations. The associations of traditional cardiovascular risk markers with HbA1c groups were assessed using logistic and linear regressions and ANOVA models. Results. Of the 1187 participants, 158 (13%) had a previous diabetes diagnosis, up to 568 (48%) were at high risk (5.7%-6.4% (39-46 mmol/mol) HbA1c), and 67 (6%) potential new cases of diabetes (≥6.5% (48 mmol/mol)) were identified. Individuals with higher HbA1c levels were more likely to have albuminuria (OR 3.14, 95% CI 1.26-7.82) and dyslipidaemia (OR 2.37, 95% CI 1.29-4.34) and visited the clinic more often (OR 2.52, 95% CI 1.26-4.99). Almost all traditional CVD risk factors showed a positive association with HbA1c. Conclusions. Screening in this remote Indigenous Australian community highlights the high proportion of individuals who are at high risk of diabetes as indicated by HbA1c and who also had an accentuated cardiovascular risk profile.

In 2009 the Ceduna Koonibba Aboriginal Health Service, an Indigenous-specific service, and Statewide Gambling Therapy Service joined together to investigate the impact that gambling was having on the Aboriginal people living in this region. Both organisations were funded through the state-based Office for Problem Gambling to provide gambling intervention. A number of signs indicate that the community development approach has proven effective. Towards the end of the first year of the project six people signed up for one-on-one therapy to address gambling; a small group of women met regularly to learn more about how to overcome gambling and provide support to each other. In general, there has been a notable improvement in the level of engagement with the program amongst health and welfare workers in the town, with the Project Officers regularly meeting with staff across agencies.

Over the past decade, there has been increased international interest in understanding and recognizing the contribution of Indigenous natural and cultural resource management, including Indigenous ranger work, to the sustainable management of social-ecological systems. In Australia, Indigenous rangers are responsible for managing land and seas that represent approximately 44% of the national protected area estate. Governments and other coinvestors seek to evaluate this ranger work and its contribution to biodiversity conservation and other public goods. However, current monitoring and evaluation approaches are based in conceptions of value and benefits and do not capture the full range of contributions and meanings associated with this work. We present an empirical case study from northern Australia in which we explore how to properly account for the full complexity and richness of Indigenous ranger work. We demonstrate that the work of being an Indigenous ranger at a Yolŋu (Indigenous people of Northeast Arnhem Land) land and sea management organization, (the Dhimurru Aboriginal Corporation or Dhimurru), can be understood as three sets of knowledge practices: the practices of "knowing and being known by Yolŋu country"; the practices of "mobilizing the Dhimurru Vision Statement"; and, the practices of "being ralpa" (Ralpa is a Yolŋu concept that means being willing to work and prepared to take on leadership responsibilities.) We contend that these knowledge practices represent criteria for judging the effectiveness of Yolŋu ranger work. The Dhimurru knowledge community of senior Yolŋu landowners and their collaborators, judge the effectiveness of Yolŋu ranger work based on whether Yolŋu rangers demonstrate these practices. By integrating such criteria into Dhimurru's formal monitoring and evaluation processes endorsed by its government funding partners, Dhimurru can more effectively and fully demonstrate the contribution of Yolŋu rangers to the Yolŋu vision for ecologically and culturally sustainable management of the Dhimurru Indigenous Protected Area in the Northern Territory as part of Australia's national conservation estate.

The parasitological, clinical efficacy and tolerability of albendazole in the treatment for both giardiasis and hookworm infection in a remote Aboriginal population was investigated. Albendazole at a dose rate of 400 mg daily for 5 days was highly effective in reducing hookworm egg numbers and both Giardia antigen and cysts. The 36.6% prevalence of Giardia prior to treatment fell to 12% between days 6 and 9, 15% for days 10–17 and rose to 28% between days 18 and 30. Tolerability and clinical efficacy were excellent. The effect of albendazole on hookworm was longer lasting than that on Giardia, reducing percent infection from over 76–2% on days 6–9 and zero by day 18–30 despite conditions highly conducive to rapid re-infection. We conclude that albendazole is highly efficacious against both parasites when used as described but that long term community benefit may require additional education programmes to avoid re-infection with Giardia although treatment strategies would seem appropriate for hookworm.

