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Physical activity has positive health implications for individuals living with neurodegenerative diseases. The success of physical activity programs, particularly in culturally and linguistically diverse populations, is typically dependent on their alignment with the culture, lifestyle and environmental context of those involved. Aboriginal families living in remote communities in the Top End of Australia invited researchers to collaborate with them to co-design a physical activity and lifestyle program to keep individuals with Machado-Joseph disease (MJD) walking and moving around. The knowledge of Aboriginal families living with MJD, combined with findings from worldwide MJD research, formed the foundation for the co-design. An experience-based co-design (EBCD) approach, drawing from Indigenous and Participatory methodologies, was used. An expert panel of individuals with lived experience of MJD participated in a series of co-design phases. Prearranged and spontaneous co-design meetings were led by local community researchers within each phase. Data was collected using a culturally responsive ethnographic approach and analysed thematically. Sixteen panel members worked to develop the ‘Staying Strong Toolbox’ to cater for individuals with MJD who are ‘walking strong’; or ‘wobbly’; or ‘in a wheelchair’. Based on the ‘Staying Strong Framework’, the Toolbox was developed as a spiral bound A3 book designed to guide the user to select from a range of activities to keep them walking and moving around and to identify those activities most important to them to work on. The ‘Staying Strong Toolbox’ is a community driven, evidence based resource for a physical activity and lifestyle program for Aboriginal families with MJD. The Toolbox provides a guide for health professionals and support workers to deliver person-centred support to Aboriginal families with MJD, and that can be modified for use by other families with MJD or people with other forms of ataxia around the world.

Background: Culturally diverse populations (including Aboriginal and Torres Strait Islander people, people of diverse genders and sexualities, and culturally and linguistically diverse people) in nonurban areas face compounded barriers to accessing mental health care. Health information technologies (HITs) show promising potential to overcome these barriers. Objective: This study aims to identify how best to improve a mental health and well-being HIT for culturally diverse Australians in nonurban areas. Methods: We conducted 10 co-design workshops (N=105 participants) in primary youth mental health services across predominantly nonurban areas of Australia and conducted template analysis on the workshop outputs. Owing to local (including service) demographics, the workshop participants naturalistically reflected culturally diverse groups. Results: We identified 4 main themes: control, usability, affirmation, and health service delivery factors. The first 3 themes overlap with the 3 basic needs postulated by self-determination theory (autonomy, competence, and relatedness) and describe participant recommendations on how to design an HIT. The final theme includes barriers to adopting HITs for mental health care and how HITs can be used to support care coordination and delivery. Hence, it describes participant recommendations on how to use an HIT. Conclusions: Although culturally diverse groups have specific concerns, their expressed needs fall broadly within the relatively universal design principles identified in this study. The findings of this study provide further support for applying self-determination theory to the design of HITs and reflect the tension in designing technologies for complex problems that overlap multiple medical, regulatory, and social domains, such as mental health care. Finally, we synthesize the identified themes into general recommendations for designing HITs for mental health and provide concrete examples of design features recommended by participants.

Background: The clinical profile of Aboriginal and Torres Strait Islander adults admitted to hospital with neurological injury is not well documented. Understanding these profiles may enable health professionals to provide more culturally responsive health care for this patient group. This study aimed to report the clinical profile of Aboriginal and Torres Strait Islander adults admitted to a regional Queensland hospital due to stroke or traumatic brain injury (TBI). Method: A 2-year retrospective medical record review of Aboriginal and Torres Strait Islander adults (≥18 years) admitted to a regional Queensland hospital with principal diagnoses of stroke or TBI. Results: There were 132 Aboriginal and Torres Strait Islander adult stroke (51.5%) or TBI (48.5%) admissions. The mean ages were 56.7 years for stroke and 42.7 years for TBI. The majority of patients (83.3%) were of Aboriginal descent with others identifying as Torres Strait Islander only, or both Aboriginal and Torres Strait Islander. Patients were from 26 diverse home locations across northern Australia, primarily Outer Regional or Remote/Very Remote geographical locations. All patients’ language backgrounds were documented as English only. Over 90% of stroke and 50% of TBI patients presented with medical co-morbidities. Conclusions: Patients had diverse geographical locations and cultural backgrounds, with many likely impacted by dislocation from home and country, as well as potential delays in receiving treatment. Despite this diversity, English was documented in patients’ medical records as their only language. The majority of patients also presented with multiple medical co-morbidities. Health professionals should consider these factors to ensure patients receive optimum and culturally responsive health care.

