Rural and Remote Health

Online ISSN: 1445-6354
Publications
Article
Approximately one billion people world-wide lack access to adequate amounts of safe water. Most are in developing countries, especially in rapidly expanding urban fringes, poor rural areas, and indigenous communities. In February and March 2005, a field study of 107 households was conducted to evaluate the use and performance of the Manz BioSand filter in the Artibonite Valley of Haiti. Approximately 2000 filters had been installed in this area over the preceding 5 years by the staff in Community Development at Hospital Albert Schweitzer, Deschappelle, Haiti. Interviews, observations, and water samplings were carried-out by two teams of Haitian enumerators, each consisting of a nurse and a filter technician. Water analyses were performed by Haitian lab technicians using the membrane filtration method to determine Escherichia coli counts. The enumerators and the lab technicians completed a 2 week training program before beginning the study; they worked under the direct supervision of the primary investigator. Laboratory quality was monitored by running 10% blank and 10% duplicate samples. The households contained an average of 5.4 persons. Filters had been in use for an average of 2.5 years, and participants were generally satisfied with their filter's performance. Shallow, hand-dug wells provided the only source of water for 61% of the households, with 26% using water piped from springs or deep wells, and 13% having access to both. Only 3% had plumbing in their homes. Source water from shallow wells contained an average of 234 E. coli cfu/100 mL. Piped sources averaged 195 E. coli cfu/100 mL. Of the source water samples 26% contained 0-10 E. coli cfu/100 mL. Of the filtered water samples 97% contained 0-10 E. coli cfu/100 mL (80% with 0 cfu/100 mL, and 17% with 1-10 cfu/100 mL). Overall bacterial removal efficiency for the filters was calculated to be 98.5%. Turbidity decreased from an average of 6.2 NTU in source water samples to 0.9 NTU in the filtered water. None of the households treated the water after filtering; 91% used the filtered water only for drinking. No problems related to filter construction were observed; 13% were found to have significantly decreased flow rates (all restored by cleaning the filter). Recontamination was found to occur, with only 3% of the samples from the filters' spouts containing >10 E. coli cfu/100 mL and 22% of the stored filtered water samples at point-of-use containing >10 cfu/100 mL. The Manz BioSand filters are an attractive option for supplying water treatment to family units in rural areas of poorly developed countries.
 
Demographic and behavioral factors associated with the odds of having high body mass index 
Article
In rural regions of the United States of America, estimates of pediatric obesity often exceed national averages. This problem may be particularly pronounced in Appalachian regions, where significant health and economic disparities abound. This study presents the findings of a body mass index (BMI) screening program for 6-11 year old children living in a rural Appalachian community. County-wide estimates of high BMI (>or=85th percentile) were obtained to understand the health status and needs of our pediatric community and to compare obesity prevalence rates with national averages. An additional aim was to identify subpopulations of children who may warrant clinical intervention due to demographic and behavioral risks factors of high BMI. A school-based BMI screening was conducted of 6-11 year old children in southeastern Ohio. Investigators collected 3 sets of height and weight measurements from approximately 2000 elementary school students between 2006 and 2007. Caregivers for a subset of this population also completed a health behaviors questionnaire. Thirty-eight percent of children had high BMI, with 17% at risk for overweight and 20.9% overweight. Boys were 23% more likely than girls to be overweight (chi(2)(1) = 95% CI = 1.08, 1.40) and 11% more likely to become overweight with each year of age (OR = 1.11, 95% CI = 1.07, 1.15). Overweight children were more likely to view television, eat meals at school, and live with a caregiver who smokes. Consistent with expectations, prevalence of high BMI in this sample of rural Appalachian children exceeds national averages. Prevalence of overweight varied by age and sex; boys are particularly vulnerable to developing obesity, especially as they age. Preliminary survey data suggest that eating breakfast at home and at school and increased hours of television viewing may be associated with higher BMI, especially in younger boys.
 
Article
Though relatively rare, advanced abdominal pregnancy (AAP) can have dramatic and catastrophic consequences for the foetus and the mother. Difficult to diagnose pre-operatively, AAP presents special challenges to the physician working in remote areas with limited resources for diagnosis and management. Case report: A case of AAP received in our hospital in Kolofata, Cameroon, is presented and followed by a review of 163 other cases reported from 13 countries since 1946. A physician working in a remote district with an active maternity service should expect to encounter several cases of AAP during his or her working lifetime. Pre-operative diagnosis of AAP allows time for thoughtful preparation of the patient, family and medical team; however, to be diagnosed, AAP must first be considered. Diagnosis requires a high index of suspicion, and this should be triggered by any of a number of symptoms and signs reported in many cases of AAP. An unusual echographic appearance of the placenta was present in our case and prompted a more thorough investigation that confirmed the diagnosis. This finding has been reported by others and should be added to the list of signs and symptoms that might lead to a diagnosis of AAP in time to save the surgeon from an unpleasant and dangerous surprise.
 
Article
With adolescent health a priority on the WHO agenda, research into the diet, weight status and metabolic profile of adolescents is indicated. The present study aimed to assess the diet and metabolic parameters of a rural sample of adolescents. One hundred adolescents (17 years of age) were recruited from schools in Nea Madytos, Thessaloniki, Greece. Two previous-day food recalls were collected for each participant, and weight, height, waist circumference, serum lipids and fasting glucose levels were measured. The prevalence of underweight/overweight, central obesity, dyslipidemia and impaired fasting glucose (IFG) were calculated. Overweight was present in half the boys (51.2%) and one-fifth of the girls (21.3%). In the total sample 7.1% were underweight and another 7.1% were diagnosed with central obesity. Boys had an increased risk of abdominal obesity (OR:1.405, CI:0.7-2.8), IFG (OR:1.200, CI:0.3-4.9) and elevated triglycerides (OR:1.514, CI:1.0-2.4) and serum cholesterol levels (OR:1.806, CI:1.1-3.1). Central obesity increased the chances of IFG (OR:8.000, CI:1.6-39.1) and doubled the prevalence of dyslipidemia (OR:2.190, CI:0.5-9.1). Under-reporting of energy was found among overweight participants and was further verified by an inverse relationship between BMI and the ratio of energy intake to energy expenditure. Adolescents identified a dietary pattern high in fats in lieu of protein. Irrespectively of their weight status, teenagers consume a high fat diet; therefore, dietary counseling, as a means of preventive medicine, should be applied to all weight categories. In addition, the prevalence of obesity in a rural sample of adolescents appears to be higher compared with the whole of Greece.
 
Rural adult population aged 18-55 years, 2004 BRFSS data (weighted n = 8222794) 
presents the aggregated data of the rural group who 
Comparison of contraception choice preferences of urban and rural adults aged 18-55 years, 2004 BRFSS data 
Article
Although sexually active US adults wanting to prevent pregnancy have a wide variety of birth control methods readily available, there is little research that documents the contraceptive choices of rural adults in comparison to urban adults. This study compared the contraceptive choices of rural with urban adults. The comparative analysis joins the recent dialog in population health focused on assessing health related differences to detect if these are indicative of rural health disparities. Design: This was a cross-sectional study analyzing 2004 Behavioral Risk Factor Surveillance Survey (BRFSS) data. Place of residence was ascertained by re-coding the state/county FIPS code as either urban or rural, based on 2003 Rural-Urban Continuum Codes from the US Office of Management and Budget (setting: US households; participants: US adults 18-55 years). Main outcome measures: characteristics and contraceptive method choice of rural adults using birth control. A multivariate regression model performed with 'use of birth control' as the dependent variable yielded that rural in comparison with urban adults 18-55 years were more likely to use female or male sterilization, non-injectable and injectable hormones for birth control. They were less likely to use: condoms, a diaphragm or NuvaRing, emergency contraception, withdrawal or rhythm methods. Additionally, in comparison with urban adults, rural persons younger than 35 years, those who had children younger than 18 years living with them, those who were partnered, males and those living in households with an income of less than US$35,000 were more likely to report using some form of contraception. There were differences in the contraception choices of urban and rural adults. How much primary care provider preferences explains the differences is not known and bears further exploration. These results should prove useful to healthcare providers as well as public health family planning programs.
 
Article
The geographic maldistribution of physicians (their concentration in urban areas and shortage in rural areas) has long been an important political issue in post-war Japan. The aim of this study was to evaluate long-term transition in the geographic distribution of physicians, and to reveal which rural physician characteristics predict their retention in rural areas after 22 years. A record-linkage study was conducted to extract a physician cohort by merging the 1980 and 2002 Physician Census in which all licensed physicians are legally required to register. Physician characteristics in 1980 that predicted rural practice in 2002 were identified. Data were used from the 93 077 physicians who were recorded in both 1980 and 2002 Physician Censuses. The number of physicians increased by 52% between 1980 and 2002. In both 1980 and 2002, the physician-to-population ratios in rural areas were approximately half that in urban areas, indicating that the physician maldistribution had not improved. In 1980, 82 414 (88.5%) physicians worked in urban areas and 10 663 (11.5%) worked in rural areas. In 2002, 76 435 (92.7%) of the 1980 urban physicians were still practicing in cities, but only 5958 (55.9%) of the 1980 rural physicians had stayed in their rural area. Logistic regression analysis showed that primary-care discipline and rural practice in 1980 positively predicted rural practice in 2002 (OR [95% CI]: 1.28 [1.23-1.35] and 16.18 [15.43-16.95], respectively). However, female sex and age in 1980 were negative predictors for rural practice in 2002 (OR [95% CI]: 0.80 [0.74-0.86] and 0.91 [0.90-0.94], respectively). The rapid increase of physicians between 1980 and 2002 has not substantially affected their geographic distribution. Baseline rural practice, primary care discipline and male sex of physicians were found to be predictors of rural practice after 22 years.
 
