Long-term trends in supply and sustainability of the health workforce in remote Aboriginal communities in the Northern Territory of Australia

"They feel shame sometime, but that is why we need to talk to them…we need to tell them how important it is not to feel shame": Hepatitis B related shame and improving hepatitis B care in Aboriginal and Torres Strait Islander communities in the Top End of the Northern Territory, according to the Aboriginal health workforce

BACKGROUND

The Aboriginal health workforce has unique insights given their healthcare experience and interactions with their communities. The aims of this project were to explore their perceptions of hepatitis B related shame and ways to improve hepatitis B care in Aboriginal and Torres Strait Islander communities of Northern Territory's Top End, Australia.

METHODS

We conducted a qualitative study with guidance from the Menzies School of Health Research Infectious Diseases Indigenous Reference Group. The Aboriginal health workforce was asked to participate in semi-structured interviews exploring hepatitis B related shame and ways to improve hepatitis B care. Qualitative data were evaluated using reflexive thematic analysis.

RESULTS

There were fifteen semi-structured interviews with participants representing eight different communities. The experience of shame was reported by the Aboriginal health workforce to be common for individuals diagnosed with hepatitis B and comprised feelings of fear related to transmitting the virus, to being isolated, and to being at fault. Shame was mediated by poor health literacy, communication, the lack of culturally safe spaces and was perpetuated by intersecting stereotypes. Improvements in care can be achieved by utilising the Aboriginal health workforce more effectively, improving communication and the availability of culturally safe spaces, emphasising community connection, and reframing hepatitis B as a chronic condition.

CONCLUSIONS

Hepatitis B related shame was an important issue and impactful in Aboriginal and Torres Strait Islander communities in the Top End of the Northern Territory. There were many facets to shame in these communities and it was mediated by several factors. The Aboriginal health workforce has emphasised several pathways to improve care and diminish the impact of shame, such as improving communication and the availability of culturally safe spaces.

"A Huge Gap": Health Care Provider Perspectives on Cancer Screening for Aboriginal and Torres Strait Islander People in the Northern Territory

Cancer is one of the leading causes of death for Aboriginal and Torres Strait Islander people in the Northern Territory (NT). Accessible and culturally appropriate cancer screening programs are a vital component in reducing the burden of cancer. Primary health care plays a pivotal role in facilitating the uptake of cancer screening in the NT, due to the significant challenges caused by large distances, limited resources, and cultural differences. This paper analyses health care provider perspectives and approaches to the provision of cancer screening to Aboriginal people in the NT that were collected as part of a larger study. Semi-structured interviews were conducted with 50 staff from 15 health services, including 8 regional, remote, and very remote primary health care (PHC) clinics, 3 hospitals, a cancer centre, and 3 cancer support services. Transcripts were thematically analysed. Cancer screening by remote and very remote PHC clinics in the NT is variable, with some staff seeing cancer screening as a "huge gap", while others see it as lower priority compared to other conditions due to a lack of resourcing and the overwhelming burden of acute and chronic disease. Conversely, some clinics see screening as an area where they are performing well, with systematic screening, targeted programs, and high screening rates. There was a large variation in perceptions of the breast screening and cervical screening programs. However, participants universally reported that the bowel screening kit was complicated and not culturally appropriate for their Aboriginal patients, which led to low uptake. System-level improvements are required, including increased funding and resourcing for screening programs, and for PHC clinics in the NT. Being appropriately resourced would assist PHC clinics to incorporate a greater emphasis on cancer screening into adult health checks and would support PHCs to work with local communities to co-design targeted cancer screening programs and culturally relevant education activities. Addressing these issues are vital for NT PHC clinics to address the existing cancer screening gaps and achieving the Australian Government pledge to be the first nation in the world to eliminate cervical cancer as a public health problem by 2035. The implementation of the National Lung Cancer Screening Program in 2025 also presents an opportunity to deliver greater benefits to Aboriginal communities and reduce the cancer burden.

"Putting the power back into community": A mixed methods evaluation of a chronic hepatitis B training course for the Aboriginal health workforce of Australia's Northern Territory

BACKGROUND

Chronic hepatitis B (CHB) is endemic in the Aboriginal and Torres Strait Islander population of Australia's Northern Territory. Progression to liver disease can be prevented if holistic care is provided. Low health literacy amongst health professionals is a known barrier to caring for people living with CHB. We co-designed and delivered a culturally safe "Managing hepatitis B" training course for the Aboriginal health workforce. Here, we present an evaluation of the course.

OBJECTIVES

1. To improve course participants CHB-related knowledge, attitudes, and clinical practice. 2. To evaluate the "Managing hepatitis B" training course. 3. To enable participants to have the skills and confidence to be part of the care team.

METHODS

We used participatory action research and culturally safe principles. We used purpose-built quantitative and qualitative evaluation tools to evaluate our "Managing hepatitis B" training course. We integrated the two forms of data, deductively analysing codes, grouped into categories, and assessed pedagogical outcomes against Kirkpatrick's training evaluation framework.

RESULTS

Eight courses were delivered between 2019 and 2023, with 130 participants from 32 communities. Pre- and post-course questionnaires demonstrated statistically significant improvements in all domains, p<0.001 on 93 matched pairs. Thematic network analysis demonstrated high levels of course acceptability and significant knowledge acquisition. Other themes identified include cultural safety, shame, previous misinformation, and misconceptions about transmission. Observations demonstrate improvements in post-course engagement, a deep understanding of CHB as well as increased participation in clinical care teams.

CONCLUSIONS

The "Managing hepatitis B" training course led to a sustained improvement in the knowledge and attitudes of the Aboriginal health workforce, resulting in improved care and treatment uptake for people living with CHB. Important non-clinical outcomes included strengthening teaching and leadership skills, and empowerment.

The Kimberley Dental Team: A process evaluation of a volunteer dental programme serving remote Aboriginal communities in Australia

OBJECTIVES

This study aims to conduct a process evaluation of the Kimberley Dental Team (KDT), a not-for-profit, volunteer organization providing care to remote Aboriginal communities in Western Australia.

METHODS

A logic model was constructed to detail the operational context of the KDT model. Subsequently, the fidelity (the extent to which each of the programme's elements were implemented as planned), dose (types and quantity of services provided) and reach (demographic characteristics and communities serviced) of the KDT model were evaluated using service data, deidentified clinical records and volunteer rosters maintained by KDT from 2009 to 2019. Trends and patterns of service provision were analysed using total counts and proportions over time. A Poisson regression model was used to explore changed in the rates of surgical treatment over time. The associations between volunteer activity and service provision was also investigated using correlation coefficients and linear regression.

RESULTS

A total of 6365 patients (98% identifying as Aboriginal or Torres Strait Islander) were seen over the 10-year period with services being provided across 35 different communities in the Kimberley. Most services were provided to school-aged children, consistent with the programme's objectives. The peak preventive, restorative and surgical rates occurred among school-aged children, young adults and older adults respectively. A trend was observed indicating a reducing rate of surgical procedures from 2010 to 2019 (p < .001). The volunteer profile showed significant diversity beyond the conventional dentist-nurse structure and 40% being repeat volunteers.

CONCLUSIONS

The KDT programme maintained a strong focus on service provision to school-aged children over the last decade with the educational and preventive components being central to the care being provided. This process evaluation found that the dose and reach of the KDT model grew with an increase in resources and was adaptive to perceived community need. The model was shown to evolve through gradual structural adaptations contributing to its overall fidelity.

An evaluation of the quality of ear health services for Aboriginal children living in remote Australia: a cascade of care analysis

BACKGROUND

In the Northern Territory (NT) the prevalence of otitis media (OM) in young Aboriginal children living in remote communities has persisted at around 90% over the last few decades. OM-associated hearing loss can cause developmental delay and adversely impact life course trajectories. This study examined the 5-year trends in OM prevalence and quality of ear health services in remote NT communities.

METHODS

A retrospective analysis was performed on de-identified clinical data for 50 remote clinics managed by the NT Government. We report a 6-monthly cascade analysis of the proportions of children 0-16 years of age receiving local guideline recommendations for surveillance, OM treatment and follow-up at selected milestones between 2014 and 2018.

