Remote Australia Online

Objective: To create supportive environments to reduce sugary drink consumption and increase water consumption by partnering with remote Aboriginal and Torres Strait Islander communities in Cape York. Methods: This paper applied qualitative and quantitative methods to evaluate a co-designed multi-strategy health promotion initiative, implemented over 12 months from 2017 to 2018. Outcome measures included changes in community readiness, awareness of the social marketing campaign and changes in drink availability. Changes in store drink sales were measured in one community and compared to sales in a control store. Results: Community readiness to address sugary drink consumption increased in two of the three communities. Awareness of social marketing campaign messaging was high (56–94%). Availability of drinking water increased in all communities. Water sales as a proportion of total drink volume sales increased by 3.1% (p<0.001) while sugary drink volume sales decreased by 3.4% (p<0.001). Conclusions: A multi-component strategy with strong engagement from local government, community leaders and the wider community was associated with positive changes in community readiness, drink availability and sales. Implications for public health: Partnering with community leaders in the co-design of strategies to create environments that support healthy drink consumption can stimulate local action and may positively affect drink consumption.

Purpose: The potential quality of life benefits of breast reconstruction (BR) for women who have undergone mastectomy for breast cancer have long been recognised. While many women will not want to have BR, international best-practice guidance mandates that all should be given the choice. The aim of this article is to highlight potential policies to support patients’ informed discussion of BR options and to improve access to BR for women living in underserved locations. Methods: Ninety semi-structured interviews were conducted from May 2015 to May 2017 with a convenience sample of 31 breast reconstructive surgeons, 37 breast cancer health professionals and a purposive sample of 22 women who underwent mastectomy as part of their breast cancer treatment. Breast, plastic reconstructive surgeons and health professionals based in major cities also provided information about how they cared for patients from more remote areas. Results: Analysis of interview data revealed a range of barriers that were grouped into four major categories describing issues for women living outside major cities: population characteristics associated with lower socioeconomic status; locational barriers including limited health services resources and distance; administrative barriers such as hospital policies and inadequate support for women who need to travel; and surgical workforce recruitment barriers. Conclusions:Suggestions for potential solutions included the following: greater geographical centralisation of BR services within major cities; the creation of designated breast centres with minimum caseload requirements similar to the UK’s system; and a buddy system, whereby smaller hospitals network with multidisciplinary teams based in larger hospitals.

Introduction: Australia, a canine rabies free country, is threatened by the current spread of the disease across the Indonesian Archipelago. This spread has brought rabies to only 300 km from northern Australia. A high risk of incursion has been identified in specific areas of northern Australia (Sparkes et al., 2015), which are characterised by the presence of remote Indigenous communities. In addition, Australia is home to a large wild dog population (including dingoes, feral dogs and dingo-dog hybrids) which is distributed throughout most of the Australian continent. Hence, the incursion of rabies into wild dog populations in Australia would make disease control very challenging and would represent a threat to human health, domestic animals and wildlife populations in Australia. In this context, disease spread models can be used to predict the spatial spread of infectious diseases and evaluate mitigation strategies for responding to an incursion. However, reliable data on dingo density ─ a key ecological parameter for wildlife disease spread modelling ─ is lacking in northern Australia and has been identified as a major research gap in the literature (Gabriele-Rivet et al., 2019). The objectives of this project are to 1) generate data on wild dog ecology, including movement and density distributions, and 2) predict the spread of rabies within wild dog populations, based on parameters relevant to the wild dog populations in northern Australian. Materials and methods: The study area selected is the Northern Peninsula Area region (NPA), located on the tip of Cape York Peninsula, Queensland. The NPA covers a land area of 1 072 sq. km, and includes 5 remote Indigenous communities located close to each other (see Figure 1). Using passive infrared motion detectors, a camera-trap study was conducted between 9th May 2016 and 15th May 2017. Twenty-eight camera traps were deployed within 21 road-based stations, systematically separated by 2 kilometer intervals. In addition, two focal point stations were established, located at the refuse dump and the local abattoir. All photographs collected were carefully examined and assigned to either ‘Domestic-like’, ‘Dingo-like’ or ‘Unsure’ categories based on information indicating domestication and dingo phenotypic features (for example, erect ears, tapered muzzle and bushy tail). Profiles of identifiable dingoes (i.e. Marked) were developed using combinations of distinctive natural characteristics such as color patterns, tail shape and size, body size, sex and scars. Individuals which did not display distinctive characteristics and therefore could not be linked to any of the ‘Marked’ profiles were categorised as ‘Unmarked’. A habitat mask shapefile was created which delimitated the ocean shore of Cape York Peninsula and excluded all habitats unsuitable for dingoes ─ such as water areas, mangroves and human populated areas comprising the five Indigenous communities. A maximum likelihood spatially explicit mark-resight model was used to estimate the density of dingoes across this habitat mask, while allowing population density to vary over space and between seasons (dry vs wet seasons). The effects of various covariates on the detection probability function were explored such as the type of camera stations (road-based vs focal point stations) and season. The best-fitting model was selected based on Akaike’s Information Criterion. Density estimates and information on dingo movement obtained from the camera-trap study are being used to parameterise a stochastic spatial model of rabies spread in wild dogs. This agent-based, discrete time model is implemented in Python, based on a daily time step, over a time period of 1 year or longer. Following the density distributions in the NPA obtained from the camera-trap study, the model randomly distributes centroid points across the study area (excluding areas unsuitable for dingoes). Each point represents the center of a home range for a pack of dingoes. Using a variety of home range estimates derived from the literature, a circular bivariate (2 dimensional) Gaussian distribution is fitted for each dingo to obtain the probability density function that the dingo is located at any specific location around the centroid of its home range. Probability of contact between each pair of dingoes simulated within the model is calculated at each time step based on the probability density function estimated for each dingo and the distance between the two home range centroid points. Disease spread is then simulated following a SEIIR (Susceptible – Exposed – Infectious Pre-clinical – Infectious Clinical – Dead) model. It is parameterised based on published canine rabies pathogenesis information and the probability of contact between each modelled individual. Outputs generated by the model ─ such as the number of individuals infected, the length of the epidemic and the spatial distribution of the spread over time ─ are assessed. Results: The twenty-eight camera traps captured 1.374 million photographs over a total of 7 648 camera trap days. Dingoes were identified in 1.3% of these photographs, from which 10 030 photographs displayed marked dingoes compared to 510 photographs containing unmarked dingoes. The marked individuals consisted of a total of 66 unique dingo profiles, over half of which were sighted at multiple camera stations. Of these, the maximum distance separating cameras which detected the same individuals (i.e. maximum movement observed per dingo) ranged between 0.6 and 11.3 km (median 4.0 km). Figure 1 illustrates the layout of the camera stations across the study area, with the number of sightings (marked and unmarked combined) per camera trap day. Final density estimates and preliminary results in relation to the stochastic spatial rabies spread model will be presented. Conclusion: The present study provides data on wild dog density in northern Australia, which currently represents a research gap in the literature on Australian wild dog ecology. Using this information, the model developed will help predict the spread of rabies in wild dogs and ultimately, provide the tools needed to better prepare for ─ and respond to ─ a potential rabies incursion in northern Australia. Overall, this project will help protect Indigenous communities, wildlife populations and the ecosystem in Australia.

