Remote Australian Communities Research Articles

Mailed versus frozen transport of nasal swabs for surveillance of respiratory bacteria in remote Indigenous communities in Australia

BackgroundSurveillance programs and research for acute respiratory infections in remote Australian communities are complicated by difficulties in the storage and transport of frozen samples to urban laboratories for testing. This study assessed the sensitivity of a simple method for transporting nasal swabs from a remote setting for bacterial polymerase chain reaction (PCR) testing.MethodsWe sampled every individual who presented to a remote community clinic over a three week period in August at a time of low influenza and no respiratory syncytial virus activity. Two anterior nasal swabs were collected from each participant. The left nare specimen was mailed to the laboratory via routine postal services. The right nare specimen was transported frozen. Testing for six bacterial species was undertaken using real-time PCR.ResultsOne hundred and forty participants were enrolled who contributed 150 study visits and paired specimens for testing. Respiratory illnesses accounted for 10% of the reasons for presentation. Bacteria were identified in 117 (78%) presentations for 110 (79.4%) individuals; Streptococcus pneumoniae and Haemophilus influenzae were the most common (each identified in 58% of episodes). The overall sensitivity for any bacterium detected in mailed specimens was 82.2% (95% CI 73.6, 88.1) compared to 94.8% (95% CI 89.4, 98.1) for frozen specimens. The sensitivity of the two methods varied by species identified.ConclusionThe mailing of unfrozen nasal specimens from remote communities appears to influence the utility of the specimen for bacterial studies, with a loss in sensitivity for the detection of any species overall. Further studies are needed to confirm our finding and to investigate the possible mechanisms of effect.Clinical trial registrationAustralia and New Zealand Clinical Trials Registry Number: ACTRN12609001006235.

Age-dependent decline of association between obesity and coronary heart disease: a cohort study in a remote Australian Aboriginal community

ObjectiveTo determine whether the association between obesity and coronary heart disease (CHD) in Aboriginal adults depends on age.Design, setting and participantsA cohort study with up to 20 years of follow-up...

“We Made the Rule, We Have to Stick to It”: Towards Effective Management of Environmental Tobacco Smoke in Remote Australian Aboriginal Communities

Smoking prevalence in remote Australian Aboriginal communities remains extraordinarily high, with rates reported of up to 82%. Widespread exposure to environmental tobacco smoke (ETS) is exacerbated by overcrowded housing. Implementation of existing smoke-free policies is challenged by the normalization of smoking and a lack of appropriate regulation resources. This paper celebrates a grassroots approach to control of environmental tobacco smoke (ETS) in these settings. We report on selected findings from a tobacco intervention study in Arnhem Land, Northern Territory in 2007–2012. In community-level tobacco use surveys at baseline (n = 400 ≥ 16 years), participants reported concern about the constant exposure of non-smokers to tobacco smoke. Suggestions for action included restricting smoking in private and public spaces. We selected three case studies illustrating management of ETS from observational data during the study’s intervention phase. Using a critical realist approach, the context and mechanisms that contributed to specific strategies, or outcomes, were examined in order to develop a hypothesis regarding more effective management of ETS in these environments. Our results suggest that in discrete, disadvantaged communities, enhanced local ownership of smoke-free policies and development of implementation strategies at the grassroots level that acknowledge and incorporate cultural contexts can contribute to more effective management of ETS.

Audit of a State-wide store and forward teledermatology service in Australia

In 2008, the Skin Emergency Telemedicine Service was established at the Princess Alexandra Hospital (PAH) in Brisbane. We conducted an audit by evaluating all email communication during 2012, and administering a clinician questionnaire. A total of 167 cases were discussed via 685 email communications (46 being in-house PAH referrals). The highest number of external referrals came from Mt Isa (27%), located 1200 km from the nearest dermatology clinic, with a further 25% sent from centres located 50-600 km from a clinic. The main referring condition was rash (65%), followed by skin lesions (13%). The most commonly provided telemedicine diagnoses were dermatitis/eczema (23%), infection (20%) and drug eruption (17%). Most external referrals received a reply within 3 hours of the enquiry. Junior doctors (2nd-4th postgraduate year) represented the majority of referring clinicians (62% of questionnaire respondents). There were 111 potential questionnaire recipients. Responses were received from 34 clinicians, a response rate of 31%. Overall 100% of respondents stated that the service was useful to them and 97% said they would use it again in the future with one respondent stating ‘possibly’. It seems likely that teledermatology will serve an important role in the provision of healthcare to Queensland, and other remote Australian communities in the future.

