Remote Australia Online

This chapter unpacks the concept of ‘listening to Country’ engaged to discuss making, performing and attending intercultural dance on Indigenous land. After introducing Marrugeku, a dance theatre company whose practice forms the primary case study for the book, the chapter gives an overview of new dramaturgies, expanded dramaturgies and Indigenous dramaturgies. Through examples from Marrugeku’s production Crying Baby (2000) directed by the author and created in the Kunwinjku community of Kunbarlanja, in remote northern Australia, the chapter explains dramaturgies to make place and time visible, dramaturgies of incompleteness and the role of the cultural dramaturg. The chapter introduces a discussion of the fundamental ways listening to Country differs from the ‘dance in nature’ of the early modernists that will be expanded in the following chapters.

Background Pharmacists internationally have successfully expanded their role to provide service delivery to remote rural communities. Aim This study evaluated Australian rural community pharmacists? perspectives of expanded services, to identify priorities, areas of concern, enablers and barriers to their implementation. Method A self-administered questionnaire was distributed to rural and remote Australian (all states and territories) pharmacists between September and December 2019; respondents were asked to rank health issues and the expanded pharmacy services that could potentially address these issues in their communities. Questions were also included to evaluate health service accessibility, skills/knowledge, workspace limitations, time and support for the implementation of these services. Potential associations between demographic factors and responses were also assessed. Results Of the 92 returned responses analysed, the top three heath concerns were: Mental health, Cardiovascular disease and Diabetes. Depression screening/referral, diabetes management and vaccinations were the top three areas rated for expanded services. There was agreement (90%; 83/92) that pharmacists had the skills and knowledge for implementation, while time and space were reported as barriers for 50% (46/92) and 25% (23/92) of pharmacists, respectively. The majority of the pharmacists (80%; 74/92) felt services were not easily accessible, and all (92/92, 100%) agreed that service provision would improve community health outcomes. Conclusion Rural pharmacists were supportive of the delivery of expanded pharmacy services, describing improved health outcomes and increased access to health services as potential benefits. Successful implementation of these expanded services would require both an understanding of pharmacist resources available and local community health needs.

Purpose Self-determination policies and the expansion of bilingual schooling across Australia's Northern Territory (NT) in the 1970s and 1980s provided opportunities for Aboriginal educators and communities to take control over schooling. This paper demonstrates how this occurred at Shepherdson College, a mission school turned government bilingual school, at Galiwin'ku on Elcho Island in North East, Arnhem Land, in the early years of the policies between 1972 and 1983. Yolŋu staff developed a syncretic vision for a Yolŋu-controlled space of education that prioritised Yolŋu knowledges and aimed to sustain Yolŋu existence.Design/methodology/approach This paper uses archival data as well as oral histories, focusing on those with a close involvement with Shepherdson College, to elucidate the development of a Yolŋu vision for schooling.Findings Many Yolŋu school staff and their supporters, encouraged by promises of the era, pushed for greater Yolŋu control over staffing, curriculum, school spaces and governance. The budgetary and administrative control of the NT and federal governments acted to hinder possibilities. Yet despite these bureaucratic challenges, by the time of the shift towards neoliberal constraints in the early 1980s, Yolŋu educators and their supporters had envisioned and achieved, in a nascent way, a Yolŋu schooling system.Originality/value Previous scholarship on bilingual schooling has not closely examined the potent link between self-determination and bilingual schooling, largely focusing on pedagogical debates. Instead, this paper argues that Yolŋu embraced the “way in” offered by bilingual schooling to develop a new vision for community control through control of schooling.

The use of the capability approach as an evaluative tool for Information and Communication Technology (ICT) policy and programs in developing countries, in particular at a grass-roots community level, is an emerging field of application. However, one of the difficulties with ICT for development (ICT4D) evaluations is in linking what is often no more than a resource, for example basic access, to actual outcomes, or means to end. This article argues that the capability approach provides a framework for evaluating the strength of this linkage and that the latter is a key determinant of whether or not communities sustain ICT4D programs beyond the initial start-up phase. The argument is made by describing an evaluative application of the capabilities approach to community ICT4D programs using two Indigenous community case studies conducted in Cape York, in the far north-east of Australia. Key to the evaluative approach is the identification of community defined, context specific concepts of well-being and constitutive valued functionings and the derivation from this of required capabilities. This move away from normative definitions of capabilities or capability types to a definition that reflects the Indigenous culture, history, circumstances, and well-being aspirations of each community is intended to give a voice to the people and at the same time provide a deeper informational base—through narrative—for policy and program design than has previously been available. The article concludes that by operationalising the capability approach in a context and purpose specific way, policy and program design can be improved so as to include more communities on the margin and thereby achieve more socially inclusive ICT based development. A process is also outlined for using the evaluative application of the capability approach for community ICT4D within a policy feedback loop.

