Patterns of resident health workforce turnover and retention in remote communities of the Northern Territory of Australia, 2013-2015

Patterns of health workforce turnover and retention in Aboriginal Community Controlled Health Services in remote communities of the Northern Territory and Western Australia, 2017-2019

BACKGROUND

Aboriginal Community Controlled Health Services (ACCHSs) in Australia aim to optimise access to comprehensive and culturally safe primary health care (PHC) for Aboriginal populations. Central to quality service provision is the retention of staff. However, there is lack of published research reporting patterns of staff turnover and retention specific to ACCHSs. This study quantified staff turnover and retention in regional and remote ACCHSs in the Northern Territory (NT) and Western Australia (WA), and examined correlations between turnover and retention metrics, and ACCHSs' geographical and demographic characteristics.

METHODS

The study used 2017-2019 payroll data for health workers in 22 regional and remote PHC clinics managed by 11 ACCHSs. Primary outcome measures included annual turnover and 12-month stability rates, calculated at both clinic and organisation levels.

RESULTS

There was a median of five client-facing (Aboriginal health practitioners, allied health professionals, doctors, nurses/midwives, and 'other health workers' combined) and two non-client-facing (administrative and physical) staff per remote clinic, at any timepoint. Mean annual turnover rates for staff were very high, with 151% turnover rates at the clinic level and 81% turnover rates at the organisation level. Mean annual turnover rates for client-facing staff were 164% and 75%, compared to 120% and 98% for non-client-facing staff, at clinic and organisational levels, respectively. Mean 12-month stability rates were low, with clinic-level stability rates of only 49% and organisation-level stability rates of 58%. Mean annual clinic-level turnover rates were 162% for non-Aboriginal staff and 81% for Aboriginal staff. Both workforce metrics were moderately to highly correlated with the relative remoteness of clinics, size of regular clients serviced, and average annual headcount of employees in each clinic (p values < 0.01).

CONCLUSIONS

Participating ACCHSs in remote NT and WA have very high turnover and low retention of healthcare staff. Overall, clinic-level turnover rates increase as distance from regional centres increases and are lower for Aboriginal staff, suggesting that greater employment of Aboriginal staff could help stabilise staffing. Improved retention could reduce burden on ACCHSs' resources and may also support quality of service delivery due to improved cultural safety and continuity of care.

Primary health care utilisation and delivery in remote Australian clinics during the COVID-19 pandemic

INTRODUCTION

The COVID-19 pandemic period (2020 to 2022) challenged and overstretched the capacity of primary health care services to deliver health care globally. The sector faced a highly uncertain and dynamic period that encompassed anticipation of a new, unknown, lethal and highly transmissible infection, the introduction of various travel restrictions, health workforce shortages, new government funding announcements and various policies to restrict the spread of the COVID-19 virus, then vaccination and treatments. This qualitative study aims to document and explore how the pandemic affected primary health care utilisation and delivery in remote and regional Aboriginal and Torres Strait Islander communities.

METHODS

Semi-structured interviews were conducted with staff working in 11 Aboriginal Community-Controlled Health Services (ACCHSs) in outer regional, remote and very remote Australia. Interviews were transcribed, inductively coded and thematically analysed.

RESULTS

248 staff working in outer regional, remote and very remote primary health care clinics were interviewed between February 2020 and June 2021. Participants reported a decline in numbers of primary health care presentations in most communities during the initial COVID-19 lock down period. The reasons for the decline were attributed to community members apprehension to go to the clinics, change in work priorities of primary health care staff (e.g. more emphasis on preventing the virus entering the communities and stopping the spread) and limited outreach programs. Staff forecasted a future spike in acute presentations of various chronic diseases leading to increased medical retrieval requirements from remote communities to hospital. Information dissemination during the pre-vaccine roll-out stage was perceived to be well received by community members, while vaccine roll-out stage information was challenged by misinformation circulated through social media.

CONCLUSIONS

The ability of ACCHSs to be able to adapt service delivery in response to the changing COVID-19 strategies and policies are highlighted in this study. The study signifies the need to adequately fund ACCHSs with staff, resources, space and appropriate information to enable them to connect with their communities and continue their work especially in an era where the additional challenges created by pandemics are likely to become more frequent. While the PHC seeking behaviour of community members during the COVID-19 period were aligned to the trends observed across the world, some of the reasons underlying the trends were unique to outer regional, remote and very remote populations. Policy makers will need to give due consideration to the potential effects of newly developed policies on ACCHSs operating in remote and regional contexts that already battle under resourcing issues and high numbers of chronically ill populations.

Clinical effectiveness and analytical quality of a national point-of-care testing network for sexually transmitted infections integrated into rural and remote primary care clinics in Australia, 2016-2022: an observational program evaluation

Background

To address inequitable diagnostic access and improve time-to-treatment for First Nations peoples, molecular point-of-care (POC) testing for chlamydia, gonorrhoea and trichomonas was integrated into 49 primary care clinics across Australia. We conducted an observational evaluation to determine clinical effectiveness and analytical quality of POC testing delivered through this national program.

Methods

We evaluated (i) implementation by measuring trends in mean monthly POC testing; ii) clinical effectiveness by comparing proportions of positive patients treated by historical control/intervention period and by test type, and calculated infectious days averted; (iii) analytical quality by calculating result concordance by test type, and proportion of unsuccessful POC tests.

Findings

Between 2016 and 2022, 46,153 POC tests were performed; an increasing mean monthly testing trend was observed in the first four years (p < 0.0001). A greater proportion of chlamydia/gonorrhoea positives were treated in intervention compared with historical control periods (≤2 days: 37% vs 22% [RR 1.68; 95% CI 1.12, 2.53]; ≤7 days: 48% vs 30% [RR 1.6; 95% CI 1.10, 2.33]; ≤120 days: 79% vs 54% [RR 1.46; 95% CI 1.10, 1.95]); similarly for trichomonas positives and by test type. POC testing for chlamydia, gonorrhoea and trichomonas averted 4930, 5620 and 7075 infectious days, respectively. Results concordance was high [99.0% (chlamydia), 99.3% (gonorrhoea) and 98.9% (trichomonas)]; unsuccessful POC test proportion was 1.8% for chlamydia/gonorrhoea and 2.1% for trichomonas.

Interpretation

Molecular POC testing was successfully integrated into primary care settings as part of a routinely implemented program achieving significant clinical benefits with high analytical quality. In addition to the individual health benefits of earlier treatment, fewer infective days could contribute to reduced transmissions in First Nations communities.

Funding

This work was supported by an Australian National Health and Medical Research Council Partnership Grant (APP1092503), the Australian Government Department of Health, Western Australia and Queensland Departments of Health.

Responding to the AMR threat: data and information needs of stakeholders working in regional and remote Australia

Our qualitative analysis of interviews with remote Australian healthcare professionals found that they require reliable, local antimicrobial resistance (AMR) data reflecting the geographical diversity of the population they serve. The optimal use of AMR data must consider challenges within this setting, including high staff turnover, limited diagnostic capacity, and antibiotic shortages.

A good life for people living with disability: the story from Far North Queensland

PURPOSE

People with disability in regional, rural and remote Australia have poorer service access compared to people from metropolitan areas. There is urgent need for reform. This study's aim was to explore the needs and aspirations of people with lived experience of disability in Far North Queensland (FNQ) to inform a new service framework.

MATERIALS AND METHODS

Twenty-five individuals with diverse experience of disability were engaged in semi-structured interviews. Participants were recruited from four sites that differed geographically, culturally, and socioeconomically. Using an inductive then deductive thematic approach to data analysis, statements of needs and aspirations were compiled and aligned with three pre-determined vision statements.

