Specialist clinics in remote Australian Aboriginal communities: where rock art meets rocket science

Effectiveness of ear, nose and throat outreach programmes for Aboriginal and Torres Strait Islander Australians: a systematic review

OBJECTIVE

To examine the ability of ear, nose and throat (ENT) outreach programmes to improve health outcomes among Aboriginal and Torres Strait Islander people.

METHODS

We conducted a systematic literature search of nine databases (Medline, CINAHLS, PsycINFO, Embase, Cochrane, Scopus, Global health, Informit Rural health database and Indigenous collection) and grey literature sources for primary studies evaluating ENT outreach services for Aboriginal and Torres Strait Islander people. This review included English language studies of all types, published between 2000 and 2018, that supplied ENT outreach services to Aboriginal and Torres Strait Islander Australians and provided data to evaluate their aims. Two authors independently evaluated the eligible articles and extracted relevant information. Risk of bias was assessed using the Mixed Methods Assessment Tool.

RESULTS

Of the 506 studies identified, 15 were included in this review. These 15 studies evaluated eight different programs/activities. Studies were heterogeneous in design so a meta-analysis could not be conducted. Seven studies measured health-related outcomes in middle ear or hearing status; six reported overall positive changes one reported no clinically significant improvements. Five programmes/activities and their corresponding studies involved Aboriginal and Torres Strait Islander people and organisations in delivery and evaluation, but involvement in programme or study design was unclear.

CONCLUSION

While some studies demonstrated improved outcomes, the overall ability of ENT programmes to improve health outcomes for Aboriginal and Torres Strait Islander children is unclear. The impact of ENT outreach may be limited by a lack of quality evidence, service coordination and sustainability. Community codesign and supporting and resourcing local capacity must be a component of outreach programmes and ongoing evaluation is also recommended. Improvements in these areas would likely improve health outcomes.

PROSPERO REGISTRATION NUMBER

CRD42019134757.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Review of Aboriginal child health services in remote Western Australia identifies challenges and informs solutions

BACKGROUND

Despite a national focus on closing the gap between Aboriginal and non-Aboriginal child health outcomes in Australia, there remain significant challenges, including provision of health services in very remote communities. We aimed to identify and map child health services in the very remote Fitzroy Valley, West Kimberley, and document barriers to effective service delivery.

METHODS

Identification and review of all regional child health services and staffing in 2013. Verification of data by interview with senior managers and staff of key providers in the Western Australian Country Health Service, Kimberley Population Health Unit, Nindilingarri Cultural Health Services and non-government providers.

RESULTS

We identified no document providing a comprehensive overview of child health services in the Fitzroy Valley. There were inadequate numbers of health professionals, facilities and accommodation; high staff turnover; and limited capacity and experience of local health professionals. Funding and administrative arrangements were complex and services poorly coordinated and sometimes duplicated. The large geographic area, distances, extreme climate and lack of public and private transport challenge service delivery. The need to attend to acute illness acts to deprioritise crucial primary and preventative health care and capacity for dealing with chronic, complex disorders. Some services lack cultural safety and there is a critical shortage of Aboriginal Health Workers (AHW).

CONCLUSIONS

Services are fragmented and variable and would benefit from a coordinated approach between government, community-controlled agencies, health and education sectors. A unifying model of care with emphasis on capacity-building in Aboriginal community members and training and support for AHW and other health professionals is required but must be developed in consultation with communities. Innovative diagnostic and care models are needed to address these challenges, which are applicable to many remote Australian settings outside the Fitzroy Valley, as well as other countries globally. Our results will inform future health service planning and strategies to attract and retain health professionals to work in these demanding settings. A prospective audit of child health services is now needed to inform improved planning of child health services with a focus on identifying service gaps and training needs and better coordinating existing services to improve efficiency and potentially also efficacy.

