Indhumathi Babu is a paediatric registrar, currently working at Eastern Health. She received a bachelor’s degree of medicine and surgery from India and worked as a resident at Ballarat Health Services. She is interested in pursuing further training in paediatrics with special interests in allergy/immunology and neonatology.
Introduction: Many children undergo stressful procedures as part of their medical treatment. One of which is the magnetic resonance imaging (MRI). Going through a tunnel with loud noises can be very scary and it is challenging to keep some children still for the MRI. General anaesthesia (GA), distraction techniques can be useful in those situations but there is a role for sedation in some children to address anxiety and ensure a still child for quality images. The availability of guidelines and facilities to provide sedation for children in rural/ regional hospitals minimises travel, risks of GA and the waiting time. At our regional hospital, children who needed MRI but cannot stay still, got admitted for MRI under sedation. They were sedated as per protocol with 1:1 nursing care. After the MRI, once they are up and feeding, they were discharged. The purpose of this study was to see how successful our regional hospital was in providing sedation for children requiring MRI and how well were we using our sedation protocol.
Methods: A retrospective study of sedation episodes were analysed in a regional hospital over the period of Sep2015 to Oct2017. Data was collected from patients between the ages of 1 day to 18 years of age. Demographic data, fasting status, non-pharmacological techniques, drugs used, adverse effects, indication and type of MRI were studied. Success and failure rate of sedation were calculated. A primary outcome was defined as completion of a quality MRI scan. A failed outcome was the MRI requiring rebooking. Adherence to local sedation protocol was checked.
Results: Of the total 80 episodes identified, there were 74% Brain, 6% Spine, 10% Brain and spine, 1% Brain and orbit, 9% musculoskeletal MRI. Chloral hydrate (oral), midazolam (oral, intranasal, buccal, and intravenous) and ketamine (intravenous) were the drugs used. Adverse events occurred on 30% of occasions. In 4% of occasions these were classed as severe eg desaturations, dizzy spells. Distraction, verbal reassurance and sleep deprivation were also used. Success rate was 89%. eight MRI Brain, one MRI spine had unsuccessful sedation. Of these, two occurred when the protocol was followed, seven episodes had variations in the protocol. A limitation of the study was the quality of documentation of the medical record.
Conclusions: This audit shows that sedation can be done successfully in regional and rural hospitals with an understanding of the role of these medications and access to MRI facilities.
Dr Kerryn Bagley is a Lecturer in Social Work in the La Trobe Rural Health School, at La Trobe University, Bendigo. Her research is focused on social work and human service sector responses to FASD, disability and mental health, and consumer participation in research.
Introduction: Co-design is an increasingly popular method of service improvement in health and social services. Co-design involves service end-users in the front-end design. The purpose of co-design is to use multiple sources of knowledge to transform services through increasing service acceptably and accessibility, and tailoring services to user expectations and needs. In rural and regional Australia, co-design methods of service and community development are particularly important because of service and resource shortages and high levels of unmet need. Additionally, co-design methods have great potential in rural communities because of high levels of social capital and volunteer participation. In this project we use co-design to explore how to address the major issue of exclusion of children with disability from mainstream primary schools.
Aim: The research aim was to trial a method of co-design in a regional setting to create an online education package to support inclusion of children with disability in mainstream primary schools.
Method: The co-design method involved a series of six workshops over eight-months. Participants (n=12) including parents, teachers, education support staff, and allied health professionals, engaged in creative activities and group reflection and deliberation to design the package. The package outlines a collaborative team-based approach to supporting two children with disability attending mainstream primary school; one child with National Disability Insurance Scheme (NDIS) funding and the other with no NDIS funding.
Co-design participation was evaluated using process and outcome evaluation methods. Process evaluation included a survey method and qualitative analysis of group discussions. Outcome evaluation was completed through thematic analysis of individual semi-structured interviews.
Results: Co-design was effective for supporting participants to collaborate and share knowledge and experiences. The online learning package designed by participants is accessible and acceptable for the range of people who support children with disability to participate in mainstream school. Challenges of the method were difficulties relating to scheduling, and time and resources required for intensive design work and effective deliberations. Study findings include several strategies for managing group dynamics and influences of power on group decision-making.
Conclusion: Co-design methods of service and community development can be highly effective in rural and regional settings. Process and outcome evaluation findings relating to the co-design method provide direction for improving applications in other settings. Research findings demonstrate how participation-based methods can address significant health and social challenges impacting Australian rural and regional communities.