RESULTS

Needs and aspirations aligned well with the vision statements which were to: feel "included, connected, safe and supported"; have "opportunities to choose one's own life and follow one's hopes and dreams"; and have "access to culturally safe services close to home." To realise this vision in FNQ, support to navigate and coordinate services across sectors is essential.

CONCLUSION

People of FNQ of all abilities, need and aspire to experience "a good life" like their fellow Australians. Any new service model must focus on providing service navigation and co-ordination amid the complexities of service delivery in FNQ.

Developing an integrated clinical decision support system for the early identification and management of kidney disease-building cross-sectoral partnerships

BACKGROUND

The burden of chronic conditions is growing in Australia with people in remote areas experiencing high rates of disease, especially kidney disease. Health care in remote areas of the Northern Territory (NT) is complicated by a mobile population, high staff turnover, poor communication between health services and complex comorbid health conditions requiring multidisciplinary care.

AIM

This paper aims to describe the collaborative process between research, government and non-government health services to develop an integrated clinical decision support system to improve patient care.

METHODS

Building on established partnerships in the government and Aboriginal Community-Controlled Health Service (ACCHS) sectors, we developed a novel digital clinical decision support system for people at risk of developing kidney disease (due to hypertension, diabetes, cardiovascular disease) or with kidney disease. A cross-organisational and multidisciplinary Steering Committee has overseen the design, development and implementation stages. Further, the system's design and functionality were strongly informed by experts (Clinical Reference Group and Technical Working Group), health service providers, and end-user feedback through a formative evaluation.

RESULTS

We established data sharing agreements with 11 ACCHS to link patient level data with 56 government primary health services and six hospitals. Electronic Health Record (EHR) data, based on agreed criteria, is automatically and securely transferred from 15 existing EHR platforms. Through clinician-determined algorithms, the system assists clinicians to diagnose, monitor and provide guideline-based care for individuals, as well as service-level risk stratification and alerts for clinically significant events.

CONCLUSION

Disconnected health services and separate EHRs result in information gaps and a health and safety risk, particularly for patients who access multiple health services. However, barriers to clinical data sharing between health services still exist. In this first phase, we report how robust partnerships and effective governance processes can overcome these barriers to support clinical decision making and contribute to holistic care.

Outpatient nurse staffing relationship with organizational, nurse and patient outcomes: A scoping review

Background

Nurses are an integral part of outpatient healthcare settings and are needed to provide effective patient care. Ample research and reviews have been done on nurse staffing in inpatient settings relationship with a variety of organizational, nurse and patient outcomes, however there is no review of outpatient nurse staffing relationship with organizational, nurse and patient outcomes.

Objectives

The purpose of this paper is to present a scoping review that evaluates the state of the literature on relationships among nurse staffing and organizational, nurse and patient outcomes in the outpatient setting.

Methods

The review used PRISMA guidelines for scoping reviews. The search focused on nurse staffing and organizational outcome in outpatient settings and synonyms for those terms. PubMed, Ebscohost CINAHL, and Ebscohost Global Health were searched. Articles were included if they measured nurse staffing relationship with any organizational, nurse and patient outcome in an outpatient setting. Extraction was completed in a matrix first then charted into synthesis tables.

Results

Thirty-seven studies were included in the review. Nurse staffing was measured in the literature by perceived staffing adequacy, types of healthcare workers staffed, full-time equivalents, nurse vacancies, proportion of nurses to total staff, agency or float nurse use, presence of nurse on the healthcare team and nurse to patient ratios. Nurse staffing of a variety of measures was associated with better patient outcomes, lower costs, and lower nurse turnover. Only one study of the 37 included did not show a positive outcome of better nurse staffing, which showed that increased nurse staffing was associated with less patient engagement in psychotherapy.

Conclusions

Outpatient care setting stakeholders and policy makers should consider improving nurse staffing, as stronger nurse staffing is associated with better patient outcomes lower costs and less nurse turnover. In addition, better staffing helps improve nurses' attitudes towards their job and increase job satisfaction. Most of the studies included in this review only focused on the staffing measure of perceived staffing adequacy. While perceived staffing adequacy is a useful measure of nurse staffing able to capture nurses' perception, it should not be used in isolation and more researchers should focus on gaps in outpatient nurse staffing with more objective measures such as fulltime equivalents.

Tweetable abstract

A 37 article scoping review on nurse staffing in outpatient care found that stronger staffing was linked with better patient outcomes, lower costs, and less turnover.

"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.

Exploring the nursing student experience at a remote Australian university campus: a qualitative study

Background

Nurses constitute most of the rural and remote Australian health workforce, however staff shortages in these regions are common. Rural exposure, association, and undertaking rural clinical placements can influence health students’ decision to work rurally after graduation, however attending university in rural and remote regions has been shown to be a great contributor. An improved understanding of these nursing students’ experiences may inform changes to teaching and support strategies for these students, which in turn could improve their retention and completion rates, contributing to a more sustainable rural and remote Australian nursing workforce. This study aimed to explore and describe students’ experiences of studying nursing in the context of a satellite university campus located in a remote town, with a focus on education delivery methods, staff, support, student services, and barriers and enablers to successful study.

Methodology

Nine students participated in this qualitative descriptive study. Semi-structured interviews were undertaken, allowing participants to reflect on their experiences as nursing students in the context of a geographically remote satellite university campus. The resulting data were grouped into common themes and summarised.

Results

Students were generally positive regarding lectures delivered by videoconference or recorded lectures, as they allowed for greater flexibility which accommodated their busy personal lives. Face-to-face teaching was especially valuable, and students were particularly positive about their small cohort size, which enabled the creation of strong, supportive relationships between students, their cohort, and teaching and support staff. However, barriers related to student demographics and some difficulties with course engagement and campus staffing were experienced.

Conclusions

The experiences of nursing students at remote university campuses are different from those experienced by traditional, metropolitan university students. Although these nursing students face additional barriers unique to the remote campus context, they benefit from a range of enabling factors, including their close relationships with other students, staff, family, and their local community.

Peripheral intravenous catheter insertion and use of ultrasound in patients with difficult intravenous access: Australian patient and practitioner perspectives to inform future implementation strategies

Objective

To understand healthcare worker and patient experience with peripheral intravenous catheter (PIVC) insertion in patients with difficult intravenous access (DIVA) including the use of ultrasound (US).

Methods

Descriptive study using 1-on-1 semi-structured interviews conducted between August 2020 and January 2021. Purposeful sampling was used to recruit healthcare practitioners (HCPs) and patients with DIVA who had PIVC experience. Data were analysed using inductive thematic analysis. Interview data were than mapped to the implementation theory Behaviour Change Wheel to inform implementation strategies.

Results

In total 78 interviews (13 patients; 65 HCPs) were completed with respondents from metropolitan (60%), regional (25%) and rural/remote (15%) settings across Australia. Thematic analysis revealed 4 major themes: i) Harmful patient experiences persist, with patient insights not leveraged to effect change; ii) ‘Escalation’ is just a word on the front lines; iii) Heightened risk of insertion failure without resources and training; and iv) Paving the way forward–‘measures need to be in place to prevent failed insertion attempts. Themes were mapped to the behaviour change wheel and implementation strategies developed, these included: staff education, e-health record for DIVA identification, DIVA standard of care and DIVA guidelines to support escalation and ultrasound use.

Conclusion(s)

DIVA patients continue to have poor healthcare experiences with PIVC insertion. There is poor standardisation of DIVA assessment, escalation, US use and clinician education across hospitals. Quality, safety, and education improvement opportunities exist to improve the patient with DIVA experience and prevent traumatic insertions. We identified a number of implementation strategies to support future ultrasound and DIVA pathway implementation.

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.

Perceptions of Australian remote area nurses about why they stay or leave: A qualitative study

AIM

The aim of this study was to examine the perspectives of experienced Australian remote area nurses about remote nursing staff retention strategies.