RESULTS

Between 6,326 and 6,557 individual children were included in the 6-monthly analyses. On average, 57% (95%CI: 56-59%) of eligible children had received one or more ear examination in each 6-monthly period. Of those examined, 36% (95%CI: 33-40%) were diagnosed with some type of OM, of whom 90% had OM requiring either immediate treatment or scheduled follow-up according to local guidelines. Outcomes of treatment and follow-up were recorded in 24% and 23% of cases, respectively. Significant decreasing temporal trends were found in the proportion diagnosed with any OM across each age group. Overall, this proportion decreased by 40% over the five years (from 43 to 26%).

CONCLUSIONS

This cascade of care analysis found that ear health surveillance and compliance with otitis media guidelines for treatment and follow-up were both low. Further research is required to identify effective strategies that improve ear health services in remote settings.

"The most culturally safe training I've ever had": the co-design of a culturally safe Managing hepatitis B training course with and for the Aboriginal health workforce of the Northern Territory of Australia

BACKGROUND

The Aboriginal health workforce provide responsive, culturally safe health care. We aimed to co-design a culturally safe course with and for the Aboriginal health workforce. We describe the factors which led to the successful co-design, delivery, and evaluation of the "Managing hepatitis B" course for the Aboriginal health workforce.

METHODS

A Participatory Action Research approach was used, involving ongoing consultation to iteratively co-design and then develop course content, materials, and evaluation tools. An Aboriginal and Torres Strait Islander research and teaching team received education in chronic hepatitis B and teaching methodologies. Pilot courses were held, in remote communities of the Northern Territory, using two-way learning and teach-back methods to further develop the course and assess acceptability and learnings. Data collection involved focus group discussions, in-class observations, reflective analysis, and use of co-designed and assessed evaluation tools.

RESULTS

Twenty-six participants attended the pilot courses. Aboriginal and Torres Strait Islander facilitators delivered a high proportion of the course. Evaluations demonstrated high course acceptability, cultural safety, and learnings. Key elements contributing to success and acceptability were acknowledging, respecting, and integrating cultural differences into education, delivering messaging and key concepts through an Aboriginal and Torres Strait Islander lens, using culturally appropriate approaches to learning including storytelling and visual teaching methodologies. Evaluation of culturally safe frameworks and findings from the co-design process led to the creation of a conceptual framework, underpinned by meeting people's basic needs, and offering a safe and comfortable environment to enable productive learning with attention to the following: sustenance, financial security, cultural obligations, and gender and kinship relationships.

CONCLUSIONS

Co-designed education for the Aboriginal health workforce must embed principles of cultural safety and meaningful community consultation to enable an increase in knowledge and empowerment. The findings of this research can be used to guide the design of future health education for First Nations health professionals and to other non-dominant cultures. The course model has been successfully transferred to other health issues in the Northern Territory.

Expenditure projections for community home-based care services for older adults with functional decline in China

INTRODUCTION

Difficulty in identifying the functional status of older adults creates an imbalance between the supply and demand for community home-based care. Using a multi-level functional classification system to guide care cost measurement may optimize care resources and meet diverse eldercare demands.

METHODS

The Markov model was used to project the older population size in different functional decline (FD) statuses. The project cost and the man-hour costing method were combined to forecast the cost of community home-based care for older adults with FD.

RESULTS

The projected cost of eldercare increased from 1668.623 billion yuan in 2020 to 2836.754 billion yuan in 2035. By 2035, the total cost for community-based home care for those in pathological development of FD statuses such as "viability disorder," "acute disease," "somatic functional disorder," and "sub-disorder" was projected to be 1094.591 billion, 433.855 billion, 1256.236 billion, and 52.072 billion yuan, respectively, which is 1.24, 1.58, 1.78, and 0.49 times higher than the results by the man-hour costing method. Family caregiving costs are about three times those of professional caregivers.

CONCLUSION

The escalating cost of providing graded care for older adults, particularly by family caregivers, presenting a significant evidence for the need to optimize resource allocation and develop a robust human resources plan for community home-based care.

The 'ABC' of respiratory disorders among adult Indigenous people: asthma, bronchiectasis and COPD among Aboriginal Australians - a systematic review

BACKGROUND

Aboriginal Australians are reported to have higher presence of chronic respiratory diseases. However, comprehensive evidence surrounding this is sparse. Hence, a systematic review was undertaken to appraise the current state of knowledge on respiratory health in the adult Aboriginal Australians, in particular among the three most common respiratory disorders: asthma, bronchiectasis and chronic obstructive pulmonary disease (COPD).

METHODS

A systematic review of primary literature published between January 2012 and October 2022, using the databases PubMed and Scopus, was conducted. Studies were included if they reported adult Aboriginal Australian prevalence's or outcomes related to asthma, bronchiectasis or COPD, and excluded if adult data were not reported separately, if Aboriginal Australian data were not reported separately or if respiratory disorders were combined into a single group. Risk of bias was assessed by both Joanne Briggs Institute checklists and Hoys' bias assessment. Summary data pertaining to prevalence, lung function, symptoms, sputum cultures and mortality for each of asthma, bronchiectasis and COPD were extracted from the included studies.

RESULTS

Thirty-seven studies were included, involving approximately 33 364 participants (71% female). Eighteen studies reported on asthma, 21 on bronchiectasis and 30 on COPD. The majority of studies (94%) involved patients from hospitals or respiratory clinics and were retrospective in nature. Across studies, the estimated prevalence of asthma was 15.4%, bronchiectasis was 9.4% and COPD was 13.7%, although there was significant geographical variation. Only a minority of studies reported on clinical manifestations (n=7) or symptoms (n=4), and studies reporting on lung function parameters (n=17) showed significant impairment, in particular among those with concurrent bronchiectasis and COPD. Airway exacerbation frequency and hospital admission rates including mortality are high.

DISCUSSION

Although risk of bias globally was assessed as low, and study quality as high, there was limited diversity of studies with most reporting on referred populations, and the majority originating from two centres in the Northern Territory. The states with the greatest Aboriginal Australian population (Victoria and New South Wales) reported the lowest number of studies and patients. This limits the generalisability of results to the wider Aboriginal Australian population due to significant environmental, cultural and socioeconomic variation across the population. Regardless, Aboriginal Australians appear to display a high prevalence, alongside quite advanced and complex chronic respiratory diseases. There is however significant heterogeneity of prevalence, risk factors and outcomes geographically and by patient population. Further collaborative efforts are required to address specific diagnostic and management pathways in order to close the health gap secondary to respiratory disorders in this population.

"I Don't Think It's on Anyone's Radar": The Workforce and System Barriers to Healthcare for Indigenous Women Following a Traumatic Brain Injury Acquired through Violence in Remote Australia

Aboriginal and Torres Strait Islander women experience high rates of traumatic brain injury (TBI) as a result of violence. While healthcare access is critical for women who have experienced a TBI as it can support pre-screening, comprehensive diagnostic assessment, and referral pathways, little is known about the barriers for Aboriginal and Torres Strait Islander women in remote areas to access healthcare. To address this gap, this study focuses on the workforce barriers in one remote region in Australia. Semi-structured interviews and focus groups were conducted with 38 professionals from various sectors including health, crisis accommodation and support, disability, family violence, and legal services. Interviews and focus groups were audiotaped and transcribed verbatim and were analysed using thematic analysis. The results highlighted various workforce barriers that affected pre-screening and diagnostic assessment including limited access to specialist neuropsychology services and stable remote primary healthcare professionals with remote expertise. There were also low levels of TBI training and knowledge among community-based professionals. The addition of pre-screening questions together with professional training on TBI may improve how remote service systems respond to women with potential TBI. Further research to understand the perspectives of Aboriginal and Torres Strait Islander women living with TBI is needed.

What does microbiology have to do with the Hearing for Learning Initiative (HfLI)?