Jacqueline Ballard has been practising as a registered nurse for 10 years. She has worked across a diverse range of health services and clinical areas, including tertiary, metropolitan, rural and remote facilities. She has a background in paediatric and emergency nursing, previously working in Far West Local Health District as the Paediatric Clinical Nurse Consultant, developing new models of care in clinical practice. Jacqueline currently works as the Nurse Manager for Nursing Policy, Practice and Initiatives in Far West Local Health District. The position is responsible for the provision of leadership, management and support of contemporary nursing and midwifery policy, programs and projects across Far West LHD. Jacqueline is passionate about supporting nurses in the workforce and engaging the next generation of nurses and midwives. New and innovative models of clinical care, with a focus on rural and remote health care settings. Jacqueline has a Bachelor of Nursing through University Technology Sydney, and a Post Graduate Certificate of Disaster and Refugee Health through James Cook University. Jacqueline completed a Master of Public Health through University of New South Wales, and recently completed the Executive Clinical Leadership Program through the Clinical Excellent Commission in 2018.
Contextualisation of health care across Australia’s diverse rural and remote communities is critical in ensuring service alignment to community needs, the design and delivery of effective and sustainable services, responsive professional practice and enhanced health outcomes. Health care that seeks to improve the health of these populations needs to be more than evidence-based, care providers must also engage with local organisations and agencies in the identification of their health needs and solutions design, implementation and evaluation if services are to be impactful and sustainable. However, rural community perspectives of their unmet needs, experiences and expectations of health care can be marginalised with the control of health services being centralised and firmly entrenched within health systems. Enabling rural and remote community voices to be heard, and the effective interpretation of these voices, is critical if we are to address inequities and disadvantages that contribute to the poorer health and life outcomes of some of Australia’s most marginalised populations. This presentation describes the co-design, implementation and evaluation of a community informed health service and associated model of nursing practice in far west New South Wales, Australia. The Primary Health Care Registered Nurse: Schools Based Program is underpinned by a collaboration between school education, a local health district and a university department of rural health. The program and model of nursing practice have been informed by community perspectives of unmet health needs (child and adolescent mental health and wellbeing, limited support of families with children already experiencing complex and chronic conditions, and social concerns associated with student exposure to traumatic life events), previous community experiences of healthcare (illness orientated approaches, service provision focused on service needs in preference to community needs and pre-packaged care) and community expectations of health care (care that is focused on illness prevention, health promotion, the early identification of needs and service activation, integrated and coordinated care centred on the needs of service recipients and families). These findings informed the exploration of theories and principles to guide service provision and nursing practice. Identified theories included family-centred care, trauma-informed care, primary health care and integrated care. This new service and model of practice challenge illness orientated, hospital-centric, de-contextualised service and practice and have the potential to transform the lives of some of Australia’s most marginalised children, adolescents and families and the practice of registered nurses in these contexts.
Rochelle Barbaro is employed at Numurkah District Health as the Allied Health Educator via a grant through Going Rural Health, which is an initiative run by Melbourne University Department of Rural Health. Rochelle's background is as an occupational therapist with a particular focus in community paediatrics in rural area.
Aim: This case study discusses an emerging interdisciplinary model for allied health student placement provision in small rural health services. The aim of developing this model is to move from student placement as an operational activity which is at times reactive, to a proactive approach incorporated within strategic planning.
Method: A partnership model emerged as a result of two recent appointments (research coordinator and allied health clinical educator) in a small Victorian rural health service. These roles have overlapping and reinforcing responsibilities to build workforce, evaluation and research capacity whilst, supporting evidence based practice and translation of research to practice. The partnership identified early the challenges for student placements in small rural health services.
Relevance: There are different needs involved with types of student placements; clinical or research/project based. In addition, many rural allied health positions are part-time and often staff are the sole clinician for their discipline due to funding allocation. This leads to lack of time and resourcing to support students, and adds burden to the clinician’s already busy role. The rural context has its own unique challenges; climatic events such as drought and flood, economic impacts of rural business collapse, and ongoing challenges with service access and availability. Rural communities turn to the local health service for support and solutions when challenges arise, highlighting the importance of strategic planning to meet community needs.
Results: Currently (August 2018) the allied health educator has increased placements to n=5 (previously 2016, n=1; 2017, n=1). Resources have been designed to promote placement learning opportunities. Networks have been strengthened, including a new partnership with the local area Department of Education. Processes and awareness is being developed for an interdisciplinary approach to supervision for better utilisation of the range of skills, knowledge and experience available at the service and in the community. The many benefits that students can contribute to the service and the community are also being explored and highlighted in the process of opening placement learning opportunities.