Past efforts to address endemic rates of sexually transmissible infections amongst young Aboriginal people living in remote/very remote Australian communities have had limited success. Peer education has been used in youth sexual health promotion but has received limited evaluation and has not been tested in remote Aboriginal settings. The Young Deadly Free youth peer education programme trained Aboriginal young people in 15 remote/very remote communities as peer educators to deliver sexual health education to other young people. Semi-structured interviews were conducted with the project team and regional coordinators to understand the barriers and enablers to implementing peer education in remote communities. Programme credibility, the offer of financial gratuities, and the recruitment of peer educators with prior sexual health knowledge and/or group facilitation experience were identified as programme enablers. Implementation challenges included programme rigidity, cultural sensitivities, and retention and expectations of peer educators. Seven implications for policy and practice are identified to increase the efficacy and long term-impacts of youth peer education. Peer education for youth sexual health promotion in remote communities can be effective if young peer educators are supported appropriately and the peer education programme is part of a comprehensive sexual health promotion strategy.

Worldwide, organizations struggle to attract professionals in rural and remote (R&R) areas. Undertaking a placement in an R&R area as part of a program of study has been shown to increase the likelihood of graduates taking up positions in locations that are difficult to staff. We applied behavioral insights to develop low cost, scalable interventions to encourage pre-service teachers to undertake internships in R&R areas of Australia. We tested the effectiveness of removing behavioral barriers when researching R&R areas and adding social triggers to make the R&R opportunity relevant. Our first randomized controlled trial (RCT) tested the use of personalized communication from an influential messenger to highlight the benefits of an R&R internship. Our second RCT tested the offer of social support by allowing pre-service teachers to complete the R&R internship with a “buddy”, rather than alone. Our behavioral approaches trebled R&R internship applications in RCT 1. These findings provide insights for cost-effectively increasing R&R internships in teaching, healthcare or social work.

In 2020, the Barunga Festival would have celebrated its 35th anniversary. In mid-June of 2021, as many as 4,000 individuals were expected to descend on an aboriginal community of 300 residents located 400 km south of Darwin. This case describes the challenge to the Festival's promoters as they seek to sustain peak socio-economic impact in their role as community development change agents in a diverse and dynamic environment. The reader is tasked with clarifying goals, deciding what is at stake, and setting a course of action to realize those objectives.

The majority of Australian students learned remotely in term two (April-June 2020), in response to state government directives to close schools during the 'first wave' of Covid-19. This created myriad challenges for students, teachers and parents. Accordingly, this study seeks to capture these multiple perspectives of the remote learning experience. Forty interviews were conducted at the end of term two, with students, teachers and parents. The findings represent an integrated framework for engagement in the context of remote education. Engaging students was a top priority for teachers - albeit students felt less engaged with teachers. Student-peer engagement varied considerably. Lack of social interaction was a challenge for many students. Parents remained pragmatic, but largely unengaged with teachers. For the most part, students found online learning to be less personalised. While the pandemic has expedited emergency technology adoption in schools, this is not equivalent to the purposeful integration of technology over time.

Australia is free from canine rabies. The spread of the disease in Indonesia has increased the risk of rabies incursion in northern Australia. Remote Indigenous communities, such as those in the Northern Peninsula Area (NPA), contain large populations of free-roaming domestic dogs surrounded by dingo populations, creating optimal conditions for rabies establishment. A cross-sectional survey of NPA hunters revealed that hunting practices using domestic dogs create opportunities for dingo-dog interactions. Dingo purity analyses on scats of canine origin collected in the NPA region demonstrated that dingoes visit areas around the communities, increasing the likelihood of contact with roaming domestic dogs. A scoping review on the ecology of dingoes identified density, home range size and contacts between dingoes, three key ecological parameters for disease spread modelling, as major research gaps especially in northern Australia. Dingo population density and home range size in the NPA were estimated from spatially explicit mark-resight models based on data from a one-year camera-trap study. This study also revealed a substantial temporal overlap and spatial correlation in activity between dingoes and domestic dogs, further supporting the likelihood for disease spread at the wild-domestic interface. A novel spatial stochastic rabies spread model, which incorporated field-derived dingo ecological parameters and landscape heterogeneity specific to the NPA, predicted a high probability (59%) of spread to other packs following the introduction of the disease into the dingo population from a roaming or hunting domestic dog. Outbreaks were generally larger when rabies was introduced during the dry season and in areas around the communities. Overall, this research provides compelling evidence of the importance of improving Australia’s preparedness for a potential rabies incursion in high-risk areas, to prevent serious consequences in remote Indigenous communities.