BACKGROUND

There is low retention of remote area nurses in remote Australia. Retention of remote area nurses can be improved by a supportive environment including good management, professional development and supervision.

METHOD

This is a qualitative study using in-depth interviews with seven registered nurses with a minimum of 3 years remote area nursing experience. Participants were interviewed by phone, with the interviews audio-recorded then transcribed and analysed thematically.

RESULTS

Participants had on average 12 years of experience as a remote area nurse. They valued teamwork, effective and flexible management practices and the ability to maintain their own cultural and social connectedness. A flexible service model with regular short breaks, filled by returning agency nurses to enable continuity of care and cultural connections, was seen as a viable approach.

CONCLUSION

Flexible management practices that encourage short breaks for remote area nurses may increase retention. This would need to occur within a supportive management framework.

IMPLICATIONS FOR NURSING MANAGEMENT

Management strategies that reduce isolation from personal and social networks can increase the retention of skilled remote area nurses.

Surveying the changing climate of Northern Territory medical workforce retention

INTRODUCTION

Low retention is a significant contributor to medical workforce shortages in rural and remote regions of Australia, including in the Northern Territory (NT). Many of these areas are susceptible to climate change, which could exacerbate workforce retention problems.

OBJECTIVE

To examine factors influencing medical workforce retention in the NT, including the potential impact of climate change.

DESIGN

Cross sectional online survey of NT medical professionals, distributed via email through professional networks. Predominantly quantitative mixed methods (descriptive statistics, multivariate logistic regression, thematic analysis). Main 2 outcome measures reported were proportion of respondents intending to leave the NT, timeframe of intention to leave and motivating factors.

FINDINGS

Of 1407 registered practising medical professionals in the NT, 362 responded who met inclusion criteria (26% estimated response rate) and 351 completed all questions. Of the latter, 143 (41%) intended to leave the NT, 102 (29%) were unsure, and 106 (30%) did not intend to leave. Among doctors in training (DITs) 67 (55%) intended to leave and 29 (24%) were unsure. The best multivariable predictive model included only practice type (with general practitioners/rural generalists and non-GP specialists significantly less likely to intend to leave compared to DITs), and location of primary medical degree (with non-NT training non-significantly associated with greater intention to leave). Of those intending to leave 94 (66%) reported planning to do so within two years. Training and career development opportunities, job dissatisfaction, moving to a preferred location and family-related factors were all important motivators. Of those considering leaving, 58 (24%) identified climate change as a motivating factor.

CONCLUSION

Retention remains a key challenge in addressing rural workforce shortages. In addition to established factors, climate change is an important driver that has the potential to worsen workforce shortages in susceptible regions.

Ear microbiota and middle ear disease: a longitudinal pilot study of Aboriginal children in a remote south Australian setting

Background

Otitis media (OM) is a major disease burden in Australian Aboriginal children, contributing to serious long-term health outcomes. We report a pilot analysis of OM in children attending an outreach ear and hearing clinic in a remote south Australian community over a two-year period. Our study focuses on longitudinal relationships between ear canal microbiota characteristics with nasopharyngeal microbiota, and clinical and treatment variables.

Results

Middle ear health status were assessed in 19 children (aged 3 months to 8 years) presenting in remote western South Australia and medical interventions were recorded. Over the two-year study period, chronic suppurative OM was diagnosed at least once in 7 children (37%), acute OM with perforation in 4 children (21%), OM with effusion in 11 children (58%), while only 1 child had no ear disease. Microbiota analysis of 19 children (51 sets of left and right ear canal swabs and nasopharyngeal swabs) revealed a core group of bacterial taxa that included Corynebacterium, Alloiococcus, Staphylococcus, Haemophilus, Turicella, Streptococcus, and Pseudomonas. Within-subject microbiota similarity (between ears) was significantly greater than inter-subject similarity, regardless of differences in ear disease (p = 0.0006). Longitudinal analysis revealed changes in diagnosis to be associated with more pronounced changes in microbiota characteristics, irrespective of time interval. Ear microbiota characteristics differed significantly according to diagnosis (P (perm) = 0.0001). Diagnoses featuring inflammation with tympanic membrane perforation clustering separately to those in which the tympanic membrane was intact, and characterised by increased Proteobacteria, particularly Haemophilus influenzae, Moraxella catarrhalis, and Oligella. While nasopharyngeal microbiota differed significantly in composition to ear microbiota (P (perm) = 0.0001), inter-site similarity was significantly greater in subjects with perforated tympanic membranes, a relationship that was associated with the relative abundance of H. influenzae in ear samples (r_s = − 0.71, p = 0.0003). Longitudinal changes in ear microbiology reflected changes in clinical signs and treatment.

Conclusions

Children attending the ear and hearing clinic in a remote Aboriginal community present with a broad spectrum of OM conditions and severities, consistent with other remote Aboriginal communities. Ear microbiota characteristics align with OM diagnosis and change with disease course. Nasopharyngeal microbiota characteristics are consistent with the contribution of acute upper respiratory infection to OM aetiology.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12866-022-02436-x.

Development of a framework to promote rural health workforce capability through digital solutions: A qualitative study of user perspectives

A high-quality, sustained, health workforce contributes to a healthy population. However, a global reality is that rural health services, and the workforces that provide those services, are under unprecedented pressure. It is posited that improving a rural health practitioners' capability could help to retain them working rurally for longer. Capability refers to skills and experience and the extent to which individuals can adapt to change, generate new knowledge and continue to improve their performance. With rapidly increasing access to, and use of, digital technology worldwide, there are new opportunities to build capability and leverage personal and professional support for those who are working rurally. In 2021, semi-structured interviews were conducted in rural Australia with thirteen General Practitioners and allied health professionals. Thematic analysis was adopted to analyse the data and map it to the Health Information Technology Acceptance Model. Whilst it could be assumed that low technology literacy would act as a barrier to the use of digital tools, the study demonstrated that this was not a significant impediment to participants' willingness to adopt digital tools when social and professional networks weren't available face to face to address their capability challenges. The findings provide insight into the concept of health workforce capability and important considerations when designing capability support. This includes key features of health apps or digital tools to support the capability of the rural health workforce. Understanding the factors that make up a health professionals' capability and the motivations or cues to act to build or maintain their capability may have a positive effect on their retention in a rural location.

Workplace locations of allied health and nursing graduates who undertook a placement in the Northern Territory of Australia from 2016 to 2019: An observational cohort study

OBJECTIVE

The aim of the study is to determine the current work locations of allied health professionals and nurses who undertook a student placement in the Northern Territory of Australia from 2016-2019.

DESIGN

An observational cohort study was conducted in October 2020, with students emailed a link to an on-line survey, plus two reminders.

SETTING

Primary health care in the Northern Territory of Australia.

PARTICIPANTS

All allied health and nursing students who undertook a student learning placement in the Northern Territory from 2016-2019 (n = 1936).

MAIN OUTCOME MEASURES

Practicing nurses and allied health professionals were asked about their work history and locations (coded using the Modified Monash Model of remoteness and population size).

RESULTS

The response rate was 14.2% (275/1936 students). Most respondents reported that their placement positively influenced them to consider working: in a rural or remote location (76%), in the Northern Territory (81%), and with marginalised or under-served populations (74%). Of the respondents, 224 had graduated and 203 were currently working in their health profession. A total of 31.4% of respondents reported that they had worked in a remote or rural location after graduation.

CONCLUSIONS

The student placement had a positive effect on the likelihood of students working in a rural or remote location. A focus on recruiting students with a remote upbringing/background and offering longer placements would likely be successful in helping build the health professional workforce in remote locations.

Discourses within the roles of Remote Area Nurses in Northern Territory (Australia) government-run health clinics

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

Workforce safety in the remote health sector of Australia: a scoping review

OBJECTIVES

To scope the evidence surrounding workplace health and safety risks for the remote health workforce in Australia and to collate the recommendations to address those risks.