Enabling factors for specialist outreach in western KwaZulu-Natal

Background

There exists a major disparity in access to specialist care between patients in urban and rural areas. Specialists are a scarce resource and are concentrated in urban areas. Specialist outreach attempts to fill the gap in service provision for patients situated remotely. While there is international evidence that multifaceted specialist outreach has achieved varying levels of success, factors that influence the effectiveness of outreach have not yet been fully elucidated in South Africa.

Aim

This study attempts to uncover some of the factors that enable good multifaceted specialist outreach.

Setting

The study was conducted in hospitals in western KwaZulu-Natal province. This health area is served by a tertiary hospital and 20 peripheral hospitals; three of these are regional level and the majority are district level hospitals. Specialist outreach emanates from the tertiary hospital.

Methods

Specialists providing outreach services from the tertiary hospital and medical officers at seven receiving hospitals were interviewed to explore perceptions regarding factors that might enable successful specialist outreach. Framework analysis on the transcribed interviews was carried out using NVivo version 11.

Results

A major positive finding concerns the relationships formed between outreach specialists and doctors at the recipient hospitals. The management of the programme with respect to structure, dependability, data management, transport provision, communication technology and public health systems was also seen as beneficial in specialist outreach.

Conclusion

Specialist outreach plays an essential role in providing equality in health care. To enable effectiveness, it is important to make full use of the multifaceted nature of this intervention.

Health professional and community perspectives on reducing barriers to accessing specialist health care in metropolitan Aboriginal communities: A semi-structured interview study

AIM

To describe the perspectives of health professionals and communities on an innovative health service delivery project, Hearing EAr health and Language Services (HEALS). HEALS was a government funded initiative to improve access to specialist ear, nose and throat and speech pathology services for Aboriginal families living in metropolitan areas.

METHODS

Semi-structured interviews were conducted with 21 health-care professionals (clinicians, health service managers and Aboriginal health workers) and 16 care givers of children who participated in HEALS. Interviews took place at four Aboriginal Community Controlled Health Services in metropolitan Australia or by telephone. Interview transcripts were analysed thematically.

RESULTS

We identified five major themes: leveraging partnerships (building on collaborative research, integrating and expanding existing networks, engaging the Aboriginal community), intrinsic and extrinsic motivation (seizing opportunities for altruism, empowered by collegiality, taking pride in achievements), removing common barriers (circumventing waiting times and cost, providing culturally appropriate services, raising awareness), strategic service delivery (proactive service delivery, encouraging flexibility and innovation, offering convenience and support), and service shortfall (pressured timeframes, desire for more sustainable services).

CONCLUSION

HEALS facilitated improved health-care access by providing prompt, no-cost services that were strategically targeted to address multiple barriers. HEALS' model of care was built upon strong pre-existing research partnerships, the knowledge and support of five Aboriginal Community Controlled Health Services, and the willingness and motivation of local health-care professionals to help Close the Gap. HEALS highlights the importance of tailoring health services to the needs of Aboriginal families, and provides a framework for other health service delivery initiatives.

Outcomes of using telehealth for the provision of healthcare to Aboriginal and Torres Strait Islander people: a systematic review

OBJECTIVE

To examine reported outcomes of health services delivered by telehealth to Indigenous Australians.

METHODS

Systematic review of the literature. Searches were conducted to identify articles that reported a telehealth service used to provide clinical services to Indigenous Australians. Articles were screened for inclusion using pre-defined criteria. Findings were synthesised narratively and reported using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines.

RESULTS

14 articles, describing 11 distinct telehealth services, were selected based on the inclusion criteria. Authors of included studies report that telehealth has improved social and emotional wellbeing, clinical outcomes and access to health services for Indigenous Australians. Further, it has reduced travel and improved screening rates. Indigenous people report positive perceptions of their telehealth interaction.

CONCLUSION

Telehealth is used to address poor accessibility to health services and for targeted screening programs for at risk populations. Reported outcomes from existing services demonstrate the potential of telehealth for health service delivery for Indigenous Australians. Confidence in the findings of this review is reduced by the predominance of descriptive studies and small sample sizes in many of the included articles.