Although Australia is free from canine rabies, an incursion from nearby rabies-infected Indonesian islands is a realistic threat. The ubiquitous presence of dingoes in the wild, in association with large populations of free-roaming domestic dogs from northern Australian Indigenous communities, increases the risk of a rabies outbreak. Using a newly developed simulation model, we investigated the potential spread of rabies in a northern Australian dingo population. Nearly 60% of model simulations resulted in more than one pack infected. When spread did occur, outbreaks affected a median of 22 dingoes (an estimated 14% of the population in this area). The duration of infection, proportion of the population infected and spatial spread of the outbreak was greatest when rabies was introduced during the dry season and close to communities. Our results demonstrate that an incursion of rabies into the northern Australian dingo population would likely lead to a rabies outbreak, which would in turn pose a substantial threat to Indigenous communities in northern Australia.

BACKGROUND: Limited access to obstetrics and gynaecology (O&G) services in rural and remote Australia is believed to contribute to suboptimal birth outcomes. AIMS: To describe the characteristics of pregnancy aeromedical transfers, in-hospital outcomes, and patient access to O&G services, as compared to whole of Australia data. MATERIALS AND METHODS: We conducted a cohort study of women who required aeromedical retrieval for pregnancy-related issues between the 1 January 2015 and 31 December 2017. RESULTS: Hospital outcome data were collected on 2171 (65.2%) mothers and 2438 (100.0%) babies. The leading retrieval reason was threatened preterm labour and delivery (n = 883; 40.7%). Most patients were retrieved from rural and remote areas (n = 2224; 93.0%). Retrieved patients were significantly younger (28.0 vs 30.0 years, 95% CI 27.7-28.3), more likely to be overweight or obese (52.2% vs 45.1%, 95% CI 47.5-56.9) and to have smoked during their pregnancy (14.0% vs 9.9%, 95% CI 12.5-15.5) compared to Australian pregnant women overall. Over one-third of transferred women gave birth by Caesarean section (n = 812; 37.4%); the median gestational age at birth was 33.0 (95% CI 32.7-33.3) weeks. Early gestation is associated with low birth weights (median = 2579.5 g; 95% CI 2536.1-2622.9), neonatal resuscitation (35.4%, 95% CI 33.5-37.3), and special care nursery admission (41.2%, 95% CI 39.3-43.2). There were 42 (1.7%, 95% CI 1.2-2.2) stillbirths, which was significantly higher than seen Australia-wide (n = 6441; 0.7%). CONCLUSION: This study found that pregnant women retrieved by the Royal Flying Doctor Service were younger, with higher rates of obesity and smoking.