DESIGN

A five-stage scoping review framework refined by Cooper et al was used for this review. Informit Health Collection, Ovid Emcare, Medline, Web of Science Core Collection, ProQuest and the grey literature were searched in October 2020 using a combination of key words derived from the eligibility criteria. No date restriction was placed on the search. Title and abstract screening, full-text review and data extraction were performed by three reviewers. Data were analysed by the lead author using qualitative thematic analysis.

ELIGIBILITY CRITERIA

Articles were eligible for inclusion if they were published research or industry reports, focused on safety for the remote health workforce in Australia, identified hazards/safety risks or recommendations to reduce risk, and were written in English.

RESULTS

The search yielded 312 articles, of which 18 met the inclusion criteria. A wide range of hazards/safety risks and recommendations were identified within the literature, which related to safety culture, isolation, safe environment, and education and training. Some recommendations, such as the use of a risk management approach, good post-incident support, safer clinics and accommodation, and improved access to education and training, had been discussed in the literature for over a decade, with a high level of agreement regarding their importance. Two articles briefly evaluated the impact of some recommendations.

CONCLUSION

While many recommendations have been developed to improve the safety of the remote health workforce in Australia, there is little evidence of their implementation and evaluation. As many remote health professionals report ongoing or worsening workplace safety issues, there is an urgent need for the implementation and evaluation of the workforce safety strategies recommended in the literature and required by legislation.

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.

Evaluation of the initial implementation of a nationwide diabetic retinopathy screening programme in primary care: a multimethod study

OBJECTIVES

The Australian Government funded a nationwide diabetic retinopathy screening programme to improve visual outcomes for people with diabetes. This study examined the benefits and barriers of the programme, image interpretation pathways and assessed the characteristics of people who had their fundus photos graded by a telereading service which was available as a part of the programme.

DESIGN

Multimethod: survey and retrospective review of referral forms.

SETTING

Twenty-two primary healthcare facilities from urban, regional, rural and remote areas of Australia, and one telereading service operated by a referral-only eye clinic in metropolitan Sydney, Australia.

PARTICIPANTS

Twenty-seven primary healthcare workers out of 110 contacted completed a survey, and 145 patient referrals were reviewed.

RESULTS

Manifest qualitative content analysis showed that primary healthcare workers reported that the benefits of the screening programme included improved patient outcomes and increased awareness and knowledge of diabetic retinopathy. Barriers related to staffing issues and limited referral pathways. Image grading was performed by a variety of primary healthcare workers, with one responder indicating the utilisation of a diabetic retinopathy reading service. Of the people with fundus photos graded by the reading service, 26.2% were reported to have diabetes. Overall, 12.3% of eyes were diagnosed with diabetic retinopathy. Photo quality was rated as excellent in 46.2% of photos. Referral to an optometrist for diabetic retinopathy was recommended in 4.1% of cases, and to an ophthalmologist in 6.9% of cases.

CONCLUSIONS

This nationwide diabetic retinopathy screening programme was perceived to increase access to diabetic retinopathy screening in regional, rural and remote areas of Australia. The telereading service has diagnosed diabetic retinopathy and other ocular pathologies in images it has received. Key barriers, such as access to ophthalmologists and optometrists, must be overcome to improve visual outcomes.

A decentralised point-of-care testing model to address inequities in the COVID-19 response

The COVID-19 pandemic is growing rapidly, with over 37 million cases and more than 1 million deaths reported by mid-October, 2020, with true numbers likely to be much higher in the many countries with low testing rates. Many communities are highly vulnerable to the devastating effects of COVID-19 because of overcrowding in domestic settings, high burden of comorbidities, and scarce access to health care. Access to testing is crucial to globally recommended control strategies, but many communities do not have adequate access to timely laboratory services. Geographic dispersion of small populations across islands and other rural and remote settings presents a key barrier to testing access. In this Personal View, we describe a model for the implementation of decentralised COVID-19 point-of-care testing in remote locations by use of the GeneXpert platform, which has been successfully scaled up in remote Aboriginal and Torres Strait Islander communities across Australia. Implementation of the decentralised point-of-care testing model should be considered for communities in need, especially those that are undertested and socially vulnerable. The decentralised testing model should be part of the core global response towards suppressing COVID-19.

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.

Retention of the Aboriginal Health, Ageing, and Disability Workforce: Protocol for a Mixed Methods Study

Background

Despite a plethora of research into Aboriginal employment and recruitment, the extent and nature of the retention of frontline Aboriginal people in health, ageing, and disability workforces are currently unknown. In this application, frontline service delivery is defined as Aboriginal people who are paid employees in the health, ageing, and disability service sectors in roles that involve direct client, participant, or patient contact. There is a need to identify the factors that inhibit (push) and promote (pull) staff retention or departure of this workforce from the sectors. This study will provide additional insight about this topic.

Objective

The objective of this project is to uncover the factors that influence the retention of frontline Aboriginal workers in the health, ageing, and disability workforces in New South Wales (NSW) who do not have university qualifications. The aim of the proposed project aims to discover the push and pull factors for the retention of the frontline Aboriginal workforce in the health, ageing, and disability sectors in NSW in relation to their role, employment, and community and design evidence-based strategies for retaining the Aboriginal frontline workforce in the health, ageing, and disability sectors in NSW.

Methods

The proposed research will use a mixed methods approach, collecting both quantitative and qualitative data via surveys and interviews to capture and represent the voices and perspectives of Aboriginal people in a way that the participants chose.

Results

Indigenous research methodologies are a growing field in Aboriginal health research in Australia. A key strength of this study is that it is led by Aboriginal scholars and Aboriginal controlled organizations that apply an Indigenous methodological framework throughout the research process.

Conclusions

This study uses a mixed methods design. The survey and interview questions and model were developed in partnership with Aboriginal health, ageing, and disability service workers rather than relying only on research publications on the workforce, government policies, and human resources strategies. This design places a strong emphasis on generalizable findings together with an inductive approach that explores employers and workers’ lived experience of the Aboriginal health workforce in NSW. Excluding workers who have graduated from university places a strong focus on the workforce who have obtained either school or Technical and Further Education or registered training organizations qualifications. Data collection was conducted during the COVID-19 pandemic, and results will include the unique experiences of Aboriginal workers and employers delivering services in an extremely challenging organizational, community, and personal context.

International Registered Report Identifier (IRRID)

PRR1-10.2196/25261

Studying nursing at Australian satellite university campuses: A review of teaching, learning and support

Distribution of the Australian health workforce is uneven, with the majority of health professionals favouring metropolitan areas over rural and remote regions. Although nurses account for the largest proportion of the Australian rural and remote health workforce, difficulties with staff recruitment and retention can impact the health care outcomes of these vulnerable populations. Satellite university campuses that offer undergraduate nursing programs might therefore contribute to a more sustainable rural and remote nursing workforce. This narrative literature review aimed at investigating the barriers and enablers that affect students enrolled at satellite nursing campuses, education delivery methods and academic and non-academic strategies employed to enhance the student learning experience. The literature was reviewed across 6 health and education databases. After screening, 12 articles met the inclusion criteria and were analysed, and the data were synthesised using a thematic approach. Three themes arose from the review: student characteristics and associated barriers and enablers to studying nursing at a satellite campus; teaching strategies and learning experiences; and academic and pastoral support. Students studying at satellite campuses were found to have different education experiences and faced challenges unique to their context; however, home support networks and small class sizes were seen as enabling factors. Education delivery methods and support strategies varied depending on remoteness and resources available. Consideration of the factors that affect satellite campus nursing students has the potential to increase student satisfaction and retention, which could result in a more sustainable rural and remote nursing workforce.