Although most people gamble safely, national prevalence rates indicate that approximately 0.2 to 1% of the Australian population experience problems with gambling. An issue that has not been extensively researched in Australia is whether the nature of gambling, and the associated harms is consistently observed across the nation. In particular, are there are differences between metropolitan and rural areas in people’s experiences with gambling and the associated impacts? A qualitative study involving interviews with 10 help-seekers affected by problem gambling examined the nature of gambling in rural and remote areas and the potential barriers and challenges associated with help-seeking. Particular issues relevant to rural gamblers that set them apart from metropolitan gamblers were: limitations in leisure choices in rural areas; the problem of social familiarity in relation to anonymous help-seeking; and the dearth of specialized services. This study highlights the need to consider the role of rural-specific barriers, motivating and protective factors in developing service delivery models and specialized interventions for problem gambling in rural and remote communities.

Background Inequalities in access to renal services and acute care for rural and remote populations in Australia have been described but not quantified. Aim To describe: the coverage of renal disease management services in rural and remote Australia; and the characteristics of patients who had an aeromedical retrieval for renal disease by Australia's Royal Flying Doctor Service (RFDS). Method Data from the RFDS, the Australian Bureau of Statistics, and Health Direct were used to estimate provision of renal disease management services by geographic area. RFDS patient diagnostic data was prospectively collected from 2014-2018. Results Many rural and remote areas have limited access to regular renal disease management services. Most RFDS retrievals for renal disease are from regions without such services. The RFDS conducted 1636 aeromedical retrievals (AMRs) for renal disease, which represented 1.6% of all retrievals. Among retrieved patients, there was a higher proportion of men than women (54.6% vs. 45.4%, p < 0.01), while Indigenous patients (n = 546, 33.4%) were significantly younger than non-Indigenous patients (40.9 vs. 58.5, p < 0.01). There were significant differences in underlying diagnoses triggering retrievals between genders, with males being more likely than females to be transferred with acute renal failure, calculus of the kidney and ureter, renal colic, obstructive uropathy, and kidney failure (all p < 0.01). Conversely, females were more likely to have chronic kidney disease, disorders of the urinary system, acute nephritic syndrome, tubulo-interstitial nephritis, and nephrotic syndrome (all p < 0.01). Conclusion AMRs for acute care were from rural areas without regular access to renal disease prevention or management services. This article is protected by copyright. All rights reserved.