<h4>Objectives</h4>To measure rates of detection via screening, perceived self-imposed delays in seeking medical attention, and support seeking in a sample of regional and remote people with a cancer diagnosis and to test whether an association exists between these behaviours and minimising problems and resignation, a need for self-control and reliance and fatalism. Correlations and binary logistic regressions were conducted to test the associations between demographic characteristics, attitudes and behaviours.<h4>Results</h4>Females were more likely to have had their cancer detected via screening (OR = 10.02, CI = 3.49 - 28.78). Younger participants (r = -.103, p =.009) were slightly more likely to seek at least one form of support and online support was sought more often by younger patients (r = -.269, p < .001), females (r = .152 , p <.001), those from higher socioeconomic (SES) areas (r = .100 , p = .012), and those with higher education levels (r = .247 , p < .001). Younger (r = -.161, p < .001), and female (r = .82, p = .013), participants were also slightly more likely to seek support specifically through cancer support groups. No significant relationships between minimising problems and resignation, needs for control and self-reliance or fatalism and detection via screening, support seeking, or perceived self-imposed delays to seeking medical attention were apparent, with the exception that those with higher fatalism (predetermined health) were slightly less likely to report seeking support or information online (OR = 0.79, CI = 0.65 - 0.95) and slightly more likely to report using Cancer Council's support services (OR = 1.24, CI = 1.02, 1.52).<h4>Conclusions</h4>Strategies to improve the accessibility and appropriateness of support available for regional and remote cancer patients should consider interventions that remove barriers to access associated with age, gender, and education as opposed to those which address the attitudinal traits measured here. This article is protected by copyright. All rights reserved.

Without proper attention, houses disassemble. In public housing, property management regimes are charged with performing the repairs and maintenance necessary to combat this entropic tendency. This article argues that such governance regimes can accelerate housing?s disassembly, through rules that restrict housing interventions, bureaucratic technologies that misrecognize housing failure, and processes that defer and delay necessary fixwork. It analyzes Indigenous housing in the Northern Territory of Australia, in terms of three specific legal-bureaucratic instruments and the temporalizations they constitute: the lease and promise; the tender and repetition; the condition report and waiting. The article considers the effects of these pairings in Alice Springs town camps and the challenge of thinking beyond bureaucratic housing regimes.

Following publication of our study comparing the costs of two models of care intended for rural Aboriginal communities in New South Wales, Australia, we have analysed the data comparing scope of practice between the two models. By way of background, Aboriginal people are less likely to access dental services than other Australians. It is well established in the literature that enhancing access to and use of services by Aboriginal Australians requires tailoring to local needs, customs and language; ensuring staff are culturally competent; and having explicit strategies to promote and sustain participation. Our retrospective study of 2 years of patient data compared two models of service delivery designed exclusively for Aboriginal people. Model A (fly in, fly out) included a fixed clinic in a major city and visiting services to rural areas. Model B (community based) located clinicians within rural communities and existing community facilities (health clinics, schools, Aboriginal health services). We previously reported the cost and outputs comparison, which found model B provided 47% more treatment at 25.2% of the cost. We are now reporting on the scope of practice differences between the two models. Scope of practice has been selected as a proxy for effectiveness because treatment that requires several service visits over time enables behavioural change and implies patient engagement in the service. This study compared the scope of practice, measured in grouped dental item numbers using the Australian Dental Association schedule of services, for the two models. De-identified patient dental item numbers for models A and B related to the provision of dental services to Aboriginal public patients were clustered according to typical service groupings and analysed for the period 1 January 2014 to 31 December 2015. Data were recorded for nine clusters of care as shown in Table 1.

Background The study objective was to reveal reservoirs potentially leading to Staphylococcus aureus infections in haemodialysis clinic clients in the tropical north of the Australian Northern Territory (NT). This client population are primarily Aboriginal Australians who have a greater burden of ill health than other Australians. Reservoir identification will enhance infection control in this client group, including informing potential S. aureus decolonisation strategies. Methods and findings The study participants were 83 clients of four haemodialysis clinics in the Darwin region of the NT, and 46 clinical staff and researchers who had contact with the clinic clients. The study design was longitudinal, encompassing swabbing of anatomical sites at two month intervals to yield carriage isolates, and also progressive collection of infection isolates. Swab sampling was performed for all participants, and infection isolates collected for dialysis clients only. Analysis was based on the comparison of 139 carriage isolates and 27 infection isolates using whole genome sequencing. Genome comparisons were based on of 20,651 genome-wide orthologous SNPs, presence/absence of the mecA and pvl genes, and inferred multilocus sequence type and clonal complex. Pairs of genomes meeting the definition of “not discriminated” were classed as defining potential transmission events. The primary outcome was instances of potential transmission between a carriage site other than a skin lesion and an infection site, in the same individual. Three such instances were identified. Two involved ST762 (CC1) PVL- MRSA, and one instance ST121 PVL+ MSSA. Three additional instances were identified where the carriage strains were derived from skin lesions. Also identified were six instances of potential transmission of a carriage strains between participants, including transmission of strains between dialysis clients and staff/researchers, and one potential transmission of a clinical strain between participants. There were frequent occurrences of longitudinal persistence of carriage strains in individual participants, and two examples of the same strain causing infection in the same participants at different times. Strains associated with infections and skin lesions were enriched for PVL and mecA in comparison to strains associated with long term carriage. Conclusions This study indicated that strains differ with respect to propensity to stably colonise sites such as the nose, and cause skin infections. PVL+ strains were associated with infection and skin lesions and were almost absent from the carriage sites. PVL- MRSA (mainly CC1) strains were associated with infection and also with potential transmission events involving carriage sites, while PVL- MSSA were frequently observed to stably colonise individuals without causing infection, and to be rarely transmitted. Current clinical guidelines for dialysis patients suggest MRSA decolonisation. Implementation in this client group may impact infections by PVL- MRSA, but may have little effect on infection by PVL+ strains. In this study, the PVL+ strains were predominant causes of infection but rarely colonised typical carriage sites such as the nose, and in the case of ST121, were MSSA. The important reservoirs for infection by PVL+ strains appeared to be prior infections.