Contextualizing Mental Health Nursing Encounters in Australian Remote Aboriginal Communities: Part 2, Client Encounters and Interviews

Edited by Jacquelyn H. Flaskerud, RN, PhD, FAANUniversity of California—Los Angeles, School of Nursing, Los Angeles, California, USAKnowledge of the history and oppression of Australian Aboriginal ...

STI in remote communities: improved and enhanced primary health care (STRIVE) study protocol: a cluster randomised controlled trial comparing ‘usual practice’ STI care to enhanced care in remote primary health care services in Australia

BackgroundDespite two decades of interventions, rates of sexually transmissible infections (STI) in remote Australian Aboriginal communities remain unacceptably high. Routine notifications data from 2011 indicate rates of chlamydia and gonorrhoea among Aboriginal people in remote settings were 8 and 61 times higher respectively than in the non-Indigenous population.Methods/designSTRIVE is a stepped-wedge cluster randomised trial designed to compare a sexual health quality improvement program (SHQIP) to usual STI clinical care delivered in remote primary health care services. The SHQIP is a multifaceted intervention comprising annual assessments of sexual health service delivery, implementation of a sexual health action plan, six-monthly clinical service activity data reports, regular feedback meetings with a regional coordinator, training and financial incentive payments. The trial clusters comprise either a single community or several communities grouped together based on geographic proximity and cultural ties. The primary outcomes are: prevalence of chlamydia, gonorrhoea and trichomonas in Aboriginal residents aged 16–34 years, and performance in clinical management of STIs based on best practice indicators. STRIVE will be conducted over five years comprising one and a half years of trial initiation and community consultation, three years of trial conditions, and a half year of data analysis. The trial was initiated in 68 remote Aboriginal health services in the Northern Territory, Queensland and Western Australia.DiscussionSTRIVE is the first cluster randomised trial in STI care in remote Aboriginal health services. The trial will provide evidence to inform future culturally appropriate STI clinical care and control strategies in communities with high STI rates.Trial registrationAustralian and New Zealand Clinical Trials Registry ACTRN12610000358044

The Bruininks-Oseretsky Test of Motor Proficiency-Short Form is reliable in children living in remote Australian Aboriginal communities

BackgroundThe Lililwan Project is the first population-based study to determine Fetal Alcohol Spectrum Disorders (FASD) prevalence in Australia and was conducted in the remote Fitzroy Valley in North Western Australia. The diagnostic process for FASD requires accurate assessment of gross and fine motor functioning using standardised cut-offs for impairment. The Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2) is a norm-referenced assessment of motor function used worldwide and in FASD clinics in North America. It is available in a Complete Form with 53 items or a Short Form with 14 items. Its reliability in measuring motor performance in children exposed to alcohol in utero or living in remote Australian Aboriginal communities is unknown.MethodsA prospective inter-rater and test-retest reliability study was conducted using the BOT-2 Short Form. A convenience sample of children (n = 30) aged 7 to 9 years participating in the Lililwan Project cohort (n = 108) study, completed the reliability study. Over 50% of mothers of Lililwan Project children drank alcohol during pregnancy. Two raters simultaneously scoring each child determined inter-rater reliability. Test-retest reliability was determined by assessing each child on a second occasion using predominantly the same rater. Reliability was analysed by calculating Intra-Class correlation Coefficients, ICC(2,1), Percentage Exact Agreement (PEA) and Percentage Close Agreement (PCA) and measures of Minimal Detectable Change (MDC) were calculated.ResultsThirty Aboriginal children (18 male, 12 female: mean age 8.8 years) were assessed at eight remote Fitzroy Valley communities. The inter-rater reliability for the BOT-2 Short Form score sheet outcomes ranged from 0.88 (95%CI, 0.77 – 0.94) to 0.92 (95%CI, 0.84 – 0.96) indicating excellent reliability. The test-retest reliability (median interval between tests being 45.5 days) for the BOT-2 Short Form score sheet outcomes ranged from 0.62 (95%CI, 0.34 – 0.80) to 0.73 (95%CI, 0.50 – 0.86) indicating fair to good reliability. The raw score MDC was 6.12.ConclusionThe BOT-2 Short Form has acceptable reliability for use in remote Australian Aboriginal communities and will be useful in determining motor deficits in children exposed to alcohol prenatally. This is the first known study evaluating the reliability of the BOT-2 Short Form, either in the context of assessment for FASD or in Aboriginal children.