IMPLICATIONS

Telehealth models of care facilitated through partnerships between Aboriginal community-controlled health services and public hospitals may improve both patient outcomes and access to specialist services for Indigenous people.

Effectiveness of the Koorliny Moort out-of-hospital health care program for Aboriginal and Torres Strait Islander children in Western Australia

OBJECTIVES

To determine whether the Koorliny Moort program could reduce emergency department presentations, hospital admissions and length of stay, and improve attendance at out-of-hospital appointments for Aboriginal and Torres Strait Islander children in Western Australia.

DESIGN

Children were enrolled in the program from 1 August 2012. Each child acted as their own control. Evaluation data were collected from 1 August 2010 to 31 July 2014. Occasions of service and person-time in days were compared for each child before and after referral to the program.

SETTING AND PARTICIPANTS

Aboriginal children aged 0-16 years residing in three WA regions (Kimberley, Pilbara, Perth metropolitan) who were referred to the Koorliny Moort program.

INTERVENTIONS

Partnerships with primary care providers; nurse-led care coordination; and outreach care by paediatricians, nurses and social workers closer to the home of the child.

MAIN OUTCOME MEASURES

Emergency department presentations; hospital admissions; length of hospital stay; non-attended appointments.

RESULTS

A total of 942 children were referred to the program. There were significant decreases after referral to the program in the incidence of emergency department presentations (incident rate ratio [IRR], 0.47; 95% CI, 0.43-0.53; P < 0.001), of hospitalisation (IRR, 0.70; 95% CI, 0.62-0.79; P < 0.001), and of non-attended appointments (IRR, 0.83; 95% CI, 0.74-0.94; P < 0.001), as well as in the mean length of hospital stay (IRR, 0.23; 95% CI, 0.21-0.25; P < 0.001).

CONCLUSIONS

Health-seeking behaviour and health outcomes for Aboriginal children can be improved by engaging Aboriginal families in their health care, providing effective communication between health service providers, and delivering a coordinated program of Aboriginal service provider-led care.

Internal medicine in the bush: a clinical audit of a rural and remote outreach programme

BACKGROUND

Provision of internal medicine services in rural Australia is always problematic.

AIM

The aim was to undertake an audit of an outreach service operating in Northern New South Wales since 2006.

METHODS

The service is conducted eight times a year, involving a consultant and an advanced trainee who travel by car to the towns of Moree and Mungindi and conduct clinics in a general practice setting, an Aboriginal medical service and a local health district clinic. Since 2008, a cardiology service and a diabetes service have been added on a fly-in fly-out basis. Case records of all patients enrolled in the service between February 2006 and July 2013 were reviewed in determining the demographics, clinical presentations and level of service coverage. The experience of the authors in establishing the service provided insights into the challenges and the success factors involved.

RESULTS

Five hundred and eighty-three patients were seen on a total of 1070 occasions relating to a wide variety of clinical presentations. Of these, 31.3% were indigenous compared with 20% in the local statistical area, and both indigenous and non-indigenous patients were seen in all settings. Patients fell into 15 different diagnostic categories with indigenous patients more likely to present for diabetes (P < 0.001) and hepatitis B (P < 0.01), but less likely to present for treatment of hepatitis C (P < 0.01).

CONCLUSIONS

In providing an outreach service to a mixed community, flexibility in both setting and personnel are essential. Diabetes and liver disease are highly prevalent in indigenous patients, but the low numbers presenting for hepatitis C requires further study.

Rural outreach by specialist doctors in Australia: a national cross-sectional study of supply and distribution

BACKGROUND

Outreach has been endorsed as an important global strategy to promote universal access to health care but it depends on health workers who are willing to travel. In Australia, rural outreach is commonly provided by specialist doctors who periodically visit the same community over time. However information about the level of participation and the distribution of these services nationally is limited. This paper outlines the proportion of Australian specialist doctors who participate in rural outreach, describes their characteristics and assesses how these characteristics influence remote outreach provision.