Article
Lack of access to safe drinking water is a major health issue for more than one billion people globally. In areas where community-wide water treatment is not possible, point-of-use (POU) solutions are necessary. The biosand filter (BSF) is one of several such POU technologies available to treat water in the home to reduce the risk of infection. This study was conducted to evaluate the use and performance of BSFs in the rural communities surrounding San Juan del Sur, Nicaragua. Approximately 600 filters had been installed in this area over the preceding 2 years by local workers supported by US and Canadian NGOs. This field study was conducted In July and August 2009. Unannounced household visits were carried out by US volunteers supported by a local interpreter and driver. Visits were made to a convenience sample of 199 households where BSFs had been in place for an average of 12 months. Water for analysis was collected from wells, filter spouts and storage buckets and an 11 item questionnaire was administered. Laboratory analyses were performed on water samples using the membrane filtration method to determine Escherichia coli colony forming units (CFUs). Forty-five of 199 households visited had discontinued use of their BSF. In the 154 households tested, median CFU of E. coli per 100 mL of water from the source, filter spout and storage vessel were 313, 72, and 144, respectively. Median bacterial removal efficiency for the filters was 80%. Although biosand filtration reduced CFUs in 74% of households in which it was used, in only 26 cases (17%) did it reduce CFUs to <10 CFUs/100 mL. Recontamination was an important problem and reduced the overall efficacy (from well to storage bucket) to 48%. Participants were generally satisfied with their filter's performance, citing improved health and better tasting water. Water quality testing of BSFs deployed in the field showed results somewhat inferior to previous reports. Possible explanations include lack of use of best practices and the inclusion of some filers in the analysis that may not have been in active use. Despite these results and high rates of recontamination in the storage bucket, most households members were pleased with their filters and claimed that their use had enhanced their health. This inconsistency could be due to inaccurate responses to the questionnaire for purposes of secondary gain.
 
Most common 15 causes of death with mean time from onset of symptoms to presentation at hospital in patientreported days (12 outlying cases with symptom duration >365 days excluded). LRI, Lower respiratory tract infection.
Leading primary causes of death in adults (aged ≥15 years)
Leading primary causes of death in children (aged <15 years)
Seasonality of leading primary causes of death
Causes of death associated with ≥ 50% of deaths occurring within 1day of hospital admission
Article
In Sub-Saharan Africa (SSA) sound planning is required as interest increases in the decentralization of healthcare financing and the implementation of a sector-wide approach to health care. For this, improved knowledge of national morbidity and mortality is essential. Data from remote areas of SSA are needed to ensure that public health priority-setting and actions reflect the situation in all regions, not just those easily accessed and readily researched. In order to understand the causes, circumstances and changes over time of death in a remote and underserved region, this study sought information on all deaths in a district hospital over a 17 year period. The study design was a retrospective review of the hospital records (in registers) of all patients hospitalized in Kolofata District Hospital, a rural public hospital in the Far North Region of Cameroon, 1 January 1993 to 31 December 2009. A line listing was extracted of all 1281 inpatient deaths, and this included dates of admission and death; patient name, address, sex and ethnic group; presenting complaint; duration of symptoms; summary of physical examination; and the diagnosis presumed to be the cause of death. Children under the age of 15 years and males comprised the majority of deaths (63.9% and 56.0%, respectively). Causes of death were related to the seasons. Infectious diseases including acute lower respiratory tract infection, malaria and diarrhoeal diseases were the leading causes of death; AIDS caused most adult deaths. A total of 67% of patients presented within 1 week of symptom onset, and 56.8% of deaths occurred on or before the day after admission. Deaths due to AIDS, malaria and complications of pregnancy increased over time. Among Kolofata District residents, death from vaccine-preventable measles and neonatal tetanus were rare, particularly in the later study years. The proportion of deaths attributed to non-communicable diseases did not increase in the 17 year period. To reduce mortality in this world region, priority should be given to the prevention and management of lower respiratory tract infections, malaria, diarrhoeal diseases, AIDS, and the complications of pregnancy. The planning of health resources and activities should take into account seasonal variations in the causes of death. Improvements to emergency services and community education that emphasises the need for earlier presentation when ill should reduce deaths that occur soon after hospital admission. Death due to measles and neonatal tetanus has become rare, a reflection of the effectiveness in this area of the national vaccination program.
 
Article
The indigenous populations of the Arctic are prone to middle ear infections starting with an early age first episode, followed by frequent episodes of acute otitis media (AOM) during childhood. A high proportion develop chronic otitis media. Acute mastoiditis is a serious complication of AOM in childhood with postauricular swelling, erythema, and tenderness, protrusion of the auricle, high fever and general malaise. The disease may protrude intracranially. The incidence rates for acute mastoiditis in the Western world range from 1.2 to 4.2 cases/100 000 per year. There exists no epidemiological data on acute mastoiditis in the Arctic region. A retrospective search was made for the WHO ICD-10 code DH70.0 (denoting acute mastoiditis) using the National Greenland Inpatient Register for the period 1994-2007, inclusive. Fifteen patients were registered and their medical records were retrieved. Four patients were obviously misclassified, leaving 11 patients for evaluation. The medical records were available for 10 patients. The diagnostic inclusion criterion was written clinical signs of acute mastoiditis. Based on the case series the incidence rate was calculated to be 1.4 for the total Greenlandic population and 7.4 for children 0 and 10 years of age. Median age was 14 months (5-105 months) and eight were female (72%). Seven of the 10 were exclusively treated with antibiotics and three underwent additional ear surgery. Bacteriological examination was performed in five of 10. One 8 month-old girl presented with a contemporary facial nerve paralysis and was treated with intravenous antibiotics; one 8 year-old girl was evacuated to Copenhagen for urgent surgery due to signs of meningitis. Acute CT scan showed a cerebellar abscess and a thrombosis in the lateral sigmoid sinus vein. An extensive cholesteatoma was found and eradicated during surgery. Six weeks later the patient returned home with a maximal conductive hearing loss as the only complication. All patients recovered from the disease. The incidence of acute mastoiditis in Greenland is comparable to the incidence elsewhere, although AOM occurs more frequently among small children in the Greenlandic population. The disease is serious and must be treated immediately with intravenous antibiotics, followed by urgent surgery if there is no improvement.
 
Article
Early detection of breast cancer by screening mammography aims to increase treatment options and decrease mortality. Recent studies have shown inconsistent results in their investigations of the possible association between travel distance to mammography and stage of breast cancer at diagnosis. The purpose of the study was to investigate whether geographic access to mammography screening is associated with the stage at breast cancer diagnosis. Using the state's population-based cancer registry, all female residents of New Hampshire aged > or =40 years who were diagnosed with breast cancer during 1998-2004 were identified. The factors associated with early stage (stages 0 to 2) or later stage (stages 3 and 4) diagnosis of breast cancer were compared, with emphasis on the distance a woman lived from the closest mammography screening facility, and residence in rural and urban locations. A total of 5966 New Hampshire women were diagnosed with breast cancer during 1998-2004. Their mean driving distance to the nearest mammography facility was 8.85 km (range 0-44.26; 5.5 miles, range 0-27.5), with a mean estimated travel time of 8.9 min (range 0.0-42.2). The distribution of travel distance (and travel time) was substantially skewed to the right: 56% of patients lived within 8 km (5 miles) of a mammography facility, and 65% had a travel time of less than 10 min. There was no significant association between later stage of breast cancer and travel time to the nearest mammography facility. Using 3 categories of rural/urban residence based on Rural Urban Commuting Area classification, no significant association between rural residence and stage of diagnosis was found. New Hampshire women were more likely to be diagnosed with breast cancer at later stages if they lacked private health insurance (p<0.001), were not married (p<0.001), were older (p<0.001), and there was a borderline association with diagnosis during non-winter months (p=0.074). Most women living in New Hampshire have good geographical access to mammography, and no indication was found that travel time or travel distance to mammography significantly affected stage at breast cancer diagnosis. Health insurance, age and marital status were the major factors associated with later stage breast cancer. The study contributes to an ongoing debate over geographic access to screening mammography in different states, which have given contradictory results. These inconsistencies in the rural health literature highlight a need to understand the complexity of defining rural and urban residence; to characterize more precisely the issues that contribute to good preventive care in different rural communities; and to appreciate the efforts already made in some rural states to provide good geographic access to preventive care. In New Hampshire, specific subgroups such as the uninsured and the elderly remain at greatest risk of being diagnosed with later stage breast cancer and may benefit from targeted interventions to improve early detection.
 
Article
Many First Nations children live in communities that face diverse social and health challenges compared with their non-Aboriginal peers, including some of the most socio-economically challenging situations in Canada. These differences can be seen in broad indicators of the social determinants of health. Studies of mortality in Aboriginal populations across Canada are often restricted by the lack of Aboriginal identifiers on national death records. While some studies have utilised a record-linkage approach, this is often not possible for the entire country or for recent data. Some researchers have adopted a geographic approach and examined mortality and morbidity in areas that have a high percentage of Aboriginal identity residents, and have uniformly reported elevated rates of mortality and morbidity compared with other areas. The purpose of this article was to examine child and youth mortality (aged 1 to 19 years) in areas where a high percentage of the population identified as First Nations in comparison with areas where there is a low percentage of Aboriginal identity residents. Using a geographic threshold table approach, areas with a high percentage of Aboriginal identity peoples were classified as either First Nations, Métis, or Inuit communities based on the predominant identity group. The upper one-third of the total Aboriginal population distribution was used as a cut-off for high percentage First Nations areas, where 97.7% of the population aged 1-19 were of First Nations identity in 2006 ( N =140 779). Mortality rates were then calculated for high-percentage First Nations identity areas and compared with low-percentage Aboriginal identity areas, excluding high-percentage Métis or Inuit identity areas. Deaths were aggregated for the 3 years surrounding the 2001 and 2006 census periods, and a total of 473 deaths were recorded for 2000-2002 and 493 deaths for 2005-2007. Analysis was facilitated via the correspondence of six-digit residential postal codes on vital statistics records to census geographical areas using automated geo-coding software (Statistics Canada; PCCF+). Age-standardized mortality rates for children and youth in high-percentage First Nations identity areas were significantly higher than in low-percentage Aboriginal identity areas. The rate ratio for all-cause mortality for boys was 3.2 (CI: 2.9-3.6) for 2005-2007 and 3.6 (CI: 3.2-4.2) for girls. Mortality rates for injuries had the largest difference, with rate ratios of 4.7 (CI: 4.0-5.5) and 5.3 (CI:4.5-6.3) for boys in 2000-2002 and 2005-2007 and 5.5 (CI: 4.4-6.8) and 8.3 (CI: 6.8-10.1) for girls in the same period. A strength of this study is that it is the first to use national-level vital statistics registration data across two time periods to report mortality by cause for children and youth living in high-percentage First Nations areas. Vital events were geographically coded to high-percentage First Nations identity areas and compared with low-percentage Aboriginal identity areas at the Dissemination Areas level. This area-based methodology allows for mortality to be calculated for children and youth by sex and by detailed cause of death for multiple time periods. The results provide key evidence for the persistent differences in the causes of death for children and youth living in high-percentage First Nations identity areas.
 
