Aboriginal and Torres Strait Islander people face complex challenges in gaining consistent access to the range of services required to live successfully in remote Australia. Geographical distance from urban centres, environmental extremes, high costs and cross-cultural considerations are factors in people being able to choose and use services that best meet their needs. For people with disabilities, accompanying ill-health, limited transport and low levels of community understanding of their situation are additional obstacles.
The purpose of this paper is to share the findings of research on ways to improve the positive impact of services on the lives of Aboriginal and Torres Strait Islander people with disabilities in remote Australia. It presents six key insights that have emerged from the activities of our organisation over the last decade, with special reference to our research with Aboriginal people with disabilities in four communities in the Northern Territory and South Australia in 2015-16.
Notable observations arising from the research are that people tend to be passive in their responses to service providers, that community knowledge and education levels on disability are very low, benchmarks and standards relevant to remote communities are applied unevenly and that competencies to work cross-culturally are under-developed among service providers. We find that groups that support empowerment and advocacy for people with disabilities are largely absent from remote communities. A significant theme is that the design of services for Aboriginal people with disabilities in remote locations tends to be transactional in character rather than transformative, a point developed further in the paper.
Through case studies and examples, we offer greater depth and human insight to the subject, as well as bringing out the voices and perspectives of people with disabilities. The paper proceeds to make recommendations orientated towards improving services, an aim best accomplished by integrating what has been learned from research into augmented national strategies, standards and approaches. We argue that for disability in remote communities to be better understood, greater knowledge should be generated in ways that empower people with disabilities themselves.
The fundamental challenge for people with disabilities in remote Australia is how best to gain access to care and support services within a community environment that encourages social and economic inclusion. We recommend that further strategic, design and operational work is conducted to tackle the challenges and problems we describe in the paper.
Warner Adam is a member of Lake Babine Nation and the Chief Executive Officer for the Carrier Sekani Family Services serving eleven First Nations in the Northwestern region of BC. Mr Adam is also the Vice Chair for the First Nations Health Council. This is a political advocacy council mandated by the BC Chiefs to establish a First Nations Health Authority. Mr Adam is also the founding President of the Aboriginal Child Care Society of BC. This organisation is instrumental in the development of child care programming in BC First Nation Communities. Warner has served on numerous community boards, federal, provincial and First Nations committees. He has also served on the Carrier Sekani Tribal Council executive board, the Lake Babine Nation Council and treaty tables. Mr Adam focuses on holistic healing of First Nations health and child welfare matters through indigenous values and epistemology. He believes that capacity building in communities includes the development of programs for the positive growth of children, respective of cultural diversity. Warner is instrumental in research and design of programs that are culturally based in serving First Nations people. He is keen in working toward policy to improve the lives of First Nations and marginalised peoples.
As with many other indigenous populations, First Nations communities in British Columbia Canada remain extremely disadvantaged in access to high quality, timely and culturally sensitive primary care services that meet their individual community needs. First Nations people in British Columbia suffer some of the worst burdens of chronic disease and fall at the bottom of just about every social determinant of health. Health issues are increased for those living in rural and remote areas due to limited access to services, geography, mistrust and poverty.
In north central British Columbia Carrier Sekani Family Services was created to reassert First Nations control of justice, health, child and family services, all of which have been negatively impacted by colonization. For over 25 years, Carrier Sekani Family Services (CSFS) has been working to offer holistic wellness services to 11 member First Nations extending over an expansive geographical area of 76,000 square miles.
This presentation will focus on Carrier and Sekani First Nation efforts to develop a sustainable, high quality and community-based model of primary care service delivery. Through discussion that will include personal stories and data from a comprehensive evaluation, we will provide insight into CSFS primary care model including lessons learned/challenges, successes and recommendations for policy shifts to improve primary care service delivery to remote and semi-remote Aboriginal communities.
Specifically we will address how the model has created:
Chloe Agale is an occupational therapist who works within the Queensland Government’s Department of Housing and Public Works. Chloe’s role is based within the Remote Area Housing Service Centre and focuses on providing specialist housing support to elderly tenants or tenants with disabilities who reside in remote Indigenous communities located within the Cape York Peninsula, Northern Peninsula Area and Torres Straits. Chloe is passionate about providing quality allied health services to people residing in remote areas and supporting them to successfully age-in-place. Chloe enjoys traveling to remote parts of Far North Queensland and tackling the unique challenges that are faced by Aboriginal and Torres Strait Island people who reside in these areas. Prior to her role with the Department of Housing and Public Works, Chloe spent time working in the mining industry within Western Australia.