The chapter raises questions around notions of social and educational inclusion for First Peoples’ communities in the remote regions of the Northern Territory. Critically analyzing the terms of reference for inclusive practices in education, it critically analyses the historical context of social and pedagogical encounters between educators and First Peoples’ communities. Based on their own experiences as educators, the authors are critical of contemporary practices and question their effectiveness and value. Exploring everyday dilemmas of teachers at work in a remote community and utilizing the practice of poetry, the testimony contained in this work suggests that the situation regarding black and white relations in terms of education continues to be deeply troubling and requires urgent systemic change. However, this research is not completely devoid of hope; through an examination of both challenging and successful classroom teaching methods, it arrives at a phenomenological approach and proposes experiential learning as one way of moving forward.

Introduction:The management of early childhood caries (ECC) is challenging.Objectives:A model of care based on Atraumatic Restorative Treatment and the Hall Technique (ART-HT) to manage ECC was evaluated among remote Aboriginal communities in Australia.Methods:Aboriginal communities in the North-West of Western Australia were invited to participate and consenting communities were randomized into early or delayed intervention for the management of ECC. Children were examined at baseline and at the 11-mo follow-up. The early intervention group (test) was provided with the ART-based dental care at baseline while the delayed intervention group (control) was advised to seek care through the usual care options available within the community. At follow-up, both groups were examined by calibrated examiners, and were offered care using the ART-HT approach. Changes from baseline to follow-up in caries experience were tested using paired tests. Multivariate analysis after multiple imputation of missing data used generalised estimating equation (GEE) controlling for clustering within communities.Results:A total of 25 communities and 338 children (mean age = 3.6 y, SD 1.7) participated in the study (test = 177). At follow-up, 231 children were examined (68% retention, test = 125). At follow-up, children in the test group had more filled teeth (test filled teeth = 1.2, control filled teeth = 0.2, P < 0.001) and decreased levels of decayed teeth (mean test = 0.7 fewer teeth with decay, mean control = 1.0 more tooth with decay, P < 0.001). GEE analysis controlled for baseline caries experience, age, sex, and community water fluoride levels found increased rates of untreated decayed teeth (RR = 1.4, P = 0.02) and decreased rates of filled teeth (RR = 0.2, P < 0.001) at follow-up among the control group.Conclusion:A model of care relying on the principles of minimally invasive atraumatic approaches enabled the delivery of effective dental services to young children (<6 y) in remote Aboriginal Australian communities resulting in increased levels of care and improved oral health.Knowledge Transfer Statement:This cluster-randomized trial tested a multi-component model of dental care to young children with ECC in remote Aboriginal communities in Australia. The intervention, based on the atraumatic approaches using minimally invasive techniques encompassing preventive care, Atraumatic Restorative Treatment and the Hall Technique (ART-HT), delivered more restorative care and reduced the incidence of caries. This model of care was more effective than available standard care and should be incorporated into mainstream service delivery programs.