Conclusion: The interdisciplinary team of social worker (research coordinator) and occupational therapist (allied health educator), are working to promote rural student placement opportunities and explore ways to overcome barriers. The essential strategic element of this emerging model is understanding complex community needs and incorporating community engagement. Moving forward the team are now researching models which may be adapted and replicated at the health service.
Megan Barr is a speech pathologist and special education teacher who has worked with children with a hearing loss for more than 20 years. She is currently a PhD student at The University of Newcastle where she teaches in the speech pathology and special and inclusive education programs. She has worked at centres that service large areas of NSW, including the Sydney Children’s Cochlear Implant Centre and 17 years at the Royal Institute for Deaf and Blind Children in the Hunter. She has spent the last five years working with Indigenous children at a local school.
Children living in rural areas have reduced access to specialised services. Children with a hearing loss require timely access to specialised hearing testing and intervention to achieve optimal speech and language outcomes. To date, there has been little national research examining the access to services for children in rural and urban Australia. This presentation reports preliminary results from a national study investigating the experience of accessing services for children 0-12 years old with a hearing loss in rural and urban Australia. Parents of children with a hearing loss and the specialist professionals who work with these children were invited to complete a survey with closed and open questions regarding the child’s hearing loss and the availability of specialist services. The majority of children in the study used spoken language to communicate and attended mainstream education. The preliminary results indicated that children with a hearing loss in rural Australia had reduced quality and frequency of service. Families of children with a hearing loss in rural areas experienced higher costs than urban families due to travel costs and reduced capacity to work. While parents were generally satisfied with teleintervention, they viewed face-to-face intervention as more effective. Also, families reported a range of experiences about accessing the National Disability Insurance Scheme (NDIS). Some parents reported that the NDIS had improved services for their child, while other parents reported multiple challenges. The implications of the findings for rural service providers and the National Disability Insurance Scheme (NDIS) will be discussed.
Dr Kristine Battye is the Managing Director of KBC Australia, a public policy consulting firm with specific expertise in needs assessment, program and service planning and evaluations in rural, remote and regional areas. Kristine is an applied researcher, tailoring methodology to the real-world requirements for program evaluation, needs assessments, service modelling at national, state and regional levels. Kristine has a consulting portfolio of over 120 projects and had the opportunity to work across much of rural and remote Australia.
There is some evidence and a common perception that GPs are increasingly reluctant to provide care in residential aged care facilities (RACFs). Barriers identified in previous studies include high out of hours demands, poor interoperability of systems requiring considerable duplication of record keeping, cumbersome communication methods, high volume of unremunerated work including travel and inadequate remuneration to meet the needs of residents with complex health needs.
A recent evaluation of a pilot of GP video conferencing into RACFs reinforced these concerns. GPs described the high volume of communication they received from RACFs including multiple faxes, emails and telephone calls on any given day requesting medication changes, script renewals or pathology requests, each requiring time to locate and update records and respond. Similarly, GPs highlighted the amount of time spent on duplicating and updating practice records following face to face visits to facilities. These small tasks can compound, resulting in considerable time spent on activities for which the GP is unable to claim remuneration, either from Medicare or directly from patients. Further, a considerable proportion of the activity undertaken in the provision of GP care in RACFs does not directly involve the resident and therefore does not fit within the fee for service model.
GPs’ capacity to provide comprehensive care is often limited by their need to visit facilities after or before the usual practice opening hours, reducing opportunities to engage with regular RACF nursing staff and limiting access to practice tools and supports such as practice nurses.
There was considerable commonality in these issues between both urban and rural areas.
Health Care Homes are being trialled as a mechanism to fund and facilitate optimal care for people with chronic disease using a bundled payment arrangement to enable flexibility in how care is delivered. It recognises the limitations of fee for service models where complex and ongoing care is required.
Which leads us to ask: Could a similar approach be adopted for remunerating primary health care in RACFs?
A bundled payment for care of a RACF resident based on an assessment of level of need/complexity could factor in regular communication between the RACF and the practice, the added time involved in providing care offsite from the clinic setting and encourage better integration with general practice systems.
Dr Kristine Battye is the Managing Director of KBC Australia a public policy consulting firm with specific expertise in needs assessment, program and service planning and evaluations in rural, remote and regional areas. Kristine is an applied researcher, tailoring methodology to the real world requirements for program evaluation, needs assessments, service modelling at national, state and regional levels. Kristine has a consulting portfolio of over 120 projects and had the opportunity to work across much of rural and remote Australia.