Article
In any healthcare system an appropriate structure is essential to operational efficiency. Patients must be able to easily access healthcare workers and/or health centers in their own community. In the first contact with a healthcare practitioner, particularly if that contact is with a GP, 90% of patient needs can be met. If the initial problem cannot be managed, the decision will be made to refer the patient to a specialist. Except in an emergency, all patients should be seen first by a primary healthcare physician who decides whether a referral to secondary care is necessary. This avoids system inefficiencies such as disadvantaged groups suffering from lack of specialist care due to specialist doctors being overwhelmed by the inappropriate self-referrals. In the Kashan region, Islamic Republic of Iran, patients can be classified according to their type of health insurance, which dictates the type of specialist referral available: (1) Closed-loop referral (Imam-Khomeini Welfare Committee); (2) Semi-closed-loop referral (Rural Health System Insurance); and (3) Open referral (social security insurance, therapeutic services insurance, self-insured [private] and the non-insured). The organisation of the Iranian health system has been proposed by WHO as a model for other communities. The present study examined patterns of patient self-referral direct to specialist according to health insurance system in the rural Kashan region, and established the reasons for patient self-referral to specialists. A random sample of 1036 individuals was selected from people attending public outpatient clinics and specialists' offices in the private health sector. Of the sample, 413 (40%) were insured by the Imam-Khomeini Welfare Committee (closed loop referral); 145 (14%) by rural health system insurance (semi-closed-loop referral); and 478 (46%) were covered by social security or therapeutic services insurance, out of pocket and other cost payment procedures (open referral). The subjects were interviewed individually in the waiting room by means of a questionnaire before or after their specialist visit. The self-referral rate in the triple insurance structure was calculated. The data were analyzed using a chi2 statistical test. Of the closed-loop referral system patients, 6.8% were self-referred, as were 29.7% of semi-closed referral system patients and 75.5% of open referral system patients (chi2 = 504; p <0.0001). The self-referral rate to the public sector was 60.5%, while to the private sector it was 36.4%, (chi2 = 449; p <0.001). The main reason patients gave for by-passing GPs and self-referring to specialists were: the specialist's high degree of skill in the specific area of the health problem (54%); waste of time to see the GP for a referral (14.9%); and that the patient's information about the referral system was poor (10.5%). The findings of this small study demonstrate the high degree of difference in the rates of referral by GP and self-referral according to the healthcare delivery system structure (insurance type and sector). The universal availability of health insurance may be one of the reasons for the similar health status of rural and urban populations in Iran. The findings may be regarded as preliminary to further research into this area of health system design.
 
Article
The 'Commission on the Future of Health Care in Canada' recognized that people living in rural and remote areas of Canada are at a disadvantage in health status, access to care and health professionals, and it considers the fight against these problems as a national priority. Although some attention has been paid to the prevalence of chronic diseases, very few studies have studied specifically the management and health issues in populations with chronic diseases in relation to rurality. The objective of this study was to describe systematic gaps across rural and urban populations in incidence, mortality, morbidity, material and human resources utilization, and drug management for three important chronic diseases: atherosclerosis, osteoporosis and diabetes. Three retrospective population-based cohort studies were used. Three study populations were selected: an atherosclerotic population including patients newly hospitalized for a myocardial infarction (MI), an osteoporotic population including the at risk population who have suffered from a fragility fracture (FF) and, finally, a diabetic population that includes only incident cases of diabetes patients. For each of the three chronic diseases, variables were selected and classified in six categories: incidence, mortality, morbidity, material resources utilization, physician consultation and drug treatment. The Statistical Area Classification (SAC) was used as the rurality definition and contains six categories including two urban areas--Census Metropolitan Areas (CMA), or metropolitan areas, and Census Agglomeration (CA), or small towns--and four rural areas: Strong, Moderate, Weak and No Metropolitan influenced zones (MIZ), depending on the proportion of the workforce that commutes to urban areas. Each disease-related variable was described using age- and sex-adjusted rates. For comparing rates between rurality classes, the adjusted relative risks were calculated using the CMA as the reference group. The X2 was used to test for the equality of risks. A common pattern was identified from this study: for all three studied diseases, the material resources utilization rates and the specialist (other than internist) consultation rates were almost always statistically lower in small towns and rural areas when compared with metropolitan areas. Mortality rates and drug utilization rates were very similar among regions, except for hormone replacement therapy in women where utilization rates were higher in small towns and rural areas compared with metropolitan areas. Among observations that were not common to all three chronic diseases, the first is that MI incidence was greater in small towns and in Weak MIZ compared with metropolitan areas, fragility fractures seem to be marginally more frequent in small towns but less frequent in rural areas compared with metropolitan areas, while an increased incidence rate of diabetes is observed in remote region and a smaller risk in moderate MIZ compared with metropolitan areas. For both atherosclerosis and diabetes, morbidity rates were always statistically higher in small towns and in rural areas. This was not the case for patients with osteoporotic fractures where similar morbidity rates across regions were observed, except in strong MI which show the lowest morbidity rate. There was substantially lower utilization of specialized services in non-metropolitan areas for all three diseases (myocardial infarction, osteoporosis, and diabetes). However, this did not translate into consistent differences in mortality and morbidity outcomes. This suggests that the impact of differential care utilization is specific to each disease, with indications that some important services may be under-utilized in rural areas, while others may be over-utilized in urban areas without improvement in outcomes.
 
Article
Somaliland is a self-declared state, not recognized by the nations of the world. Sixty percent of the population are herders or small scale farmers. Gross national product and other data are not available, but it is evident, according to surveys conducted by the United Nations, that most of the population has a low income. The health-care system consists of a public sector, which covers primary care, hospital care, immunizations, and tuberculosis care. The major clinical problems are tuberculosis, malaria and childhood diarrhea. Lack of trained personnel is a major difficulty in the health care system. This paper describes visits to health care facilities in Somaliland, and suggests some improvements for the system.
 
Participating communities (in red) of the Nunavut Inuit Child Health Survey, 2007-2008.  
. Among those taking any vitamins or supplements, only 26% reported taking any vitamin D during pregnancy, and 83.1% reported taking any iron or folate.
Article
Indicators of socioeconomic status, health behaviours and health histories are important for evaluating population health and indicators associated with 'indigeneity' features, prominently as determinants of health for Indigenous peoples. Health surveillance of young children, who represent society's most vulnerable, can provide meaningful data regarding achieving an optimal healthy start in life. A cross-sectional health survey of Inuit children, aged 3-5 years, was conducted between 2007 and 2008. The latitude of the communities ranged from 56 degrees 32'N to 72 degrees 40'N. A bilingual research team conducted face-to-face interviews which included the use of questionnaires covering factors associated with indigeneity, the physical and socio-economic environment, health behaviours and health histories. Weighted prevalence estimates were calculated. The participation rate was 72.3%; 388 randomly selected children participated. Indicators of traditional food utilization and sharing were highly prevalent and Inuktitut was spoken by 65.2% of preschoolers in the Inuktitut speaking regions. A large percent of the preschoolers lived in a crowded dwelling (53.9%) and in public housing (69.7%), and in a home in need of major repairs (37%). There was an average of 2 smokers per household but the majority of homes restricted smoking to outside the home (83.1%). The majority of mothers smoked during pregnancy (82.5%). For children who were not adopted, there was a high prevalence of breastfeeding initiation (80.6%). A high prevalence of children were ever hospitalized, excluding deliveries (41.6%), and within the past year 40.7% of the children had to be taken to the health centre or hospital for a respiratory problem. Indicators of indigeneity suggest the Inuktitut language is thriving and that children are learning Inuit ways through extended family contact and country food utilization and sharing. The high prevalence of smoking restrictions in the home is evidence of the success of public health messaging but further work is needed to improve health behaviours. The high prevalence of household crowding, homes in need of major repairs, public housing and income support all indicate chronic economic and social disadvantages that have negative implications for children's health. Interventions are needed to improve housing and reduce poverty for families with young children.
 
Article
Studies from the early 20th Century suggest that Inuit had a low prevalence of dental caries. However, Inuit children now experience a high prevalence of tooth decay and dental caries. The main objectives of this study were to provide an estimate of the prevalence and correlates of parental-reported oral health among Inuit preschool-aged children in Nunavut. Inuit preschool-aged children aged 3 to 5 years from 16 of Nunavut's 25 communities were randomly selected to participate in the Nunavut Inuit Child Health Survey conducted in 2007 and 2008. The parent/primary caregiver was asked to give written informed consent for their child's participation. Caregivers were asked to rate their child's oral and dental health and if their child had any 'decayed, extracted or filled baby teeth': an affirmative response designated a child as having reported-caries experience (RCE). Interviewer administered questionnaires included household characteristics, nutritional supplements, past-month qualitative food frequency questionnaire (FFQ), and a 24 hour dietary recall with repeat 24 hour recalls on a 20% sub-sample. The overall participation rate was 72.3% (388 children). Among the participating children, 53% percent were female and the mean age was 4.4 +/- 0.9 years. The weighted prevalence of RCE was 69.1% (95% CI: 63.7-74.4%). Caregivers rated their child's oral and dental health as: 'very good' (9.5%), 'good' (44.5%), 'fair' (29.5%) and 'poor' (16.6%). Very few children were taking a fluoride supplement (4.6%, 95% CI: 2.3-6.9%) or a vitamin D supplement (4.9%, 95% CI: 2.4-7.4%). Sixteen percent of children (95% CI: 12.3.-20.1) were taking a multivitamin and multimineral supplement containing vitamin D and calcium but not fluoride. In univariate analyses using data from the qualitative FFQ, children with RCE drank milk less often than children without RCE (1.6 +/- 0.1 vs 2.2 +/- 0.2 times per day, respectively, t-test p <or=0.01). Also, children with RCE drank more soda pop compared with children without RCE (0.8 +/- 0.1 vs 0.5 +/- 0.1 times per day, respectively, t-test p <or=0.05). Consistent with findings from the FFQ, children with RCE drank less milk in the previous day than children without RCE (225.9 +/- 17.0 vs 325.6 +/- 44.8 g/day respectively, p <or=.01). Reported-caries experience was also more common among children who did not take any nutritional supplements containing vitamin D, calcium or fluoride than among those who did (75.5% vs 60.0% respectively, chi(2) p <or=0.01). Multivariable logistic regression revealed that a higher frequency of milk intake was independently protective against having RCE (OR = 0.84, 95% CI: 0.73-0.97). A higher frequency of high-sugar food intake was independently associated with having RCE (OR = 1.11, 95% CI: 1.02-1.12). A high prevalence of RCE was found among Inuit preschool-aged children in Nunavut Territory, Canada. In this cross-sectional health survey, milk intake showed protective associations while sugar intake showed deleterious associations with RCE, which is compatible with emerging literature on milk in animal- and population-based research, and with existing literature on the deleterious effects of acidic sugary drinks on dental health. This study emphasizes the likely importance of nutritional health education and better access to nutritious foods for promoting oral health. It also demonstrates the continued importance of oral health initiatives that are currently in place in Nunavut.
 