Objectives We aimed to compare the incidence, subtypes and aetiology of stroke, and in-hospital death due to stroke, between Aboriginal and non-Aboriginal people in Central Australia, a remote region of Australia where a high proportion Aboriginal people reside (40% of the population). We hypothesised that the rates of stroke, particularly in younger adults, would be greater in the Aboriginal population, compared with the non-Aboriginal population; we aimed to elucidate causes for any identified disparities.Design A retrospective population-based study of patients hospitalised with stroke within a defined region from 1 January 2011 to 31 December 2014.Setting Alice Springs Hospital, the only neuroimaging-capable acute hospital in Central Australia, serving a network of 50 healthcare facilities covering 672 000 km2.Participants 161 residents (63.4% Aboriginal) of the catchment area admitted to hospital with stroke.Primary and secondary outcome measures Rates of first-ever stroke, overall (all events) stroke and in-hospital death.Results Of 121 residents with first-ever stroke, 61% identified as Aboriginal. Median onset-age (54 years) was 17 years younger in Aboriginal patients (p&lt;0.001), and age-standardised stroke incidence was threefold that of non-Aboriginal patients (153 vs 51 per 100 000, incidence rate ratio 3.0, 95% CI 2 to 4). The rate ratios for the overall rate of stroke (first-ever and recurrent) were similar. In Aboriginal patients aged &lt;55 years, the incidence of ischaemic stroke was 14-fold greater (95% CI 4 to 45), and intracerebral haemorrhage 19-fold greater (95% CI 3 to 142) than in non-Aboriginal patients. Crude prevalence of diabetes mellitus (70.3% vs 34.0%, p&lt;0.001) and hypercholesterolaemia (68.9% vs 51.1%, p=0.049) was greater, and age-standardised in-hospital deaths were fivefold greater (35 vs 7 per 100 000, 95% CI 2 to 11) in Aboriginal patients than in non-Aboriginal patients.Conclusions Stroke incidence (both subtypes) and in-hospital deaths for remote Aboriginal Australians are dramatically greater than in non-Aboriginal people, especially in patients aged &lt;55 years.

In a context of ongoing colonization and dispossession in Australia, many Aboriginal people live with experiences of health research that is done 'on' rather than 'with' or 'by' them. Recognizing the agency of young people and contributing to Aboriginal self-determination and community control of research, we used a peer research methodology involving Aboriginal young people as researchers, advisors, and participants in a qualitative sexual health study in one remote setting in the Northern Territory, Australia. We document the methodology, while critically reflecting on its benefits and limitations as a decolonizing method. Findings confirm the importance of enabling Aboriginal young people to play a central role in research with other young people about their own sexual health. Future priorities include developing more enduring forms of coinvestigation with Aboriginal young people beyond data collection during single studies, and support for young researchers to gain formal qualifications to enhance future employability.

The Northern Territory (NT) government operates remote clinics which are primarily staffed by Aboriginal Health Practitioners and Remote Area Nurses (RANs). RAN practice has been described as particularly complex due to high health needs, workforce shortages and high levels of turnover in remote Aboriginal communities. While individual incentives are offered, there has been little examination of the role and why the work takes such a toll on RANs. This study aims to identify dominant discourses underpinning RAN practice and how these discourses reflect tensions and reinforce power relations that impact on the RAN role. Discourses were identified from a Foucauldian-inspired discourse analysis of 29 interviews with RANs in six remote NT communities. Five dominant discourses were identified, namely, that permanent RANs are preferred to agency RANs, RANs portray themselves as experienced and certain, RANs use autonomous clinical judgement, Aboriginal staff are important and RAN's belief in making a difference. However, the experience of RANs suggested that there are many types of employment that learning from was also important, RANs often struggled to work with Aboriginal staff and they were unsure if they were making a difference. Furthermore, these discourses created tensions between RANs who were permanent-agency, older-younger, experienced-newer and certain-reflexive. Deconstructing these rigid discourses could allow the RAN role to be reconstructed in ways that lead to better retention, job satisfaction and health outcomes.