Factors supporting retention of health and wellbeing staff in Aboriginal health services: a strength-based case study

BACKGROUND

Aboriginal Community Controlled Health Services are fundamental to improving the health and welfare of Aboriginal peoples. A key element that contributes to the effectiveness of these services are Aboriginal health and wellbeing staff. However, Aboriginal health and wellbeing staff often suffer high rates of stress and burnout. Current literature focuses on proposed strategies to increase staff retention in Aboriginal Health Services, yet, there is limited information available showcasing what has actually worked.

METHOD

This was an intrinsic strengths-based case study of one regional Aboriginal Community Controlled Health Service. Semi-structured research yarning interviews were conducted with past and present staff employed in health and wellbeing roles to highlight the factors that staff felt contributed to their retention.

RESULTS

Ten interviews were conducted between February and April 2018. Six key themes emerged: social accountability, teamwork and collaboration, cultural safety, supervision, professional advancement, and recognition. We add to the literature by identifying the importance of bi-directional communication, and showing that social accountability, teamwork and collaboration, cultural safety, supervision, professional advancement, and recognition continue to be important factors that contribute to health and wellbeing staff retention in Aboriginal Health Services.

CONCLUSION

This exemplar Aboriginal Health Service may provide insights into future strategies to improve staff retention in other health services.

Evaluating antimicrobial prescribing practice in Australian remote primary healthcare clinics

BACKGROUND

Inappropriate antimicrobial prescribing contributes to the emergence of antimicrobial resistance. Gaps exist in the understanding of antimicrobial prescribing in the remote setting. We aimed to assess adherence to guidelines and appropriateness of antimicrobial prescribing in Central Australia.

METHODS

A retrospective study assessing antimicrobial prescriptions in ten Aboriginal clinics (three in remote communities and seven in regional centre) using a validated evaluation tool. Antimicrobials prescribed between 1 January-31 December 2018 were randomly selected for inclusion into the study. The main outcome measures were the rates of guideline adherence and inappropriate prescribing.

RESULTS

A total of 180 prescriptions were included (96.1% Aboriginal, 32.2% male). Ninety-nine (55.0%) prescriptions were written by general practitioners (GPs), 57 (31.7%) by nurses and 24 (13.3%) by others. Forty-three (25.7%) assessable prescriptions were deemed inappropriate and 75 (44.4%) did not adhere to guidelines. Prescriptions written by GPs were less likely to adhere to guidelines, particularly GPs located in remote communities. The most common reasons for inappropriate prescribing were incorrect dosage/frequency and antimicrobial not indicated. Skin and soft-tissue infection was the commonest indication, with 29 of 41 (70.7%) prescriptions deemed appropriate. Prescriptions for lower respiratory-tract infection had the lowest rate of appropriateness, with one of seven prescriptions deemed appropriate (14.3%). Antimicrobials with the lowest rate of appropriateness were ciprofloxacin, amoxicillin-clavulanate and cefalexin, at 50%, 56%, and 62%, respectively.

CONCLUSION

A quarter of antimicrobial prescriptions written in select remote central Australian Aboriginal primary healthcare clinics were deemed inappropriate. The implementation of a comprehensive antimicrobial stewardship program is recommended.

Interchangeability, immunogenicity and safety of a combined 10-valent pneumococcal Haemophilus influenzae protein D conjugate vaccine (Synflorix) and 13-valent-PCV (Prevenar13) schedule at 1-2-4-6 months: PREVIX_COMBO, a 3-arm randomised controlled trial

•

A mix of Synflorix^TM (S) and Prevenar13^TM (P) at 1–2-4–6 months (SSSP) is safe.

•

At 7 months the SSSP schedule is immunogenic against 13 serotypes* and protein D.

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One-month dose of Synflorix is immunogenic* (8 of 10 serotypes)

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Two-month dose of Prevenar13 is poorly immunogenic** (8 of 13 serotypes)

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Two-month dose of Synflorix is superior (8 serotypes) or similar (4) to Prevenar13 *GMC ≥ 0·35 µg/mL **GMC ≤ 0·35 µg/mL.

•

A 4-dose schedule is superior to either 3-dose schedule, particularly against 6B, 19F, and 23F.

Background

Aboriginal children living in remote communities are at high risk of early and persistent otitis media. Streptococcus pneumoniae and non-typeable Haemophilus influenzae (NTHi) are primary pathogens. Vaccines with potential to prevent early OM have not been evaluated in this population. We compared immunogenicity (ELISA and opsonophagocytic activity) of a combination of Synflorix™ (PHiD-CV10, 10 serotypes and protein D of NTHi) and Prevenar13™ (PCV13, 10 serotypes plus 3, 6A, and 19A), with recommended schedules.

Methods

This open-label superiority trial randomised (1:1:1) Aboriginal infants at 28 to 38 days of age, to PCV13 (P) at 2–4-6 months (_PPP), PHiD-CV10 (S) at 2–4-6 months (_SSS), or PHiD-CV10 at 1–2–4 plus PCV13 at −6 months (SSSP). Primary outcomes (blinded) were immunogenicity against PCV13-only serotypes 3, 6A, 19A, and PHiD-CV10-only protein D at 7 months. Secondary outcomes include immunogenicity against all serotypes at 2, 4 and 7 months.

Findings

Between 2011 and 2017, 425 infants were allocated to _PPP(143), _SSS(141) or SSSP(1 4 1). An intention to treat approach including all available data was used. The SSSP group had superior immunogenicity against serotypes 3, 6A, and 19A compared to _SSS (OPA GMT ratios 8.1 to 59.5, p < 0.001), and against protein D compared to _PPP (GMC ratio 11.9 (95%CI 9.7 to 14.6)). Immune responses to protein D and 3, 6A, and 19A in SSSP were not significantly lower (i.e. no harm) than either _SSS or _PPP. For ten common serotypes responses at 2, 4 and 7 months were superior for SSSP (following 1-, 2-, and 4- doses) than _SSS and _PPP (following 0-, 1-, and 3- doses). At 4 months, _SSS was superior to _PPP. Reactogenicity and hospitalisations were rare and unrelated to the intervention.

Interpretation

From two months, the 1–2–4–6-month combined schedule (SSSP) was safe and significantly more immunogenic than 2–4–6-month schedules. The earlier responses may be beneficial in high-risk populations.

Otitis media guidelines for Australian Aboriginal and Torres Strait Islander children: summary of recommendations

Introduction

The 2001 Recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Islander populations were revised in 2010. This 2020 update by the Centre of Research Excellence in Ear and Hearing Health of Aboriginal and Torres Strait Islander Children used for the first time the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

Main recommendations

We performed systematic reviews of evidence across prevention, diagnosis, prognosis and management. We report ten algorithms to guide diagnosis and clinical management of all forms of otitis media. The guidelines include 14 prevention and 37 treatment strategies addressing 191 questions.

Changes in management as a result of the guidelines

A GRADE approach is used.

Targeted recommendations for both high and low risk children.

New tympanostomy tube otorrhoea section.

New Priority 5 for health services: annual and catch‐up ear health checks for at‐risk children.

Antibiotics are strongly recommended for persistent otitis media with effusion in high risk children.

Azithromycin is strongly recommended for acute otitis media where adherence is difficult or there is no access to refrigeration.

Concurrent audiology and surgical referrals are recommended where delays are likely.

Surgical referral is recommended for chronic suppurative otitis media at the time of diagnosis.

The use of autoinflation devices is recommended for some children with persistent otitis media with effusion.

Definitions for mild (21–30 dB) and moderate (> 30 dB) hearing impairment have been updated.

New “OMapp” enables free fast access to the guidelines, plus images, animations, and multiple Aboriginal and Torres Strait Islander language audio translations to aid communication with families.