Article
First Nation communities were highly impacted by the 2009 H1N1 influenza pandemic. Multiple government bodies (ie federal, provincial, and First Nations) in Canada share responsibility for the health sector pandemic response in remote and isolated First Nation communities and this may have resulted in a fragmented pandemic response. This study aimed to discover if and how the dichotomy (or trichotomy) of involved government bodies led to barriers faced and opportunities for improvement during the health sector response to the 2009 H1N1 pandemic in three remote and isolated sub-arctic First Nation communities of northern Ontario, Canada. A qualitative community-based participatory approach was employed. Semi-directed interviews were conducted with adult key informants (n=13) using purposive sampling of participants representing the two (or three) government bodies of each study community. Data were manually transcribed and coded using deductive and inductive thematic analysis to reveal positive aspects, barriers faced, and opportunities for improvement along with the similarities and differences regarding the pandemic responses of each government body. Primary barriers faced by participants included receiving contradicting governmental guidelines and direction from many sources. In addition, there was a lack of human resources, information sharing, and specific details included in community-level pandemic plans. Recommended areas of improvement include developing a complementary communication plan, increasing human resources, and updating community-level pandemic plans. Participants reported many issues that may be attributable to the dichotomy (or trichotomy) of government bodies responsible for healthcare delivery during a pandemic. Increasing formal communication and collaboration between responsible government bodies will assist in clarifying roles and responsibilities and improve the pandemic response in Canada's remote and isolated First Nation communities.
 
Swab results received according to day. 
Article
Pandemic Influenza (A/H1N1/2009) caused worldwide concern because of its potential to spread rapidly in human populations. In Scotland, Government policy had been to seek to contain the spread of the virus for as long as possible in order to allow time for service preparations, and for vaccine development and supply. The first major Scottish outbreak of pandemic A/H1N1/2009 was in the rural area of Cowal and Bute. After two initial cases were identified, contact tracing found a cluster of cases associated with a football supporters' bus. Within 3 weeks, 130 cases had been identified in the area. Rapid provision of treatment doses of anti-viral medication to cases and prophylactic treatment of asymptomatic close contacts, advice on self-isolation and, where required, interruption of transmission by temporary school closure, were successful in containing the outbreak. Pre-existing Major Incident and Pandemic Flu plans were used and adapted to the particular circumstances of the outbreak and the area. Supporting operational decision-making as close to the cases as possible allowed for speed and flexibility of response. Contact tracing and tracking of cases and results was performed by specialist public health staff who were geographically removed from the cases. This was possible because of effective use of existing telephone conferencing facilities, clarity of roles, and frequent communication among staff working on all areas of the response. Basing the work on established plans, staff experience of rural areas and rural service provision was successful.
 
Births at Tennant Creek Hospital, Northern Territory, 1994 to 2010. Data sources: Mothers and Babies reports 4-6 (for 1994 to 2007); NT Department of Health Perinatal Data Analyst, pers. comm., 18 July 2012 (for 2008 & 2009); Midwives Data Collection, NT Department of Health; unpubl. data, 2010 (for 2010). 4-6  
Age groups of Barkly women who gave birth at or were referred to Alice Springs Hospital in 2010.
Flowchart of Barkly women and births in 2010. Data source: Midwives Data Collection, NT Department of Health; unpubl. data, 2010.  
Article
A 2007 review of maternity services in Australia's Northern Territory (NT) noted the dissatisfaction of women in the Barkly region where the birthing service closed in 2006. The review recommended improved integration of maternity services, a consumer focus, and a pilot study of birthing in Tennant Creek Hospital (TCH) in the Barkly region. Barkly region is sparsely populated, with 5700 people in 320 000 km2. The town of Tennant Creek with 3100 population is the only centre of more than 1000 people. In the Barkly region, 64% of the population and 74% of birthing women are Aboriginal. Current NT Department of Health (NT DoH) policy requires all women to give birth in a town with facilities for operative delivery. For most Barkly women this means travelling 500 km to Alice Springs with limited support for travel and accommodation. Emergency air evacuation is arranged for all women who enter labour or give birth while in the Barkly region, whether at TCH or elsewhere. This project was a collaboration between Anyinginyi Health Aboriginal Corporation and NT DoH to examine clinical data to inform a discussion of re-introducing birthing to TCH. Women who were resident in the Barkly region and gave birth in NT in 2010 were identified from the NT Midwives Data Collection. Women who gave birth in Central Australia were managed at Alice Springs Hospital (ASH), either for the birth or afterwards. Antenatal, birthing, postnatal and neonatal data were extracted from ASH records. In total 99 women were identified as residents in the Barkly region from all those who gave birth in 2010. Of these, 83 gave birth in Central Australia, and their records were reviewed for this study, showing that 69 (83%) were Aboriginal; 42 were resident in Tennant Creek; and 29% were aged under 20 years with one under 16 years. Regarding delivery, 53 (64%) women had an unassisted vaginal birth; of 18 women who had had a previous caesarean section, 5 (28%) had a vaginal birth; of the 25 women who had had a normal vaginal birth previously and had no indications for obstetric consultation at the time of labour, three underwent emergency caesarean section. There were 86 infants, all liveborn; 16% were preterm; 21% were of low birth weight; and 6% weighed more than 4.5 kg. Six women gave birth in the Barkly region, two at TCH and four in health centres in remote townships. These mothers and babies were evacuated immediately following birth to ASH, irrespective of indications for referral. Eleven women were evacuated to ASH in labour and six of these were preterm. Opportunities exist to improve maternity care through improved collaboration, even when women cannot give birth in or near their home community due to the absence of birthing services. The remote location of the Barkly region presents challenges to providing maternity care that addresses medical, cultural, psychological and social needs of the childbearing population. Because of this, every opportunity should be taken to optimise maternity care by improvements in continuity of care and carer, improved communication between service providers, and the use of evidence-based guidelines.
 
cont'd 
Article
Raw seafood consumption has frequently been linked to gastroenteritis and Norovirus is a common cause. In February and March 2010, there was an increase cases of gastroenteritis on the remote island of Agios Efstratios in the Northern Aegean Sea, Greece. A massive increase in seafood consumption associated with a religious festival a few days prior to the outbreak suggested seafood as the vehicle of transmission. An outbreak investigation team visited the island in order to document the outbreak and find epidemiological evidence for its source. The whole island was used as a cohort in the retrospective cohort study that was conducted. Sixty-four of the 181 participants reported having had symptoms of gastroenteritis, of which 34 were considered primary cases. People who consumed any raw seafood imported to the island were 21.5 times (95% CI: 8.95-51.8) more likely to develop symptoms of gastroenteritis in the 72 hours following exposure. Consumption of local seafood was not found to be a risk factor. Despite the lack of laboratory evidence, all four Kaplan's criteria were met and the outbreak was thought to have been caused by Norovirus. The outbreak investigation demonstrates epidemiological methods for use in a remote setting, where the means for laboratory and environmental investigation may be absent or limited.
 
Survey response rate for rural doctors by state or territory 1 
Summary of Difficult Airway Society UK (DAS UK) algorithm for difficult airways. Reproduced with the permission of the Difficult Airway Society (UK). The DAS algorithms are designed to facilitate a safe approach to difficulties during intubation. Certain categories of equipment are needed for each stage (alternative means of laryngoscopy, classic or intubating laryngeal mask airways, fibreoptic intubation devices and equipment to create a surgical airway and deliver oxygen through it). Difficulties with bag-mask ventilation should also be anticipated and require adjunct equipment such as nasal and oral pharyngeal airways, a means to detect end-tidal carbon dioxide and a means to detect inadvertent oesophageal intubation.  
GP-anaesthetist responses to questions regarding the availability of difficult airway equipment in rural Australia, n = 292 
Recommendations for rural GP-anaesthetists and rural hospitals in Australia 6,8 
Article
In rural Australia, general practitioners (GPs) form the frontline for provision of medical services. Besides responsibilities for primary care via private practice, rural doctors often provide emergency and inpatient services for rural hospitals. The aim of this study was to determine access to difficult airway equipment and training among the GP-anaesthetist cadre in rural Australia. Design: an online survey regarding availability of difficult airway equipment, access to ongoing training and inviting comments on rural anaesthesia in general. Setting: a questionnaire was distributed to rural doctors in January 2012 via membership databases of the Rural Doctors Association of Australia and state-based Rural Doctor Workforce Agencies. Participants: 293 participants identified as a GP-anaesthetist working in rural Australia (65% response rate). Of these 83% were male, 17% female with the percentage of respondents from each state concordant with the distributions indicated by the 2010 Rural Health Workforce National Minimum Dataset. Main outcome measure: closed-ended questions were quantified and open-ended questions analysed to determine issues relevant to GP-anaesthetists. Only 53% of GP-anaesthetists reported access to a difficult airway trolley or box in their facility. Lack of availability of certain airway equipment was reported among GP-anaesthetists, with very few having access to advanced intubation aids such as videolaryngoscopes or fibreoptic devices (flexible fibrescopes and/or malleable fibreoptic stylets). Open-ended questions suggested that GP-anaesthetists desired such aids to manage difficult airways. Only 79% had access to surgical airway or paediatric airway equipment. Of the respondents, 58% reported involvement in prehospital medicine but only 12% had received training in this challenging environment. A formal arrangement for prehospital responses existed for only 7% of respondents. Despite the existence of well-publicised algorithms for difficult airway management and the need for specific equipment to manage the difficult airway, Australian GP-anaesthetists report difficulty accessing essential equipment for these infrequent but life-threatening events. This is surprising in the light of recommendations from the Australian and New Zealand College of Anaesthetists. The consequences of difficulty in airway management can be catastrophic. Equipment needs must be balanced against important considerations including ease of use, initial and ongoing training, and cost. Suggestions for affordable equipment and ongoing training for rural GP-anaesthetists are made. The involvement of GP-anaesthetists in prehospital responses occurs in the absence of formal arrangements and with a dearth of training. There is scope to improve rural prehospital responses in Australia, utilising the advanced skills of GP-anaesthetists in resuscitation and airway management.
 