In the last five years, tenancy management of housing across a number of Indigenous communities in Queensland has been transferred from local councils to the state government. This has enabled residents to receive a new housing specific occupational therapy service funded by the National Partnership Agreement on Remote Indigenous Housing. The agreement aims to close the gap between Indigenous and non-Indigenous populations by addressing housing-related issues. The primary goal of the Occupational Therapy Service is to provide specialist housing support to community members so that they are able to remain healthy and safe within their homes.
The focus of this paper is on how occupational therapists providing this specialist support have identified the need to deliver a service that is responsive to the unique cultural needs of Aboriginal and Torres Strait Island people. Examples include the inclusion of family members during the therapy process, utilising local translators, observing cultural practices (e.g. sorry business or gender protocols) and exploring housing solutions that enable clients to remain on their traditional land. These variations aim to acknowledge and address the strong cultural ties that influence the way clients will interact with others and their environment as well the activities that they will undertake.
This paper will provide an overview and examples of how occupational therapists have adapted their service delivery to meet the housing needs of indigenous people residing in remote communities throughout Far North Queensland.
Susan Aiton is Team Leader for Remote Programs at Carers NT, based in Darwin. Sue has been working in the community services sector for nearly 25 years in the areas of disability, early childhood and aged care, including Indigenous-specific programs, in northern NSW. The last four-and-a-half years Sue has worked at Carers NT further developing her skills. Her work takes her across the Top End of the NT, delivering respite programs, support and information to unpaid family carers in remote communities during the Dry season. Cultural activities are an integral part of these programs and are determined by the families and care recipients. When it is the Wet season and remote road travel is compromised, Sue works in the Urban Troopy program. This program targets urban Indigenous people with early stages of dementia, taking them out for social interaction and trips to country. Travelling to communities and building supportive relationships with remote family carers has become a passion for Sue, who just loves being out in the bush.
The organisation provides unique, flexible and culturally appropriate support options for indigenous Australians with a disability or who are frail aged and living in the Top End of the NT. Support is available in more than 33 remote communities. The Remote Respite Camp program, Troopy program, Wellbeing Troopy program and Urban Troopy program provide culturally respectful support on country.
Camps are delivered in communities on request during the dry season and are aimed at low care, frail aged indigenous females. A local person from the community is engaged to work as a support worker on camps, utilising a brokerage model; the aim being to contribute to strengthening community capacity, employment opportunities and skills development. The camp setup is self-sufficient with solar power, tents, sleeping equipment and all food supplied for the duration of the camp. Participants assist in camp duties and all staff focus on wellness, reablement and restorative approaches aiming at improving quality of life. Activities are planned in consultation with the participants, often with an after-dinner movie under the stars!
The Troopy program is delivered on request by, and in consultation with a community and is managed by local providers and their staff in the community. A Troopcarrier, fuel and a small budget for the outings is supplied. This provides the opportunity for carers and recipients in remote communities to access meaningful, on –country support, determined by them and delivered by familiar local people. Respite outings include fishing, hunting, gathering craft materials, funeral attendance, camping and visits to other communities to see family.
The recent Aged Care reform has posed some particular challenges in the change in approaches to providing support for remote clients. All referrals must be made through the Federal government “My Aged Care” portal, by service providers or by self-referral. When a service provider initiates the referral My Aged Care then attempts to make contact with the client. This can prove difficult in remote communities. If contact isn’t able to be made after 2 phone calls the referral is closed and then becomes the responsibility of the client to make contact to complete an assessment. Our experience on community tells us that phones are often lost, out of credit, people mightn’t answer an unfamiliar number or they may have given their phone to another and no longer have phone access.
Dr Penny Allen is Senior Research Fellow with the Rural Clinical School, University of Tasmania. Penny completed her PhD in cancer epidemiology at University College London and has extensive research experience in epidemiology, public health and evaluations of health care interventions. Penny collaborates with clinicians, communities and health services to conduct research designed to improve health and health care provision in regional and remote communities in Tasmania. Penny’s research is focused on the rural medical workforce and the provision of emergency care in rural communities. Penny also provides research mentorship and support to Rural Clinical School students, facilitating real world research experiences for 4th and 5th year medical students.