Where would we be without microbiology in tackling the high prevalence of otitis media (OM; middle ear infection) and disabling hearing loss that disadvantage Australian First Nations children living in remote communities? Understanding the microbiology of OM in this population has been critical in directing innovative clinical trials research and developing appropriate evidence-based practice guidelines. While these processes are critical to reducing disadvantage associated with OM and disabling hearing loss, a remaining seemingly insurmountable gap has remained, threatening progress in improving the lives of children with ear and hearing problems. That gap is created by the crisis in primary health care workforce in remote communities. Short stay health professionals and fly-in fly-out specialist services are under-resourced to manage the complex needs of the community, including prevention and treatment of otitis media and hearing loss rehabilitation. Hence the rationale for the Hearing for Learning Initiative – a workforce enhancement model to improve sustainability, cultural appropriateness, and effectiveness of evidence-based ear and hearing health care for young children in remote settings. This paper summarises the role of microbiology in the pathway to the Hearing for Learning Initiative.

Nursing in a different world: Remote area nursing as a specialist-generalist practice area

OBJECTIVE

Remote area nurses provide primary health care services to isolated communities across Australia. They manage acute health issues, chronic illness, health promotion and emergency responses. This article discusses why their generalist scope of practice should be formally recognised as a specialist nursing practice area.

DESIGN

Constructivist grounded theory, using telephone interviews (n = 24) with registered nurses and nurse practitioners.

SETTING

Primary health care clinics, in communities of 150-1500 residents across Australia.

PARTICIPANTS

A total of 24 nurses participated in this study.

RESULTS

Nurses' perceived their clinical knowledge and skill as insufficient for the advanced, generalist, scope of practice in the remote context, especially when working alone. Experience in other settings was inadequate preparation for working in remote areas. Knowledge and skill developed on the job, with formal learning, such as nurse practitioner studies, extending the individual nurse's scope of practice to meet the expectations of the role, including health promotion.

CONCLUSION

Remote area nursing requires different knowledge and skills from those found in any other nursing practice setting. This study supports the claim that remote area nursing is a specialist-generalist role and presents a compelling case for further examination of the generalist education and support needs of these nurses. Combined with multidisciplinary collaboration, developing clinical knowledge and skill across the primary health care spectrum increased the availability of health resources and subsequently improved access to care for remote communities. Further research is required to articulate the contemporary scope of practice of remote area nurses to differentiate their role from that of nurse practitioners.

Forecasting Future Demand of Nursing Staff for the Oldest-Old in China by 2025 Based on Markov Model

BACKGROUND

An aging population and an increase in the proportion of disabled elderly have brought an unprecedented global challenge, especially in China. Aside lack of professional long-term care facilities, the shortage of human resource for old-age care is also a major threat. Therefore, this study tries to forecast the demand scale of nursing staff for the oldest-old in 2025 in China servicing as a reference for the development plan of human resource for elderly nursing.

METHODS

Based on CLHLS (Chinese Longitudinal Healthy Longevity Survey) 2011 and 2014, Logit model was used to construct the transition probability matrix of the elderly's health status (health/mild/moderate/severe disability and death). By using the data of the elderly population aged 65 or over in the 2010 national population census, we projected the number of Chinese oldest-old population in different health status by 2025 through Markov model and projected the scale of the demand of nursing staff combined with the human population ratio method.

RESULTS

The forecast shows that the Chinese oldest-old population is about 52.6 million, among which 46.9 million are healthy, 3.7 million are mild, 0.8 million are moderate, and 1.2 million are severely disabled in 2025. Concurrently, the demand scale of nursing staff will be 5.6 million according to the low standard and 11.5 million according to the high standard. Thus, human resource supply of long-term care is worrying.

CONCLUSION

In 2025, the population size of the Chinese oldest-old will be further expanded, and the demand of care will increase accordingly, leading to a vast gap in the nursing staff. Therefore, it is urgent to build a professional nursing staff with excellent comprehensive quality and reasonable quantity, to ensure the sustainable development of China's elderly care service industry.

Improving Access to Cancer Treatment Services in Australia’s Northern Territory—History and Progress

Cancer is the leading cause of death in the Northern Territory (NT), Australia’s most sparsely populated jurisdiction with the highest proportion of Aboriginal people. Providing cancer care to the NT’s diverse population has significant challenges, particularly related to large distances, limited resources and cultural differences. This paper describes the developments to improve cancer treatment services, screening and end-of-life care in the NT over the past two decades, with a particular focus on what this means for the NT’s Indigenous peoples. This overview of NT cancer services was collated from peer-reviewed literature, government reports, cabinet papers and personal communication with health service providers. The establishment of the Alan Walker Cancer Care Centre (AWCCC), which provides radiotherapy, chemotherapy and other specialist cancer services at Royal Darwin Hospital, and recent investment in a PET Scanner have reduced patients’ need to travel interstate for cancer diagnosis and treatment. The new chemotherapy day units at Alice Springs Hospital and Katherine Hospital and the rapid expansion of tele-oncology have also reduced patient travel within the NT. Access to palliative care facilities has also improved, with end-of-life care now available in Darwin, Alice Springs and Katherine. However, future efforts in the NT should focus on increasing and improving travel assistance and support and increasing the availability of appropriate accommodation; ongoing implementation of strategies to improve recruitment and retention of health professionals working in cancer care, particularly Indigenous health professionals; and expanding the use of telehealth as a means of delivering cancer care and treatment.

How can the healthcare system deliver sustainable performance? A scoping review

BACKGROUND

Increasing health costs, demand and patient multimorbidity challenge the sustainability of healthcare systems. These challenges persist and have been amplified by the global pandemic.

OBJECTIVES

We aimed to develop an understanding of how the sustainable performance of healthcare systems (SPHS) has been conceptualised, defined and measured.

DESIGN

Scoping review of peer-reviewed articles and editorials published from database inception to February 2021.

DATA SOURCES

PubMed and Ovid Medline, and snowballing techniques.

ELIGIBILITY CRITERIA

We included articles that discussed key focus concepts of SPHS: (1) definitions, (2) measurement, (3) identified challenges, (4) identified solutions for improvement and (5) scaling successful solutions to maintain SPHS.

DATA EXTRACTION AND SYNTHESIS

After title/abstract screening, full-text articles were reviewed, and relevant information extracted and synthesised under the five focus concepts.

RESULTS

Of 142 included articles, 38 (27%) provided a definition of SPHS. Definitions were based mainly on financial sustainability, however, SPHS was also more broadly conceptualised and included acceptability to patients and workforce, resilience through adaptation, and rapid absorption of evidence and innovations. Measures of SPHS were also predominantly financial, but recent articles proposed composite measures that accounted for financial, social and health outcomes. Challenges to achieving SPHS included the increasingly complex patient populations, limited integration because of entrenched fragmented systems and siloed professional groups, and the ongoing translational gaps in evidence-to-practice and policy-to-practice. Improvement strategies for SPHS included developing appropriate workplace cultures, direct community and consumer involvement, and adoption of evidence-based practice and technologies. There was also a strong identified need for long-term monitoring and evaluations to support adaptation of healthcare systems and to anticipate changing needs where possible.

CONCLUSIONS

To implement lasting change and to respond to new challenges, we need context-relevant definitions and frameworks, and robust, flexible, and feasible measures to support the long-term sustainability and performance of healthcare systems.

The community nurse in Australia. Who are they? A rapid systematic review

AIM

This study aimed to profile the community nurse in Australia.

BACKGROUND

The need for nurses in the community health care sector is increasing in response to shorter hospital stays, an aging population and chronic disease. The increase in demand has not been followed by appropriate workforce planning, leading to structural issues and lack of qualified nursing workforce in the community sector.

EVALUATION

MEDLINE and ProQuest Public Health and grey literature were searched for records published between 2010 and 2020 relative to the profile of the community nurse in Australia. Twenty-five records (21 publications, 2 databases and 2 reports) were included in the review. Abstracted data followed the principles of workforce planning and included demographics, qualifications and roles.

KEY ISSUES

Inconsistent definitions, self-reported data and a focus on practice nurses have contributed to data irregularities. Little is known about the specific aspects of community nursing work.