Australian Aborigines in remote areas have very high rates of kidney disease, which is marked by albuminuria. We describe a ‘multihit’ model of albuminuria in young adults in one remote Aboriginal community.Urinary albumin/creatinine ratios (ACRs) were measured in 655 subjects aged 15–39 years and evaluated in the context of birthweights, a history of ‘remote’ poststreptococcal glomerulonephritis (PSGN; ≥5 years earlier) and current body mass index (BMI). Birthweight had been <2.5 kg (low birthweight, LBW) in 25.4% of subjects and 22.8% had a remote history of PSGN.ACR levels rose with age. It exceeded the microalbuminuria threshold in 33.6% of subjects overall (25% of males and 45% of females). In multivariate models, birthweight (inversely), remote PSGN and current BMI were all independent predictors of ACR levels. The effects of birthweight and PSGN and their combination were expressed through amplification of ACR levels in relation to age and around the group median BMI of 20.8 kg/m2. In people with BMI <20.8 (57.8% of all males and 40.3% of the females), LBW and PSGN alone had minimal effects on ACR, but in combination they strikingly amplified ACR in relation to age. Those with BMI ≥20.8 (which included 42.2% of the males and 59.7% of the females) had higher ACR levels, and both LBW and a PSGN history, separately and in combination, were associated with striking further amplification of ACR in the context of age. Much of the great excess of disease in this population is explained by high rates of the early life risk factors, LBW and PSGN. Their effects are expressed through amplification of ACR in the context of increasing age and are further moderated by levels of current body size. Both early life risk factors are potentially modifiable.

Objective To generate domestic dog demographic information to aid population and disease management in the Aboriginal and Torres Strait Islander communities of the Northern Peninsula Area, Queensland, Australia. Methods Sight-resight surveys using standard and modified methods were conducted to estimate the free-roaming dog population size. A cross-sectional questionnaire of dog owners was used to gather dog demographic information and investigate owners' dog management behaviours. A survey was also conducted to estimate the total dog population size. Results The mean total dog population size was estimated to be 813 (range, 770-868). The roaming dog population was 430 or 542 (95% confidence interval (CI) 254-608; 95% CI 405-680, standard and modified methods, respectively). Therefore, the roaming population represents 52.8% or 66.7% of the total population based on the sight-resight methodology. We surveyed 65 dog owners who owned 165 dogs (1 : 1 ratio of male : female dogs). Only 14% (95% CI 9-19) of dogs were sterilised and significantly more males were entire (P = 0.02). Although most dogs were pets (65%), hunting dogs were significantly more likely to be taken outside of the resident community (P < 0.001). The birth rate was 2.4 puppies/dog-owning house/year, which was higher than the death rate (1.7 dogs/dog-owning house/year). In the previous 12-months, 90% of the 109 deaths were dogs aged 0-2 years old. Conclusion This study demonstrated that most of the dog population in the NPA is free-roaming and that the population has increased, likely because of a lack of population management strategies such as sterilisation. This information will be used to develop population and disease management strategies in the NPA.