Summary Background The effectiveness of healthy food promotion on food and beverage sales in real-world food retail settings has been shown in randomised trials. The effectiveness of restrictions on the promotion of unhealthy food is, however, less clear. We aimed to assess the effect of restricted unhealthy food promotion, specifically those items contributing most to free sugar sales, on food and beverage sales. Methods In this community-level pragmatic, partially randomised, parallel group trial, stores were randomly assigned by a statistician using a single sequence of random assignments to the intervention group, in which a co-designed strategy restricted merchandising of unhealthy food, or to a control group of usual retail practice. The trial was done in partnership with an organisation operating 25 stores in remote Australia. The primary analysis was based on difference in weekly sales with the strategy compared with no strategy in free sugar from all foods and beverages (g/total MJ; primary outcome), targeted food or beverages (weight and free sugars; g/total MJ), and gross profit (AU$) using mixed models. This trial is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12618001588280. Findings Between June 13 and Aug 15, 2018, 20 stores were recruited; ten stores were randomly assigned to the intervention group and ten stores to the control group. The trial was done between Sept 2 and Dec 2, 2018. The Healthy Stores 2020 strategy resulted in a reduction in sales of free sugar of 2·8% (95% CI –4·9 to –0·7). Targeted beverages were reduced by 8·4% (–12·3 to –4·3) and associated free sugar by 6·8% (–10·9 to –2·6), sugar-sweetened soft drinks by 13·2% (–18·5 to –7·6), and associated free sugar by 13·4% (–18·7 to –7·7). Reductions in sales of free sugar from confectionery of 7·5% (–14·3 to –0·2) and in weight sold (–4·6%, –11·1 to 2·3) resulted; however, the reduction in weight was not statistically significant. No differences in sales of table sugar and sweet biscuits were observed. Gross profit was not impacted adversely; a small increase resulted (5·3%, 0·3 to 10·5). Interpretation Restricted merchandising of unhealthy foods and beverages, while allowing for complementary merchandising of healthier foods and beverages in a real-world store setting and co-designed with retailers, can achieve both public health and business relevant gains. Funding Australian National Health and Medical Research Council.

This Handbook outlines in detail the features and challenges of rural and remote mental health service delivery and pragmatic considerations to address these, to ensure people in less populated areas receive an equivalent quality of service to their city-dwelling counterparts. The scope of the book includes general descriptions of the rural and remote context as well as the professional and ethical considerations involved in working in these areas. The book includes information specific to the professions that contribute to effective and efficient mental health services, as well as addressing specific areas of practice that warrant focused attention because of their importance. In order to cover the field comprehensively, the Handbook has four sections. The first section deals with the general context of rural and remote practice including a description of the general features of the setting and the importance of attention to ethical and professional standards. The second section of the Handbook describes different ways of working in rural and remote contexts. Rural and remote contexts provide many opportunities for innovation and creativity but it is imperative that novel approaches do not compromise the quality and integrity of the service. The third section covers individual professions in detail and the fourth section focuses specifically on particular areas of practice that present challenges for rural and remote areas. Academics will find this Handbook a valuable evidence-based resource to enhance their teaching of undergraduate and postgraduate mental health students. Practitioners will find this book an important reference guide to enrich and broaden their rural and remote experiences. They will be informed of the latest research evidence and will be provided with practical advice and strategies to promote advanced clinical practice in this challenging context.

Background: To report the prevalence of current and previous uveitis within the indigenous population living within Central Australia. Design: Population-based cross-sectional study in Central Australia. Participants: One thousand eight hundred and eighty-four subjects who identified themselves as indigenous Australians, presenting to the remote clinics during the 36-month period between July 2005 and June 2008. Methods: Clinical assessments for active or previous uveitis were performed. Data were collected using a standardized form. Main Outcome Measures: Prevalence of various types of uveitis. Results: Four of 1881 subjects had evidence of previous or current anterior uveitis, giving a prevalence for anterior uveitis of 0.21% (95% confidence interval, 0.01-0.42%). Eleven of 1854 patients had signs of previous posterior uveitis, giving a prevalence for posterior uveitis of 0.59% (95% confidence inteval 0.24-0.94%). Nine of the 11 patients with posterior uveitis cases (82%) had presumed toxoplasma retinochoroiditis. There were no cases of intermediate uveitis or panuveitis observed in this study. There were no observed cases consistent with well-recognized clinical uveitic syndromes, such as Behçet's disease or Vogt-Koyanagi-Harada syndrome. Conclusions: A distinct pattern of uveitis appears to be present among indigenous population of remote Central Australia. Posterior uveitis was commoner than anterior uveitis with a predominance of toxoplasma retinochoroiditis. Environmental factors appeared to be more important in this genetically distinct population, with infective causes and ocular trauma being the most common aetiologies of uveitis.