How Barunga Aboriginal community implemented and sustained an anaemia program - A case study evaluation

ISSUE ADDRESSED

Anaemia persists as a public health issue in many Aboriginal communities despite having standard practice guidelines. This case study reveals how Barunga Aboriginal Community in the Northern Territory (NT), Australia, implemented an Anaemia Program (1998-2016) which contributed to low anaemia prevalence in children aged under 5 years.

METHODS

This retrospective qualitative case study used purposive sampling to describe the Anaemia Program and factors influencing its implementation. Themes were developed from convergence of three data sources: interviews, program observation and document review. Data were inductively analysed by an Aboriginal and non-Aboriginal researcher and themes were validated by Barunga community health practitioners and compared to practice guidelines and implementation literature.

RESULTS

Health practitioners reported that the Anaemia Program contributed to a marked reduction in childhood anaemia prevalence over time. This was supported by available prevalence data. The locally adapted Anaemia Program was unique in the NT with a novel approach to community supplementation for anaemia prevention in addition to anaemia treatment. Supportive implementation influences included: Aboriginal leadership and the use of culturally supportive processes which reinforced the development of trust and strong relationships facilitating community acceptance of the Program. Routine, opportunistic and flexible health care practice, a holistic approach and a stable, skilled and experienced team sustained program implementation.

CONCLUSIONS

The holistic and successful Barunga Anaemia Program is supported by evidence and guidelines for treating and preventing childhood anaemia. The contextualisation of these guidelines aligned with the literature on effective Aboriginal primary health care implementation. SO WHAT?: This Anaemia Program provides a model for implementation of evidence-informed guidelines in an Aboriginal primary health care setting.

Motivations and Career Decisions in Occupational Therapy Course: A Qualitative Inquiry of Asia-Pacific International Students in Australia

PURPOSE

This study aims to understand the motivations of academic voyage and post-graduation career decisions of occupational therapy international students in Australia. The following two research questions guided this study: why do international students choose to study in Australia instead of ones in their own countries? And why do international students choose to study occupational therapy program(s) in Australia instead of ones in their own countries?

PATIENTS AND METHODS

A qualitative design with phenomenology was employed to recruit 20 participants for the data collection procedures, including interview sessions, focus group activity, and member checking interview. The participants were studying one of the accredited occupational therapy programs in Australia as international students.

RESULTS

Six themes were yielded. All participants expressed that due to the excellent education, reasonable tuition fees and living standard, and the positive career opportunities, almost all expressed their positive experiences of their Australian voyage as international students and tended to stay in Australia after they gained the registration career development. More importantly, the notions of contribution to Australian communities are captured as many considered Australia as an important place in their lives.

CONCLUSION

University leaders may wish to take action in upgrading their international students' services, particularly career development services. Government agencies may take this study as a blueprint for upgrading the current regulations for international students, particularly in establishing a targeted immigration visa for recent graduates who want to establish their own businesses or invest in Australia.

Impact of Systematic Tailored Assessment for Responding to Suicidality (STARS) Protocol Training on Mental Health Professionals' Attitudes, Perceived Capabilities, Knowledge, and Reluctance to Intervene

BACKGROUND AND AIMS

Systematic Tailored Assessment for Responding to Suicidality (STARS) protocol and associated training were developed with the key objectives of supporting clinicians to conduct a suicide enquiry, obtaining a comprehensive account of psycho-social factors contributing to suicidality, and collaboratively developing a safety plan with clients. STARS training aims to address knowledge, attitudes and capabilities that influence intervention behavior/skills. This study aimed to examine associations between clinician characteristics and pre-training competencies in suicide risk assessment (SRA), as well as the impact of STARS training workshop on clinician competencies; and to determine the predictors of SRA training outcomes.

METHOD

Australian mental health professionals working with suicidal persons who undertook the STARS 2-day face-to-face workshop between 2018 and 2020 completed an online survey at pre- and post-training. Of the 222 participants who completed the pre-training questionnaire, 144 (64.9%) also completed the post-training questionnaire. Participants were mostly female (75.7%), had completed a university degree (86.4%), had <10 years of experience in suicide prevention (71.7%), and were allied and mental health professionals (78.1%). We used linear mixed-effects regression for statistical analyses.

RESULTS

STARS participants who reported higher perceived capability at baseline had significantly greater formal and informal training, more years of experience in suicide prevention, and were more likely to have experienced client suicide and/or suicide attempt and to report fewer SRA related fears. We found overall significant positive impacts of STARS training on clinician competencies (attitudes, perceived capability, declarative knowledge) from pre- to post-training. The most distinct changes following STARS training were for perceived capability and declarative knowledge. Participants who had more positive attitudes after training were significantly more likely to have had less prior supervision/mentoring. Reluctance to intervene was not found to significantly change after training.

CONCLUSIONS

We found evidence that attitudes, perceived capability and declarative knowledge changed positively from pre- to post-STARS training among mental health professionals. Underpinned by the minimum standardized SRA competencies, STARS training may be critical for informing evidence-based knowledge and skills in SRA and safety planning.

Ending rheumatic heart disease in Australia: the evidence for a new approach

■The RHD Endgame Strategy: the blueprint to eliminate rheumatic heart disease in Australia by 2031 (the Endgame Strategy) is the blueprint to eliminate rheumatic heart disease (RHD) in Australia by 2031. Aboriginal and Torres Strait Islander people live with one of the highest per capita burdens of RHD in the world. ■The Endgame Strategy synthesises information compiled across the 5-year lifespan of the End Rheumatic Heart Disease Centre of Research Excellence (END RHD CRE). Data and results from priority research projects across several disciplines of research complemented literature reviews, systematic reviews and narrative reviews. Further, the experiences of those working in acute rheumatic fever (ARF) and RHD control and those living with RHD to provide the technical evidence for eliminating RHD in Australia were included. ■The lived experience of RHD is a critical factor in health outcomes. All future strategies to address ARF and RHD must prioritise Aboriginal and Torres Strait Islander people's knowledge, perspectives and experiences and develop co-designed approaches to RHD elimination. The environmental, economic, social and political context of RHD in Australia is inexorably linked to ending the disease. ■Statistical modelling undertaken in 2019 looked at the economic and health impacts of implementing an indicative strategy to eliminate RHD by 2031. Beginning in 2019, the strategy would include: reducing household crowding, improving hygiene infrastructure, strengthening primary health care and improving secondary prophylaxis. It was estimated that the strategy would prevent 663 deaths and save the health care system $188 million. ■The Endgame Strategy provides the evidence for a new approach to RHD elimination. It proposes an implementation framework of five priority action areas. These focus on strategies to prevent new cases of ARF and RHD early in the causal pathway from Streptococcus pyogenes exposure to ARF, and strategies that address the critical systems and structural changes needed to support a comprehensive RHD elimination strategy.

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.

Could health information systems enhance the quality of Aboriginal health promotion? A retrospective audit of Aboriginal health programs in the Northern Territory of Australia

BACKGROUND

In Australia, health services are seeking innovative ways to utilize data stored in health information systems to report on, and improve, health care quality and health system performance for Aboriginal Australians. However, there is little research about the use of health information systems in the context of Aboriginal health promotion. In 2008, the Northern Territory's publicly funded healthcare system introduced the quality improvement program planning system (QIPPS) as the centralized online system for recording information about health promotion programs. The purpose of this study was to explore the potential for utilizing data stored in QIPPS to report on quality of Aboriginal health promotion, using chronic disease prevention programs as exemplars. We identify the potential benefits and limitations of health information systems for enhancing Aboriginal health promotion.

METHODS

A retrospective audit was undertaken on a sample of health promotion projects delivered between 2013 and 2016. A validated, paper-based audit tool was used to extract information stored in the QIPPS online system and report on Aboriginal health promotion quality. Simple frequency counts were calculated for dichotomous and categorical items. Text was extracted and thematically analyzed to describe community participation processes and strategies used in Aboriginal health promotion.