Objective The Royal Flying Doctor Service Western Operations (RFDSWO) provides critical care transfer and retrieval services across 2.5 million km2 to a population of 2.58 million people, providing both primary and secondary retrievals across Western Australia. Flying on average 26 million km/y, retrievals are undertaken with the use of rotary and fixed wing aircraft. Our current fleet includes 16 Pilatus PC-12NGs turboprops, 2 Pilatus PC-24 jets, and access to 1 helicopter (Bell 412). A Hawker XP800 Jet was retired in 2019 after 10 years of service. Our retrieval teams are formed of either a doctor and a nurse or a nurse only on fixed wing missions and a doctor and critical care paramedic for helicopter emergency medical services missions. We present our experiences and caseload statistics over the past 5 years. Methods We performed an analysis of our retrieval database looking at the workload from January 1, 2012, to December 31, 2016. This included the number of patients, age, ethnicity, type of retrieval, priority, diagnosis, and distances covered. Results Forty-three thousand forty-one patients underwent Royal Flying Doctor Service air transfer over a 5-year period. Aboriginal patients comprise around 3.1% of the Western Australian population but accounted for 33% of RFDSWO retrieval missions. There was a mean transfer rate of 8,608 patients per year, which was relatively consistent across the study period. The modal age was 55 to 59 years, but Aboriginal patients were younger with a mean age of 36.5 years (Aboriginal) versus 49.7 years (non-Aboriginal). The types of retrieval undertaken were as follows: primary (17.3%), secondary (81%), and repatriation (1.7%). The urgency/priority of missions was as follows: immediate (7.3%), urgent (54.5%), and semiurgent (38.1%). The 3 most common diagnosis (International Statistical Classification of Diseases, 10th Revision) categories were trauma/injury (22.9%), cardiovascular (22.3%), and gastrointestinal (10.5%). The modal distance flown was 700 km per mission. Conclusion RFDSWO has 1 of the largest retrieval workloads in the world, covering a landmass comparable with Western Europe. This brings with it a variety of challenging cases and complex logistics, often in extremely harsh and remote environments. We bring a wide breadth of experience in the area of retrieval medicine, and our aim is to share these experiences with other teams.

This paper examines why many older people living in remote parts of northern Australia areunable to access appropriate, or in some cases, any care services to support ageing in place. Several major factorsare identified from the research literature as impacting on what appears to be a neglect of support for ageing innorthern regions of Australia. The first is geographical and population related challenges. The second is theAustralian Government’s adoption of neoliberal market models in structuring its aged care service organisation andprovision. The third factor is the dearth of model design fit-for-purpose to the needs of remote communities. Analternative grounded or ‘bottom up’ approach is proposed, based on evidence from a broad range of relevantresearch into remote communities, as well as local case studies in northern Australia. Findings from a case study arepresented that further illuminate areas of neglect in supporting ageing in remote communities. A key argumentbased on these findings is for a more flexible funding base that approaches the design and management of servicesat a community rather than an individual level. Important themes emerging from this discussion include theuniqueness of need in each remote community; the critical importance of drawing on local understanding of thekind of resource needs that exist in a community before ‘rolling’ out support services, and finally; the capacity oflocal community members through volunteering, to stretch and adapt resources to solve practical problemsassociated with ageing in remote places.

Kakadu Plum (Terminalia ferdinandiana) as a Sustainable Indigenous Agribusiness. In northern Australia, commercial use of plant products can provide Aboriginal people with important livelihood opportunities. Kakadu Plum (Terminalia ferdinandiana Exell.) is a species endemic to northern Australia with exceptional phytochemical properties and industry applications. Aboriginal people have a long history of customary use of many parts of this plant, and as scientific research provides evidence for commercial applications, it is under increasing demand. It has the highest level of ascorbic acid of any fruit in the world and also commercially important antioxidants. This paper reviews the unique characteristics of T. ferdinandiana fruit as a commercial plant product, the people and landscapes in which it grows, and the current state of knowledge for building a successful agribusiness based on these factors. It demonstrates the great potential T. ferdinandiana has as a sustainable Indigenous business and identifies the important research and development gaps that need to be addressed. These include improved understanding of taxonomy, floral biology, and drivers of variability in the properties in T. ferdinandiana leaves and fruit; better understanding of aspirations of Aboriginal suppliers for participation in the agribusiness supply chain; and specific supply chain models that suit Aboriginal suppliers of T. ferdinandiana to service a range of potential national and international markets.

Over the 10 years of ‘Closing the Gap’, several interventions designed to improve outcomes for Aboriginal and Torres Strait Islander students have been trialled. In 2014 the Australian Government announced the ‘Flexible Literacy for Remote Primary Schools Programme’ (FLFRPSP) which was designed primarily to improve the literacy outcomes of students in remote schools with mostly Aboriginal and Torres Strait Islander students. The programme, using Direct Instruction (DI) or Explicit Direct Instruction, was extended to 2019 with more than $30 million invested. By 2017, 34 remote schools were participating in the Northern Territory, Queensland and Western Australia. This paper analyses My School data for 25 ‘very remote’ FLFRPSP schools with more than 80% Aboriginal or Torres Strait Islander students. It considers Year 3 and 5 NAPLAN reading results and attendance rates for participating and non-participating primary schools in the 3 years before the programme's implementation and compares them with results since. Findings show that, compared to very remote schools without FLFRPSP, the programme has not improved students' literacy abilities and results. Attendance rates for intervention schools have declined faster than for non-intervention schools. The paper questions the ethics of policy implementation and the role of evidence as a tool for accountability.