The published evidence for allied health interventions and services is limited, particularly in relation to service models and models of care in rural and remote Australia. Furthermore, there is limited published research or evidence of the effectiveness of various workforce strategies, including cost effectiveness for rural and remote Allied Health. It is likely that much of the evidence, particularly around workforce and service models sits in the grey literature and/or in ‘local intelligence’ of what works (or not). A recent report by The International Centre for Allied Health Evidence, June 2018, prepared in response to the review of MBS items highlights a similar paucity of evidence of the impact of allied health services across the sector, not just in relation to rural and remote service delivery.
Traditional notions of evidence hinge on scientifically controlled research studies with a focus on measurement of intervention effect, reliability and replicability. Such studies have been and continue to be undertaken in relation to allied health interventions, predominantly in acute settings. However most allied health services in Australia are provided outside acute clinical settings and increasingly the evidence being sought is not about specific interventions per se, but rather about the impact of allied health services in ‘real world’ environments.
A forum of researchers, education providers, rural workforce agencies, allied health, other health care service providers and policy makers, convened by SARRAH identified opportunities to build the evidence base for allied health in the real world. Examples include:
- linking with PHNs to co-design and evaluate models of care and service delivery strategies where allied health is a component of the multidisciplinary team
- identifying and evaluating emergent models of allied health intervention
- establishing partnerships with rural and remote NDIS service providers to analyse model and workforce requirements
- identifying private practice models in rural and regional areas and determine key ingredients for viability
- documenting case studies of service providers around Communities of Practice for priority areas e.g. NDIS, aged care, solo practitioner models
- establishing and evaluating service learning models in rural and remote locations to determine impact on service capacity, learning outcomes for allied health students and early career health professionals, perceptions of remote practice.
While allied health peak bodies have a role in building the evidence base in rural and remote Australia, the need for improving evidence collection, analysis and dissemination is common across the allied health sector and requires a coordinated and collaborative approach.
Top 20 abstracts
Over the last two decades, Carol Bennett has worked at senior executive levels in national health and aged care organisations and has served on national and international boards and advisory groups. Carol has been National CEO of Alzheimer’s Australia, Consumers Health Forum of Australia, Rural Health Workforce Australia and the Victorian Alcohol and Drug Association. She has also managed her own consulting business, working with national peak groups, and is a current member of the Medicines Australia Advisory Council, Australian Health Practitioner Regulation Agency National Paramedicine Board and Director of Lifeline Canberra.
Ongoing chronic pain is an epidemic in Australia. One in five people are living with chronic pain and this number rises to one in three over the age of 65. People with chronic pain have the greatest levels of disability in our community. It is the leading cause of early retirement from the workforce, with back problems and arthritis accounting for around forty per cent of forced retirements. The level of workforce participation in people with chronic pain could be as low as nineteen per cent.
The estimated cost of chronic pain, calculated over a decade ago, was thirty four billion per year. Untreated chronic pain also has profound consequences in every area of life, commonly resulting in decreased enjoyment of normal activities, loss of function, role change and relationship difficulties, and these experiences can exacerbate feelings of isolation and stigmatisation. It can also severely impact mental health, with over a quarter of adults with severe or very severe pain experiencing high or very high levels of psychological distress.
While a quarter of Australians live with chronic pain, data also tells us that this burden is disproportionately harder to bear in rural and remote areas of our country. Recent data released by the Australian Institute of Health and Welfare shows that people living in our rural regions are also more likely to misuse pharmaceuticals, with use of opioid analgesics nearly twice as high as in major cities. This is consistent with data from the National Wastewater Drug Monitoring Program reported higher levels of drugs in regional areas than capital city areas. Much of this use is likely to be related to initial management of chronic pain conditions.
While it is well known that pain management services along with pain specialists and allied health professionals trained in pain management are limited in rural and remote Australia, there needs to be broader recognition of the fact that these access issues often delay treatment and therefore increase levels of disability and reduce capacity to return-to-work while impacting quality of life.
Our presentation will discuss the development of the National Action Plan on Pain management, in particular highlighting our priorities to improve timely access to appropriate pain management strategies for all Australians. We will discuss new research on the economic burden of pain findings in regional and rural Australia and provide an overview of how this epidemic can be more effectively managed in regional centres.