A recent rise in cannabis use in Indigenous communities in northern Australia may have compounded existing patterns of other substance use. This paper describes these patterns in Arnhem Land in the 'Top End' of the Northern Territory (NT). Economic impacts of the cannabis trade are also described. In a descriptive cross-sectional study, random samples included 336 people (169 males, 167 females) aged 13-36 years. Consensus classification of lifetime and current use of cannabis, alcohol, tobacco, kava, inhalants (petrol) and other drugs was derived based on health workers' proxy assessments. A sample (n=180, aged 13-36) was recruited opportunistically for interview. Lifetime cannabis users among those interviewed (n=131, 81 males, 50 females) described their current cannabis use, usual quantities purchased and consumed, frequency and duration of cannabis use and other substance use. In the random samples, 69% (63-75%) of males and 26% (20-31%) of females were lifetime cannabis users (OR=7.4, 4.5-12.1, p<0.001). The proportion of males currently using cannabis was 67% (60-73%) while the proportion of females currently using cannabis was 22% (16-27%) (OR=7.9, 4.8-13.1, p<0.001). Current cannabis users were more likely than non-users to be also using alcohol (OR=10.4, 4.7-23.3, p<0.001), tobacco (OR=19.0, 7.9-45.8, p<0.001) and to have sniffed petrol (OR=9.1, 4.6-18.0, p<0.001) but were less likely to be using kava (OR=0.4, 0.2-0.9, p<0.001). Among those interviewed, higher tobacco consumption in current users and greater alcohol use in lifetime users was associated with increased cannabis use. Action is required to reduce cannabis use, especially in combination with other substances.

The objective of this study was to describe patterns of substance use among remote Aboriginal community populations. The setting was the eastern Arnhem Land (Miwatj) region of the Northern Territory's (NT) 'Top End', with a population of 4217 Aboriginal people over 15 years of age using a cross-sectional description and comparison. Sample 1 (n = 689) from the region used data from health-worker consensus classification of kava, alcohol, tobacco, petrol and cannabis use. Sample 2 (n = 101) from one community used self-reported use, age at commencement, duration, amounts consumed and expenditure. In 1999 (sample 1), 46% of males and 18% of females were kava users, alcohol: 53% males, 12% females, tobacco: 68% males, 65% females, and cannabis: 31% males, 8% females. Less than 5% sniffed petrol. In one community in 2000, 39% males and 20% females reported using cannabis during the previous month. In this community between 1999 and 2000, the proportion of current kava users among men declined (77-52%, p = 0.015) with a tendency in women for a decrease in the proportion of tobacco users (87-69%, p = 0.096). The increase in the proportion of cannabis users in men (21-39%, p = 0.068) was not statistically significant. However, in women the increase was significant (0-20%, p = 0.013). Gross expenditure on tobacco and kava were similar in 2000: both greater than cannabis and alcohol. Median years used ranged from 4 years for cannabis and 20 years for tobacco. The data supported anecdotes of a recent rise in cannabis use, especially in women. Kava use declined in men. Tobacco use patterns in women may have been changing. Average per capita consumption of alcohol was low compared with other 'Top End' areas. Such varied and dynamic substance use patterns pose challenges for research and policy.

Objectives To examine long-term trends in acute myocardial infarction (AMI) incidence and survival among Aboriginal and non-Aboriginal people.Design Retrospective cohort study.Setting, participants All first AMI hospital cases and deaths due to ischaemic heart disease in the Northern Territory of Australia (NT), 1992–2014.Main outcome measures Age standardised incidence, survival and mortality.Results The upward trend in Aboriginal AMI incidence plateaued around 2007 for males and 2001 for females. AMI incidence decreased for non-Aboriginal population, consistent with the national trends. AMI incidence was higher and survival lower for males, for Aboriginal people and in older age groups. In 2014, the age standardised incidence was 881 and 579 per 100 000 for Aboriginal males and females, respectively, compared with 290 and 187 per 100 000 for non-Aboriginal counterparts. The incidence disparity between Aboriginal and non-Aboriginal population was much greater in younger than older age groups. Survival after an AMI improved over time, and more so for Aboriginal than non-Aboriginal patients, because of a decrease in prehospital deaths and improved survival of hospitalised cases.Conclusions There was an important breakpoint in increasing trends of Aboriginal AMI incidence between 2001 and 2007. The disparity in AMI survival between the NT Aboriginal and non-Aboriginal populations reduced over time as survival improved for both populations.