Deficits in the rural medical workforce is an international issue. In Australia, The Rural Clinical School intervention is effective for initial recruitment of rural doctors. However, the extent of survival is not yet established. This paper summarises rural survival over a 10-year period.

In the review of rural, regional and remote education in Australia, Halsey briefly reflected on the old conundrum of how traditional Indigenous culture and ‘western’ knowledge (as represented in mainstream curriculum) might be integrated in remote schooling contexts. The recommendation supplied was for ‘greater opportunity in the curriculum for learning about and valuing home and Homelands knowledge and life skills’ (Halsey, 2018, p. 32). However, what appears a simple recommendation rests upon a complex definition of ‘homeland’ and a long history of Indigenous negotiation with balanda (white) educational policies and practices in north-east Arnhem Land. At the Warramiri Yolŋu homeland of Gäwa, a philosophy of education has developed to encompass a profound place-based prioritisation. Following a critical Indigenous methodological framework designed by Yolŋu Elders, community research from Gäwa will be outlined to elucidate this localised Indigenous ‘on country’ and ‘through country’ pedagogy, and a practical demonstration of the philosophy in terms of the incorporation of a Warramiri ‘turning’ seasonal-cycle curriculum will also be briefly discussed.

High prevalence of chronic middle ear disease has persisted in Australian Aboriginal children, and the related hearing impairment (HI) has been implicated in a range of social outcomes. This study investigated the association between HI in early childhood and youth offending. Background: High prevalence of chronic middle ear disease has persisted in Australian Aboriginal children, and the related hearing impairment (HI) has been implicated in a range of social outcomes. This study investigated the association between HI in early childhood and youth offending. Method: This was a retrospective cohort study of 1533 Aboriginal children (born between 1996 and 2001) living in remote Northern Territory communities. The study used linked individual-level information from health, education, child protection and youth justice services. The outcome variable was a youth being “found guilty of an offence”. The key explanatory variable, hearing impairment, was based on audiometric assessment. Other variables were: child maltreatment notifications, Year 7 school enrolment by mother, Year 7 school attendance and community ‘fixed- effects’. The Cox proportional hazards model was used to estimate the association between HI and youth offending; and the Royston R2 measure to estimate the separate contributions of risk factors to youth offending. Results: The proportion of hearing loss was high in children with records of offence (boys: 55.6%, girls: 36.7%) and those without (boys: 46.1%; girls: 49.0%). In univariate analysis, a higher risk of offending was found among boys with moderate or worse HI (HR: 1.77 [95% CI: 1.05–2.98]) and mild HI (HR: 1.54 [95% CI:1.06–2.23]). This association was attenuated in multivariable analysis (moderate HI, HR: 1.43 [95% CI:0.78–2.62]; mild HI, HR: 1.37 [95% CI: 0.83–2.26]). No evidence for an association was found in girls. HI contributed 3.2% and 6.5% of variation in offending among boys and girls respectively. Factors contributing greater variance included: community ‘fixed-effects’ (boys: 14.6%, girls: 36.5%), child maltreatment notification (boys: 14.2%, girls: 23.9%) and year 7 school attendance (boys: 7.9%; girls 12.1%). Enrolment by mother explained substantial variation for girls (25.4%) but not boys (0.2%). Conclusion: There was evidence, in univariate analysis, for an association between HI and youth offending for boys however this association was not evident after controlling for other factors. Our findings highlight a range of risk factors that underpin the pathway to youth-offending, demonstrating the urgent need for interagency collaboration to meet the complex needs of vulnerable children in the Northern Territory.

Collaboration between government agencies and communities for sustainable water governance in remote Indigenous communities is espoused as a means to contribute to more equitable, robust, and long-term decision-making and to ensure that water services contribute to broader considerations of physical, social, and economic prosperity. In Australia, the uptake of collaborative water governance in remote Aboriginal and Torres Strait Island contexts has been slow and few examples exist from which to inform policy and practice. This study identifies barriers to uptake of collaborative sustainable water governance, drawing from qualitative interviews with water practitioners working in remote Indigenous Australia and analysis of key project documentation. Thematic analysis revealed discrete barriers across five key categories: (1) governance arrangements, (2) economic and financial, (3) capacity and skills, (4) data and information, and (5) cultural values and norms, with many barriers identified, unique to the remote Indigenous Australian context. The paper provides insights into how to address these barriers strategically to create transformative and sustainable change for Indigenous communities. The results contribute to the greater body of knowledge on sustainable and collaborative water governance, and they are of relevance for broader water management, policy, and research. View Full-Text

In Australia and internationally, rural-based industries are an important component of the national fabric, with meaningful contributions to socio-cultural, environmental and economic factors. Resources-based industries such as mining, gas, petroleum, and primary industries including agriculture play a particularly important role in this contribution both in the region they are situated but also nationally and internationally. Yet, it is often those in rural communities that are significantly impacted by economic downturns, environmental stressors such as drought, isolation and limited access to health services. It is important to acknowledge the role that industry can have in both contributing to the economy and also in supporting the health and wellbeing of those in their communities, including employees. The mining industry has been in sharp relief with a focus on the health of its workers who work long shifts, perform repetitive tasks and are often living a long way from family or friends. This chapter explores research challenges that face both industry and academics as they address issues of mental health and healthy lifestyle behaviours in the mining industry. Focusing on research that began in 2014 with the Centre for Resources Health and Safety and the Australian Minerals Council, the chapter examines the importance of working with industry partners and communities, the significance of face-to-face engagement with companies, methodological challenges of researching in regional areas and often in very remote locations, as well as intervention options and outcomes.