Article
Colonoscopy remains the gold standard for the investigation and management of bowel pathology. A 2009 National Bowel Cancer Screening Program Quality Working Group report revealed that small rural towns in inner regional Victoria, Australia, for example Echuca (Rural and Remote Metropolitan Areas [RRMA] 4), registered 10.5 colonoscopies per 1000 population versus 18.5 per 1000 in the state capital Melbourne. Reasons for this discrepancy include lack of skilled practitioners in rural communities and travel time for patients to attend larger centres when the required bowel preparation or mobility issues limit access. Ideally, services are high quality, safe and local. This study assessed the quality and safety of a rural GP colonoscopy service. The indications, findings, caecal intubation rates, complications and completion time were recorded for 3000 serial colonoscopies performed by one rural procedural GP from 1995 to 2011 in Victorian Echuca. Quality was assessed using caecal intubation rate, polyp and colorectal carcinoma detection rates, and completion time. Safety was determined by complication rates. The caecal intubation rate was 97% (excluding stenosing lesions), polypectomy detection rate was 39%, carcinoma detection rate was 2%, and the average time to completion was 17 min. Re-admission rates were 1.6/1000 for haemorrhage and 1.2/1000 for perforation. There were no deaths. The results from this study compare favourably with published international standards, validate Australian general practice procedural training standards, and validate the additional quality measure of 'colonoscopy completion time'. Rural GPs can provide a safe and high quality service. Extending this service model to similar settings could improve reduced access to colonoscopy for rural Australians.
 
Article
The 50th annual National Scientific Conference of the Australian Society for Medical Research was held in Cairns, Queensland, 13-16 November 2011. The theme, 'Indigenous Health: ACTION on Prevention' highlighted the direct action being undertaken by health and medical researchers, as well as allied health professionals, to improve long-term health outcomes for Indigenous Australians. © R Yazbeck, P Dawson, N Rogers, C West, R Keogh, D Wallace, S Polyak, K Nowak, R Burt, J Taylor, L Dunn, A Philp, E Parkinson-Lawrence, 2012.
 
The receiver operator characteristic (ROC) curves for waist circumference to predict the presence of two or more risk factors of the metabolic syndrome, as defined by the International Diabetes Federation for females. 
Article
The determination of cutoff points for healthy waist circumference (WC) is of paramount importance for prevention, optimum management, and prognostication of obesity, the metabolic syndrome (MetS), type 2 diabetes mellitus, and coronary heart disease. The aim of this project was to establish the cutoff level for WC in rural Basrah in Iraq, one of the eastern Mediterranean and Middle East (Arab) populations. This was a community-based, cross-sectional survey for establishing the normal value for WC among a rural district population in Basrah (Abu-Al-khasib), Iraq. A stratified sampling procedure was used for sample selection. The cutoff level yielding maximum sensitivity and specificity for predicting the presence of multiple risk factors was 97 cm in men and 99 cm in women. Sensitivity and specificity using these cutoff values were 70% and 50%, respectively, in men and 70% and 45%, respectively, in women. We propose the optimal cutoff point for WC for the diagnosis of MetS in the Iraqi adult rural population as 99 cm in women and 97 cm in men.
 
Article
Introduction: In remote Australia timely access to pathology results and subsequent follow-up of patients for treatment is very challenging due to the long distances to the nearest laboratory. Point-of-care testing (POCT) offers a practical solution for pathology service provision in such remote communities. Since 2008, POCT for haemoglobin A1c (HbA1c) has been conducted in remote Northern Territory (NT) health centres for diabetes management of Indigenous patients through the national Quality Assurance in Aboriginal and Torres Strait Island Medical Services (QAAMS) Program. Methods: Point-of-care testing HbA1c results performed on Indigenous diabetes patients in the NT from July 2008 to April 2011 was accessed via the NT's electronic patient information system. Patients who had three or more HbA1c results performed by POCT across this period were assessed to determine their overall change in glycaemic control. An audit of 40 of these Indigenous diabetes patients (who exhibited a decrease in HbA1c levels of more than 1.5%) was undertaken to compare clinical and operational efficiency of POCT versus laboratory testing over an equivalent time period (15 months). Results: No change in glycaemic control was observed when these patients received laboratory HbA1c testing prior to the introduction of POCT. Long turnaround times for receipt of results and follow-up consultation with patients were identified during this period, compared to immediate receipt and actioning of results using POCT. Frequency of HbA1c testing was higher with POCT than for the laboratory. Conclusions: This audit demonstrates that POCT can significantly improve the timeliness and clinical follow-up of pathology results in remote locations, while also reinforcing the clinical and cultural effectiveness of POCT and its critical role in assisting to improve diabetes management in Indigenous Australians.
 
Article
Mediterranean countries such as Greece have experienced rapid social change in the last decade. These community changes affect nutritional habits and there is a tendency for the traditional healthy Mediterranean diet to be abandoned. The parents of children from one rural Greek village on Crete (Neapolis), and one rural village in Sweden (Kisa) were invited to their primary health care centers for an interview and to fill in a validated nutrition questionnaire, KidMed. There were no differences (p = 0.48) in total KidMed score between the Cretan and Swedish children, adjusted for gender and age. However, there were some significant differences in scores on certain KidMed questions. Parents of the Cretan children reported significantly higher daily use of olive oil at home and more regular nut consumption, but also more commercially baked goods or pastries for breakfast. The parents of Swedish children reported significantly higher use of cereals, grains or bread for breakfast. The mean BMIs were similar for the Cretan (Neapolis mean 16.8, 95% CI 13.5-23.0) and for the Swedish children (Kisa mean 17.4, 95% CI 13.7-25.5) The results suggest the possibility of changing nutritional habits, measurable among young children in rural areas. The study raises the question of whether Cretan children may have abandoned some aspects of the traditional Mediterranean diet. It may also be that Swedish children have changed their diet in favor of a more Mediterranean food choice. The major limitation of the study is the small sample size, and further, larger studies are warranted.
 
Article
There is major maldistribution of physicians in the Democratic Republic of the Congo (DRC). While 70% of Congolese live in rural areas, relatively few doctors practice there. Of the 25 medical schools in the DRC (14 public and 11 private) only one private medical school is located in a rural area. The purpose of this article was to analyse and compare the graduates of an urban- and a rural-located university in DRC. The 6 first classes of the Catholic University of Graben (UCG) Medical School at Butembo (rural) and Université Evangélique en Afrique (UEA) at Bukavu (urban) (43 and 120 graduates, respectively) were compared according to their rural or urban employment, among other variables. In total, 97.7% of graduates from the rural-located medical school were employed in the province where they trained, the majority (81.4%) in rural areas. In contrast, 40.0% of graduates from the urban-located school were employed in the province where they trained, with 23.7% working in a rural area. Over 55% of all graduates worked 78 km of their training medical school. Only 2.5% of the rural-school graduates entered residency programs, compared with 15.2% for urban-school graduates. The results support the policy of establishing medical schools in rural areas, and also provide indications of approaches likely to increase the number and expertise of rural-located physicians.
 
Ethical models for Aboriginal research 
Conceptual model of the key groups involved in the consensus process 
Research priorities to expand e-health and track its impact 
Article
In Canada, telehealth has been successfully implemented in a number of Aboriginal communities with subsequent improvements to access to health care and quality of life. However, there are many knowledge gaps that limit our understanding of the broad range of Aboriginal e-health issues; a research agenda is urgently required. The objective of this research was to develop an Aboriginal e-health research agenda designed to address the substantial knowledge gaps that impede e-health deployment and adoption particularly in rural and remote Aboriginal communities in Canada. A consensus method based on Aboriginal culture, values and approaches to consensus was developed to achieve this. In this consensus methodology, a core group of Aboriginal telehealth leaders, led by a research facilitator, engaged in an iterative process of individual and group review of research data. The reviewed data included stakeholder interview data, questionnaires, literature and other resources and was prioritized in order to develop recommendations for an Aboriginal e-health research agenda. A total of 40 stakeholders including Aboriginal Telehealth Knowledge Circle (ATKC) members, communities of practice and regional, provincial and federal leaders and policy-makers participated in the consensus process. The research recommendations showed a high degree of consistency among stakeholders. Participants reached consensus on 6 areas: research ethics, internet-based e-health services data, educational resources, sustainability models, best practices and exploration of innovative applications. An ATKC consensus process was successfully applied to reach consensus on an Aboriginal e-health research agenda, demonstrating the potential of Indigenous research approaches for defining levels of agreement on complex topics. The resulting conceptual map for e-health research can be used as a springboard for partnership-based research initiatives involving Aboriginal communities, governments and researchers, and may be of interest to Indigenous e-health researchers at an international level.
 
Article
Populations that are developing (westernizing) are suffering the highest rates of increases in diabetes incidence and prevalence worldwide, with the most notable and documented increases in Canada seen among the First Nations. Less is known about the Métis (mixed blood) or the rural populations in general. To date, no studies have assessed the contributions of ethnicity to diabetes risk-factors. Our objective was to examine diabetes risk factors in First Nations, Métis and non-Aboriginal individuals residing in rural or remote locations, investigating whether ethnicity contributed to any differences. From the databases of three separate community-based diabetes screening projects in Alberta we created a unique subject pool of 3148 adults without diabetes (1790 First Nation, 867 Métis, and 491 non-Aboriginals). Age, body mass index (BMI), waist circumference, reported history of gestational diabetes (GDM) or babies over nine pounds (females only), hemoglobin A1c (A1c) fasting plasma glucose (FPG) or random plasma glucose (RPG) were assessed. Chi-square tests and logistic regression analysis were used to identify between-group differences. The highest mean values for waist circumference (104.7 cm) and BMI (31.2) were found in First Nations subjects (p<0.01). First Nations individuals had the highest prevalence of overweight/obesity (84.4%), abnormal waist circumference (76.8%) and history of GDM (9.0%) (p<0.01). The RPG was also higher in First Nations, but there were no differences between groups with respect to mean FPG and A1c levels, and there were no differences with respect to the prevalence of pre-diabetes or undiagnosed diabetes. Métis (OR 0.80; p = 0.01) and non-Aboriginal individuals (OR 0.62; p< 0.01) were less likely to be obese after age/gender adjustment, compared with First Nations. Métis (OR 0.70; p<0.01) and non-Aboriginals (OR 0.35; p<0.01) were also less likely than the First Nations group to have abnormal waist circumferences. Individuals in the non-Aboriginal group had a lower prevalence of pre-diabetes (OR 0.50; p = 0.01) compared with both the Métis and First Nations groups. First Nations individuals had more risk factors for diabetes than Métis and non-Aboriginal individuals, although Métis rates appeared intermediate. While these risk-factor differences did not translate to more undiagnosed diabetes or pre-diabetes, they are consistent with known rates of diagnosed diabetes in Alberta.
 