Jaclyn Bishop is a pharmacist with experience spanning acute health, education, government and consultancy. She is undertaking a PhD with the National Centre for Antimicrobial Stewardship (NCAS) and Melbourne University, which is focused on the challenges faced by regional and remote hospitals in implementing and sustaining antimicrobial stewardship (AMS) programs. Since commencing her PhD, she has published a narrative review titled 'Meeting the challenge for effective antimicrobial stewardship programs in regional, rural and remote hospitals—what can we learn from the published literature?' She has also presented at national conferences on novel qualitative research undertaken on the topic.
Background: Antimicrobial stewardship (AMS) incorporates any actions that promote the effective use of antimicrobials to optimise patient clinical outcomes, while minimising unintended effects including antimicrobial resistance. Antimicrobial resistance has been recognised locally and globally as an urgent health priority.
Barriers to the delivery of AMS programs in Australian regional and remote hospitals (RRH) have been described (e.g. a lack of on-site infectious diseases expertise, limited pharmacy resources, difficulty recruiting staff).
Since 2013, all hospitals in Australia have been required to have an AMS program in place that meets the National Safety and Quality Health Service (NSQHS) accreditation requirements. Despite this, little is known about the sustainability of AMS programs in RRH.
Aim: To explore the features of sustained AMS programs in Australian RRH.
Method: Purposive and snowball sampling were utilised to recruit clinical champions or lead AMS clinicians who have knowledge and/or experience with at least one hospital AMS program that has been sustained for greater than two years. The AMS programs described were in hospitals with an Australian Standard Geography Standard Remoteness Area group of inner regional, outer regional, remote or very remote. Recruitment continued until saturation of themes was reached. Semi-structured interviews were conducted which were audio-taped, transcribed verbatim and analysed using the Framework Method.
Results: Fifteen multidisciplinary participants consented to an interview including infectious diseases physicians (5), pharmacists (5), microbiologists (2), infection control practitioners (2) and general practitioners (1).
The most prominent features of sustained AMS programs in RRH identified were:
- a network or state-wide approach to program delivery
- passionate local champions
- dedicated funding for AMS human resources
- governance and accountability at both the clinician and executive levels
- engagement across the clinical professions and executive
- low staff turnover.
Key risks to the sustainability of AMS programs in RRH included:
- shifting hospital priorities
- burnout of key staff.
Conclusion: AMS programs in RRH are more sustainable when there is a clear structure. This includes dedicated funding for AMS staff, clear governance and accountability arrangements and support from a network or state-wide program. These can help to counter the threat of shifting priorities in hospitals. AMS programs that rely heavily on passionate champions can be challenged by burnout in key staff. Strengthening AMS support structures and capacity building in local staff appear critical to sustain AMS programs in RRH.
Professor Irene Blackberry is Director and John Richards Chair of Rural Ageing and Aged Care Research at La Trobe University, Wodonga. The Centre is the only interdisciplinary rural ageing research centre in Australia. Professor Blackberry has a medical background and is an expert in pragmatic trials of complex multifactorial health services. Her passion is to improve access to care for older people. She is the Principal Investigator of the Verily Connect project.
Aims: The Virtual Dementia Friendly Rural Communities (Verily Connect) project is a trial of online technologies to increase support for rural carers of people living with memory loss and/or dementia. This project aims to develop an online supportive community that carers can access any time and any day of the week.
Methods: Twelve rural communities across Victoria, New South Wales, and South Australia are trialling Verily Connect strategies of carer peer support groups that meet via video-conference and a tailor-made website and mobile application (app) that helps carers to connect to each other and to services. The project is being implemented and evaluated using a randomised stepped-wedge cluster design and mixed methods of data collection.
Relevance: In rural areas, carers of people living with dementia may have difficulty obtaining peer support due to wishing to maintain privacy, low numbers of others in a similar situation in their community, and/or for reasons of preference about with whom they discuss sensitive personal issues. Geographical distance from larger population centres, which provide more anonymity and choice of confidantes, makes obtaining targeted support challenging. The Verily Connect project is testing whether using online communication strategies can increase support for isolated rural carers.
Results: The project is currently underway. Preliminary results indicate that despite potential benefits in using online technologies, there are challenges for carers in finding the time and motivation needed to learn about and use these technologies.
Conclusion: In addition to trialling the effectiveness of online technologies for supporting rural carers, it is vital to find ways to secure awareness of and buy-in by potential users, so that any benefits can be maximised.