RESULTS

39 Aboriginal health promotion projects were included in the analysis. 34/39 projects recorded information pertaining to the health promotion planning phases, such as statements of project goals, 'needs assessment' findings, and processes for consulting Aboriginal people in the community. Evaluation findings were reported in approximately one third of projects and mostly limited to a recording of numbers of participants. For almost half of the projects analyzed, community participation strategies were not recorded.

CONCLUSION

This is the first Australian study to shed light on the feasibility of utilizing data stored in a purposefully designed health promotion information system. Data availability and quality were limiting factors for reporting on Aboriginal health promotion quality. Based on our learnings of QIPPS, strategies to improve the quality and accuracy of data entry together with the use of quality improvement approaches are needed to reap the potential benefits of future health promotion information systems.

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.

The impact of hearing impairment on early academic achievement in Aboriginal children living in remote Australia: a data linkage study

Background

The prevalence of otitis media (OM) and related hearing loss has remained persistently high among some groups of Australian Aboriginal children who are also reported to have poor academic outcomes. The general literature remains inconclusive about the association between OM-related hearing loss and academic performance in primary school. This study aimed to investigate this association in Aboriginal children living in the Northern Territory (NT) of Australia.

Methods

A retrospective, observational cohort study was conducted for 2208 NT Aboriginal children, aged about 8 years, living in remote and very remote communities. The explanatory variable was audiometrically determined hearing level as recorded in the Remote Hearing Assessment dataset. The outcome variable consisted of scale scores in the five domains of the National Assessment Program – Literacy and Numeracy (NAPLAN) for Year 3. Other linked datasets used in the study included school attendance records, perinatal records and community level information on relative remoteness, socioeconomic disadvantage and housing crowdedness. Fixed effects linear regression models were used for statistical analyses.

Results

Compared with children with normal hearing and after controlling for a range of covariates, children with mild hearing impairment (HI) scored lower in Writing and Spelling by 15.0 points (95% CI: − 22.4 to − 7.6, p < 0.0005) and 5.0 points (95% CI: − 9.6 to − 0.3, p = 0.037), equivalent to 7.3 and 2.1% of the mean score, respectively. Children with moderate or worse HI scored lower in Writing and Numeracy by 13.4 points (95% CI, − 24.8 to − 1.9, p = 0.022) and 15.2 points (95% CI, − 27.6 to − 2.7, p = 0.017), both equivalent to 6.3% of the mean score the respective domain. Other factors associated with poorer NAPLAN results included being male, lower Year 2 school attendance, low birthweight, average household size> 5 persons, living in a very remote community and speaking English as a second language.

Conclusions

OM-related HI was independently associated with poorer early year academic achievement in Aboriginal children living in remote NT communities. Interventions to improve academic outcomes for Aboriginal children must incorporate actions to address the negative impact associated with HI through early detection, effective treatment and ongoing support for affected children.

'We can work together, talk together': an Aboriginal Health Care Home

Objective The aim of this study was to identify an Aboriginal community's aspirations for health service improvement during implementation of the Commonwealth's Health Care Homes (HCH) reform. Methods This study was a qualitative study consisting of Aboriginal-controlled phenomenological enquiry in a large Aboriginal community in north-central Arnhem Land. Results A representative sample of 60 Aboriginal health service users identified shortcomings in their current experience of primary health care, including low cultural security. These shortcomings reduced access to care. Participants described several ways that care could be reorientated to match their needs during HCH implementation. Principally, patients voiced the need for: (1) restructuring care teams to foster culturally secure relationship-based care; and (2) reorientating the Aboriginal Health Practitioner role from acute care to strength-based competencies as the focal point of care continuity: self-management support, care coordination and navigation, health coaching and cultural mentorship for non-Aboriginal staff. Conclusions For HCH to be successful, service providers need to engage with service users to identify and implement patient-centred strategies to improve access, acceptability and patient activation. What is known about the topic? Success of the Commonwealth's HCH reform is contingent on improving care access and patient activation to better manage chronic conditions What does this paper add? This is the first opportunity that this Aboriginal community has had to articulate their aspirations for high quality healthcare. Beyond the strong alignment with the HCH building blocks, their care preferences posit practical and achievable workforce and delivery system reforms that may improve primary health care in other remote Aboriginal communities. What are the implications for practitioners? The long-term success of the HCH reform will require iterative engagement with service users to identify and implement patient-centred strategies to improve access and acceptability of care. Service model alignment with patient care preferences will improve patient activation and is particularly important when working with vulnerable populations.

Cost impact of high staff turnover on primary care in remote Australia

Objectives The aim of this study was to estimate the costs of providing primary care and quantify the cost impact of high staff turnover in Northern Territory (NT) remote communities. Methods This cost impact assessment used administrative data from NT Department of Health datasets, including the government accounting system and personnel information and payroll systems between 2004 and 2015, and the primary care information system from 2007 to 2015. Data related to 54 government-managed clinics providing primary care for approximately 27200 Aboriginal and non-Aboriginal people. Main outcome measures were average costs per consultation and per capita, cost differentials by clinic, year and levels of staff turnover. Linear regression and dominance analysis were used to assess the effect of staff turnover on primary care costs, after adjusting for remoteness and weighting analysis by service population. Both current and constant prices were used. Results On average, in constant prices, there was a nearly 10% annual increase in remote clinic expenditure between 2004 and 2015 and an almost 15% annual increase in consultation numbers since 2007. In real terms, the average costs per consultation decreased markedly from A$273 in 2007 to A$197 in 2015, a figure still well above the Medicare bulk-billing rate. The cost differentials between clinics were proportional to staff turnover and remoteness (both P<0.001). A 10% higher annual turnover rate pertains to an A$6.12 increase in costs per consultation. Conclusions High staff turnover exacerbates the already high costs of providing primary care in remote areas, costing approximately A$50 extra per consultation. This equates to an extra A$400000 per clinic per year on average, or A$21million annually for the NT government. Over time, sustained investments in developing a more stable primary care workforce should not only improve primary care in remote areas, but also reduce the costs of excessive turnover and overall service delivery costs. What is known about the topic? Population size and geographical remoteness are important cost drivers in remote clinics, whereas elsewhere in Australia the high use of short-term staff to fill positions has been identified as a major contributor to higher nurse turnover costs and to overall health service costs. Nursing staff expenditure accounts for a large proportion (46%) of total expenditure in NT remote health services, whereas expenditure on Aboriginal Health Practitioners (AHPs) comprises only 6%. Annual nurse turnover rates in remote NT clinics average approximately 150%, whereas levels of 40% in other contexts are considered high. What does this paper add? Annual expenditure for NT remote clinics has increased, on average, by 10% per annum between 2004 and 2015, but small declines in real expenditure have been observed from a maximum in 2012. Expenditure on nursing staff comprises 40% of overall expenditure in remote clinics, whereas expenditure on AHPs comprises less than 5%. The cost impact of every 10% increase in remote nurse and AHP annual turnover has been quantified as an extra A$6.12 per primary care consultation, which equates, on average, to an extra A$400000 per remote clinic, and an extra A$21million overall for the NT Department of Health each year. The average real expenditure per primary care consultation has decreased from A$273 in 2007 to A$197 in 2015, representing a statistically significant linear trend reduction of A$7.71 per consultation annually. What are the implications for practitioners (and other decision-makers)? Adjusting policy settings away from the high use of short-term staff to investment in appropriate training 'pipelines' for the remote primary care workforce may, in the medium and longer term, result in reduced turnover of resident staff and associated cost savings. Targeted recruitment and retention strategies that ensure individual primary care workers are an optimal fit with the remote communities in which they work, together with improved professional and personal support for staff residing in remote communities, may also help reduce turnover, improve workforce stability and lead to stronger therapeutic relationships and better health outcomes.