Introduction: While approximately 32% of Australians live in regional or remote areas, only 15% of medical specialists work in these areas. These figures may under-represent the true shortage of specialists in rural areas, which is obscured by heavy reliance on locums and international medical graduates. Like many regional areas, Tasmanian Health Service-North West (THS-NW) struggles to attract and retain medical specialists. Over the last 5-10 years there has been an increasing reliance on international medical graduates and locums to fill service gaps. It is not unusual to credential over 40 locums per month. Shortages of specialists in regional centres may have serious consequences for the health of people living in rural areas. With an ageing rural medical workforce, the problem of medical specialist shortages is likely to worsen in the future. This research aims to describe longitudinal specialist workforce trends and to identify strategies for maximising recruitment and retention of medical specialists.
Methods: Two methods will be utilised for the research: a retrospective analysis of 20 years of medical specialist HR data; and a qualitative study consisting of in-depth interviews with medical specialists who have left within the last 5 years or are ‘long stayers’.
Results: THS-NW medical specialist workforce human resources records will be analysed to describe the demographic and professional characteristics of the medical specialist workforce. Turnover, retention and stability rates will be described and survival analysis will be used to investigate differences between employment durations of sub-groups (e.g. by gender, speciality, type of registration). In-depth interviews will be conducted with approximately 15 medical specialists who have left THS-NW and 15 ‘long stayers’. Interviews will be transcribed and thematic analysis used to identify 'tipping points' for staff who have left, and factors most likely to contribute to retention.
Discussion: The North West of Tasmania, like many areas, is geographically distinct so factors identified as important for specialist recruitment and retention in this region may be unique. However, evidence of enablers and disablers will provide practical strategies to improve retention in many hard to staff areas for medical, allied health and nursing professionals.
Dr Judith Anderson has been a registered nurse in rural Australia for more than 20 years, working in a variety of settings. Her background has been strongly focussed on improving health outcomes for people living in rural and remote areas and the provision of nursing education. In 2010, she completed her PhD on change management in small rural health services. Judith has also had a history of working in mental health services, aged care, management and in community engagement in rural health services. Currently Judith works for Charles Sturt University, as a Senior Lecturer for the School of Nursing, Midwifery and Indigenous Health, where she coordinates undergraduate and postgraduate nursing courses. She is currently supervising several PhD students, including one studying the development of caring behaviours in recently graduated nurses. At Charles Sturt University, Judith has been involved in teaching nursing and paramedic students for several years and has undertaken research about student experiences in learning and how this can be improved. This overall history has led to a further interest in researching the impact of teaching methods, particularly the need to prepare students for the provision of palliative care in rural areas.
Objective: This paper explores the perceptions of new graduate nurses regarding their readiness for practice when faced with patients experiencing end of life care issues while working in geographically and professionally isolated health facilities.
Background: There are a range of health professionals that provide care to people in the palliative stage of life, however nurses spend more time with people in this stage than any other health professional. For this reason, it is important that graduate nurses have core capabilities required to care for palliative patients. There is limited literature that explores the phenomena of the experience of newly graduated nurses working in rural areas and how they cope with end of life care.
Methodology: This paper reports on a qualitative interpretative study with data collected in semi-structured interviews. The seven participants were registered nurses who had graduated within the previous 2 years and were working in rural and regional areas of NSW. Ethics approval was obtained prior to interviews commencing. A thematic analysis of the interviews was conducted. This paper reports on one of the themes which was the isolation that these newly graduated nurses experienced whilst caring for the person at the end of life when working in rural areas.
Results: The sub themes that emerged from the theme of isolation were; geographical isolation, professional isolation, readiness to lead clinical practice for the dying person, and feeling competent in communicating with families and carers.
Conclusions: While palliative care is viewed as an important aspect of undergraduate nursing education, it is recognised as an area of practice that newly graduate nurses feel they are not adequately prepared for. This paper identifies the need to incorporate skills such as; having conversations and communicating effectively with patients and families experiencing end of life care issues; the resilience to work in isolation in rural and remote areas; and the ability to lead and make decisions, in undergraduate nursing curricula. By doing so newly graduated nurses will be better prepared to care for people at the end of life in rural areas.
Emma Anderson is a PhD student in the Anton Breinl Research Centre for Health Systems Strengthening at James Cook University. As a science graduate from Glasgow University, Emma undertook research at Kings College London, The Royal Free Hospital London and Astra Zeneca. After the birth of two children, Emma changed direction, working in research governance and management both in the UK and Australia to allow more time to be spent with the family. In recent years Emma has returned to research with a particular interest in the challenges of ageing at home and the social support that is provided by both family and community especially in rural areas. This interest has been fostered by her grandparents ageing in place and the strength and the support that they provided to the family.