Contextualizing Mental Health Nursing Encounters in Australian Remote Aboriginal Communities: Part I, History and Customs

Edited by Jacquelyn H. Flaskerud, RN, PhD, FAANUniversity of California—Los Angeles, School of Nursing, Los Angeles, California, USADelivering competent mental health nursing care to remote Aborigi...

Cytokine gene polymorphism among Indigenous Australians

The health profile of Indigenous Australians is characterised by high rates of classic 'lifestyle' diseases. Potential roles of inflammation in pathophysiology of these diseases requires investigation. It is not clear if genetic regulation of inflammation in Indigenous Australians is similar to other populations. This study characterised frequencies of single nucleotide polymorphisms (SNPs) for eight cytokine genes for 100 individuals from a remote Indigenous Australian community and assessed novel genetic variants in four cytokine genes. We used a commercially-available allelic discrimination assay for SNP genotyping; re-sequencing was undertaken by standard Sanger sequencing methodologies for 26 samples. Frequencies of cytokine gene SNPs differed significantly from the Caucasian population (P < 0.001-0.044). Twenty-five novel variants were identified across four re-sequenced genes; frequencies ranged from <5% to 100%. Genotype frequencies observed in Indigenous Australians did not consistently resemble reported HapMap frequencies in Northern and Western European populations, Yoruba Nigerian or Han Chinese. Our findings indicate Indigenous Australians might have an inherited propensity for strong inflammatory responses. Preliminary evidence of novel genetic variants highlights the need to catalogue the extent of genetic variation in specific population groups. Improved understanding of differences in genetic variation between specific population groups could assist in assessment of risk for lifestyle diseases.

Decreasing rates of natural deaths in a remote Australian Aboriginal community, 1996–2010

To examine the trends of all-cause natural mortality for people aged 15 years and over in a remote Australian Aboriginal community between 1996 and 2010. The annual population in the community by gender and age group was obtained from the Australian Bureau of Statistics (ABS). All known deaths and all records of start of renal replacement therapy (RRT) for renal failure were recorded between 1996 and 2010. Five-year aggregated death rates were calculated and the changes in natural mortality over the interval were evaluated. Mortality was compared with those of the Northern Territory (NT) Indigenous and non-Indigenous people as a whole from 1998 to 2006. Rates of natural deaths were lower in the third interval 2006-2010 relative to the first interval 1996-2000, with higher, but more rapidly falling rates for females than males. Reductions were prominent for both sexes in the 65 and over age groups, but death rates in females of earlier middle age also trended lower. The trends applied whether or not the starting of RRT was considered as a natural death. There was a similar trend in rates of natural death in the aggregate Indigenous population of NT. The downward trends probably reflect improvements in risk factor status since the 1960s, all-of-life health interventions, as well as better chronic disease management in the last two decades. The higher death rates in females than males in this community remain unexplained, but the rapid rate of decline of female death rates predicts that this gap will soon be minimised.