Between 2015-2017, we worked with Australia’s largest telecommunications provider to examine the issue of cyber safety as it related to Australia’s remote Aboriginal communities. In this chapter, we reflect on our experience with survey-based research in remote Indigenous communities and recount our own failed attempts to navigate data collection. We argue that although often required by commercial and policy domains, quantitative data can be problematic when applied to Indigenous policy issues. We therefore advocate for an intercultural research model that is truly intercultural, from the researched, to the researchers.

With 2020 being designated the Year of the Nurse and Midwife, it is opportune to acknowledge and recognise the role that nurses undertake in primary care environments. Nurses and midwives play a pivotal role in the delivery of high-quality health care, particularly in geographically challenged areas of Australia, where they may be the only provider of care within their communities. Rural and remote health services require strategic planning to develop and implement solutions responsive to the challenges of rural and remote communities. Maintenance of health services in rural and remote areas is a challenge, crucial to the equity of health outcomes for these communities. Many small communities rely on visiting medical officers to provide the on-call care to facility services, including emergency departments, urgent care centres, acute wards and aged care facilities. It is increasingly difficult to maintain the current rural workforce models, particularly the provision of after-hours ‘on-call’ care necessary in these communities. An alternative model of health care service delivery staffed by nurse practitioners (NP) is one proposed solution. NPs are educated, skilled and proven in their ability to provide an after-hours or on-call service to meet the expectations of rural and remote communities. Achievement of high-quality health care that is cost-efficient, safe and demonstrates improved patient outcomes has been reported in NP-led health care delivery impact evaluations. The value of an NP locum service model is the provision of a transparent, reliable service delivering consistent, equitable and efficient health care to rural and remote communities.

Background The majority of patients living in remote communities of Central Australia must relocate to Alice Springs for their dialysis treatments. There is limited information available, about the challenges and barriers that Aboriginal patients encounter in the process of returning back to their communities after renal transplantation. Aim To determine the length of stay of patients in Alice Springs and challenges faced subsequent to renal transplantation, before they could safely return to their remote communities. Methods All transplant recipients from 2012 who are aged 18 were analysed retrospectively. Results Thirty-six patients received renal transplantation from Central Australia. Of them, 25 were from very remote communities of whom 24 were aboriginal. Average length of stay in Alice Springs post transplantation prior to returning to community was 17.2?weeks (121?days). The most common challenge faced prior to returning to community was the need for monitoring and titration of immunosuppressive medication (100%) followed by infections (90%) and admissions to hospital (85%). The other common barrier was optimizing glycaemic control (80%). Less common barriers included proficiency with self-monitoring of blood sugar levels (BSL) (50%), social factors (40%), blood pressure control (25%), safe housing (20%), leukopenia (25%) and rejection episodes (15%). Conclusion Multiple challenges are faced during post-transplantation period in Alice Springs which prolong the time before recipients from remote communities can return home. Some barriers such as titration of immunosuppression are inherent in the transplant journey. However, some factors might be modifiable prior to transplantation. This article is protected by copyright. All rights reserved.

We tested the effect of an annual caries preventive intervention, delivered by a fly-in/fly-out oral health professional team, with Indigenous children residing in a remote Australian community. Around 600 Indigenous children aged 5 to 17 years were invited to participate at baseline, of who 408 had caregiver consent. One hundred and ninety-six consented to the epidemiological examination and intervention (Intervention group) and 212 consented to the epidemiological examination only (Comparison group). The intervention, which occurred annually, comprised placement of fissure sealants on suitable teeth, and application of povidone-iodine and fluoride varnish to the whole dentition, following completion of any necessary restorative dental treatment. Standard diet and oral hygiene advice were provided. Caries increment (number of tooth surfaces with new dental caries) in both deciduous and permanent dentitions was measured at the 2-year follow-up. Comparison group children had significantly higher number of new surfaces with advanced caries in the permanent dentition than the Intervention group (IRR = 1.61; 95% CI: 1.02–2.54; p = 0.04); with a preventive fraction of 43%. The effect of intervention remained significant with children in the Comparison group developing significantly more advanced caries lesions in the permanent dentition than the Intervention group children in the adjusted multivariable analysis (IRR = 2.21; 95% CI: 1.03–4.71). Indigenous children exposed to the intervention had less increment in advanced dental caries in the permanent dentition than those not exposed to the intervention.