OBJECTIVE: This study investigates whether the regional pharmacy school at James Cook University in North Queensland is providing graduates geared to address the pharmaceutical needs of the state's regional, rural and remote communities. DESIGN: A cross-sectional study of practice locations of James Cook University pharmacy graduates in 2019 compared to those from other Australian pharmacy schools. PARTICIPANTS: Pharmacists from the James Cook University pharmacy program and those from other Australian pharmacy schools working in Queensland. MAIN OUTCOME MEASURES: Comparison of the proportion of James Cook University pharmacy graduates practising in the seven Modified Monash Model rurality classifications in Queensland to graduates from other pharmacy schools. Comparison of Index of Relative Social Advantage and Disadvantage for local government areas in these practice locations. Association between Modified Monash Model for hometown and Australian practice locations for domestic James Cook University pharmacy graduates. RESULTS: Of 973 James Cook University pharmacy graduates, 640 (65.8%) practised within Queensland in 2019. Compared to other Australian pharmacy graduates practising in Queensland at this time, James Cook University graduates had significantly higher odds of practising in local government areas with greater social disadvantage (lower Index of Relative Social Advantage and Disadvantage indices [<975]) and in rural and remote locations. Of 822 domestic James Cook University graduates, 84.5% were from a regional, rural or remote area, and compared to their hometown Modified Monash Model classification, two-thirds of these graduates practised in settings with the same or more rural Modified Monash Model classification. CONCLUSIONS: This study indicates that regional pharmacy schools have potential to attract and retain graduates in regional, rural and remote areas, including disadvantaged and/or rural towns.

Small businesses account for almost 98% of all actively trading NSW businesses (NSW Government, 2019), with 30% of those being located in regional NSW1. 72% of small businesses owners are aged over 40 years (NSW Government, 2019). 67% of small business owners are male (NSW Government, 2019). What this might mean for mental health and wellbeing withinsmall business is largely an unknown factor given thatresearch and programs specifically targeted towards small business mental health are limited. There is even less research and programs looking specifically to rural, regional and remote contexts2.There are a range of mental health risk factors that may be unique to those who own or work in small business including (but not limited to): financial pressures, high work demands, long work hours, market variability, and a lack of focus on self-care and work-life boundaries (Black Dog Institute & Everymind, 2019). In rural settings, these stressors can be compounded by issues of drought, bush fire, floods, and other adversities, in addition to everyday rural realities that may include economic downturn, corporatisation, 'boom and bust' variables, small town decline, aging populations, wealth disparities within a given community, climate change and dependence on local natural and social environments (see Austin et al, 2019; Irwin, 2019).

Background & problem Birthing On Country (BOC) is an international movement for returning childbirth to First Nations peoples and their communities. The RISE Framework was developed to guide evidence-based BOC implementation but has not yet been tested in a remote Australian community setting. Aim To test the transferability and acceptability of the RISE Framework in a remote multilingual setting in a Yolŋu (First Nations) community in Northern Australia. Methods Working in partnership with one remote Yolŋu community, we used a decolonising participatory action research (D-PAR) approach to begin co-designing services and test the acceptability of the RISE Framework. A three-phased transferability process was developed: Warming the ground; Co-Interpreting; and Acceptability Testing. Findings The RISE Framework was customized to the local Yolŋu context and called ‘Caring for Mum on Country’. It was articulated in two languages: Djambarrpuyŋu and English. We successfully used it to guide discussions at a community gathering privileging the voices of senior women to inform the design of local maternity services. Discussion Using the D-PAR approach, the RISE Framework was readily adapatable to this complex, remote and multilingual setting. It resonated with the Yolŋu community and proved useful for identifying current limitations of existing maternity services and importantly facilitating the design of Yolŋu centred strength-based maternity services. Conclusion The RISE Framework, combined with our transformative methodology, offers a promising approach to guiding complex interventions for returning services to First Nations communities in diverse contexts. Testing in other settings will further contribute to growing an evidence-base for BOC service planning and implementation.