This qualitative phenomenological study aims to contribute to a deeper understanding of the cancer journey in a rural context by exploring, articulating and analysing the unique challenges faced by people following a cancer diagnosis in the Central West of NSW. Cancer survival rates in Australia rival the best across the world, yet there is clear evidence that people with cancer in rural and regional areas have not had equitable access to the range of services considered best cancer care. The two main aims of the study are to:(i) identify, explore and fully describe people’s experiences of the processes involved in receiving a diagnosis of cancer; and (ii) interpret the meaning this phenomenon holds for people with cancer in the context of rural NSW. The research question for the study was: What are the experiences of people in the Central West of NSW in relation to being diagnosed with cancer? Criterion sampling was used to recruit eight participants ensuring each had experience with the phenomena of a cancer diagnosis in the Central West region. Using Moustakas’ (1994)phenomenological approach enabled the development of a rich description of the experience of a diagnosis of cancer and the meaning embedded in that experience. Semi-structured interviews generated data and the language used; the words, phrases, images and metaphors chosen by the participants shaped the research and illuminated each individual experience of a cancer diagnosis. The participants described the journey of cancer and the impact on his or her life. Four primary themes emerged: Shock at the diagnosis, Grief for the life that’s lost, A thirst for information and A new life. For many the impact of cancer was dramatic and all-encompassing; the chaos of a cancer diagnosis was profound and individual. The Impact of Rurality was a theme which cut powerfully across the primary themes revealing the burden faced by each participant in this context. Participants spoke of feeling isolated, uncertain, and lacking support during their cancer diagnosis and treatment period. For each participant, their cancer ‘life world’ became a long-term search for meaning which resulted in changing their concept of ‘who I was’ to ‘who I am now’; that is, how to live with, through and beyond cancer. Participants felt the absence of care coordination, education and support from health professionals throughout their journey contributed to their existential crisis following diagnosis. Each cancer journey is a unique experience for both the person affected and their loved ones, and this was evident from the interviews with the participants. This study revealed the importance of a primary and community health, nurse-led model of care coordination, supported by medical specialists, a multidisciplinary team and clinical practice guidelines. This would ensure information and support with navigating the health care system would be provided across the continuum of care. In the rural context, staff development and education are imperative, both online and face to face, to increase awareness of the inherently life changing nature of cancer and provide a knowledge base for nurses and other clinicians.

Remote indigenous students in the Australian context are often the most vulnerable learners in the nation. Many factors impact on the potential for success. For those living in remote areas and whose language and culture are very different from that represented in and through school, the chances for success in mathematics remain limited. Often the achievement gap increases the longer students remain at school making for wide gaps in the achievement, and hence life prospects for students as they transition into the world of work. This case study reports on the successes of a boarding school that draws its students from many remote communities and how they have structured programs to build the strengths of the students. Vocational Education and Training is the touchstone to the initiatives offered by the school. The paper uses the voices of the teachers and leaders to offer an explanation as to how the practices of the school contribute to the success of learners and learning.

This chapter reflects on the predicaments encountered while bringing ethnographic and linguistic archival materials, and in particular an Aranda, German, Loritja [Luritja], and Dieri dictionary manuscript compiled by Carl Strehlow and with more than 7,600 entries, into the public domain. This manuscript, as well as other unique documents held at the Strehlow Research Centre in Alice Springs and elsewhere in Australia, is surrounded by competing views about ownership and control. In this case study I discuss my research and work with Western Aranda people concerning the transcription and translation into English of the dictionary manuscript. I also discuss the immense difficulties I faced in seeing the dictionary through to final publication. I encountered vested interests in this ethno-linguistic treasure that I had not been aware of and ownership claims that I had not taken into account. They arose from diverse quarters – from academia, from individuals in the Lutheran church, from Indigenous organisations, and from the Northern Territory Government. One such intervention almost derailed the dictionary work by actions that forced the suspension of the project for over 12 months. In this chapter I track the complex history of this manuscript, canvas the views of various stakeholders, and detail interpretations and reactions of Aranda people to the issues involved.