Background: soil-transmitted helminths are a problem worldwide, largely affecting disadvantaged populations. The little data available indicates high rates of infection in some remote Aboriginal communities in Australia. Studies of helminths were carried out in the same remote community in the Northern Territory in 1994–1996 and 2010–2011; (2) Methods: fecal samples were collected from children aged <10 years and examined for helminths by direct smear microscopy. In the 2010–2011 study, some fecal samples were also analyzed by agar plate culture and PCR for Strongyloides stercoralis DNA. Serological analysis of fingerprick dried blood spots using a S. stercoralis NIE antigen was also conducted; (3) Results and Conclusions: a reduction in fecal samples positive for S. stercoralis, hookworm and Trichuris trichiura was seen between the studies in 1994–1996 and 2010–2011, likely reflecting public health measures undertaken in the region to reduce intestinal helminths. Comparison of methods to detect S. stercoralis showed that PCR of fecal samples and serological testing of dried blood spots was at least as sensitive as direct smear microscopy and agar plate culture. These methods have advantages for use in remote field studies.

Aims: This report represents the third draft of the Charles Darwin University (CDU) Yolŋu Aboriginal Consultancy Initiative’s case study of gambling. The case study is Part A3 of a wider project called Gambling Practice and Policy in the Northern Territory: A Research Program funded through the Community Benefit Fund of the Northern Territory Government. The aim of Part A3 is “Through a series of workshops with key individuals in Yolŋu Matha, to provide a genuine Yolŋu perspective on gambling practices, the meaning of problem gambling, and potential intervention strategies”. The current report presents this perspective. Methods: Fourteen Yolŋu consultants contributed to the project. They did this through discussions among themselves and in their communities, through a planning meeting where the wider project and the A3 questions and the methodology were discussed, through a full-day workshop at CDU, and through speaking (or in one case writing) their reflections on key questions on video. Most of the material for this report is taken from the recordings which were made in English (six statements) and Yolŋu languages (seven). Yolŋu consultancy methodology entails people working hard to reach agreement. Consequently, differences of opinion are often left to one side. Therefore, in the recording sessions, people are recorded alone, so some of the key differences are able to emerge. The representation of the findings was further developed through discussions and feedback during a symposium on Gambling research at CDU, and will be further developed following feedback from the Community Benefit Fund.

High quality education opens doors for Australian children — yet, this promise seems out of reach for many in majority-Indigenous remote communities. To a casual observer, the path to school may be a short walk, but the metaphorical distance these children need to traverse to the classroom is immense, littered with potholes, and often misunderstood by outsiders. And when children in remote communities do reach the classroom, the staff who greet them must be nothing short of exemplary teachers and administrators.The best intentions and resourcing for decades haven’t always translated into higher quality instruction or significant improvement in broader education outcomes. But results are being achieved with a program that prioritises: • high impact instruction; • a focus on attendance; • pre-school programs for zero to three year olds; and • community engagement. This scalable model includes professional learning and instructional coaching for 24 schools in the Kimberley Region of Western Australia and is the basis of my experience working in majority-Indigenous remote communities. This paper discusses observations during school visits and professional learning, interactions with educators and community, and explores what is — and isn’t — working.

The challenge of reaching common understanding of the processes and significance of environmental change amounts to a procedural vulnerability in climate change research that hinders successfully translating knowledge into equitable and effective adaptation policy. This article presents findings from research with Indigenous participants in West Arnhem, Australia, and identifies a procedural vulnerability to climate change research, where perceptions of change and their meaning have their context in Dreaming that supersedes and parallels Western scientific discourses of hazard and risk, but that are marginalised in studies and policies on climate change. This paper argues that moves to adapt remote Indigenous Australian communities to climate change risk missing the mark if they (a) assume that a strong reliance on particular ecosystem configurations makes Indigenous cultures universally vulnerable to environmental change, (b) do not recognise cosmologically embedded risks that are determined by Indigenous capacity to take care of country, and (c) do not recognise colonisation as an ongoing disaster in Indigenous Nations, and therefore treat secondary disasters such as poverty, ill health and welfare dependence as primary contributors to high climate change vulnerability. Procedural vulnerabilities contribute to policy failure, and in Australian contexts pose a risk of conceiving solutions to climate change vulnerability that involve moving people out of the way of environmental risks as they are conceived within colonial traditions, while moving them into the way of risks as conceived through the eyes of remote Indigenous communities. This research joins recent publications that encourage researchers and policy-makers to epistemologically ground proof risk assessments and to listen and engage in conversations that create ways of ‘seeing with both eyes’, while not being blind to the hazards of colonisation.