CONCLUSION

A lack of concrete data has overshadowed a community nursing workforce crisis with implications for patients' health and safety across the lifespan.

IMPLICATIONS FOR NURSING MANAGEMENT

There is urgent need for nurse managers globally to refocus nursing recruitment to the community sector to maintain quality and ensure sustainability of the nursing workforce.

Effects of turnover and stability of health staff on quality of care in remote communities of the Northern Territory, Australia: a retrospective cohort study

OBJECTIVES

To evaluate the relationship between markers of staff employment stability and use of short-term healthcare workers with markers of quality of care. A secondary objective was to identify clinic-specific factors which may counter hypothesised reduced quality of care associated with lower stability, higher turnover or higher use of short-term staff.

DESIGN

Retrospective cohort study (Northern Territory (NT) Department of Health Primary Care Information Systems).

SETTING

All 48 government primary healthcare clinics in remote communities in NT, Australia (2011-2015).

PARTICIPANTS

25 413 patients drawn from participating clinics during the study period.

OUTCOME MEASURES

Associations between independent variables (resident remote area nurse and Aboriginal Health Practitioner turnover rates, stability rates and the proportional use of agency nurses) and indicators of health service quality in child and maternal health, chronic disease management and preventive health activity were tested using linear regression, adjusting for community and clinic size. Latent class modelling was used to investigate between-clinic heterogeneity.

RESULTS

The proportion of resident Aboriginal clients receiving high-quality care as measured by various quality indicators varied considerably across indicators and clinics. Higher quality care was more likely to be received for management of chronic diseases such as diabetes and least likely to be received for general/preventive adult health checks. Many indicators had target goals of 0.80 which were mostly not achieved. The evidence for associations between decreased stability measures or increased use of agency nurses and reduced achievement of quality indicators was not supported as hypothesised. For the majority of associations, the overall effect sizes were small (close to zero) and failed to reach statistical significance. Where statistically significant associations were found, they were generally in the hypothesised direction.

CONCLUSIONS

Overall, minimal evidence of the hypothesised negative effects of increased turnover, decreased stability and increased reliance on temporary staff on quality of care was found. Substantial variations in clinic-specific estimates of association were evident, suggesting that clinic-specific factors may counter any potential negative effects of decreased staff employment stability. Investigation of clinic-specific factors using latent class analysis failed to yield clinic characteristics that adequately explain between-clinic variation in associations. Understanding the reasons for this variation would significantly aid the provision of clinical care in remote Australia.

Understanding and responding to the cost and health impact of short-term health staffing in remote and rural Aboriginal and Torres Strait Islander community-controlled health services: a mixed methods study protocol

INTRODUCTION

Access to high-quality primary healthcare is limited for remote residents in Australia. Increasingly, remote health services are reliant on short-term or 'fly-in, fly-out/drive-in, drive-out' health workforce to deliver primary healthcare. A key strategy to achieving health service access equity, particularly evident in remote Australia, has been the development of Aboriginal Community Controlled Health Services (ACCHSs). This study aims to generate new knowledge about (1) the impact of short-term staffing in remote and rural ACCHSs on Aboriginal and Torres Strait Islander communities; (2) the potential mitigating effect of community control; and (3) effective, context-specific evidence-based retention strategies.

METHODS AND ANALYSIS

This paper describes a 3-year, mixed methods study involving 12 ACCHSs across three states. The methods are situated within an evidence-based programme logic framework for rural and remote primary healthcare services. Quantitative data will be used to describe staffing stability and turnover, with multiple regression analyses to determine associations between independent variables (population size, geographical remoteness, resident staff turnover and socioeconomic status) and dependent variables related to patient care, service cost, quality and effectiveness. Qualitative assessment will include interviews and focus groups with clinical staff, clinic users, regionally-based retrieval staff and representatives of jurisdictional peak bodies for the ACCHS sector, to understand the impact of short-term staff on quality and continuity of patient care, as well as satisfaction and acceptability of services.

ETHICS AND DISSEMINATION

The study has ethics approval from the Human Research Ethics Committee of the Northern Territory Department of Health and Menzies School of Health Research (project number DR03171), Central Australian Human Research Ethics Committee (CA-19-3493), Western Australian Aboriginal Health Ethics Committee (WAAHEC-938) and Far North Queensland Human Research Ethics Committee (HREC/2019/QCH/56393). Results will be disseminated through peer-reviewed journals, the project steering committee and community/stakeholder engagement activities to be determined by each ACCHS.

Feasibility of once weekly exenatide-LAR and enhanced diabetes care in Indigenous Australians with type 2 diabetes. (Long-acting-Once-Weekly-Exenatide laR-SUGAR, "Lower SUGAR" study)

AIMS

To assess the feasibility and metabolic effects of once weekly supervised injection of exenatide-LAR in addition to standard care in Indigenous Australians with type 2 diabetes.

METHODS

Two communities in Central Australia with longstanding specialist clinical outreach services were allocated by random coin toss to receive once-weekly exenatide-LAR injection with weekly nurse review and adjustment of medication for 20 weeks (community with exenatide-LAR) or to weekly nurse review in addition to standard care over 20 weeks (community without exenatide-LAR). The primary outcome was the feasibility of the intensive diabetes management model of care with and without weekly supervised exenatide-LAR. Secondary outcomes included change in HbA1c.

RESULTS

13 participants from community with exenatide-LAR and 9 participants from the community without exenatide-LAR were analysed. 85% of individuals in the community with exenatide-LAR and 67% in the community without exenatide-LAR attended more than half of clinic visits. Median difference in the change in HbA1c from baseline to final visit, adjusted for baseline HbA1c, between the community with exenatide-LAR and the community without exenatide-LAR was -3.1%, 95% CI (-5.80%, -0.38%; p = 0.03).

CONCLUSIONS

Weekly exenatide-LAR combined with weekly nurse review demonstrated greater improvements in HbA1c, highlighting its potential for use in remote communities. This article is protected by copyright. All rights reserved.

A community-based service enhancement model of training and employing Ear Health Facilitators to address the crisis in ear and hearing health of Aboriginal children in the Northern Territory, the Hearing for Learning Initiative (the HfLI): study protocol for a stepped-wedge cluster randomised trial

Background

Almost all Aboriginal children in remote communities have persistent bilateral otitis media affecting hearing and learning throughout early childhood and school years, with consequences for social and educational outcomes, and later employment opportunities. Current primary health care and specialist services do not have the resources to meet the complex needs of these children.

Method/design

This stepped-wedge cluster randomised trial will allocate 18 communities to one of five 6-monthly intervention start dates. Stratification will be by region and population size. The intervention (Hearing for Learning Initiative, HfLI) consists of six 20-h weeks of training (delivered over 3 months) that includes Certificate II in Aboriginal Primary Health Care (3 modules) and competencies in ear and hearing data collection (otoscopy, tympanometry and hearScreen), plus 3 weeks of assisted integration into the health service, then part-time employment as Ear Health Facilitators to the end of the trial. Unblinding will occur 6 months prior to each allocated start date, to allow Community Reference Groups to be involved in co-design of the HfLI implementation in their community. Relevant health service data will be extracted 6-monthly from all 18 communities. The primary outcome is the difference in proportion of children (0 to 16 years of age) who have at least one ear assessment (diagnosis) documented in their medical record within each 6-month period, compared to control periods (no HfLI). Secondary outcomes include data on sustainability, adherence to evidence-based clinical guidelines for otitis media, including follow-up and specialist referrals, and school attendance. Structured interviews with staff working in health and education services, Ear Health Trainees, Ear Health Facilitators and families will assess process outcomes and the HfLI broader impact.

Discussion

The impact of training and employment of Ear Health Facilitators on service enhancement will inform the health, education and employment sectors about effectiveness of skills and job creation that empowers community members to contribute to addressing issues of local importance, in this instance ear and hearing health of children.

Trial registration

ClinicalTrials.gov NCT03916029. Registered on 16 April 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05215-7.