Article
The chronic diseases associated with overweight and obesity are major contributors to the excess disease burden of Aboriginal Australians. Surveillance of overweight and obesity is required to monitor these conditions, and to develop and evaluate interventions to improve health and wellbeing. Remote Aboriginal communities in Australia's Northern Territory (NT) are where approximately two-thirds of the NT Aboriginal people live, a proportion which has been stable over many years. However the remote communities suffer significant socioeconomic disadvantage including limited education and employment opportunities, and poor quality and overcrowded housing. Approximately one-third of Aboriginal people in NT live in central Australia, which consists of the Alice Springs and Barkly districts. The Healthy School-Aged Kids Program includes health promotion and child health screening, and is run in remote Aboriginal communities of NT. This report provides estimates of prevalences of overweight and obesity among children in central Australia who participated in health checks as part of Healthy School-Aged Kids Program in 2010. All children in remote central Australian Aboriginal communities were invited to participate in health checks. Children who attended were weighed and measured. Date of birth, sex, height and weight for each child were used to determine prevalence of overweight (≥+1 standard deviation [SD] BMI-for-age) and obesity (≥+2 SD BMI-for-age) according to WHO Growth standards. Differences in proportions of overweight and obesity by age group and sex, and their statistical significance were calculated. Weight, height, sex and age data were available for 996 children from a population of 1764. It was found that 22.1% of girls and 20.7% of boys were overweight; and 5.1% of girls and 5.8% of boys were obese as defined by BMI-for-age. Prevalence of overweight but not obesity increased with age (for overweight z=3.28, p=0.0011; for obesity z=0.68; p=0.50). The prevalences of overweight and obesity as estimated by BMI-for-age among children in remote central Australian Aboriginal communities were compared with those in other Australian surveys. They appear unlikely to reflect future relative risk of the chronic diseases with which overweight and obesity are associated. Routine collection of data on BMI-for-age may not provide adequate estimation of future risk of chronic disease burden attributable to overweight and obesity among these children. Alternative measures for surveillance for overweight such as waist circumference may prove more useful. Appropriate interventions to reduce risk of chronic disease are required, including interventions to reduce prevalences of overweight and obesity.
 
Contact attempts 
Mode of Interview 
Article
Introduction: Equitable recruitment strategies, designed to ensure improved opportunities to participate in the research, are needed to include First Nations (FN) communities. The purpose of this article is to report on a set of successful strategies trialed with rural and FN communities in Canada. The strategies discussed were designed as part of a larger mixed-method study examining the effectiveness of Group Medical Visits (GMVs) on the quality of primary healthcare (PHC) in both FN reserve and northern communities in British Columbia (BC). Methods: Community partners and the study's decision-maker partners helped to identify and recruit primary care practices and reserve communities who were offering GMVs. Eleven communities (6 rural and 5 FN reserve) within the Northern Health Authority, BC participated in the study. Participants completed a survey either in person or via telephone. Content analysis was conducted on team meeting and field notes, focusing on issues related to the data collection process. Financial analysis was conducted on monetary resources spent on recruitment efforts in the various communities. Data were recorded regarding the number of times potential participants were contacted and mode of interview. Descriptive statistics were used to examine whether there were differences by mode of data collection, gender, and FN status. Logistic regression was used to examine whether FN status remained statistically significant after controlling for sex, education, employment status, age and health status. Results: Once people were contacted, participation rate was 68% with 269 (n=90 men, n=179 women) people. Of those who participated in the survey, 42% were from FN communities. Content analysis revealed two overarching categories: (1) communication and coordination of the geographically dispersed research team and participating communities was maintained using synchronous and asynchronous methods; and (2) flexibility was needed to tailor recruitment strategies. Financial resources required to achieve equitable recruitment across these communities can cost up to 17 times more than travel to sites accessible by a direct flight or car. The farther away from Prince George (BC's capital in the north), the more resources were needed to ensure equitable recruitment from a community. Community partners played a critical role in recruiting potential participants. Team members, particularly those from urban areas, require support to successfully navigate working in small northern communities. Conclusions: Achieving equity in recruitment requires flexibility, trusting partnerships within each community and regular communication among the research team. A significant portion of time and resources needs to be allocated towards travel to these communities. While achieving equity in recruiting research participants poses a number of challenges, including greater costs, research that ensures participation opportunities for rural and FN communities is likely to better inform effective strategies to meet the needs of these communities.
 
Article
Indigenous children in Australia have higher dental caries levels than their non-Indigenous counterparts. Indigenous communities in South Australia's mid-north region have identified dental health as one of their top health priorities. In response to this, an oral health program based at the Pika Wiya Health Service in Port Augusta was established, with a dentist providing care for adults, and a dental therapist providing care for children, 2 days per week each. The purpose of this article is to compare the socio-demographic and oral health characteristics of children attending for care at the Pika Wiya Health Service Dental Clinic with those of their counterparts attending the general Port Augusta School Dental Service (SDS). Both Indigenous and non-Indigenous children were included. Data were obtained from the South Australian Dental Service (SADS), which routinely collects socio-demographic and dental information from patients seen through their system. Examinations were conducted by SADS-employed dental professionals. A full enumeration of children attending for care at Pika Wiya and the Port Augusta SDS from March 2001 to March 2006 was included. Surface level tooth data was captured using the EXACT treatment charting and management information system. The Socio-Economic Indices For Areas (SEIFA) were used to determine socio-economic status, and the dmft (sum of decayed, missing and filled teeth in the deciduous dentition) and DMFT (sum of decayed, missing and filled teeth in the permanent dentition) indices were used to assess oral health outcomes. Both measures were used for children aged 6-10 years because in such age groups children have a mixed dentition (both primary and permanent teeth are present). Caries prevalence (dmft/DMFT>0) and severity (mean dmft/DMFT) were calculated, as well as the Significant Caries Index (SiC) and Significant Caries Index 10 (SiC 10). The SiC is the mean dmft/DMFT of the one-third of the sample with the highest caries score; while the SiC 10 is the mean dmft/DMFT of the one-tenth of the sample with the highest caries score. In the 5 year observation period, 760 children were seen at the Pika Wiya Dental Service while over 6800 were seen at the Port Augusta SDS. A higher proportion of pre-school children attended for care at Pika Wiya, while proportionally more children aged > or = 11 years attended for care at the Port Augusta SDS. More females attended for care at Pika Wiya. Almost all children (99%) attending for care at Pika Wiya lived in the most disadvantaged areas according to the SEIFA scale. Children attending for care at Pika Wiya had three-times the mean number of decayed deciduous and permanent teeth than their counterparts attending the Port Augusta SDS. Over 75% of children attending for care at Pika Wiya aged 10 years or less had dental caries experience in the primary dentition compared with just over 50% of children attending for care at the Port Augusta SDS. Children attending for dental care at Pika Wiya aged 10 years or less had 1.8 times the mean dmft, 1.4 times the SiC and 1.4 times the Sic 10 of their counterparts attending for care at Port Augusta SDS. Over half the children aged > or = 6 years who attended Pika Wiya for dental care had caries experience in the permanent dentition compared with 38% of their Port Augusta SDS-attending counterparts. Children aged > or = 6 years who attended Pika Wiya for dental care had 1.9 times the mean DMFT, 1.8 times the SiC and 1.6 times the SiC 10 of their similarly-aged Port Augusta SDS-attending counterparts. Children attending for care at the Pika Wiya Dental Service were more likely to be pre-school-aged, female, Indigenous and living in a socially disadvantaged area, in comparison with children attending the Port Augusta SDS. Pika Wiya-attending children had 1.5-3 times the dental caries prevalence and severity in both the primary and permanent dentition of children attending for care at the Port Augusta SDS. The higher levels of dental caries experience, untreated disease and social disadvantage of children attending Pika Wiya provides further evidence for the need to address the health inequalities for Aboriginal children living in South Australia's mid-north region. While the Pika Wiya Oral Health Program is attempting to address some of these needs, a much broader focus to address the social and health inequalities will be required to improve the oral health characteristics of this population. It is hoped that through the Pika Wiya Dental Service's dedication to increasing Aboriginal child dental service participation rates, the proportion of untreated decay will diminish.
 
Article
(1) To identify which medical disorders are significantly associated with being a diabetic in the setting of an isolated, rural community; and (2) to determine if there are differences between Aboriginal and non-Aboriginal diabetics. population based retrospective chart review. people living in the Bella Coola Valley, Canada, and having a chart at the Bella Coola Medical Clinic as at September 2001. known diabetes related co-morbidity (retinopathy, nephropathy, coronary artery disease, peripheral vascular disease, neuropathy). There were 126 adult (>18 years old) diabetics living in the Bella Coola Valley. Prevalence rates for history of alcohol issues, retinopathy, coronary artery disease, cerebrovascular disease, peripheral vascular disease, peripheral neuropathy, hypertension, hypercholesterolemia, and nephropathy were 44%, 14%, 19%, 8%, 7%, 10%, 54%, 47%, and 7% respectively. For the 1597 non-diabetics living in the Bella Coola Valley, respective prevalence rates for these same co-morbidities were 20%, 0.3%, 2%, 1.5%, 1%, 1%, 10%, 6%, and 0.6%. The study did not demonstrate that Aboriginal people living in the Bella Coola Valley have an increased prevalence of diabetes associated co-morbidities over and above that found in the non-Aboriginal diabetic population. This was despite the fact the smoking rate was higher in the Aboriginal population. The development of diabetes in both Aboriginal and non-Aboriginal people living in the Bella Coola Valley was clearly associated with the presence of multiple co-morbidities, including hypertension, hypercholesterolemia, coronary artery disease, cerebrovascular disease, and neuropathy. Rates of diabetes associated co-morbidities were similar for both Aboriginal and non-Aboriginal diabetic populations. The authors speculate that a diet rich in fish oils (omega-3 fatty acids) accounted for the lower than expected rates of cardiovascular disease among this Aboriginal population.
 