Arts in health
Jami Bladel has been the Artistic Director and CEO of Kickstart Arts since 2006. Prior to that she was the Artistic Director of Big Wig Youth Theatre and a freelance theatre director, actor, writer, producer, dramaturge and specialist teacher. She graduated from VCA school of dramatic Art in 1987 (Acting) and later completed an education degree at University of Tasmania (dance in education, gender studies, feminist literature). Jami has a postgraduate certificate in Advanced Executive Leadership through Women in Leadership Australia, and is studying for a Masters in Leadership. During her 30+ years of working in the arts, Jami has developed and designed creative health promotion campaigns and projects, directed over 36 arts projects across a range of artforms, brokered arts and health partnerships, worked as a teaching artist and mentor to emerging teaching artists and won seven awards for excellence in social inclusion in the arts. Jami is a regular contributor to arts and social policy development sitting on reference groups and advisory councils at the federal, state and local government levels. Jami is leading the development of an arts and health centre—transforming Colonial Orphanage buildings into a centre for arts and cultural engagement and inclusion at St Johns Park in New Town.
Donna-Marie Bloice is currently employed as a clinical nurse at Townsville Women's Correctional Centre by Townsville Offender Health Service, Townsville Hospital and Health Services. Her work involves health assessments and coordinating the health management of women entering and residing at Townsville Prison. This involves referrals to Townsville Hospital and follow-up care from visiting health professionals. She has been a prison nurse for nine years and is passionate about person-centred and primary health care. Donna-Marie recently enrolled in a PhD at the School of Nursing and Midwifery and Social Sciences, CQU, with the intention of researching the aforementioned group of women once released from TWCC. She is Scottish and moved to Queensland in 2003 with her beautiful family. They are now citizens and consider Townsville home.
Australian prisons contain an over-representation of the most marginalised groups of society. Prisoners typically suffer from mental health disorders, chronic diseases and are among those who typically do not access timely health care. The key to successful Primary Health Care is to reduce health inequalities by providing person centred care. From a realistic perspective, women, who are in contact with the criminal justice system, are transient recipients of care, and are not primarily patients, but are objects of surveillance. The women have commonly had poor life experiences including trauma, abuse and often, exposed to violence. It is not uncommon for prisoners to view Offender Health Services as their local GP super clinic.
Australian women are returning to prison at a greater rate than men, with 68% of Australian Indigenous women returning within nine months.
Currently prisoners are released from prison and are often lost to follow up and consequently hospitalised as there is no formal health discharge planning in place.
There is a significant body of international research surrounding the health of prisoners, although there is very little evidence or knowledge around former prisoner’s health literacy or health service use once leaving the correctional facility. Evidence in the literature reports many women take the opportunity to seek overdue and preventative health care whilst in prison but often fail to follow up once released. It is apparent that there needs to be a strategy linking prisoner’s due for release and their elected health care providers. The study aims to follow a randomly selected and consenting group of recently released women from Townsville Women’s Correctional Centre from various communities around North Queensland. Members of this group already come from underserved communities and social determinants of crime are similar to those of health whereby most people in prison come from an underprivileged background.
The study aims to identify, using their own words, why so many women, particularly Aboriginal and Torres Strait Islander women, fail to address health issues and postulate some methods to enable and facilitate easier access and better outcomes.
There is an overwhelming agreement in the literature that more research is required to prevent health deterioration once released from prison. Continuity of care into the community for this group of vulnerable people will be key to avoidance of missed care.
Lisa Bourke is Professor and Director of the University Department of Rural Health at The University of Melbourne, based in Shepparton, Victoria. Lisa holds a PhD in Rural Sociology (Penn State University) and a Bachelor of Social Work (Monash). She is a strong advocate for maximising the wellbeing of rural consumers and increasing their access to quality and respectful health services. Her research focuses on access to care, issues facing marginalised consumers and how rural health services can be inclusive for all consumers.
One of the biggest problems in rural health is access to health services for small and geographically dispersed populations. Access to rural health care is a complex concept involving elements of availability, accessibility, affordability, acceptability, accommodation and awareness. Some have argued that access varies for the type of consumer, the rural setting and presence of the social determinants of health. Others have raised expectations as related to access and there is suggestion that access has become synonymous with many rural health problems. Given these diverse perspectives, there is a need to clarify how rural health consumers are limited in their access to health care. The aim of this study is to explore how residents in four rural towns in Victoria perceive barriers to accessing health care.
A household survey was conducted with all residents of randomly selected households in four rural Victorian communities. 3600 households were selected and almost 1900 households (2637 adults) participated in the study with a response-rate of 59%. All respondents were asked about health conditions, access to services, use of services and demographic questions. All were asked in an open ended question ‘what prevents you from accessing health services? These responses were coded and analysed statistically to identify what prevents access to care and then compared with results from the same study conducted 16 years earlier.