Human mobility plays a major role in the spread of communicable diseases. Remote Indigenous populations in Australia tend to have a higher risk of communicable diseases, and although high levels of mobility at the household, community and regional scale are prevalent in these communities, limited data are available on the movement patterns of these populations. This project is motivated by the need to understand and model human mobility in rural regions when hampered by imperfect data, and aims to develop a robust methodology with techniques incorporated to address missing data and integrate multiple sources of data. In this study, I introduce numerous innovations to shed light on imperfect movement data. I applied Generalised Linear Mixed Effects Modelling (GLMM) for longitudinal data to understand the long- and medium-term mobility in Indigenous communities. I used Multiple Imputation by Chained Equations (MICE) to address the missing data and Two Sample Two Stage Least Squares (TSTSLS) estimation to combine two data sets with different variables. The significance of this project is that it creates new knowledge for modelling human mobility with longitudinal data and making inferences based on imperfect data from multiple sources. This knowledge could be effectively used to understand human mobility which could be applied in real world situations such as infectious disease surveillance and control.

Despite substantial investment in policies, programs and services to address the over-representation of Aboriginal young people in the criminal justice system, little progress has been made over the last decade. Aboriginal young people still make up around half of the custodial population, despite the fact that only 5 per cent of the general population aged 10 to 17 years identify as Aboriginal. On any given day in New South Wales (NSW), Aboriginal youth are approximately 24 times more likely to be in custody and 14 times more likely to be under community supervision than their non-Aboriginal peers. When these statistics are considered alongside data showing that young people from regional, rural and remote areas are also more likely to be in contact with youth justice agencies than their urban peers, the need to understand the ecological and contextual factors that contribute to over-representation becomes apparent. The aim of this thesis is to understand how justice programs might be designed to more effectively respond to the ecological position and needs of Aboriginal young people from a rural community. The first study of the thesis reports the findings of a quantitative analysis of 6,750 archival records from NSW Youth Justice of young people who offended for the first time between 2013 and 2016. The study examines how the level of risk and need, as measured by a standardised risk and needs assessment, differs across rural and urban settings. Given substantial evidence of rural disadvantage in Australia, it was hypothesised that rural young people would have higher levels of risk and need than urban young people and that this would be further influenced by Aboriginality. The analysis revealed that more Aboriginal young people who were known to have offended lived in rural areas than urban areas. However, contrary to expectations, urban young people had significantly higher risk and need scores in seven of the eight domains assessed, and this was consistent for both Aboriginal and non-Aboriginal young people. It is suggested that these findings highlight the need to investigate those ecological factors that contribute to justice system involvement but which are not considered in the current assessment protocol. Based on a consultation with an Aboriginal community in a rural town in New South Wales, the second study aimed to understand how responsive programs might be designed in ways that would better meet the needs of young people who offend. Drawing on Indigenist research paradigms –particularly the notion of decolonising knowledge – the study explored: a) the types of knowledge and evidence that is important to community members when designing responsive programs; b) focus areas for programs that the community identify as important for Aboriginal young people who offend; and c) the natural resources and strengths that exist in the community to support program delivery. Eighteen Aboriginal adults participated in interviews over a six-month period, including two people with lived experience of offending as a young person. A qualitative content analysis of transcripts of the interviews identified a number of themes that reflected key community understandings of youth offending, including the need for contextually based, locally informed and community driven solutions. It is proposed that the main contribution of these two studies is the way in which it demonstrates how Western and Aboriginal community knowledge might be combined to re-define, re-create, and reframe some of the assumptions that are made about how to best meet the needs of Aboriginal young people in rural communities who have offended. The thesis highlights the importance of engaging with local knowledge in policy and program planning, and the need to carefully consider how historical, environmental, ecological, and cultural influences intersect to contribute to the significant over-representation of Aboriginal young people in the justice system. Methodologically, the thesis aims to develop a framework that can be used to guide non-Aboriginal researchers who seek to engage meaningfully and respectfully with Aboriginal communities and non-western research paradigms. It concludes with a discussion of how this approach can be used to support policy makers, program designers and practitioners in planning and providing services and programs for young people who offend in rural communities.