115Background: Indigenous women with breast cancer have substantially higher mortality then non-Indigenous women. They are more likely to live in more remote communities with potential delays to presentation, investigation and diagnosis as well as slower access to cancer treatment facilities, potentially impacting survival. Here we explore by evaluating the diagnosis of de-novo metastasis and any association of remoteness, highlighting the geographic and possibly early access to treatment. Methods: A cohort of patients was retrospectively selected comprising age- and remoteness matched Indigenous and non-Indigenous women in a 1:1 ratio from the Western Australian Cancer Registry. Further data were collected from medical records and results systems. Remoteness was defined by the ARIA system. In addition, the distance from the nearest treatment center was calculated. The survival analysis was performed by Indigenous status and remoteness. Results: The final cohort comprised 250 Indigenous and 261 non?Indigenous women. Of the total, 7.6% (19/250) and 7.7% (20/261) were identified to have de-novo metastasis. At 10 years of follow up, most de-novo metastatic patients in both groups were from remote communities, distributed as 10.1, 9.1, 7.8, 8.7 and 5.0 % in metropolitan, inner regional, outer regional, remote and very remote areas respectively. In Indigenous group with de-novo metastasis the average distance of patient from treatment center was 1720km for vs 1018 km in Non-Indigenous patient with a p-value of 0.03. In non-metastasis cohort, Indigenous patient has 1065 km v 1241 km in non-indigenous group. Considering outcomes for those developing metastatic disease, median survivals after metastatic diagnosis were shorter for Indigenous patients, 21 v 33 months, p = 0.03. Conclusions: Indigenous women in WA with metastatic breast cancer have inferior survival outcomes from diagnosis of metastases relative to non-Indigenous peers. Most de-novo metastatic patients were from remote locations in both cohorts but no relation between remoteness and de-novo metastasis, identified to be impacting survival. Future studies are needed to better elucidate if any geographical, health care disparities and improve on treatment related outcomes. It is suggested to derive targeted policies to improve survival outcome of all Indigenous cancer patients, particularly those residing in remote areas.

BACKGROUND: The number of indigenous patients with end-stage kidney disease (ESKD) is increasing in Australia, reflecting a similar trend in other countries. Because many indigenous patients live in remote areas, peritoneal dialysis (PD) is often preferred. Compared to non-indigenous PD patients, indigenous patients have increased complication rates but the effect of residential locations on outcomes remains unclear. The aim of this study is to examine the association between race and PD outcomes stratified by location. METHODS: Using the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, all adult ESKD patients commencing PD in Australia between 1995 and 2008 were included. Patients were stratified as non-indigenous or indigenous race and were grouped according to their residential location, the latter stratified into metropolitan, regional and remote areas. Outcomes evaluated included peritonitis, technique failure, peritonitis-related and all-cause mortality. RESULTS: Regional and/or remote PD patients generally have a greater risk peritonitis-related complications and/or mortality compared to metropolitan patients. However, remote indigenous PD patients had the greatest risk of all PD-related complications, including all-cause and peritonitis-related mortality. CONCLUSIONS: This registry analysis demonstrates that non-metropolitan PD patients, especially remote indigenous patients, have higher complication rates, suggesting that environmental factors are important in determining PD outcomes.

Teaching in remote schools can prove to be a challenging experience. Twenty three teachers from remote schools, located in Western Australia, were interviewed about their teaching and living experiences in isolated communities. The interview questions were designed to elicit information regarding three areas: demographic information; reasons for applying for a position in an isolated school and living in a remote community; and, professional factorsimpacting on the respondents. Interviews were conducted during a residential professional development session and involved twenty-three teachers with wide ranging ages and teaching experience. These teachers identified a number of affective factors including what attracted them to teach in remote communities, what they liked and disliked about their lifestyle and why they decided to stay in the community in which they lived and taught. Professional factors identified included teaching and learning issues; curriculum and assessment; catering for individual needs; liaising with Aboriginal Education Workers; engaging and managing students; pedagogical issues and professional development. Teachers also identified the professional benefits and challenges of teaching in remote communities. The article concludes with a short discussion on the paradoxes of living and teaching in isolated locations, followed by outlining three recommendations derived from the interview data.