Championing women working in health across regional and rural Australia - a new dual-mentorship model

BACKGROUND

Mentoring is a critical component of career development and job satisfaction leading to a healthier workforce and more productive outputs. However, there are limited data on mentorship models in regional areas and in particular for women aspiring to leadership positions. Mentorship programs that leverage off experienced mentors from diverse disciplines have the potential to foster the transfer of knowledge and to positively influence job satisfaction and build capacity within the context of workforce shortage.

METHODS

This study describes a dual-mentorship model of professional development for women working in health in regional and rural Australia. We present the framework and describe the evaluation findings from a 12-month pilot program.

RESULTS

Both academic and corporate mentors provided diverse perspectives to the mentees during the 12-month period. On average, corporate mentors met with mentees more often, and focused these discussions on strategy and leadership skills whilst academic mentors provided more technical advice regarding academic growth. Mentees reported an improvement in workplace interconnectedness and confidence at the completion of the program.

CONCLUSION

We developed a framework for establishing a professional mentorship program that matches women working in regional health with mentors from diverse sectors including business, government, philanthropy and health, to provide a holistic approach to improving career satisfaction, institutional productivity and supporting a diverse workforce in regional or resource-poor settings.

Rural Pandemic Preparedness: The Risk, Resilience and Response Required of Primary Healthcare

Pandemic situations present enormous risks to essential rural primary healthcare (PHC) teams and the communities they serve. Yet, the pandemic policy development for rural contexts remains poorly defined. This article draws on reflections of the rural PHC response during the COVID-19 pandemic around three elements: risk, resilience, and response. Rural communities have nuanced risks related to their mobility and interaction patterns coupled with heightened population needs, socio-economic disadvantage, and access and health service infrastructure challenges. This requires specific risk assessment and communication which addresses the local context. Pandemic resilience relies on qualified and stable PHC teams using flexible responses and resources to enable streams of pandemic-related healthcare alongside ongoing primary healthcare. This depends on problem solving within limited resources and using networks and collaborations to enable healthcare for populations spread over large geographic catchments. PHC teams must secure systems for patient retrieval and managing equipment and resources including providing for situations where supply chains may fail and staff need rest. Response consists of rural PHC teams adopting new preventative clinics, screening and ambulatory models to protect health workers from exposure whilst maximizing population screening and continuity of healthcare for vulnerable groups. Innovative models that emerge during pandemics, including telehealth clinics, may bear specific evaluation for informing ongoing rural health system capabilities and patient access. It is imperative that mainstream pandemic policies recognize the nuance of rural settings and address resourcing and support strategies to each level of rural risk, resilience, and response for a strong health system ready for surge events.

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.

Strategies to improve control of sexually transmissible infections in remote Australian Aboriginal communities: a stepped-wedge, cluster-randomised trial

BACKGROUND

Remote Australian Aboriginal communities have among the highest diagnosed rates of sexually transmissible infections (STIs) in the world. We did a trial to assess whether continuous improvement strategies related to sexual health could reduce infection rates.

METHODS

In this stepped-wedge, cluster-randomised trial (STIs in remote communities: improved and enhanced primary health care [STRIVE]), we recruited primary health-care centres serving Aboriginal communities in remote areas of Australia. Communities were eligible to participate if they were classified as very remote, had a population predominantly of Aboriginal people, and only had one primary health-care centre serving the population. The health-care centres were grouped into clusters on the basis of geographical proximity to each other, population size, and Aboriginal cultural ties including language connections. Clusters were randomly assigned into three blocks (year 1, year 2, and year 3 clusters) using a computer-generated randomisation algorithm, with minimisation to balance geographical region, population size, and baseline STI testing level. Each year for 3 years, one block of clusters was transitioned into the intervention phase, while those not transitioned continued usual care (control clusters). The intervention phase comprised cycles of reviewing clinical data and modifying systems to support improved STI clinical practice. All investigators and participants were unmasked to the intervention. Primary endpoints were community prevalence and testing coverage in residents aged 16-34 years for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. We used Poisson regression analyses on the final dataset and compared STI prevalences and testing coverage between control and intervention clusters. All analyses were by intention to treat and models were adjusted for time as an independent covariate in overall analyses. This study was registered with the Australia and New Zealand Clinical Trials Registry, ACTRN12610000358044.

FINDINGS

Between April, 2010, and April, 2011, we recruited 68 primary care centres and grouped them into 24 clusters, which were randomly assigned into year 1 clusters (estimated population aged 16-34 years, n=11 286), year 2 clusters (n=10 288), or year 3 clusters (n=13 304). One primary health-care centre withdrew from the study due to restricted capacity to participate. We detected no difference in the relative prevalence of STIs between intervention and control clusters (adjusted relative risk [RR] 0·97, 95% CI 0·84-1·12; p=0·66). However, testing coverage was substantially higher in intervention clusters (22%) than in control clusters (16%; RR 1·38; 95% CI 1·15-1·65; p=0·0006).

INTERPRETATION

Our intervention increased STI testing coverage but did not have an effect on prevalence. Additional interventions that will provide increased access to both testing and treatment are required to reduce persistently high prevalences of STIs in remote communities.

FUNDING

Australian National Health and Medical Research Council.

Integrating testing for chronic strongyloidiasis within the Indigenous adult preventive health assessment system in endemic communities in the Northern Territory, Australia: An intervention study

Background

The life-threatening clinical manifestations of strongyloidiasis are preventable with early detection and effective treatment. The aim of this study was to assess if there was an increase to the number and proportion of persons tested for chronic strongyloidiasis, as a result of integrating Strongyloides stercoralis serology into the existing preventive health assessment system in four Aboriginal health services in endemic communities.

Methodology

A prospective, longitudinal, before-and-after intervention study was conducted in four Aboriginal health services in remote endemically infected communities in the Northern Territory, Australia, from July 2012 to December 2016. The electronic patient information and recall systems enabled the integration of Strongyloides stercoralis serology into the adult preventive health assessment. Strongyloides reports for each health service were extracted half-yearly to examine the number and proportion of persons tested for chronic strongyloidiasis during the study and to measure the effect of the intervention.

Principal findings

The number and proportion of persons tested increased significantly during the study. From a total resident population of 3650 Indigenous adults over 15 years of age, 1686 persons (47.4%) were tested. The percentage of adults who had at least one serology test increased in all four health services to between 41% (446/1086) and 81.9% (172/210). Of the 1686 persons tested, 680 positive cases of chronic strongyloidiasis (40.3%) were identified.

Conclusions/Significance

This population health systems intervention increased the number and proportion of persons tested for chronic strongyloidiasis in four health services in endemically infected communities. This intervention is relevant to other health services with high-risk populations.

Strongyloidiasis is a neglected tropical disease that is endemic in some Aboriginal communities in the Northern Territory. This study asks if the number and proportion of persons tested for chronic strongyloidiasis can be increased by incorporating a Strongyloides serology test into the existing routine Indigenous adult preventive health assessment system in remote endemic communities. This study demonstrated that integrating Strongyloides serology test within the Indigenous adult preventive health assessment system does increase the number and proportion of people tested in endemic communities. This intervention means that life-threatening clinical complications of strongyloidiasis can be prevented by early detection and treatment. Primary health care services have an important role in increased testing in this high-risk population. Primary health care clinicians incorporated chronic strongyloidiasis with other preventable chronic and infectious diseases. The sustainable population health systems-based approach successfully increased coverage by integrating testing for chronic strongyloidiasis into the adult preventive health assessment in health services in remote Indigenous Australian endemic communities, utilising the electronic health record system. The Strongyloides report developed to measure the change in clinical practice would be replicable in other health services with high risk populations.