P5.007 AnnualChlamydia TrachomatisandNeisseria GonorrhoeaTesting in an Endemic Setting: The Role of Client and Health Centre Characteristics

Background Chlamydia trachomatis (CT) and Neisseria gonorrhoea (NG) are endemic in many remote Australian Aboriginal communities. Clinical guidelines in remote areas recommend annual sexual health testing generally in 15 – 35 year olds, yet little is known about the extent of annual testing in remote health services or factors that predict it. Methods We used baseline 2009–2010 laboratory data from 67 remote Aboriginal communities in four regions participating in a cluster randomised trial aiming to improve sexual health service delivery. We defined and calculated annual testing as the percentage of individuals with an initial negative CT/NG test that had a repeat test at 12 months, +/- 3 months. Using logistic regression we determined client and health service factors associated with an annual test. Results Among 6318 females recorded as testing negative for CT/NG, 24% had an annual test (highest in 16 –19 year olds at 26%), compared with 15% of 4241 males (highest in 20–24 year olds at 19%). Factors independently and significantly (p 90% of clients Aboriginal (AOR:1.4.95% CI: 1.2–1.6), services having an electronic medical record system (AOR:1.7.95% CI: 1.4–2.1), services using a centralised recall system (AOR:1.3.95% CI: 1.1–1.6), services being community controlled (health centre governance controlled by a local Aboriginal board) (AOR:1.4, 95% CI: 1.2–1.6) and Aboriginal health worker/s employed (AOR1.4.95% CI: 1.0 –1.9). Conclusions Our analysis identified both client and service related factors associated with higher levels of annual testing. Having Aboriginal staff members and systems which support patient recall were key factors identified for services that are amenable to change. While some factors may be indirect markers of other characteristics of the health centres or clients, these findings will help guide support to services in remote areas.

Management of chronic hepatitis B in the Torres Strait Islands: an identified need for a comprehensive public health approach to chronic hepatitis B in remote Australian Indigenous communities

We aimed to document how health service providers in the Torres Strait Island region of northern Australia respond to chronic hepatitis B, and to identify priorities for the effective clinical management of the infection. Semi-structured qualitative interviews with 61 health service providers were conducted in 2011 in the Torres Strait and north Queensland region to explore issues affecting chronic hepatitis B management. Two critical issues were identified affecting the health service response to chronic hepatitis B: (i) the absence of a systems-based approach to clinically managing the infection; and (ii) variable knowledge about the infection by the health workforce. Other issues identified were competing and more urgent health priorities, the silent nature of chronic hepatitis B infection at an individual and systems level, inadequate resources and the transient health workforce. While people living in the Torres Strait region are screened, diagnosed and informed that they are infected with chronic hepatitis B, there is an ad hoc approach to its clinical management. An effective and coordinated public health response to this infection in remote and isolated Australian Indigenous communities needs to be developed and resourced. Critical elements of this response will include the development of clinical guidelines and workforce development.

Population movement can sustain STI prevalence in remote Australian indigenous communities

BackgroundFor almost two decades, chlamydia and gonorrhoea diagnosis rates in remote Indigenous communities have been up to 30 times higher than for non-Indigenous Australians. The high levels of population movement known to occur between remote communities may contribute to these high rates.MethodsWe developed an individual-based computer simulation model to study the relationship between population movement and the persistence of gonorrhoea and chlamydia transmission within hypothetical remote communities.ResultsResults from our model suggest that short-term population movement can facilitate gonorrhoea and chlamydia persistence in small populations. By fixing the number of short-term travellers in accordance with census data, we found that these STIs can persist if at least 20% of individuals in the population seek additional partners while away from home and if the time away from home is less than 21 days. Periodic variations in travel patterns can contribute to increased sustainable levels of infection. Expanding existing STI testing and treatment programs to cater for short-term travellers is shown to be ineffective due to their short duration of stay. Testing and treatment strategies tailored to movement patterns, such as encouraging travellers to seek testing and treatment upon return from travel, will likely be more effective.ConclusionHigh population mobility is likely to contribute to the high levels of STIs observed in remote Indigenous communities of Australia. More detailed data on mobility patterns and sexual behaviour of travellers will be invaluable for designing and assessing STI control programs in highly mobile communities.