Key elements of effective postgraduate GP educational environments: a mixed methods study

OBJECTIVES

Evidence in the literature suggests that satisfaction with postgraduate general practice (GP) training is associated with the quality of the educational environment. This study aimed to examine GP registrars' level of satisfaction with a distributed model of training in a regional educational environment and investigate the relationship between satisfaction and academic performance.

STUDY DESIGN

A longitudinal 3-year study was conducted among GP registrars at James Cook University using a sequential explanatory mixed methods research design. GP registrars' satisfaction was obtained using the scan of postgraduate educational environment domains tool. A focus group discussion was conducted to explore GP registrars' perceptions of satisfaction with the educational environment.

SETTING

James Cook University General Practice Training (JCU GPT) programme.

PARTICIPANTS

Six hundred and fifty one (651) GP registrars enrolled between 2016 and 2018 at JCU GPT programme.

RESULTS

651 registrars completed the satisfaction survey between 2016 and 2018. Overall, 92% of the registrars were satisfied with the educational training environment. Registrars who had become fellows reported higher satisfaction levels compared with those who were still in training (mean=4.39 vs 4.20, p=0.001). However, academic performance had no impact on level of satisfaction with the educational environment. Similarly, practice location did not influence registrars' satisfaction rates. Four themes (rich rural/remote educational environment, supportive learning environment, readiness to continue with rural practice and practice culture) emerged from the thematic data analysis.

CONCLUSION

A clinical learning environment that focuses on and supports individual learning needs is vital for effective postgraduate medical training. This study suggests that JCU GPT programme's distributed model fostered a satisfying and supportive training environment with rich educational experiences that enhance retention of GP registrars in rural/remote North Queensland, Australia. The findings of this study may be applicable to other settings with similar training models.

Beyond the black stump: rapid reviews of health research issues affecting regional, rural and remote Australia

CHAPTER 1: RETAIL INITIATIVES TO IMPROVE THE HEALTHINESS OF FOOD ENVIRONMENTS IN RURAL, REGIONAL AND REMOTE COMMUNITIES: Objective: To synthesise the evidence for effectiveness of initiatives aimed at improving food retail environments and consumer dietary behaviour in rural, regional and remote populations in Australia and comparable countries, and to discuss the implications for future food environment initiatives for rural, regional and remote areas of Australia.

STUDY DESIGN

Rapid review of articles published between January 2000 and May 2020.

DATA SOURCES

We searched MEDLINE (EBSCOhost), Health and Society Database (Informit) and Rural and Remote Health Database (Informit), and included studies undertaken in rural food environment settings in Australia and other countries.

DATA SYNTHESIS

Twenty-one articles met the inclusion criteria, including five conducted in Australia. Four of the Australian studies were conducted in very remote populations and in grocery stores, and one was conducted in regional Australia. All of the overseas studies were conducted in rural North America. All of them revealed a positive influence on food environment or consumer behaviour, and all were conducted in disadvantaged, rural communities. Positive outcomes were consistently revealed by studies of initiatives that focused on promotion and awareness of healthy foods and included co-design to generate community ownership and branding.

CONCLUSION

Initiatives aimed at improving rural food retail environments were effective and, when implemented in different rural settings, may encourage improvements in population diets. The paucity of studies over the past 20 years in Australia shows a need for more research into effective food retail environment initiatives, modelled on examples from overseas, with studies needed across all levels of remoteness in Australia. Several retail initiatives that were undertaken in rural North America could be replicated in rural Australia and could underpin future research. CHAPTER 2: WHICH INTERVENTIONS BEST SUPPORT THE HEALTH AND WELLBEING NEEDS OF RURAL POPULATIONS EXPERIENCING NATURAL DISASTERS?: Objective: To explore and evaluate health and social care interventions delivered to rural and remote communities experiencing natural disasters in Australia and other high income countries.

STUDY DESIGN

We used systematic rapid review methods. First we identified a test set of citations and generated a frequency table of Medical Subject Headings (MeSH) to index articles. Then we used combinations of MeSH terms and keywords to search the MEDLINE (Ovid) database, and screened the titles and abstracts of the retrieved references.

DATA SOURCES

We identified 1438 articles via database searches, and a further 62 articles via hand searching of key journals and reference lists. We also found four relevant grey literature resources. After removing duplicates and undertaking two stages of screening, we included 28 studies in a synthesis of qualitative evidence.

DATA SYNTHESIS

Four of us read and assessed the full text articles. We then conducted a thematic analysis using the three phases of the natural disaster response cycle.

CONCLUSION

There is a lack of robust evaluation of programs and interventions supporting the health and wellbeing of people in rural communities affected by natural disasters. To address the cumulative and long term impacts, evidence suggests that continuous support of people's health and wellbeing is needed. By using a lens of rural adversity, the complexity of the lived experience of natural disasters by rural residents can be better understood and can inform development of new models of community-based and integrated care services. CHAPTER 3: THE IMPACT OF BUSHFIRE ON THE WELLBEING OF CHILDREN LIVING IN RURAL AND REMOTE AUSTRALIA: Objective: To investigate the impact of bushfire events on the wellbeing of children living in rural and remote Australia.

STUDY DESIGN

Literature review completed using rapid realist review methods, and taking into consideration the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement for systematic reviews.

DATA SOURCES

We sourced data from six databases: EBSCOhost (Education), EBSCOhost (Health), EBSCOhost (Psychology), Informit, MEDLINE and PsycINFO. We developed search terms to identify articles that could address the research question based on the inclusion criteria of peer reviewed full text journal articles published in English between 1983 and 2020. We initially identified 60 studies and, following closer review, extracted data from eight studies that met the inclusion criteria.

DATA SYNTHESIS

Children exposed to bushfires may be at increased risk of poorer wellbeing outcomes. Findings suggest that the impact of bushfire exposure may not be apparent in the short term but may become more pronounced later in life. Children particularly at risk are those from more vulnerable backgrounds who may have compounding factors that limit their ability to overcome bushfire trauma.

CONCLUSION

We identified the short, medium and long term impacts of bushfire exposure on the wellbeing of children in Australia. We did not identify any evidence-based interventions for supporting outcomes for this population. Given the likely increase in bushfire events in Australia, research into effective interventions should be a priority. CHAPTER 4: THE ROLE OF NATIONAL POLICIES TO ADDRESS RURAL ALLIED HEALTH, NURSING AND DENTISTRY WORKFORCE MALDISTRIBUTION: Objective: Maldistribution of the health workforce between rural, remote and metropolitan communities contributes to longstanding health inequalities. Many developed countries have implemented policies to encourage health care professionals to work in rural and remote communities. This scoping review is an international synthesis of those policies, examining their effectiveness at recruiting and retaining nursing, dental and allied health professionals in rural communities.

STUDY DESIGN

Using scoping review methods, we included primary research - published between 1 September 2009 and 30 June 2020 - that reported an evaluation of existing policy initiatives to address workforce maldistribution in high income countries with a land mass greater than 100 000 km² .

DATA SOURCES

We searched MEDLINE, Ovid Embase, Ovid Emcare, Informit, Scopus, and Web of Science. We screened 5169 articles for inclusion by title and abstract, of which we included 297 for full text screening. We then extracted data on 51 studies that had been conducted in Australia, the United States, Canada, United Kingdom and Norway.

DATA SYNTHESIS

We grouped the studies based on World Health Organization recommendations on recruitment and retention of health care workers: education strategies (n = 27), regulatory change (n = 11), financial incentives (n = 6), personal and professional support (n = 4), and approaches with multiple components (n = 3).

CONCLUSION

Considerable work has occurred to address workforce maldistribution at a local level, underpinned by good practice guidelines, but rarely at scale or with explicit links to coherent overarching policy. To achieve policy aspirations, multiple synergistic evidence-based initiatives are needed, and implementation must be accompanied by well designed longitudinal evaluations that assess the effectiveness of policy objectives. CHAPTER 5: AVAILABILITY AND CHARACTERISTICS OF PUBLICLY AVAILABLE HEALTH WORKFORCE DATA SOURCES IN AUSTRALIA: Objective: Many data sources are used in Australia to inform health workforce planning, but their characteristics in terms of relevance, accessibility and accuracy are uncertain. We aimed to identify and appraise publicly available data sources used to describe the Australian health workforce.