Rheumatic heart disease (RHD) is a disease of disparity most prevalent in developing countries and among immigrant populations. Mitral stenosis (MS) is a common sequalae of RHD and affects females disproportionately more than males. Rheumatic MS remains a significant management challenge as severe MS is usually poorly tolerated in pregnancy due to haemodynamic changes and increased cardiovascular demands of progressing pregnancy. Pregnancy remains contraindicated in current management guidelines based on expert consensus, due to a paucity of evidence-based literature.A 28-year-old aboriginal woman with known severe MS was found to be pregnant during routine health review, despite contraceptive efforts. Echocardiography demonstrated mean mitral valve (MV) gradient 14 mmHg; stress echocardiography demonstrated increased MV gradient 28–32 mmHg at peak exercise and post-exercise pulmonary artery pressure 56 + 3 mmHg with marked dynamic D-shaped septal flattening. Left ventricular systolic function remained preserved. She remained remarkably asymptomatic and underwent successful elective induction of labour at 34 weeks. Postpartum, she remained euvolaemic despite worsening MV gradients and new atrial fibrillation (AF). She subsequently underwent balloon mitral valvuloplasty with good result.Severe rheumatic MS in pregnancy carries significant morbidity and mortality, due to an already fragile predisposition towards heart failure development compounded by altered haemodynamics. Pregnancy avoidance and valvular intervention prior to conception or in the second trimester remain the mainstay of MS management; however, we present an encouraging case of successful near-term pregnancy with minimal complications in a medically managed asymptomatic patient with critical MS, who subsequently underwent valvular intervention post-partum.

Background: Indigenous people tend to exhibit a higher burden of disability than their non-Indigenous counterparts, and are often underserved by disability services. Engaging appropriately with Indigenous communities, families and individuals in the initial stages of disability assessment and planning is crucial in order to build trust and understanding of disability service models and ensure that Indigenous people receive support that is tailored to their needs and cultural realities. This article aims to identify key elements of culturally competent communication in Indigenous disability assessment and planning, and provide recommendations for strengthening capacity in this area. Methods: This qualitative research was designed to involve Aboriginal and Torres Strait Islander people at all stages and to reflect the views of Aboriginal and Torres Strait Islander researchers, people and families affected by disability and the community-controlled health sector. Semi-structured individual interviews were undertaken with staff implementing the National Disability Insurance Scheme (NDIS) (n = 4), NDIS participants (n = 24), disability support providers and organisational partners (n = 19) and Community Connectors (n = 8) in Queensland and the Northern Territory of Australia. Key themes derived from thematic analysis included appropriate and adequate engagement of individuals with disability and their families, the role of trusted relationships, and culturally safe and appropriate communication during planning meetings. Results: Overall, the research findings highlight that a low level of cultural competence in the initial stages of the disability assessment and planning process exacerbated participant confusion and distrust towards assessment staff and the NDIS. Given difficulties in communication, participant understanding of the NDIS was generally limited. The necessity of culturally safe and appropriate use of interpreters was stressed, as was the role of trusted individuals, including existing service providers, Community Connectors and family members in providing a solid base for participant understanding of the NDIS. Conclusions: Cultural competence in disability assessment and planning can be strengthened through multi-level engagement with the Aboriginal community-controlled sector and community leaders. Implementing mechanisms to enable the involvement of families, trusted service providers and Community Connectors can support a more meaningful understanding of individuals’ needs within their cultural context and in relation to their cultural roles.