Background: Aboriginal and Torres Strait Islander women experience high rates of diabetes in pregnancy (DIP), contributing to health risks for mother and infant, and the intergenerational cycle of diabetes. By enhancing diabetes management during pregnancy, postpartum and the interval between pregnancies, the DIP Partnership aims to improve health outcomes and reduce risks early in the life-course. We describe a mixed methods formative study of health professional’s perspectives of antenatal and post-partum diabetes screening and management, including enablers and barriers to care. Methods: Health professionals involved in providing diabetes care in pregnancy, from a range of health services across the Northern Territory, completed the survey (n = 82) and/or took part in interviews and/or focus groups (n = 62). Results: Qualitative findings highlighted factors influencing the delivery of care as reported by health professionals, including: whose responsibility it is, access to care, the baby is the focus and pre-conception care. The main challenges were related to: disjointed systems and confusion around whose role it is to provide follow-up care beyond six weeks post-partum. Quantitative findings indicated that the majority of health professionals reported confidence in their own skills to manage women in the antenatal period (62%, 40/79) and slightly lower rates of confidence in the postpartum interval (57%, 33/58). Conclusion: These findings regarding whose role it is to provide postpartum care, along with opportunities to improve communication pathways and follow up care have informed the design of a complex health intervention to improve health systems and the provision of DIP related care.

Background Australian Indigenous women experience high rates of social disadvantage and type 2 diabetes (T2D) in pregnancy, but it is not known how social factors and maternal behaviours impact neonatal adiposity in offspring of women with hyperglycaemia in pregnancy. Methods Participants were Indigenous (n=404) and Europid (n=240) women with gestational diabetes mellitus (GDM) or T2D in pregnancy and their offspring in the Pregnancy and Neonatal Diabetes Outcomes in Remote Australia (PANDORA) study. Social, economic factors, and maternal behaviours were measured in pregnancy and six neonatal anthropometric outcomes were examined after birth. Results On univariate analysis, maternal education <12 years (p=0.03), unemployment (p=0.001), welfare income vs no welfare income (p=0.001), lower area based socio-economic score (p<0.001), and fast food intake >2 times/week (p=0.002) were associated with increased sum of skinfolds (SSF) in offspring. Smoking was significantly associated with a reduction in anthropometric measures, except SSF. In multivariable models adjusted for ethnicity, BMI and hyperglycaemia, social and economic factors were no longer significant predictors of neonatal outcomes. Smoking was independently associated with a reduction in length, head circumference and fat free mass. Frequent fast food intake remained independently associated with SSF (β-coefficient 1.08mm, p=0.02). Conclusion In women with hyperglycaemia in pregnancy, social factors were associated with neonatal adiposity, particularly skinfold measures. Promoting smoking cessation and limited intake of energy-dense, nutrient-poor foods in pregnancy are important to improve neonatal adiposity and lean mass outcomes. Addressing inequities in social and economic factors are likely to be important, particularly for Indigenous women or women experiencing social disadvantage.

Aims/hypothesis: We aimed to assess associations between cord blood metabolic markers and fetal overgrowth, and whether cord markers mediated the impact of maternal adiposity on neonatal anthropometric outcomes among children born to Indigenous and Non-Indigenous Australian women with normal glucose tolerance (NGT), gestational diabetes mellitus (GDM) and pregestational type 2 diabetes mellitus. Methods: From the Pregnancy and Neonatal Outcomes in Remote Australia (PANDORA) study, an observational cohort of 1135 mother–baby pairs, venous cord blood was available for 645 singleton babies (49% Indigenous Australian) of women with NGT (n = 129), GDM (n = 419) and type 2 diabetes (n = 97). Cord glucose, triacylglycerol, HDL-cholesterol, C-reactive protein (CRP) and C-peptide were measured. Multivariable logistic and linear regression were used to assess the associations between cord blood metabolic markers and the outcomes of birthweight z score, sum of skinfold thickness (SSF), being large for gestational age (LGA) and percentage of body fat. Pathway analysis assessed whether cord markers mediated the associations between maternal and neonatal adiposity. Results: Elevated cord C-peptide was significantly associated with increasing birthweight z score (β 0.57 [95% CI 0.42, 0.71]), SSF (β 0.83 [95% CI 0.41, 1.25]), percentage of body fat (β 1.20 [95% CI 0.69, 1.71]) and risk for LGA [OR 3.14 [95% CI 2.11, 4.68]), after adjusting for age, ethnicity and diabetes type. Cord triacylglycerol was negatively associated with birthweight z score for Indigenous Australian women only. No associations between cord glucose, HDL-cholesterol and CRP >0.3 mg/l (2.9 nmol/l) with neonatal outcomes were observed. C-peptide mediated 18% (95% CI 13, 36) of the association of maternal BMI with LGA and 11% (95% CI 8, 17) of the association with per cent neonatal fat. Conclusions/interpretation: Cord blood C-peptide is an important mediator of the association between maternal and infant adiposity, across the spectrum of maternal glucose tolerance.