Training general practitioners in remote Western Australia in a method of screening and brief intervention for harmful alcohol use: A pilot study

High levels of alcohol-related harm are a salient feature of many rural communities in Australia. General practitioners (GPs) are uniquely placed to identify and treat patients with harmful alcohol use in remote settings, yet corresponding opportunities for education in effective brief psychological interventions for harmful alcohol use are limited. This study piloted a training model for alcohol screening and brief intervention for GPs working in Kalgoorlie-Boulder, a remote Western Australian community facing significant alcohol-related problems. Observational pilot study. Primary care. Perceived role in responding to harmful alcohol use, and confidence and knowledge of alcohol screening and brief intervention; satisfaction with a short training session focused on alcohol screening and brief intervention; and impact of training on implementation of screening and brief intervention for harmful alcohol use. Fifty per cent of GPs took up the training opportunity. GPs recognised their professional responsibility for conducting brief intervention but reported comparatively lower confidence and skills in implementing screening and intervention prior to training. The training improved knowledge and confidence in conducting alcohol screening and brief intervention. All GPs increased their frequency of alcohol screening, and 88% of GPs reported increasing the frequency of brief intervention at 6 months. Preliminary findings suggest that among participating GPs, subsequent compliance with identification and management of harmful alcohol use was improved. Further work examining methods to improve rural and remote GP participation in alcohol-related harm prevention training is required, as the potential impact on communities with disproportionately high alcohol-related difficulties is significant.

A qualitative study of a social and emotional well-being service for a remote Indigenous Australian community: implications for access, effectiveness, and sustainability

BackgroundPeople living in rural and remote Australia experience increased mental health problems compared with metropolitan Australians. Moreover, Indigenous Australians are twice as likely as non Indigenous Australians to report high or very high levels of mental health problems. It is imperative, therefore, that effective and sustainable social and emotional wellbeing services (Indigenous Australians prefer the term “social and emotional wellbeing” to “mental health”) are developed for Indigenous Australians living in remote communities. In response to significant and serious events such as suicides and relationship violence in a remote Indigenous community, a social and emotional wellbeing service (SEWBS) was developed. After the service had been running for over three years, an independent evaluation was initiated by the local health board. The aim of the evaluation was to explore the impact of SEWBS, including issues of effectiveness and sustainability, from the experiences of people involved in the development and delivery of the service.MethodsPurposive sampling was used to recruit 21 people with different involvement in the service such as service providers, service participants, and referrers. These people were interviewed and their interviews were transcribed. Interpretative Phenomenological Analysis (IPA) was used to analyse the interview transcripts to identify superordinate themes and subthemes in the data.ResultsTwo superordinate themes and nine subthemes were developed from the interview transcripts. The first superordinate theme was called “The Big Picture” and it had the sub themes: getting started; organizational factors; funding; the future, and; operational problems. The second superordinate theme was called “On the Ground” and it had the subthemes: personal struggles; program activities; measuring outcomes, and; results.ConclusionsWhile the evaluation indicated that the service had been experienced as an effective local response to serious problems, recommendations and directions for future research and development emerged that were more broadly applicable. Issues such as appropriate staffing, localising decision making, identifying priorities and how they will be evaluated, and developing flexibility in terms of job descriptions and qualifications are highlighted.

No more sun shades, please: Experiences of corporate social responsibility in remote Australian mining communities

Corporate social responsibility (CSR) is often touted as the solution to social and environmental ills associated with Australia’s mining boom. This paper extends prior research concerning mining’s social impacts and related CSR programmes by investigating the emergence of new institutional arrangements in pre-existing rural communities which are now dominated by the mining industry. The paper finds that major Australian mining companies’ increasingly decentralised management approaches to CSR policies and programming lead to crucial and sometimes troubling implementation gaps between the intentions of corporate headquarter level policies and their carrying out at the community level. The paper concludes with a discussion of the implications for remote communities in relation to how mining companies’ CSR programmes are currently implemented. The discussion offers suggestions for improving long term outcomes for remote communities through better targetted CSR programs.