This literature review has been conducted by Community Works to inform the strategic framework that is being developed by Ninti One to design and implement the Stronger Communities for Children (SCfC) program in ten remote communities in the Northern Territory from 2018. An evaluation conducted in 2017 found that the concept of collective impact was both appropriate and useful for shaping design and delivery of SCfC: The place based economic development and the development of social capital creating stronger, cohesive communities supported collective impact as appropriate elements of the SCfC to make it work. (p. 18). Specifically, the evaluation recommended that Local Community Boards (LCBs): Focus on the concept of collective impact and draw in as much advice and guidance from as many sources as possible to make informed decisions on “how” it will be done to best achieve better outcomes (p. 27). The purpose of this literature review is to assist Ninti One in considering how the Collective Impact (CI) framework can best be used in their work with remote communities. In particular, the literature review aims to help Ninti One learn from the experience of other organisations that have applied this framework to programs directed towards giving children the best start in life. To this purpose, the review presents: »» An overview of CI, including definitions of key terms and concepts (Section 2) »» A set of ‘key ingredients’ essential to effective application of the framework (Section 3) »» Examples and case studies of how CI has been used by other organisations (Section 4) »» A summary of key learning points that can be drawn from the case studies (Section 5) »» Discussion of how these key learning points may apply to the contexts of SCfC in remote communities (Section 6)

Objective The aims of this study were to review the demographic details of those who have undergone lower limb amputation (LLA) surgery in Central Australia and determine the region-specific age-adjusted incidence rate of LLA.Methods A retrospective audit of service users who underwent LLA in a Central Australian hospital from 2012 to 2017 was undertaken. Demographic, operative and postoperative outcomes data were collected. The age-adjusted incidence rate of LLA was determined using the direct method. Demographic data were analysed using descriptive parametric analysis.Results In the period 2012–17, 166 service users underwent a total of 291 amputations in 231 episodes of care (hospital admissions). The age-adjusted incidence rate of LLA was 87.4 per 100 000 for females and 104.6 per 100 000 for males in this region. In total, 84% (n = 140) of those requiring amputation surgery identified as Aboriginal Australians (P < 0.001), 54% (n = 75) of whom were female. Aboriginal Australians who underwent LLA were, on average, 13 years younger and were more likely to have type 2 diabetes (P < 0.001) and require renal dialysis (P < 0.001) than the non-Aboriginal Australian cohort. Of the Aboriginal Australians who underwent LLA, 82% (n = 103) lived very remotely (>100 km from the central town’s centre), compared with 23% of non-Aboriginal Australians (P < 0.001). In addition, 46% (n = 64) of Aboriginal Australians who underwent LLA required renal dialysis. Those requiring renal dialysis were more likely to require subsequent amputation (P = 0.014) and had a higher mortality rate following amputation (P = 0.031). Partial foot amputation was the most common level of amputation in Central Australia (38%).Conclusions Central Australia appears to have the highest incidence rate of LLA for any region in Australia, with Aboriginal Australians, particularly females and those undergoing renal dialysis, being disproportionately represented. Further studies should aim to determine targeted, culturally safe and successful methods of diabetic foot ulcer prevention, early detection and management with a view to reducing the high amputation rates for these cohorts.What is known about the topic? Large health inequalities between Aboriginal and non-Aboriginal Australians exist. Aboriginal Australians are currently fourfold as likely as non-Aboriginal Australians to have type 2 diabetes (T2D), increasing their risk of LLA. There is a geographical variance in the incidence of LLA in Australia; the Northern Territory is overrepresented, with rates two- to threefold higher than that of the national average. Regional incidence rates are not currently known.What does this paper add? This study showed that the age-adjusted incidence rate for LLA in Central Australia is significantly higher than in other regions in Australia. Most LLA surgeries undertaken in Central Australia were performed for Aboriginal Australians who have T2D, with a disproportionate representation of females and those requiring renal dialysis.What are the implications for practitioners? This study shows that there is a need for further research and preventative measures to address the high rates of LLA among Aboriginal Australians, particularly for females and those with renal impairment. These groups could benefit from targeted, culturally safe approaches to early identification, referral and management of lower limb ulceration by relevant service providers.