Recently, we identified a Staphylococcus aureus sequence type 5 (ST5) clone in northern Australia with discrepant trimethoprim-sulfamethoxazole (SXT) susceptibility results. We aimed to identify isolates of this clone using Vitek 2 SXT resistance as a proxy and to compare its epidemiology with those of other circulating S. aureus strains. We collated Vitek 2 susceptibility data for S. aureus isolates collected through our laboratory and conducted a prospective, case-control study comparing clinical, microbiological, epidemiological, and genomic data for subsets of isolates reported as SXT resistant (cases) and SXT susceptible (controls) by Vitek 2. While overall SXT resistance rates remained relatively stable from 2011 to 2018 among 27,721 S. aureus isolates, non-multidrug-resistant methicillin-resistant S. aureus (MRSA) strains almost completely replaced multidrug-resistant MRSA strains as the predominant SXT-resistant MRSA phenotype. Demographic and clinical features of 51 case-control pairs were similar, but genotyping revealed stark differences: clonal complex 5 (CC5) MRSA predominated among SXT-resistant cases (34/51 [67%]), while CC93 MRSA predominated among susceptible controls (26/51 [51%]). All CC5 isolates were an ST5 clonal lineage that possessed the trimethoprim resistance gene dfrG within SCCmec IVo; all were SXT susceptible by Etest. The replacement of Vitek 2 reported SXT-resistant multidrug-resistant MRSA by non-multidrug-resistant MRSA appears related to the emergence of an ST5-MRSA-SCCmec IVo clone that is SXT susceptible by Etest and causes clinical disease similar to that caused by ST93-MRSA-SCCmec IVa. Reliance on Vitek 2 SXT reporting may lead to unnecessary restriction of effective oral treatment options for S. aureus infections. Whether the presence of dfrG within SCCmec IVo provides a selective advantage at the population level is currently unclear.IMPORTANCE Staphylococcus aureus is an important human pathogen that causes a wide range of clinical infections. In the past 2 decades, an epidemic of community-associated skin and soft tissue infections has been driven by S. aureus strains with specific virulence factors and resistance to beta-lactam antibiotics. Recently, an S. aureus strain with discrepant antimicrobial susceptibility testing results has emerged in northern Australia. This ST5-MRSA-SCCmec IVo clone is reported as resistant to trimethoprim-sulfamethoxazole by Vitek 2 but susceptible by phenotypic methods. ST5-MRSA-SCCmec IVo is now the second most common community-associated MRSA clone in parts of Australia and causes a spectrum of clinical disease similar to that caused by the virulent ST93-MRSA lineage. Whole-genome sequence analysis demonstrates that ST5-MRSA-SCCmecIVo is causing a clonal outbreak across a large geographical region. Although phenotypic testing suggests in vitro susceptibility to trimethoprim-sulfamethoxazole, it is unclear at this stage whether the presence of dfrG within SCCmec IVo provides a selective advantage at the population level.

Comprehensive primary health care is integral to meaningful client-centred care, with nurses and midwives central to partnership approaches with individuals, families and communities. A primary health model of antenatal care is needed for Aboriginal and Torres Strait Islander women in rural and remote areas, where complex social determinants of health impact on pregnancy outcomes, early years and lifelong health. Staff experiences from a community midwifery-led antenatal program in a remote Western Australian setting were explored, with the aim of investigating program impacts from health service providers’ perspectives. Interviews with 19 providers, including community midwives, child health nurses, program managers, a liaison officer, doctors and community agency staff, examined elements comprising a culturally safe community antenatal program for Aboriginal and Torres Strait Islander women, exploring program benefits and challenges. Thematic analysis derived five themes: Organisational and Accessibility Factors; Culturally Appropriate Support; Staff Availability and Competencies; Collaboration; and Sustainability. The ability of program staff to work in culturally safe partnerships with clients in collaboration with community agencies was essential to building meaningful and sustainable antenatal strategies. Midwifery primary health care competencies were viewed as a strong enabling factor, with potential to reduce health disparities in accordance with Australian Government and research recommendations.