Access to services was identified as problematic for a range of reasons, including availability (particularly specialist care), waiting times for appointments (more frequently specialist care), cost, travel (more commonly among those from the smaller towns) and trust in the services. Access to health services was not related to age, although older residents were more likely to mention travel and availability of services than other access issues. Access was a concern in all four communities, although the specific access barriers varied across the communities. Access was not correlated with having a mental illness or disability. However, those who were bulk-billed and those seeing their GP regularly had fewer concerns about access to health care.
While access to medical specialists and allied health professionals as well as cost, travel, waiting times and trust in the service provider were identified as barriers, frequent GP utilisation was associated with less concern. This study suggests that access to, and regular use of, a GP is strongly valued by rural health consumers and provides them with a sense that they have access to health care.
Arts in health
Dr Heather Bridgman is a Clinical Health Psychologist and Lecturer in Rural Mental Health at the Centre for Rural Health, University of Tasmania. She is interested in innovative rural mental health service delivery, improving service access, rural psychology workforce and interprofessional learning and practice. She provides clinical supervision to postgraduate psychology students undertaking placement in regional and rural Tasmania. Heather has a strong community engagement focus, has been the chair of the Northern Tasmania Branch of the Australian Psychology Society (APS) and served on the Launceston Mental Health Professionals Network (MHPN) committee. She has been involved with several funded multidisciplinary projects in rural Tasmania including “Epilepsy Connect: The Development of a Telephone-Based Peer Support Program for Tasmanians Affected by Epilepsy”; “TAZREACH Promoting Health Through Health Literacy”; “Recovery Camp Tasmania – An Experiential Learning Opportunity for Students of Health Disciplines and Mental Health Consumers”’; “Evaluation of the Health and Resilient Communities Program in Rural Tasmania”; “Review of Clinical Model/Pathways for headspace”; and, “Establishing and Evaluating Bereavement Care Networks in Tasmania”. Heather has a passion for applied research that can directly benefit local communities.
The therapeutic potential of art to contribute to mental health and well-being is widely recognised. Benefits include improved self-esteem, self-confidence, communication skills, and social inclusion. The Rural Art Roadshow was a collaborative art project between the University of Tasmania (UTAS) and not-for-profit mental health and disability support service, Wellways. The Rural Art Roadshow ran annually in rural and remote Tasmania from 2015 to 2017. The project aimed to develop community resilience, reduce stigma and promote a positive image of mental health through a travelling display of art submitted by community members to the Wellways ‘Minds Do Matter’ Exhibition, held in major population centres across Tasmania. ‘Minds Do Matter’ is an annual exhibition where community members affected by mental illness are invited to enter their artwork. From this larger exhibition approximately 30 art pieces were selected to tour with the Rural Art Roadshow. Selection criteria included the portability of the artwork, subject diversity, and residential location of the artists.
The Rural Art Roadshow travelled over four weeks, visiting between four to six rural communities each year. Communities were chosen because of their relative isolation and disadvantage in accessing mental health promotion services. In total eight different towns were visited, all classified as 5 or 6 by the Modified Monash Model, with populations ranging from 316 to 4,347 residents.
A mixed-methods evaluation of 23 artists (interviewed) and 145 community members (surveyed) demonstrated the social and personal benefits for participating artists and positive contribution to rural community wellbeing. Beyond these benefits, several challenges and learnings were also identified. Early and consistent community engagement was vital for ensuring the roadshow was welcomed and promoted within the small communities. Engagement increased through identifying key champions, connecting with regional arts groups and encouraging local input into the facilitation of each exhibit. Sourcing funding to support the project, however, has continued to be challenging. The Rural Art Roadshow was initially funded through a UTAS community engagement grant, but repeated, subsequent community funding opportunities have been successful, impacting on the scope of the roadshow.
With these learnings in mind, future iterations could assess the potential direct benefits to community mental health outcomes and explore the potential for technology to play a role in promoting the roadshow. The Rural Art Roadshow is a unique and promising model for fostering conversations about mental health and promoting community resilience in rural and remote areas of Australia.