STUDY DESIGN

We conducted a scoping review in which we searched bibliographic databases, websites and grey literature. Two reviewers independently undertook title and abstract screening and full text screening using Covidence software. We then assessed the relevance, accessibility and accuracy of data sources using a customised appraisal tool.

DATA SOURCES

We searched for potential workforce data sources in nine databases (MEDLINE, Embase, Ovid Emcare, Scopus, Web of Science, Informit, the JBI Evidence-based Practice Database, PsycINFO and the Cochrane Library) and the grey literature, and examined several pre-defined websites.

DATA SYNTHESIS

During the screening process we identified 6955 abstracts and examined 48 websites, from which we identified 12 publicly available data sources - eight primary and four secondary data sources. The primary data sources were generally of modest quality, with low scores in terms of reference period, accessibility and missing data. No single primary data source scored well across all domains of the appraisal tool.

CONCLUSION

We identified several limitations of data sources used to describe the Australian health workforce. Establishment of a high quality, longitudinal, linked database that can inform all aspects of health workforce development is urgently needed, particularly for rural health workforce and services planning. CHAPTER 6: RAPID REALIST REVIEW OF OPIOID TAPERING IN THE CONTEXT OF LONG TERM OPIOID USE FOR NON-CANCER PAIN IN RURAL AREAS: Objective: To describe interventions, barriers and enablers associated with opioid tapering for patients with chronic non-cancer pain in rural primary care settings.

STUDY DESIGN

Rapid realist review registered on the international register of systematic reviews (PROSPERO) and conducted in accordance with RAMESES standards.

DATA SOURCES

English language, peer-reviewed articles reporting qualitative, quantitative and mixed method studies, published between January 2016 and July 2020, and accessed via MEDLINE, Embase, CINAHL Complete, PsycINFO, Informit or the Cochrane Library during June and July 2020. Grey literature relating to prescribing, deprescribing or tapering of opioids in chronic non-cancer pain, published between January 2016 and July 2020, was identified by searching national and international government, health service and peek organisation websites using Google Scholar.

DATA SYNTHESIS

Our analysis of reported approaches to tapering conducted across rural and non-rural contexts showed that tapering opioids is complex and challenging, and identified several barriers and enablers. Successful outcomes in rural areas appear likely through therapeutic relationships, coordination and support, by using modalities and models of care that are appropriate in rural settings and by paying attention to harm minimisation.

CONCLUSION

Rural primary care providers do not have access to resources available in metropolitan centres for dealing with patients who have chronic non-cancer pain and are taking opioid medications. They often operate alone or in small group practices, without peer support and access to multidisciplinary and specialist teams. Opioid tapering approaches described in the literature include regulation, multimodal and multidisciplinary approaches, primary care provider support, guidelines, and patient-centred strategies. There is little research to inform tapering in rural contexts. Our review provides a synthesis of the current evidence in the form of a conceptual model. This preliminary model could inform the development of a model of care for use in implementation research, which could test a variety of mechanisms for supporting decision making, reducing primary care providers' concerns about potential harms arising from opioid tapering, and improving patient outcomes.

Remote health service vulnerabilities and responses to the COVID-19 pandemic

The rapid response to the COVID-19 pandemic in Australia has highlighted the vulnerabilities of remote Aboriginal and Torres Strait Islander communities in terms of the high prevalence of complex chronic disease and socio-economic factors such as limited housing availability and overcrowding. The response has also illustrated the capability of Aboriginal and Torres Strait Islander leaders and the Aboriginal Community Controlled Health Services Sector, working with the government, to rapidly and effectively mitigate the threat of transmission into these vulnerable remote communities. The pandemic has exposed persistent workforce challenges faced by primary health care services in remote Australia. Specifically, remote health services have a heavy reliance on short-term or fly-in, fly-out/drive-in, drive-out staff, particularly remote area nurses. The easing of travel restrictions across the country brings the increased risk of transmission into remote areas and underscores the need to adequately plan and fund remote primary health care services and ensure the availability of an adequate, appropriately trained local workforce in all remote communities.

A community-based co-designed genetic health service model for Aboriginal Australians

BACKGROUND

Aboriginal and Torres Strait Islander people experience a greater burden of disease and die younger than non-Indigenous Australians, with Aboriginal people living in remote areas of the Northern Territory of Australia having the lowest life expectancy estimates. Despite a high burden of chronic disease among Aboriginal and Torres Strait Islander people, access to specialist health services remains low and models of care that increase engagement, may improve health outcomes.

METHODS

We describe client and staff perspectives of a model of clinical genetics services provided by the MJD Foundation (MJDF) in geographically and culturally complex contexts within the Northern Territory of Australia. We seek to understand the MJDF model's success in supporting Aboriginal families with the familial, neurodegenerative condition Machado-Joseph disease and how it could be applied in the provision of other specialist services. Thematic analysis was undertaken on semi-structured interviews with primary health care staff (n = 2), Non-Aboriginal MJDF Staff (n = 7) and Aboriginal MJDF Clients / Community workers (n = 13).

RESULTS

Four key themes regarding the MJDF model of service delivery were identified with the service being; 1) client led 2) accepting of various understandings of genetic disease causation 3) focused on relationships, continuity and trust between the service provider and the clients, and 4) committed to incorporating an inclusive whole-of-family practice. The MJDF model takes a community-based, person-and family-centred approach to successfully deliver effective specialist genetic health services in remote community settings. We propose that these approaches have broad application in the future design and delivery of specialist health services particularly in culturally complex settings.

Job Stress and Working Capacity among Fly-In-Fly-Out Workers in the Oil and Gas Extraction Industries in the Arctic

(1) Background: the research purpose is to identify and describe the stress and working capacity dynamics of oil and gas fly-in-fly-out (FIFO) workers in the Arctic during the fly-in period using biochemical, psychophysiological and psychological methods with further analysis of the relationship between them using objective, subjective and projective indicators. (2) Methods: The research involved 70 oil and gas FIFO specialists in the Arctic. The study of stress and working capacity was carried out using biochemical (saliva analysis for cortisol), psychophysiological (complex visual–motor reaction and variational cardiointervalometry) and psychological (questionnaire “Well-being. Activity. Mood”, M. Luscher’s color test and the subjective control level methods. (3) Results: There is a similarity in the dynamic curves of oil and gas FIFO employees’ stress and working objective, subjective and projective indicators during the fly-in period. The maximum relationships number was obtained between objective cortisol indicators in saliva (stress), complex visual–motor response indicators (operator working capacity), variational cardiointervalometry (functionality level), and interpretation coefficients (working capacity, stress, vegetative balance) according to M. Luscher’s test. (4) Conclusions: The obtained results made it possible to explain the mechanisms underlying the previously developed FIFO workers’ adaptation strategies classification, in which emergency and economic adaptation strategies were identified.

Positioning global pharmacy research partnerships to advance health equity

Interest in global pharmacy research partnerships is growing, and many Schools and Colleges of Pharmacy are looking to expand their footprint in the global health arena. This will create opportunities for increased collaboration and synergy, but there will also be concerns for potential duplication and fragmentation. Such research partnerships also present unique opportunities for addressing unmet medication-related needs of populations around the word, especially for vulnerable populations living both in high income countries (HICs) and low- and middle-income countries (LMICs). Pharmacy leaders and researchers engaged in global health partnerships or planning to start one can draw important lessons from other global health partnerships but also by studying the historical context and evolution of global health initiatives. To be meaningful, global pharmacy research partnerships must be grounded in local contexts and be sensitive to the myriad influences and actors that may determine success of their research endeavors, including health interventions. A deliberate and thoughtful investment in mentorship and faculty development for LMIC collaborators are also essential ingredients for sustainability of global research partnerships.