Aim: To determine views about older Australians as portrayed in rural and regional print media in north Queensland and whether these views differ from those in metropolitan papers.
Methods: As critical theory attempts to confront injustice in society, this study employed critical theory to identify if older people were being unjustly portrayed in rural and regional newspapers. Ten newspapers from north Queensland were selected and a search of all articles published between January 2011 and October 2014 (excluding advertisements and reader’s comments) was undertaken. Articles were selected where the following search terms were present in the headline: elder, elderly, pension(s), pensioner(s), older workers, older drivers, elderly drivers. The term old/older was excluded due to the large number of unrelated articles identified. 214 articles were initially screened resulting in 179 for analysis. In keeping with critical theory, articles were then carefully read and content assessed both textually and contextually for any negative aged bias in reporting. Bias was classified as articles that made note of age along with an underlying undesirable assumption regardless of topic.
Relevance: Negative stereotyping of older people in the media has been identified as a significant social issue. These stereotypes can be self- fulfilling and limit expectations of ageing from an individual and societal perspective, promoting discriminatory practices and impacting health and social policy. A report into the social positioning of newspapers showed that readers differentiated between metropolitan and regional newspapers with the former bringing the outside world to them and the latter informing and advising them. This puts regional newspapers in an ideal position to have a major impact on how regional and rural societies view older community members.
Results: Analysis showed that regardless of whether the subjects of articles were positive or negative, words and phrases portrayed older Australians as being less capable members of society. Newspapers were found to socially construct older people in four main ways; vulnerable victims, burdens on society and deserving or undeserving of financial aid. These results closely reflect the stereotypes portrayed in metropolitan and national newspapers.
Conclusions of the work undertaken: This study identifies the need to challenge the negative stereotypes of older people within the media to foster healthy ageing in place. This is especially important in rural areas with a greater proportion of older Australians ageing within the community than urban areas.
Dr Jane Anderson-Wurf is a part-time research fellow at the School of Medicine, University of Notre Dame, Wagga Wagga campus. She is currently working on osteoporosis research and was initially funded under a post-doctoral APHCRI scholarship. She has worked extensively in communication, particularly with overseas-trained health professionals and their supervisors. She has developed communication skills training packages and delivered many workshops on culture and health communication for training organisations throughout Australia. Her other research interests are healthy ageing, culture and communication in health care, refugee health and primary healthcare program evaluation.
Osteoporosis is a disease that often remains ‘silent’ until a debilitating fracture occurs. Fracture often precipitates lifestyle limitations including restricted mobility, causing changes in the ability of older people to remain living independently.
Research into patient experiences and behaviour has centred upon effecting change after a fracture has occurred and, rather than waiting for a fracture to occur, health care professionals need act early to address this problem. To address this problem an osteoporosis prevention education program, ‘Mind Your Bones’ was developed, piloted and evaluated involving community dwelling adults over the age of 55.
This study explored whether individual goal setting, in the context of a retirement village community, could improve strategies to strengthen bones in people and help to prevent osteoporosis.
This program was aimed at increasing knowledge and awareness of the disease, and providing strategies for maintaining strong bones and healthy independent living. The program aimed to penetrate the ‘silence’ surrounding osteoporosis and develop awareness of its prevalence as a chronic disease and the potential threat to healthy ageing by implementing an initiative in a retirement village setting.
Healthy men and women over the age of 55 were targeted with the aim of increasing their knowledge of osteoporosis and introducing strategies they could implement to prevent decline in bone health potentially reducing the risk of minimal trauma fracture occurring.
An innovative approach was utilised by partnering with a retirement village community to develop a highly focussed, individual, action program aimed at improving bone health and independence by developing individual bone health plans. Working in collaboration with residents in a retirement village community the program used peer to peer support and feedback to create a physical and social environment that reinforces positive healthy behaviour change. Osteoporosis health information was delivered and a range of individual osteoporosis prevention strategies for residents was delivered. This enabled residents to make informed decisions about their bone health based upon understanding their individual fracture risk and the facts about osteoporosis.
Survey results showed that study participants had varied levels of understanding about osteoporosis and even those diagnosed and on treatment benefited from increased knowledge about the disease. Overall, retirement village residents were very positive about the intervention and achieved changes in their individual goals.
Feedback from the retirement village residents has ensured that the program will be reproducible with the view to expanding to other interested retirement communities across Australia.