Article
There has been a significant increase in the burden of renal disease among Aboriginal Australians over the past 15 years. Urine albumin:creatinine ratio (ACR) is a well-established marker of microalbuminuria and can be conveniently performed on the DCA 2000 point-of-care testing (POCT) analyser (Bayer Australia; Melbourne, VIC, Australia) with an on-site result available in 7 min. The application of the urine ACR POCT for renal disease risk assessment was pioneered by our group in the Umoona Kidney Project. This article describes the results of the management arm of the Umoona Kidney Project, which used point-of-care urine ACR testing for the first time within a management framework to monitor albuminuria in patients at highest risk of renal disease. The article also examines the analytical quality of POCT results and overall community acceptance of the Umoona Kidney Project. Adults clinically assessed by Flinders Medical Centre renal specialists as being at greatest risk for renal disease were offered the ACE inhibitor (ACEI) perindopril on a voluntary basis. Selected renal markers, including POCT urine ACR (conducted on-site by Umoona's Aboriginal health worker team), plasma electrolytes, urea, creatinine, calculated glomerular filtration rate and blood pressure were measured six monthly. Regular quality control testing was undertaken to monitor the analytical performance of the POCT analyser. A culturally appropriate questionnaire was designed and implemented to assess community satisfaction with the project. In all, 231 patient management consultations were conducted over a two year period, with over 70% of patients having four or more (up to a maximum of eight) consultations; 35 patients (mean age 49.2 [+/-2.3] years, 54% males) participated voluntarily in the management arm. All were overtly hypertensive, hypertensive with other risk factors or had diabetes. The renal status of these patients was followed for a mean of 63 +/- 4.5 weeks. In total, 111 POCT urine ACR tests were performed for patient management (mean 3.2 tests per patient). There was no significant difference in POCT urine ACR in the study period with a median (and inter-quartile range) of 5.7 mg/mmol (1.2-15.2) pre-ACEI and 4.3 mg/mmol (1.3-16.7) post-ACEI treatment (p = 0.50, Wilcoxon signed ranks test). The calculated glomerular filtration rate altered from 110 to 118 mL/min (p = 0.019, paired t-test). There was no change in the group plasma potassium, urea and creatinine. Collectively these results indicate a stabilisation in renal function among the management group. Blood pressure (both lying and standing) fell significantly in the study period. The imprecision for urine ACR quality control POCT conducted during the management program was within nationally and internationally accepted precision goals for urine albumin, creatinine and ACR. Fifty community members completed the satisfaction questionnaire. Three-quarters of respondents felt there were no cultural barriers in providing a urine sample for urine ACR POCT. The management arm of the Umoona Kidney Project was effective in stabilising the renal function and improving the blood pressure of community members identified to be at greatest risk of kidney disease. POCT urine ACR testing can be utilised, not only for community risk assessment, but also for patient management. The Umoona Kidney Project was well accepted by the health service and community members.
 
Article
Community-based first aid training is the collaborative development of locally relevant emergency response training. The Sachigo Lake Wilderness Emergency Response Education Initiative was developed, delivered, and evaluated through two intensive 5-day first aid courses. Sachigo Lake First Nation is a remote Aboriginal community of 450 people in northern Ontario, Canada, with no local paramedical services. These courses were developed in collaboration with the community, with a goal of building community capacity to respond to medical emergencies. Most first aid training programs rely on standardized curriculum developed for urban and rural contexts with established emergency response systems. Delivering effective community-based first aid training in a remote Aboriginal community required specific adaptations to conventional first aid educational content and pedagogy. Three key lessons emerged during this program that used collaborative principles to adapt conventional first aid concepts and curriculum: (1) standardized approaches may not be relevant nor appropriate; (2) relationships between course participants and the people they help are relevant and important; (3) curriculum must be attentive to existing informal and formal emergency response systems. These lessons may be instructive for the development of other programs in similar settings.
 
Article
The purpose of this qualitative study was to develop a comprehensive understanding of Aboriginal women's experiences and perceptions of providing care to the elderly in geographically isolated communities (GIC). Research with Aboriginal women caregivers is essential as the population of Aboriginal elders is increasing, and Aboriginal women represent the majority of caregivers in their communities. This study was guided by focused ethnography, which seeks an understanding of a sub-group within a cultural group by uncovering the less obvious expressions and behaviours of the sub-group members. Using one-on-one open-ended interviews and participant observation, 13 women from a number of Aboriginal communities in northern and southern Ontario participated in this study. Data analysis was conducted by reviewing transcripts of interviews to identify codes and themes. Study findings revealed that four concentric circles represent the caring experiences of the Aboriginal women participants: the healers, the family, the Aboriginal community, and the non-Aboriginal community. Cultural values greatly informed participants' perceptions about caring for elderly persons in GIC. These values are represented in five themes: passing on traditions, being chosen to care, supporting the circle of healers, (re)establishing the circles of care, and accepting/refusing external resources. The findings from this study have significant implications for healthcare practice and future research.
 
Article
The oral health of the Indigenous community in South Australia's mid-north has been a concern for some years. There has been a history of under-utilisation of available dental services by the local community. This is in part due to the services not meeting their cultural and holistic health care needs. The Indigenous community resolved to establish a culturally sensitive dental service within the Aboriginal Health Service already operating in Port Augusta in South Australia's mid-north. To achieve this, a partnership between Pika Wiya Health Service Incorporated, the South Australian Dental Service, the University of Adelaide Dental School and the South Australian Centre for Rural and Remote Health was formed. The aim of the project partners was to establish a culturally sensitive, quality dental service that caters to the needs of the Indigenous community serviced by Pika Wiya Health Service Inc. This article describes the process of planning and implementing the first stage of this project.
 
Article
The integration of health care among providers to achieve good outcomes has been investigated in urban locations. However, more information is needed about what happens to people from rural areas, particularly when travelling away from their families and healthcare provider to receive hospital care. Therefore, a national project was conducted in 2004 that aimed: to document the experiences of people travelling to and from rural and remote areas to city hospitals; to identify factors that affect their optimal health outcomes; and to improve the exchange of information between primary healthcare providers and hospital staff. The Australian Rural Health Education Network (AHREN) coordinated the study, which consisted of several case studies. This article, part of the larger investigation, presents a segment on issues for Aboriginal people living in a rural and remote Australian area that were identified by local health workers, and suggestions that might assist in overcoming them. Research and ethics approval was obtained from our university, hospital and the Aboriginal Health Council. Three Aboriginal health workers, employed at the community controlled Aboriginal health centre, involved in transport, consented to be audiotaped in a group interview. They are named researchers. Questions were: What are the issues in transfer to and from the city hospital? What special problems exist for the Aboriginal people you are involved with? What improvements/systems changes would you suggest? Funding and equity of the Patient Assisted Transport Scheme (PATS) created problems. Raising payments for PATS and extra costs to clients and families were big issues. Antisocial arrival times, separation from family, transport to hospital and accommodation all caused distress and confusion. Potentially dangerous misunderstandings happened through language and cultural differences. Traditional people travelling unaccompanied were at risk. Often PATS notification requirements could not be met in emergencies and onsite accommodation was described as frightening and culturally inappropriate. At the time of interview, Stepdown transport did not cover people staying with families. Lack of privacy, different understandings of family and other issues important for Aboriginal people continue to add stress for families already suffering. PATS could be streamlined and more user-friendly. Aboriginal Liaison Officers in hospitals provide a link for Aboriginal clients, but unrealistic expectations may be placed on them and they are not available 24 hours a day. Strategies for improved communication are needed. A space and campfire in hospital grounds for traditional people and their families to gather would assist.
 
Keynote speakers 
Article
Research in the sciences is now beginning to acknowledge what many Aboriginal educators and students have experienced or witnessed in educational curricula, a general dismissal of Indigenous knowledge as being considered scientifically 'worthy'. This is the result of educational institutions', and the systems within which they are placed, failure to teach from broad cultural orientations. Aboriginal persons are under-represented in post-secondary education programs, with a similar disparity in the limited number of Aboriginal persons holding careers in health, science and engineering occupations. The University of Lethbridge is attempting to increase the number of Aboriginal students who successfully complete programs in a variety of areas. To that end, the Support Program for Aboriginal Nursing Students (SPANS) commenced in Fall 2007 in order to increase the numbers of Aboriginal students who enter and complete the 4 year nursing program. At one time there were as few as 2-3 Aboriginal nursing students across the 4 years of the program. Since SPANS began there are now 34 students of Aboriginal background across all 4 years of the nursing program. This is noteworthy because statistically there are only 1200 Aboriginal Registered Nurses in Canada, a daunting statistic that is alarming low. One of the objectives of SPANS is to enhance the nursing faculty and clinical instructors' understanding of Aboriginal science so that it can be integrated into the current curriculum. With this aim, an Aboriginal Science Symposium was held in May 2009 to bring nursing faculty together with other University faculty and experts in Aboriginal science. The symposium attempted to highlight the links between programs in nursing and health sciences and the need for integration with Aboriginal science. The 3 specific symposium objectives were to: (1) generate an understanding of traditional scientific knowledge; (2) bridge Aboriginal and Western scientific thought, toward and; (3) understand ways of implementing and raising awareness of how Aboriginal knowledge and understanding of science can be applied to help inform and improve teaching in all educational science settings. From keynote addresses, panel group discussions, and breakout sessions, participant responses to the symposium objectives coalesced into 4 themes: (1) Aboriginal ways of knowing: informing Western science curricula; (2) Elders and community, enhancing science education; (3) Aboriginal student experience in the science classroom; and (4) strategies and advice to meet the needs of the Aboriginal science student.
 
Article
Research shows that Australian Aboriginal women experience a significantly higher rate of mortality from cervical cancer than non-Aboriginal women. We now understand that infection with human papillomavirus (HPV) is a necessary pre-requisite for cervical cancer. This knowledge, together with the development of prophylactic vaccines against the HPV types most commonly associated with cervical cancer (16 and 18), made it vital to gain nationally representative HPV genotyping data for Australian women, including Aboriginal and Torres Strait Islander women. A research project, the 'Women, Human papilloma virus prevalence, Indigenous, Non indigenous, Urban, Rural Study' (WHINURS) was designed to obtain the HPV status of Aboriginal and non-Aboriginal women when they presented for their routine cervical screen. Family Planning NSW (FPNSW), an organisation that had previously worked in community based projects to increase Aboriginal participation in cervical screening, provided an investigator site in western NSW with the intention to recruit 50 Aboriginal women and 100 non-Aboriginal women. The method was a consultative approach, including national and local frameworks for Aboriginal and Torres Strait Islander recruitment. The FPNSW Dubbo team devised a series of strategies to maximise recruitment when this did not progress according to plan. Strategies were developed to meet this challenge, including street walks, attendance at community forums, flexible appointments, drop-in times and assistance with travel and babysitting. As a result of the activities listed above, 43 women were recruited to WHINURS, just seven short of the target. Collaborative community-based consultation, as well as the research study itself increased the number of Aboriginal women accessing cervical screening at the family planning clinic. This was sustained a year after the conclusion of the study.
 