Antimicrobial stewardship in remote primary healthcare across northern Australia

Background

The high burden of infectious disease and associated antimicrobial use likely contribute to the emergence of antimicrobial resistance in remote Australian Aboriginal communities. We aimed to develop and apply context-specific tools to audit antimicrobial use in the remote primary healthcare setting.

Methods

We adapted the General Practice version of the National Antimicrobial Prescribing Survey (GP NAPS) tool to audit antimicrobial use over 2–3 weeks in 15 remote primary healthcare clinics across the Kimberley region of Western Australia (03/2018–06/2018), Top End of the Northern Territory (08/2017–09/2017) and far north Queensland (05/2018–06/2018). At each clinic we reviewed consecutive clinic presentations until 30 presentations where antimicrobials had been used were included in the audit. Data recorded included the antimicrobials used, indications and treating health professional. We assessed the appropriateness of antimicrobial use and functionality of the tool.

Results

We audited the use of 668 antimicrobials. Skin and soft tissue infections were the dominant treatment indications (WA: 35%; NT: 29%; QLD: 40%). Compared with other settings in Australia, narrow spectrum antimicrobials like benzathine benzylpenicillin were commonly given and the appropriateness of use was high (WA: 91%; NT: 82%; QLD: 65%). While the audit was informative, non-integration with practice software made the process manually intensive.

Conclusions

Patterns of antimicrobial use in remote primary care are different from other settings in Australia. The adapted GP NAPS tool functioned well in this pilot study and has the potential for integration into clinical care. Regular stewardship audits would be facilitated by improved data extraction systems.

A "one stop liver shop" approach improves the cascade-of-care for Aboriginal and Torres Strait Islander Australians living with chronic hepatitis B in the Northern Territory of Australia: results of a novel care delivery model

Background

Aboriginal and Torres Strait Islander Australians are disproportionately affected by Chronic Hepatitis B (CHB) with a prevalence of 6.08% in the Northern Territory (NT) and liver cancer rates 6 times higher than non-Indigenous Australians. Without appropriate care, overall 25% of those living with CHB will die from either liver failure or liver cancer, outcomes that can be minimised with regular follow up, antiviral treatment and hepatocellular carcinoma (HCC) screening. This care including antiviral treatment is publicly funded in the Australian setting however the care cascade still shows inequities in access to treatment for Aboriginal Australians. We describe the impact of a mobile care delivery model, “One Stop Liver Shop”, on the cascade of care for people living with CHB in a remote Australian setting.

Methods

A retrospective analysis was performed for CHB care received between 2013 and 2018 in one very remote Northern Territory community, where the “One Stop Liver Shop” was iteratively developed with the community. Patients with positive Hepatitis B virus surface antigen (HBsAg) were identified through electronic medical records. Proportions of patients who are up-to-date with monitoring investigations and HCC screening were evaluated and compared to national guidelines and targets.

Results

Eighty-three HBsAg positive patients were evaluated. Eighty-eight percent were engaged in care, 16% of whom were receiving antiviral treatment. Liver function tests (LFT) were up to date in 71% of patients in 2013 and 88% in 2018. Viral load (VL) monitoring was up to date for 61 (73%) of patients. There were 44 patients in whom HCC screening was indicated. Of these, 38 (86.4%) were up to date with 6 monthly alpha-fetoprotein (AFP), 35 (79.5%) were up to date with 6 monthly liver ultrasound scan (USS), and 34 (77.3%) were up-to-date for both.

Conclusions

A “One Stop Liver Shop” developed with and including Aboriginal Health Practitioners bridges gaps in the availability of services to those living with CHB in a very remote community and improves the cascade of care.

Data linkage and computerised algorithmic coding to enhance individual clinical care for Aboriginal people living with chronic hepatitis B in the Northern Territory of Australia - Is it feasible?

BACKGROUND

Chronic hepatitis B (CHB) is endemic in the Aboriginal population of Australia's Northern Territory (NT). However, many people's hepatitis B virus (HBV) status remains unknown.

OBJECTIVE

1. To maximise the utility of existing HBV test and vaccination data in the NT by creating a linked dataset and computerised algorithmic coding. 2. To undertake rigorous quality assurance processes to establish feasibility of using the linked dataset and computerised algorithmic coding for individual care for people living with CHB.

METHODS

Step 1: We used deterministic data linkage to merge information from three separate patient databases. HBV testing and vaccination data from 2008-2016 was linked and extracted for 19,314 people from 21 remote Aboriginal communities in the Top End of the NT. Step 2: A computerised algorithm was developed to allocate one of ten HBV codes to each individual. Step 3: A quality assurance process was undertaken by a clinician, using standardised processes, manually reviewing all three databases, for a subset of 5,293 Aboriginal people from five communities to check the accuracy of each allocated code.

RESULTS

The process of data linking individuals was highly accurate at 99.9%. The quality assurance process detected an overall error rate of 17.7% on the HBV code generated by the computerised algorithm. Errors occurred in source documentation, primarily from the historical upload of paper-based records to electronic health records. An overall HBV prevalence of 2.6% in five communities was found, which included ten cases of CHB who were previously unaware of infection and not engaged in care.

CONCLUSIONS

Data linkage of individuals was highly accurate. Data quality issues and poor sensitivity in the codes produced by the computerised algorithm were uncovered in the quality assurance process. By systematically, manually reviewing all available data we were able to allocate a HBV status to 91% of the study population.

Primary Health Care for Aboriginal Australian Women in Remote Communities after a Pregnancy with Hyperglycaemia

Background: Hyperglycaemia in pregnancy contributes to adverse outcomes for women and their children. The postpartum period is an opportune time to support women to reduce cardiometabolic and diabetes risk in subsequent pregnancies. Aims: To identify strengths and gaps in current care for Aboriginal women after a pregnancy complicated by hyperglycaemia. Methods: A retrospective review of the 12 month postpartum care provided by primary health centres in remote Australia in 2013–2014 identified 195 women who experienced hyperglycaemia in pregnancy (gestational diabetes (GDM) (n = 147), type 2 diabetes (T2D) (n = 39), and unclear diabetes status (n = 9)). Results: Only 80 women (54%) with GDM had postpartum glycaemic checks. Of these, 32 women were diagnosed with prediabetes (n = 24) or diabetes (n = 8). Compared to women with GDM, women with T2D were more likely to have their weight measured (75% vs. 52%, p <0.01), and smoking status documented as “discussed” (65% vs. 34%, p < 0.01). Most women (97%) accessed the health centre at least once in the 12 month postpartum period but, during these visits, only 52% of women had service provision, either structured or opportunistic, related to diabetes. Conclusion: High rates of dysglycaemia among women screened for T2D after GDM in the 12 month postpartum period highlight the need for increased screening and early intervention to prevent the development of T2D and its complications. Whilst a clear strength was high postpartum attendance, many women did not attend health services for diabetes screening or management.

Remote health workforce turnover and retention: what are the policy and practice priorities?

BACKGROUND

Residents of remote communities in Australia and other geographically large countries have comparatively poorer access to high-quality primary health care. To inform ongoing policy development and practice in relation to remote area health service delivery, particularly in remote Indigenous communities, this review synthesizes the key findings of (1) a comprehensive study of workforce turnover and retention in remote Northern Territory (NT) of Australia and (2) a narrative review of relevant international literature on remote and rural health workforce retention strategies. This synthesis provides a valuable summary of the current state of international knowledge about improving remote health workforce retention.

MAIN TEXT

Annual turnover rates of NT remote area nurses (148%) and Aboriginal health practitioners (80%) are very high and 12-month stability rates low (48% and 76%, respectively). In remote NT, use of agency nurses has increased substantially. Primary care costs are high and proportional to staff turnover and remoteness. Effectiveness of care decreases with higher turnover and use of short-term staff, such that higher staff turnover is always less cost-effective. If staff turnover in remote clinics were halved, the potential savings would be approximately A$32 million per annum. Staff turnover and retention were affected by management style and effectiveness, and employment of Indigenous staff. Review of the international literature reveals three broad themes: Targeted enrolment into training and appropriate education designed to produce a competent, accessible, acceptable and 'fit-for-purpose' workforce; addressing broader health system issues that ensure a safe and supportive work environment; and providing ongoing individual and family support. Key educational initiatives include prioritising remote origin and Indigenous students for university entry; maximising training in remote areas; contextualising curricula; providing financial, pedagogical and pastoral support; and ensuring clear, supported career pathways and continuing professional development. Health system initiatives include ensuring adequate funding; providing adequate infrastructure including fit-for-purpose clinics, housing, transport and information technology; offering flexible employment arrangements whilst ensuring a good 'fit' between individual staff and the community (especially with regard to cultural skills); optimising co-ordination and management of services that empower staff and create positive practice environments; and prioritising community participation and employment of locals. Individual and family supports include offering tailored financial incentives, psychological support and 'time out'.