Background Australia has vast areas of desert, wilderness and offshore islands where nurses provide the majority of health care services. The residents of Australia's remote communities generally have poorer health status than their metropolitan counterparts. Despite recognition of Primary Health Care as a comprehensive model of acute and preventative care well suited to areas of high health and social need, there is little known about how nurses employ the Primary Health Care model in practice. Objectives This study described and explained from the perspective of nurses, the actions and interactions involved in the delivery of Primary Health Care in remote communities. Design This study was conducted from a Constructivist Grounded Theory perspective. Settings The setting was community health centres or Aboriginal Medical Services located in ‘remote’ or ‘very remote’ areas. Communities with inpatient health services were excluded. Participants Twenty four Nurse Practitioners, Registered Nurses and nursing academics participated. Participants had worked or were working, in a variety of remote communities across Australia. Length of service ranged from three months to over 15 years nursing in remote areas. Methods Data were collected through 23 telephone interviews and an expert reference group. Theoretical sampling and constant comparative analysis were used to reach theoretical saturation. Results The core issue participants faced was the inability to provide Primary Health Care. Four conditions impacted on the core issue: understanding the social world of the remote community, availability of resources, clinical knowledge and skill and, shared understanding and support. The process of doing the best you can with what you have, emerged as the way participants dealt with the inability to provide Primary Health Care. The process involved four primary activities: facilitating access to health care, continually learning, seeking understanding, and home-making in a work environment. The outcome of this process was considered to be making compromises to provide Primary Health Care. Conclusions This study describes the substantive theory: making compromises to provide Primary Health care services in the remote Australian setting. Understanding the process of making compromises could direct employers and educators in their efforts to improve the provision of Primary Health Care in a variety of settings. Increased attention to the education, resources and support of nurses is likely to increase access to safe, quality care for remote communities.

The film Remembering Yayayi emerged from a project to return raw 16mm film footage shot in 1974 at the early Pintupi outstation of Yayayi, near Papunya, by filmmaker Ian Dunlop, with Fred Myers as translator and consultant. Two subsequent remote Pintupi communities, Kintore and Kiwirrkura, were involved in the footage’s return. The material had not been available for research (or other) purposes until 2005, when VHS copies were made from the workprint deposited in the National Archives of Australia. In 2006, Myers and Stefanoff took this rare historical visual material in Pintupi language to Kintore and Kiwirrkura, showing it to individuals and family groups and holding community screenings. Responses were overwhelmingly positive. The tapes quickly became regular entertainment for patients undergoing lengthy renal dialysis sessions and Myers received multiple requests for copies. Over several years, one of Myers’ long-term Pintupi friends, Marlene Spencer Nampitjinpa, came to provide a moving personal commentary on the footage, enabling a feature documentary to be produced from it. This chapter draws on a conversation between Stefanoff and Myers to reflect on how the repatriation project became a catalyst for memory and produced new Pintupi community historical knowledge, particularly about outstation life, early efforts at developing local forms of self-determination and the transformation of lives and wellbeing over a 40-year period.

This research investigated the effects on two remote Indigenous communities of a Northern Territory (NT) of Australia education language policy, Compulsory Teaching in English for the First Four Hours of each School Day (FFHP). Although the policy was introduced in 2008, it continues to have profound effects on the policy landscape of the NT which has never re-established the bilingual policy platform. The investigation involved a critical analysis of the FFHP and an ethnographic study of its effects. The research reported here follows two qualitative lines of study – the policy text (the process and content of the policy) and policy discourse (the discourse around the policy) in addition to its effects on those it was targeting. The data gathering methods entailed collecting key texts from critical moments of the FFHP implementation - the policy itself and operational guidelines in addition to media texts and a Hansard record. The field data collection comprised interviews with both Indigenous and non-Indigenous language education experts, two community case studies (one of which retained its bilingual program at the school and one which did not as a result of the FFHP) and critical ethnographical research. The latter used purposively selected adult and child participants for group and individual interviews (a total of 53). Given the Indigenous context of the field research and the desire to accurately depict remote Indigenous perspectives, Indigenous methodologies and participatory research approaches were employed. This entailed culturally appropriate consultation with participants, checking the accuracy and interpretation of interview data and Indigenous led participant selection. The analysis of the policy and key community interviews was achieved with critical discourse analysis (CDA). The particular approach to CDA employed was that developed by Reisigl and Wodak (2001) called Historical Discourse Approach (HDA) which emphasises the historical situatedness of discourse and the political dimensions and contexts at work in political texts. CDA is also frequently paired with ethnographic data collection. All community interviews were subjected to content analysis (CA) in order to deduce the major patterns and themes that arose in relation to the effects of the FFHP. This study revealed a language and cultural hierarchy operating with the adoption of the FFHP that entails a postcolonial construction of Indigenous people as ‘invisible’ and deficient. Although not as blatant as the texts associated with the separately occurring Northern Territory Emergency Response (NTER), there are distinctly covert negative representations that similarly allude to Indigenous abnormality and failure and imply criminality. In addition, the ideologies, presuppositions and assumptions of neo-liberalism and symbolism of the nation-state operating in the policy, construe, if only covertly, Indigenous languages (ILs), culture and people as in need of mainstreaming to achieve higher socio-economic status, well-being and national ‘belonging’. This is despite evidence that categorically demonstrates attachment to language and culture enhances well-being and socio-economic status. The effects of the policy on the two communities were surprisingly similar. Both communities complained of erosion in community participation and employment at the local schools that undermined the economic independence, self-determination and governance of the local population. Community participants were critical of the erratic policy creation and implementation and marginalisation of community members. The community with suspended bilingual programs complained of greater negative academic, well-being, behaviour and cognitive effects on children and a deterioration in resilience, all of which were difficult, if not impossible, to address given the oppressive political climate ‘out bush’. Such policy failure is common throughout the Indigenous policy landscape in Australia. As a consequence of the lack of legislative protection offered to Indigenous people and abuse of international human rights entailed in the FFHP, this study highlights the need for future policy creation and evaluation to be conducted from an Indigenous perspective and governance.