Dr Catriona Arnold-Nott (MBBS FRACGP) is a GP currently working in Malanda in the Atherton Tablelands. She graduated from the University of Sydney and did her early hospital years in Darwin. This was followed by a stint working as a volunteer for AVI in Vanuatu, where she and Peter were the only doctors for a province of 25,000 people. Catriona returned to the top end of the Northern Territory to do her GP training, and it was there that Catriona and Peter had their three children Grace, Reuben and Mimi. Looking for a bit more adventure, the young family moved to Thursday Island for four years. They have now settled in the Atherton Tablelands where they live on a farm and raise cattle and strive to grow as much of their own food as they can. Catriona is passionate about compassionate medical care and she really enjoys training registrars and students.
Relevance: People living in rural and regional areas are older, have poorer health status and access to health services compared to those living in metropolitan areas. The design of health services should be informed by accurate health data for the community served. The concept of frailty has been used to assess the risk of morbidity and mortality in older people and could be a useful tool in such data collection. Frailty is related to the ageing process as an accelerated decline in the ability of body systems to respond and recover to physical insult. The more frail the individual, the higher their risk of morbidity and mortality. Frailty assessment is used by General Practitioners internationally to identify older people at risk of poor health outcomes who may benefit from targeted health interventions.
Data on frailty in a community could inform policy for rural health. The use of a frailty assessment tool would enable rural General Practitioners to identify frail clients in their practices. There is currently no consensus on the best tool with which to assess frailty. This presentation will report on a review of the literature to inform selection of a validated frailty assessment tool for use in frailty assessment in General Practice and rural and remote communities.
Aim: To investigate available tools to assess frailty and to consider which would be most useful for rural and remote communities, and in General Practice.
Methods: Medline, OVID, CINAHL, and AUSTHealth were searched using the terms rural, health assessment, Family Physician, primary care, General Practitioner and Australia in conjunction with frailty. Researchers read the abstracts and selected relevant papers from this list and then read the full texts. This literature provided the background on frailty research and identified the assessment tools used to identify frailty.
Results: There are over 20 tools to identify or detect frailty and no gold standard. Frailty screening tools have been used in a variety of settings including the community and rural areas. The Edmonton Frail Scale, which has frequently been used in primary care, is a multi-dimensional validated frailty assessment tool which does not require specialist equipment or training, and is easy to use. The researchers identified this tool to be the most appropriate validated tool to use in a rural General Practice. With this knowledge, the authors are piloting the introduction of a frailty assessment in a rural general practice.
Dr Minyon Avent is a Consultant Clinical Pharmacist at Statewide Antimicrobial Stewardship program, Queensland Health as well as The University of Queensland Centre for Clinical Research (UQCCR). She is also a lecturer in the Postgraduate Studies and Professional Development Unit, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne. Dr Avent obtained her Doctor of Pharmacy at the University of North Carolina Chapel Hill, United States of America. She is the author of a number of peer-reviewed publications and has been invited to present her results at national and international conferences. Her research interests include the optimisation of antibiotic dosing and appropriate use of antimicrobials.
Aim: Gain an understanding of factors affecting the implementation of AMS programs in rural and regional Queensland.
Methods: A multidisciplinary team (medical, nursing, pharmacy) was established to engage with rural and remote hospital and health services (HHSs) in order to develop a statewide program to support AMS programs in rural facilities in Queensland. HHS were identified who do not have an on-site Infectious Diseases Specialist support and report a high antibiotic utilisation rate. Engagement involved onsite visits by the multidisciplinary team to five facilities, across four HHSs. Pre-visit questionnaires, meetings with key AMS stakeholders and AMS focussed ward rounds were undertaken to explore the strategies for implementing or optimising existing AMS programs.
Results: Enablers for successful AMS programs were: relatively flat governance structures, engrained hub and spoke mechanisms within and between HHSs and well-established telehealth facilities. Barriers to implementing AMS activities were: no established AMS governance structure, institutional prescribing culture which was resistant to change, high turnover of clinicians, and lack of access to specialist Infectious Diseases advice. Key areas for AMS support identified included: access to specialist Infectious Diseases advice in real-time; use of telehealth for AMS ward rounds and education; assistance with monitoring of appropriate antimicrobial use with feedback to prescribers; and the prioritisation and implementation of AMS intervention strategies.
Conclusion: Through collaboration with rural facilities, a statewide AMS multidisciplinary team will deliver a tailored program of support and resources to rural facilities in Queensland.