Article
Australian Aboriginal communities in urban, rural and remote areas are continuing to suffer high rates of perinatal mortality and morbidity that will impact on the future health of the community. It has been well documented that Aboriginal women have extreme distrust of mainstream pregnancy-related health care and suggested that late entry into antenatal care is as high as 50% in the Aboriginal population. Although medical and midwifery staff have long discussed strategies to improve uptake of antenatal health care for Aboriginal women, researchers in many areas have found the recruitment of Aboriginal people into scientific studies almost impossible. This article seeks to share the strategies that have been developed over a period of time by the authors that have proved useful for recruitment and retention into research. It is anticipated that these strategies would also apply for health practitioners in maintaining their patients for clinical care management. Although each research location (regional, rural and remote) has had to spend time determining what approach is best for meeting the research outcomes, many of these suggestions become applicable to clinicians seeking to develop better connections with Aboriginal patients in their clinics. With the management of ongoing chronic health conditions for Aboriginal people a priority in 'Closing the Gap', a number of these suggestions could easily be implemented by clinicians. Remembering that each community has specific needs that must be addressed, priorities for assistance for that community will be easily identifiable after community consultation (eg transport, or ability to access medical testing). Opportunities for the use of new social media (eg Facebook) as communication tools for researchers and clinicians will have increasing applicability as further software updates are created. With open and trusting dialogues between researchers, clinicians and Aboriginal communities, we can go a long way towards understanding the needs of individual communities and working in partnerships to close the gap.
 
Article
Dementia is five-fold more prevalent among Aboriginal than non-Aboriginal Australians. Despite this, the quality of care available to people living with dementia in remote Aboriginal communities is poor. The objective of this study was to determine ways to overcome factors affecting the successful delivery of services to Aboriginal people with dementia living in remote communities, and to their families and communities. This qualitative research took place in the Kimberley Region of Western Australia. Data collection occurred in three stages: (1) interviews with service providers to identify the services available; (2) interviews with the caregivers of Aboriginal people living with dementia and community-based care workers; and (3) focus groups with community representatives and community care staff. Each stage was concluded when no new themes emerged. At each stage the transcribed information was analysed and joint interpretation identified common themes. In total, 42 service providers, 31 caregivers and community-based care workers were interviewed and 3 focus groups were conducted. Obstacles to accessing quality care were mentioned and recommendations on ways to improve care were made. The key themes that emerged were caregiver role, perspectives of dementia, community and culturally-appropriate care, workforce, education and training, issues affecting remote communities and service issues. Detailed information on how each theme affects the successful delivery of dementia care is provided. These research findings indicate that people living with dementia and their caregivers in remote Aboriginal communities are struggling to cope. They are requesting and require better community care. Implementing a culturally safe model of dementia care for remote Aboriginal communities that encompasses the recommendations made and builds on the strengths of the communities could potentially deliver the required improvements to dementia care for this population.
 
Article
An astounding 50% of blindness and 70% of vision impairment in Australia is caused by conditions that are said to be preventable or treatable. Aboriginal people suffer 10 times the rate of blindness and attend eyecare practitioners in far lower numbers than other members of the Australian population. In order to combat this problem in New South Wales (NSW), Australia, the International Centre for Eyecare Education (ICEE), with the Aboriginal Health and Medical Research Council (AHMRC) and the Office of Aboriginal and Torres Strait Islander Health (OATSIH), and local Aboriginal communities, have set up eyecare clinics in Aboriginal Medical Services (AMS) around the State. These eye clinics provide eyecare and vision correction, including the provision of spectacles and other optical aids, as well as educational programs to increase health awareness among the Aboriginal population and Aboriginal eye health workers. The first eyecare clinic was opened in AMS Redfern (Sydney) in July 2000 and ICEE now has a presence in over 60 locations throughout NSW. There have already been over 8000 consultations and 6000 pairs of spectacles provided to Aboriginal communities during this time. The program has also demonstrated that an effective Aboriginal eyecare program can be self-sustainable. The key to the success of this program has been collaboration and cooperation. This has involved working through, and with, Aboriginal community-controlled health services, which has ensured that programs are developed in accordance with community needs and cultural sensitivities. It has also involved the harnessing of the contributions of a number of State, Federal, community and professional organisations and individuals. This has provided efficiencies in service and resource provision, which are essential to the sustainability of the program.
 
A workforce model for primary maternity services in rural and remote areas, reproduced with permission S Kildea and C Cliffe.  
Maternal deaths per 100 000.  
Article
The reproductive health outcomes for Aboriginal and Torres Strait Islander mothers and infants are significantly poorer than they are for other Australians; they worsen with increasing remoteness where the provision of services becomes more challenging. Australia has committed to 'Overcoming Indigenous Disadvantage' and 'Closing the Gap' in health outcomes. Fifty-five per cent of Aboriginal and Torres Strait Islander birthing women live in outer regional and remote areas and suffer some of the worst health outcomes in the country. Not all of these women are receiving care from a skilled provider, antenatally, in birth or postnatally while the role of midwives in reducing maternal and newborn mortality and morbidity is under-utilised. The practice of relocating women for birth does not address their cultural needs or self-identified risks and is contributing to these outcomes. An evidence based approach for the provision of maternity services in these areas is required. Australian maternal mortality data collection, analysis and reporting is currently insufficient to measure progress yet it should be used as an indicator for 'Closing the Gap' in Australia. A more intensive, coordinated strategy to improve maternal infant health in rural and remote Australia must be adopted. Care needs to address social, emotional and cultural health needs, and be as close to home as possible. The role of midwives can be enabled to provide comprehensive, quality care within a collaborative team that includes women, community and medical colleagues. Service provision should be reorganised to match activity to need through the provision of caseload midwives and midwifery group practices across the country. Funding to embed student midwives and support Aboriginal and Torres Strait Islander women in this role must be realised. An evidence base must be developed to inform the provision of services in these areas; this could be through the testing of the Rural Birth Index in Australia. The provision of primary birthing services in remote areas, as has occurred in some Inuit and New Zealand settings, should be established. 'Birthing on Country' that incorporates local knowledge, on-site midwifery training and a research and evaluation framework, must be supported.
 
Article
FPA Health (Family Planning NSW) has conducted two integrated clinical and health promotion projects with Aboriginal communities in western NSW, Australia. The first was in Coonamble, a small rural community which had been selected as a pilot site for the Royal Australian College of General Practitioners Women's Aboriginal and Torres Strait Islander Project and was managed by FPA Health with support from the Dubbo/Plains Division of General Practice and Macquarie Area Health Service. The second was in Dubbo, a regional city where FPA Health had an existing centre and which had funding support from the Rio Tinto Aboriginal Foundation. The aim of this article was to share the learning and knowledge gained in managing these projects and to describe the experience of working with Aboriginal Community Liaison Workers who belong to and are supported by, the local Aboriginal community. The article aimed to illustrate the role and value of utilising these workers within a mainstream health service. The beneficial outcomes include improving service provision to Aboriginal women, adding to community knowledge about reproductive and sexual health issues and increasing the cultural knowledge and competency of a mainstream health service organisation.
 
Article
This review discusses palliative care and end-of-life models of care for Aboriginal people in the Australian state New South Wales, and considers Aboriginal palliative care needs by reflecting on recent literature and lessons derived from Aboriginal consultation. Aboriginal people in Australia account for a very small proportion of the population, have poorer health outcomes and their culture demonstrates a clear resistance to accessing mainstream health services which are viewed as powerful, isolating and not relevant to their culture, way of life, family and belief systems. Aboriginal people regard their land as spiritual and their culture dictates that an Aboriginal person needs to know their origins, emphasising the value placed on kin and also demonstrating a strong desire to remain within their own country. Currently Aboriginal people tend to not access palliative care services in mainstream facilities; and there is very little data on Aboriginal admissions to palliative care centres. Over the last two decades only two models of palliative care focusing on and developed in Aboriginal communities have been implemented. The seminal contribution to Aboriginal Palliative Care was in the form of a resource kit developed to support palliative care providers to examine their practice for cultural appropriateness for Aboriginal and Torres Strait Islanders. The 'living model' coming from this project is adaptive and flexible, enabling implementation in different Aboriginal country as a participative process with community input. The Australian government's National Indigenous Palliative Care Needs Study similarly indicated that Australian empirical research on Aboriginal palliative care service provision is in its infancy, and comprehensive data on the rates of Aboriginal access to palliative care services did not exist. What literature does exist is drawn together in an argument for the development and need for culturally specific Aboriginal palliative care models, which are culturally appropriate, locally accessible and delivered in collaboration and partnership with Aboriginal controlled health services. This is essential because Aboriginal people are a minority cultural group who are disconnected from mainstream health service delivery, and have a sense of cultural isolation when accessing mainstream services. It is preferable that palliative care is delivered in a collaboration between Aboriginal Controlled Health Service and mainstream palliative care services to ensure a dignified end of life for the Aboriginal person. These collaborations and partnerships are fundamental to ensure that a critical mass of Aboriginal clinicians are trained and experienced in end of life care and palliation. Developing palliative care programs within Aboriginal communities and training Aboriginal Health Workers, promoted and developed in partnership with the Aboriginal community, are important strategies to enhance palliative care service provision. Further partnerships should be championed in this collaborative process, acknowledging a need for palliative care models that fit with Aboriginal peoples' community values, beliefs, cultural/ spiritual rituals, heritage and place.
 
Article
Aboriginal people are particularly vulnerable to pandemic influenza A, H1N109. This was first recognized in the First Nations of Canada. There have been calls for close planning with Aboriginal people to manage these risks. This article describes the process and findings from preliminary community consultations into reducing influenza risk, including pandemic H1N1(09) swine influenza, in Aboriginal communities in the Hunter New England area of northern New South Wales, Australia. Consultation was conducted with 6 Aboriginal communities in response to the rapidly evolving pandemic and was designed to further develop shared understanding between health services and Aboriginal communities about appropriate and culturally safe ways to reduce the influenza risk in communities. Agreed risk mitigation measures identified in partnership are being introduced throughout Hunter New England area. Five theme areas were identified that posed particular challenges to limiting the negative impact of pandemic influenza; and a number of potential solutions emerged from focus group discussions: (1) local resource person: local identified 'go to' people are heard and trusted, but need to have an understanding of H1N109; (2) clear communication: information must be presented simply, clearly and demonstrating respect for local culture; (3) access to health services: sick people need to know where to get help and how to get there without infecting others; (4) households and funerals: infection control messages should be aligned with the reality of life in Aboriginal communities, and the importance of attending family and cultural gatherings; (5) social and community support issues: Aboriginal people need to have a say in how support is provided. Influenza pandemics are a serious threat to the health and social functioning of Aboriginal communities. Measures to reduce the risk of influenza in communities must be developed with the communities to maximise their acceptance. The process of engagement and ongoing respectful negotiations with communities is critical to developing culturally appropriate pandemic mitigation and management strategies.
 
Top-cited authors
Ian D Couper
  • Stellenbosch University
Therese Fish
  • Stellenbosch University
Paul Worley
  • Flinders University
Ben Marais
  • Children's Hospital at Westmead
Nathaniel W Wilson
  • Rural and Remote Health Journal, Australia