Children’s language input: A study of a remote multilingual Indigenous Australian community

Indigenous children growing up in the remote regions of Australia live in multilingual communities which are often undergoing rapid language shift. In these communities, children are exposed to a range of language input, including the traditional language of the area, a local creole and Standard Australian English. The extent to which the different languages are used may vary by age of interlocutor as well as other factors. In this paper we examine the input to five children between the ages of two and four living in a small remote community. Recordings were made of each child interacting with caregivers of different ages to identify the range of language the children are exposed to. The majority of the input was in the local creole. This represents a rapid shift from the traditional language, Walmajarri, which was widely spoken when the community was established in the late 1980s. The majority of input in the traditional language came from the older interlocutors, suggesting that the language is severely endangered. Standard Australian English was used only minimally, although once they enter the formal school system, SAE will be the only language used for their education.

Children’s language input: A study of a remote multilingual Indigenous Australian community

Children’s language input: A study of a remote multilingual Indigenous Australian community

Community-associated meticillin-resistant Staphylococcus aureus carriage in hospitalized patients in tropical northern Australia

Community-associated meticillin-resistant Staphylococcus aureus (CA-MRSA) was first reported in remote Australian Aboriginal communities. It is a prominent clinical pathogen in northern Australia with potential for transmission within the local hospital setting. To determine epidemiological characteristics of S. aureus carriage within the Royal Darwin Hospital. We screened two patient groups: an 'admission group' recruited within 48 h of admission; and an 'inpatient group' recruited five or more days after admission. S. aureus isolates were characterized by antibiotic susceptibility testing and genotyped by a multi-locus sequence type-based high-resolution melting scheme. S. aureus carriage on admission was 30.7% of 225 compared with 34.8% among 201 inpatients, with MRSA carriage of 2.2% and 18.9% respectively. We isolated CA-MRSA from 0.9% and 10.4%, and healthcare-associated (HCA)-MRSA from 1.3% and 9.0% of the admission and inpatient groups, respectively. Among the inpatient group, hospital-associated ST239 was the most common MRSA strain. CA-MRSA was represented by one clonal complex (CC) in the admission group (CC5) and seven CCs in the inpatient group (CC1, 93, 5, 6, 30, 75, 88). Inpatient carriage of multiple CA-MRSA lineages suggests selection for and transmission within the hospital of not only typical HCA-MRSA, but also diverse CA-MRSA strains.

Development and trialling of a tool to support a systems approach to improve social determinants of health in rural and remote Australian communities: the healthy community assessment tool.

IntroductionThe residents of many Australian rural and remote communities do not have the essential infrastructure and services required to support healthy living conditions and community members choosing healthy lifestyle options. Improving these social determinants of health is seen to offer real opportunities to improve health among such disadvantaged populations. In this paper, we describe the development and trialling of a tool to measure, monitor and evaluate key social determinants of health at community level.MethodsThe tool was developed and piloted through a multi-phase and iterative process that involved a series of consultations with community members and key stakeholders and trialling the tool in remote Indigenous communities in the Northern Territory of Australia.ResultsThe indicators were found to be robust, and by testing the tool on a number of different levels, face validity was confirmed. The scoring system was well understood and easily followed by Indigenous and non-Indigenous study participants. A facilitated small group process was found to reduce bias in scoring of indicators.ConclusionThe Healthy Community Assessment Tool offers a useful vehicle and process to help those involved in planning, service provision and more generally promoting improvements in community social determinants of health. The tool offers many potential uses and benefits for those seeking to address inequities in the social determinants of health in remote communities. Maximum benefits in using the tool are likely to be gained with cross-sector involvement and when assessments are part of a continuous quality improvement program.