OBJECTIVE: To investigate the factors that are associated with medical student interest in remote and very remote practice in Australia. DESIGN: Aggregated data of an annual cross-sectional survey from 2013 to 2017. SETTING: Australia. PARTICIPANTS: Medical students from 17 medical schools, at the point of finishing one year of clinical training in a rural or remote location in Australia. MAIN OUTCOME MEASURES: Intention for working in a remote or very remote location as a doctor. RESULTS: Responses were analysed from 3328 medical students. From this cohort, 37.6%, 54.0% and 7.0% of students reported future career intent in capital or major cities; regional Australia; and remote or very remote Australia respectively. Multivariable analysis indicated students interested in remote and very remote practice compared to those interested in regional practice were more likely to be from a rural background, have prior generalist intentions, felt as though their rural clinical school (RCS) experience increased interest in remote and very remote practice, and had higher rural practice self-efficacy. Odds ratios were larger for these factors when students interested in remote or very remote practice were compared with students interested in practicing in capital or major cities. CONCLUSIONS: Rural background, prior generalist intentions, rural practice self-efficacy and the overall influence of the RCS experience are associated with interest in remote and very remote practice.

Introduction: The objective of this study was to identify the key enablers of change in re-orienting a remote acute care model to comprehensive primary healthcare delivery. The setting of the study was a 12-bed hospital in Fitzroy Crossing, Western Australia. Methods: Individual key informant, in-depth interviews were completed with five of six identified senior leaders involved in the development of the Fitzroy Valley Health Partnership. Interviews were recorded and transcripts were thematically analysed by two investigators for shared views about the enabling factors strengthening primary healthcare delivery in a remote region of Australia. Results: Participants described the establishment of a culturally relevant primary healthcare service, using a community-driven, 'bottom up' approach characterised by extensive community participation. The formal partnership across the government and community controlled health services was essential, both to enable change to occur and to provide sustainability in the longer term. A hierarchy of major themes emerged. These included community participation, community readiness and desire for self-determination; linkages in the form of a government community controlled health service partnership; leadership; adequate infrastructure; enhanced workforce supply; supportive policy; and primary healthcare funding. Conclusions: The strong united leadership shown by the community and the health service enabled barriers to be overcome and it maximised the opportunities provided by government policy changes. The concurrent alignment around a common vision enabled implementation of change. The key principle learnt from this study is the importance of community and health service relationships and local leadership around a shared vision for the re-orientation of community health services.

Purpose: Skills for Life (SFL) is a social-emotional curriculum for Indigenous middle school students that was co-developed with educators and community members in a remote community of northern Australia. This preliminary study aimed to test the feasibility of processes and methods of data-gathering, the reliability of youth self-report measures, and to identify the direction of effects for an evaluation of a longer-term pilot of the curriculum. Design/Methodology/Approach: Indigenous Students in years 7-9 of a remote school participated in SFL over 2 years. The Strengths and Difficulties Questionnaire (SDQ), Kessler 6 (K6), and a purpose-designed Connected Self Scale (CSS) were administered to 63 students pre- and post-program. Findings: Only the K6, Prosocial behavior (SDQ), and two CSS subscales showed sufficient internal consistency for analysis. Change was positive but non-significant for SDQ and CSS. There was evidence of a dosage effect: students receiving the intervention over 2 years showed greater reduction in psychological distress than other students. There was no evidence of iatrogenic effects. Conclusions: The feasibility pilot is a critically important phase in the development of evaluation design and cjhoice of evaluation measures for challenging remote settings. This study found that evaluation of SFL with culturally and linguistically distinct Indigenous middle school students using self-report measures is feasible. However, the SDQ may not be suitable for this project. High levels of psychological distress suggest the need to investigate sources of life stress and potential supports for adolescent resilience in this context. This preliminary pilot aimed to trial methods and measures for evaluation of a social-emotional curriculum developed specifically for remote Australian Indigenous students who are at risk of poor psychosocial outcomes. No studies have examined the appropriateness of standardized self-report measures for evaluation of SEL with this student population in remote school settings.