Over the last few decades in Australia, as part of a larger economic reform agenda, state and federal governments have increasingly outsourced social services to non-government community service organisations. The community service sector has consequently grown significantly with individual organisations increasing staff and volunteer numbers to manage demand. This article reports on a mixed method study that explored staff communication and connectedness in two nonprofit rural community service organisations that manage their operations across vast geographical distances. Study findings suggest four main types of connectedness that can be enhanced to increase staff connectedness, top-down connectedness, team connectedness, cross-organisational connectedness and cultural connectedness. The study found that country organisations where geographical contexts require management across long distances need to create a more networked, values-explicit organisational architecture that encourages the development of staff connections between programs and levels.

Although Australia's population is concentrated in major urban centres along its coastal fringe, its less populous rural communities are important to society and the economy—supporting sectors like agriculture, which occupies over half the continent's land mass and accounts for 2.2% of value added gross domestic product (GDP) (Jackson et al., 2020). The vast distances between urban and rural centres present challenges to the provision of essential infrastructure like roads, transport, energy – and telecommunications. Within this last category, internet connectivity and skills are both increasingly necessary and historically less available to the regional and rural agricultural sector in comparison to other industries and geographic communities. The digital inclusion agenda in Australia aims to address such gaps by promoting and supporting people and communities to use technology to improve social and economic well-being. This article builds on research underpinning the Australian Digital Inclusion Index (ADII), which defines digital inclusion as the capacity of people to access, afford and use online technologies effectively. The article focuses on the nature and extent of digital inclusion for Australia's farmers (identified as farmers and farm managers) based on analysis of a customised set of primary data extracted from the ADII dataset. This analysis reveals generally low levels of digital inclusion in rural communities, particularly among farmers, with distinctive and complex characteristics across measures of Access, Affordability and Digital Ability. Our findings highlight a perplexing scenario in which farmers score poorly on the Index when compared to Australians who live in similar circumstances but are not employed in the farming sector. We attribute lower levels of access to limited internet technology options, lower data speeds, inadequate reliability and lower data allowances. Less affordability is associated with individual-level socioeconomic factors, along with lack of competition between service providers in sparse population areas, the comparative cost of building telecommunications infrastructure in the bush, and the need for redundancy in rural and remote solutions. Finally, lower digital ability scores reflect social, cultural and material practices on farms that have produced distinctive orientations to technology. We conclude the article by explaining the contributions of the paper to digital inclusion research and by making recommendations for policy development.

Problem: Inhabitants of Torres Strait Islands have the highest prevalence of diabetes in Australia and many preventable complications. In 1999, a one year randomised cluster trial showed improved diabetes care processes and reduced admissions to hospital when local indigenous health workers used registers, recall and reminder systems, and basic diabetes care plans, supported by a specialist outreach service. This study looked at whether those improvements were sustained two years after the end of the trial. Design: Three year follow up clinical audit of 21 primary healthcare centres, and review of admissions to hospital in the previous 12 months. Background and setting: Remote indigenous communities in far north east Australia, population about 9600, including 921 people with diabetes. Key measures for improvement Number of people on registers, care processes (regular measures of weight, blood pressure, haemoglobin A 1c, urinary protein concentration, and concentrations of serum lipids and creatinine), appropriate clinical interventions (drug treatment and vaccinations), and intermediate patient outcome measures (weight, blood pressure, and glycaemic control). Admissions to hospital. Strategies for change: Audit and feedback to clinicians and managers; provision of clinical guidelines and a clear management structure; workshops and training. Effects of change: The number of people on registers increased from 555 in 1999 to 921 in 2002. Most care processes and clinical interventions improved. The proportion of people with good glycaemic control (haemoglobin A 1c ≤ 7%) increased from 18% to 25% in line with increased use of insulin (from 7% to 16%). The proportion of those with well controlled hypertension (&lt; 140/90) increased from 40% to 64%. The proportion admitted to hospital with a diabetes related condition fell from 25% to 20%. Mean weight increased from 87 kg to 91 kg. Lessons learnt: In remote settings, appropriate management structures and clinical support for people with diabetes can lead to improvements in care processes, control of blood pressure, and preventable complications that result in admission to hospital. Control of weight and glycaemia are more difficult and requires more active community engagement. Priorities now include increasing the availability and affordability of good food, achieving weight loss, and increasing appropriate use of hypoglycaemic agents, including insulin.

Families in remote Queensland, Australia, face a range of challenges, including the education of their children. The question of education strategies was included in the semi-structured interviews conducted with the women. The education of their children emerged as a major concern.