A ‘wicked’ problem is one that is difficult or impossible to solve, often due to varying views, contradictory knowledge, knowledge gaps, an economic burden, and the problem’s interconnection with other problems — such as alcoholism contributing to domestic violence. For decades State, Territory and Commonwealth governments have been trying (and failing) to solve the wicked problems besetting remote Indigenous communities. Billions upon billions of taxpayer dollars have been spent with very little improvement. In some communities, the situation has regressed, with alcohol abuse, domestic violence and truancy plaguing townships that are on the verge of breaking point. Regional and Remote Indigenous Communities are unique outliers in a nation otherwise known for its wealth, education and safety. Due to high Indigenous populations, these communities are immensely challenging to understand, and their challenges hard to address. Some critics argue that the nature of Indigenous cultures is inextricably linked to the social breakdown plaguing places like Tennant Creek, Ceduna and Aurukun. Others argue that such aspersions are unfair and racist. Conditions in these towns are often more comparable to the third world than to one of the most prosperous countries on earth. The Productivity Commission estimates that governments spent approximately $33.4 billion on Indigenous peoples in 2015-16. Approximately $4.1 billion (12.23%) of this was spent on public order and safety alone. At $6,300 per person, this is ten times the amount spent on the typical Australian. The purpose of this report is to demonstrate the wicked problems Regional and Remote Indigenous communities face. While no single cause can explain Indigenous disadvantage, the severe socio-economic disadvantage experienced by these communities can be demonstrated. This undoubtedly contributes to the astronomically high rates of alcohol abuse, crime, and domestic violence.This paper will first map the socio-economic factors that shape many Regional and Remote Indigenous communities and compare them to wider Australia. It will then look at the nature of crime and domestic violence — factors that all combine to make these communities so very different to the typical Australian suburb. It will use data to highlight the severe conditions in these locations, pointing to the fact that these places are experiencing extremes that would not be tolerated anywhere else in Australia. Ultimately, as the data will demonstrate, the situation in these communities is in dire need of a radical solution. A solution that targets communities based on evidence, rather than assertions about race and culture, and focuses on establishing the safe communities that any Australian would rightfully expect on their doorstep.

There are stark health differentials between Indigenous and non-Indigenous Australians. Aboriginal and Torres Strait Islander people live 10 years less than the national average—15 years less for those in remote communities—mostly due to the high incidence and early onset of chronic conditions such as type 2 diabetes and cardiovascular disease. As the theme leader in Aboriginal Health Equity at the South Australian Health and Medical Research Institute (SAHMRI) and professor of medicine at the University of Adelaide (both in Adelaide, SA), Alex Brown's mission is to understand this grim reality in order to change it.

National Shelter welcomes the opportunity to make this submission.This submission builds on the recent work of National Shelter, other peak bodies and our member organisations and draws on the extensive work of the Australian Housing and Urban Research Institute (AHURI) and other researchers to propose a set of measures which will begin transforming our national housing system to produce sufficient affordable, well located, fit for purpose housing, to meet our nation’s dramatic shortfall of social and affordable housing and insufficient responses to homelessness.

Conditional welfare has become a prominent policy tool in recent years. One of the harshest forms of conditional welfare in Australia is arguably compulsory income management (CIM) which involves the quarantining of between 50 and 90 per cent of a participant's benefit payment for spending on food, rent and other essential items. A leading aim of all Australian income management (IM) programs since 2007 has been the reduction of alcohol and other drug (AOD) abuse by participants, which is expected to reduce associated social and community harms. Building on the mixed findings of official evaluations of IM, this qualitative study examines the views of both compulsory and voluntary IM participants and community stakeholders concerning AOD abuse in four IM sites. It concludes that there is little evidence to support the view that IM per se contributes to a significant reduction in AOD abuse.