CONCLUSION

Optimal remote health workforce stability and preventing excessive 'avoidable' turnover mandates alignment of government and health authority policies with both health service requirements and individual health professional and community needs. Supportive underpinning policies include: Strong intersectoral collaboration between the health and education sectors to ensure a fit-for-purpose workforce;A funding policy which mandates the development and implementation of an equitable, needs-based formula for funding remote health services;Policies that facilitate transition to community control, prioritise Indigenous training and employment, and mandate a culturally safe work context; andAn employment policy which provides flexibility of employment conditions in order to be able to offer individually customised retention packages There is considerable extant evidence from around the world about effective retention strategies that contribute to slowing excessive remote health workforce turnover, resulting in significant cost savings and improved continuity of care. The immediate problem comprises an 'implementation gap' in translating empirical research evidence into actions designed to resolve existing problems. If we wish to ameliorate the very high turnover of staff in remote areas, in order to provide an equitable service to populations with arguably the highest health needs, we need political and executive commitment to get the policy settings right and ensure the coordinated implementation of multiple strategies, including better linking existing strategies and 'filling the gaps' where necessary.

Working well: a systematic scoping review of the Indigenous primary healthcare workforce development literature

BACKGROUND

Strong and effective workforce models are essential for improving comprehensive Indigenous primary healthcare service (PHC) provision to Indigenous peoples in Canada, Australia, New Zealand and the USA (CANZUS nations). This review systematically scoped the literature for studies that described or evaluated models and systems that support the sustainability, capacity or growth of the Indigenous PHC workforce to provide effective PHC provision.

METHODS

Eleven databases, 10 websites and clearinghouses, and the reference lists of 5 review articles were searched for relevant studies from CANZUS nations published in English from 2000 to 2017. A process of thematic analysis was utilised to identify key conditions, strategies and outcomes of Indigenous PHC workforce development reported in the literature.

RESULTS

Overall, 28 studies were found. Studies reported enabling conditions for workforce development as government funding and appropriate regulation, support and advocacy by professional organisations; community engagement; PHC leadership, supervision and support; and practitioner Indigeneity, motivation, power equality and wellbeing. Strategies focused on enhancing recruitment and retention; strengthening roles, capacity and teamwork; and improving supervision, mentoring and support. Only 12/28 studies were evaluations, and these studies were generally of weak quality. These studies reported impacts of improved workforce sustainability, workforce capacity, resourcing/growth and healthcare performance improvements.

CONCLUSIONS

PHCs can strengthen their workforce models by bringing together healthcare providers to consider how these strategies and enabling conditions can be improved to meet the healthcare and health needs of the local community. Improvement is also needed in the quality of evidence relating to particular strategies to guide practice.

What do indigenous communities want from their surgeons and surgical services: A systematic review

BACKGROUND

This investigation was undertaken to define the factors determining the optimal and most productive relationship among indigenous communities, surgeons, and providers of surgical services.

METHODS

A systematic literature review was conducted to identify studies reporting on the experience of indigenous communities with surgeons, medical practitioners, and the providers of surgical and other health services. The databases searched were MEDLINE, EMBASE, PubMed, Web of Science, and Google Scholar, including all literature available until the search date of April 3, 2019. The reference lists of all included articles and related review articles were searched manually to identify further relevant studies. An inductive approach was used to identify common themes.

RESULTS

Thirty-three publications discussed the experiences of New Zealand Māori (n = 2), Aboriginal and Torres Strait Islanders (n = 20), North American First Nation (n = 10), and Indigenous Latin Americans (n = 1). Across all indigenous peoples, 6 themes emerged: accessible health services, community participation and community governance, continuous quality improvement, a culturally appropriate and clinically skilled workforce, a flexible approach to care, and holistic healthcare.

CONCLUSION

To provide medical and surgical services in indigenous communities successfully requires a diverse range of skills and core technical and academic competencies. Many skills lie within the definition of professionalism and advocacy as well as the ability to undertake and operationalize community consultation and empowerment. If surgical services serving Indigenous communities are to be successful in addressing health disparity, specific training in these skills will need to be developed and made available.

Costs and effects of higher turnover of nurses and Aboriginal health practitioners and higher use of short-term nurses in remote Australian primary care services: an observational cohort study

OBJECTIVES

To compare the costs and effects of higher turnover of resident nurses and Aboriginal health practitioners and higher use of agency-employed nurses in remote primary care (PC) services and quantify associations between staffing patterns and health outcomes in remote PC clinics in the Northern Territory (NT) of Australia.

DESIGN

Observational cohort study, using hospital admission, financial and payroll data for the period 2013-2015.

SETTING

53 NT Government run PC clinics in remote communities.

OUTCOME MEASURES

Incremental cost-effectiveness ratios were calculated for higher compared with lower turnover and higher compared with lower use of agency-employed nurses. Costs comprised PC, travel and hospitalisation costs. Effect measures were total hospitalisations and years of life lost per 1000 person-months. Multiple regression was performed to investigate associations between overall health costs and turnover rates and use of agency-employed nurses, after adjusting for key confounders.

RESULTS

Higher turnover was associated with significantly higher hospitalisation rates (p<0.001) and higher average health costs (p=0.002) than lower turnover. Lower turnover was always more cost-effective. Average costs were significantly (p<0.001) higher when higher proportions of agency-employed nurses were employed. The probability that lower use of agency-employed nurses was more cost-effective was 0.84. Halving turnover and reducing use of a short-term workforce have the potential to save $32 million annually in the NT.

CONCLUSION

High turnover of health staff is costly and associated with poorer health outcomes for Aboriginal peoples living in remote communities. High reliance on agency nurses is also very likely to be cost-ineffective. Investment in a coordinated range of workforce strategies that support recruitment and retention of resident nurses and Aboriginal health practitioners in remote clinics is needed to stabilise the workforce, minimise the risks of high staff turnover and over-reliance on agency nurses and thereby significantly reduce expenditure and improve health outcomes.

A national profile of Aboriginal and Torres Strait Islander Health Workers, 2006-2016

OBJECTIVE

To undertake a descriptive analysis of the Aboriginal and Torres Strait Islander Health Worker workforce to quantify the changes from 2006-2016.

METHOD

We analysed data on Indigenous Health Workers from three waves of Australian Census: 2006, 2011 and 2016. We described the workforce by gender, age and state/territory.

RESULTS

There has been overall growth in the number of Indigenous Health Workers (from 1,009 in 2006 to 1,347 in 2016), but this is not commensurate with Aboriginal and Torres Strait Islander population growth (221 Indigenous Health Workers per 100,000 people in 2006 to 207 Indigenous Health Workers per 100,000 people in 2016). The growth is in Indigenous Health Workers aged ≥45 years, with declines in the proportion of Indigenous Health Workers aged ≤44 years. There was growth in workers in two states only, Queensland (increase 4.2 percentage points) and New South Wales (increase 6.6 percentage points).

CONCLUSION

There are pressing concerns regarding the lack of growth and the ageing workforce of Aboriginal and Torres Strait Islander Health Workers. We remain concerned that little is being done to increase the retention and recruitment of this workforce. Implications for public health: Greater effort is needed to improve the recruitment and retention of Aboriginal and Torres Strait Islander Health Workers, particularly for younger age groups and males. A National Aboriginal and Torres Strait Islander Health Workforce Strategy needs to be implemented.