METHODS

We used data from the Medicine in Australia: Balancing Employment and Life (MABEL) survey, collected between June and November 2008. Weighted logistic regression analyses examined the effect of covariates: sex, age, specialist residential location, rural background, practice arrangements and specialist group on rural outreach. A separate logistic regression analysis studied the effect of covariates on remote outreach compared with other rural outreach.

RESULTS

Of 4,596 specialist doctors, 19% (n = 909) provided outreach; of which, 16% (n = 149) provided remote outreach. Most (75%) outreach providers were metropolitan specialists. In multivariate analysis, outreach was associated with being male (OR 1.38, 1.12 to 1.69), having a rural residence (both inner regional: OR 2.07, 1.68 to 2.54; and outer regional/remote: OR 3.40, 2.38 to 4.87) and working in private consulting rooms (OR 1.24, 1.01 to 1.53). Remote outreach was associated with increasing 5-year age (OR1.17, 1.05 to 1.31) and residing in an outer regional/remote location (OR 10.84, 5.82 to 20.19). Specialists based in inner regional areas were less likely than metropolitan-based specialists to provide remote outreach (OR 0.35, 0.17 to 0.70).

CONCLUSION

There is a healthy level of interest in rural outreach work, but remote outreach is less common. Whilst most providers are metropolitan-based, rural doctors are more likely to provide outreach services. Remote distribution is influenced differently: inner regional specialists are less likely to provide remote services compared with metropolitan specialists. To benefit from outreach services and ensure adequate remote distribution, we need to promote coordinated delivery of services arising from metropolitan and rural locations according to rural and remote health need.

'Nowhere to room … nobody told them': logistical and cultural impediments to Aboriginal peoples' participation in cancer treatment

BACKGROUND

Cancer mortality among Indigenous Australians is higher compared to the non-Indigenous population and attributed to poor access to cancer detection, screening, treatment and support services. A large proportion of Indigenous Australians live in rural and remote areas which makes access to cancer treatment services more challenging. Factors, such as transport, accommodation, poor socio-economic status and cultural appropriateness of services also negatively affect health service access and, in turn, lead to poor cancer outcomes.

DESIGN, SETTING AND PARTICIPANTS

Qualitative research with 30 in-depth interviews was conducted with Aboriginal people affected by cancer from across WA, using a variety of recruitment approaches.

RESULTS

The infrastructure around the whole-of-treatment experience affected the decision-making and experiences of Aboriginal patients, particularly affecting rural residents. Issues raised included transport and accommodation problems, travel and service expenses, displacement from family, concerns about the hospital environment and lack of appropriate support persons. These factors are compounded by a range of disadvantages already experienced by Aboriginal Australians and are vital factors affecting treatment decision-making and access.

CONCLUSION

To improve cancer outcomes for Aboriginal people, logistical, infrastructure and cultural safety issues must be addressed. One way of ensuring this could be by dedicated support to better coordinate cancer diagnostic and treatment services with primary healthcare services.

Orientation for general practice in remote Aboriginal communities: A program for registrars in the Northern Territory

BACKGROUND

Remote general practice can be a highly rewarding career, but poses many personal and professional challenges. It is characterised by significant geographical, professional and social isolation and a requirement for practitioners with public health, emergency and extended clinical skills. The remote practitioner faces further challenges in the remote Aboriginal community setting, including language and cultural barriers.

OBJECTIVES

This paper discusses the specific components of a remote Aboriginal community general practice registrar orientation program in the Northern Territory, and their particular importance and relevance to remote training and practice in this context.

DISCUSSION

Northern Territory General Practice Education, the regional general practice training provider in the Northern Territory, has developed a model for a comprehensive orientation program for general practice registrars planning to work in remote Aboriginal community locations. This comprises a number of core components, including communication and cultural safety training; clinical and procedural skill development; population health; self-care and personal/professional role delineation; and organisational issues. We believe it is a program that is applicable to other disciplines undertaking work in remote Aboriginal communities.