Infection with <span class="jp-italic">Strongyloides stercoralis</span> can cause life-threatening disease in immunocompromised patients. Strongyloidiasis is thought to be hyper-endemic in tropical Australia, but there are limited contemporary seroprevalence data to inform local elimination strategies. To define the temporospatial epidemiology of strongyloidiasis in Far North Queensland, tropical Australia, the serology results of 2,429 individuals tested for the infection between 2000 and 2018 were examined. The proportion of positive tests fell from 36/69 (52.2%) in 2000 to 18/222 (8.1%) in 2018 (<span class="jp-italic">P</span> < 0.001). Indigenous patients were more likely to have a positive result (Odds Ratio [OR]: 3.9, 95% CI: 3.0–5.0); however, by the end of the study period, residence in a rural or remote location (OR 3.9 (95% CI: 1.2–13.0), <span class="jp-italic">P</span> = 0.03) was a more important risk factor for seropositivity than Indigenous status (OR 1.1 (95% CI: 0.4–3.1) <span class="jp-italic">P</span> = 0.91). Ivermectin prescription data were available for the period 2004–2018, with annual prescriptions increasing from 100 to 185 boxes (<span class="jp-italic">P</span> = 0.01). The volume of ivermectin dispensed correlated negatively with seropositivity (Spearman’s rho = −0.62, <span class="jp-italic">P</span> = 0.02). An expanded environmental health program was implemented during the study period and likely contributed to the declining seroprevalence; however, the relative contributions of the individual components of this program are difficult to quantify. The seroprevalence of strongyloidiasis has declined markedly in this region of tropical Australia despite there being no targeted campaign to address the disease. Expanded prescription of ivermectin and public health interventions targeting the few remaining high-prevalence communities would be expected to expedite disease elimination.

Central Australia is a vast, geographical region spanning some 830,000 square kilometres. It is the most populous Indigenous region in Australia (44%) and a great distance from tertiary centres (1,500km). Non-invasive testing is important in this setting due to the high prevalence of cardiovascular disease and long-distance travel required for coronary angiography, the latter with significant logistical, financial, and cultural barriers. Although stress echocardiography has been extensively validated as a long-term prognostic tool in selected populations, we are not aware of prior studies in remote Indigenous and non-Indigenous individuals. To determine whether stress echocardiography can adequately risk stratify and quantify the long-term prognosis of Indigenous and non-Indigenous individuals in remote Central Australia. Consecutive individuals undergoing stress echocardiography in Central Australia between 2007 and 2017 were included. Exercise or dobutamine stress echocardiography was performed and reported via standard protocols.  Individuals were followed up for the primary outcome of all-cause mortality.One thousand and eight patients (54% Indigenous, 63% dobutamine stress) were included. Indigenous patients were younger, more likely to be female, and had a greater prevalence of cardiometabolic comorbidities (p < 0.05 for all). Overall, 797 (79%) patients had no abnormality during rest or stress echocardiography, with no difference according to ethnicity (p > 0.05).  After a mean follow up of 3.5 ± 2.4 years, 54 (5%) of patients were deceased; 127 (14%) patients underwent revascularization and were censored from follow-up. In patients with a normal test, annual mortality averaged 1.3% over 5 years of follow up, with annual mortality being significantly higher in Indigenous compared to non-Indigenous individuals (2.0% vs 0.6% respectively). Individuals with either ischemia or scar had a significantly worse long-term outcome compared to those with a normal test (Figure). In multivariate analyses, increasing age (HR 1.04 [95% CI 1.01-1.08]), chronic kidney disease (HR 4.83 [1.79-13.02]), and lack of ACEI/ARB use (HR 0.19 [95% CI 0.09-0.42]) were associated with all-cause mortality. Although Indigenous ethnicity was a univariate predictor of mortality, this association was attenuated and non-significant in multivariate analyses. Indigenous patients in remote Central Australia with a normal stress echocardiogram had a significantly higher annual rate of mortality compared to their non-Indigenous counterparts. However, this association may be in large part due to comorbid conditions. A normal test in Indigenous individuals was still able to adequately risk-stratify and identify a lower risk group of patients in whom ongoing local medical management and focusing on cardiometabolic risk factor reduction is likely to be appropriate.Abstract P5 Figure. Kaplan Meier survival curve