Sally Bristow is a registered nurse, registered midwife and lecturer at University of New England, School of Health in Nursing. Her teaching interests include chronic diseases, Aboriginal health, primary health care, women’s health, health care systems and health policy. She is a PhD candidate at the School of Health, University of New England. Sally has extensive clinical, health management and education experience. Her clinical focus in chronic care (haemodialysis, renal nursing, Aboriginal renal vascular screening in communities and midwifery) has evolved with a specific interest in chronic disease with a focus on prevention and self-management. A broad range of clinical experience in Australia—rural, remote and metropolitan—has diversified Sally’s understanding of health issues and health systems in the contemporary and developing context. This has led to have extensive experience in health management in both operational and strategic roles, enabling her to work and advise the Ministry of Health in NSW around rural health issues, Aboriginal health and renal services across the state. Sally has specific interests in mothering, rural health and chronic conditions. She has been involved in qualitative research. Her doctoral research explores the experience of rural mothers in caring for a child with a chronic health condition.
Background: Chronic health conditions are the major contributors to the burden of disease worldwide and the number of children with chronic health conditions is increasing generating additional strains on those that provide care and support for these children. Children with chronic health conditions are at risk of having poorer health outcomes and are often not able to participate in normal every day activities, experience school absenteeism, have distress that is more emotional and peer related activity restrictions compared to healthy children. Most children with chronic health conditions are cared for in their homes by their mother. Mothers are required to provide additional care for their child with a chronic health condition including demanding treatment regimens, a shift in their roles and responsibilities, and require resources above that of caring for healthy children. For rural mothers providing care in a rural setting creates its own additional barriers in accessing services for many reasons including; lack of understanding about how to navigate the health system, distance, transportation, costs and institutional/clinician trust.
Approach: The overall purpose of this research is to explore the rural mother’s experiences in caring for their child with a chronic health condition. The study will follow a qualitative methodology using Max van Manen’s (1990) interpretative phenomenological methodology. Seventeen rural mothers who identify as the caregivers of children with chronic health condition residing in rural regions of NSW participated in this study. Each mother completed a demographic data form and participle in a conversational style interview talking about her experience. The interviews were all audiotaped, transcribed and analysed using van Manen interpretative phenomenological methodology.
Outcomes/results: This research will assist in understanding the challenges and barriers rural mothers face in accessing services and assist in developing future models of care, services and resources to optimise health outcomes and access for rural children with chronic conditions.
Take-home message: Understanding the needs of rural mothers through their experiences will assist to reduce health care inequity and accessibility to services and assist in overcoming rural disadvantage.
First-time presenters Top 20 abstracts
Jane Bromley is an intern at Royal Perth Hospital, and 2018 graduate of the University of Western Australia. She spent her penultimate year of medical school on placement in the Kimberley region with The Rural Clinical School of Western Australia, where this research project was conducted.
Aim: Aboriginal children in Western Australia’s Kimberley region have high rates of developmental concerns upon entering school. The purpose of this study was to identify i) current early childhood development (ECD) practices at one Aboriginal Community Controlled Health Service (ACCHS) in the region, ii) barriers and facilitators to detecting developmental concerns, and iii) if health staff deviate from current ECD guidelines, and possible reasons for deviation.
Methods: This study utilised a mixed-method design. We audited consults of children aged 0-5yrs between January 1 2016 and December 31 2016 at the participating ACCHS. Formal child health checks (CHCs), developmental enquiry and follow-up of developmental concerns were identified. Five staff members participated in semi-structured interviews regarding ECD practices at the ACCHS. Ethics approval was obtained from the Western Australian Aboriginal Health Ethics Committee (HREC reference number 723).
Results: In total 1241 consults were audited for 177 children. A formal CHC was conducted for 56 children over 74 consults and 114 children had development enquiry documented across 190 consults. In ten of these consults a development assessment tool was used. Hearing and speech was the most commonly reviewed domain. Where follow-up was arranged it was documented to have occurred in 18% of referrals. Only 11 consults documented brief interventions or anticipatory guidance. Thematic analysis identified communication issues, practical limitations, lack of early intervention services and need for increased resources and knowledge as potential barriers to increasing ECD activities. Participating staff recognised the importance of developmental assessment.
Conclusions: We identified significant recognition of the importance of ECD assessment but also several barriers to implementation and low documented follow-up rates. There is a need to empower staff through upskilling in brief developmental assessments and interventions, to provide adequate resources, to improve communication between organisations and to promote supportive systems for early developmental interventions.
Susan Brumby is the founding director for the National Centre for Farmer Health, a partnership between the Deakin University’s School of Medicine and Western District Health Service and is based in Hamilton, Vic, Australia. The Centre provides leadership to improve the health, wellbeing and safety of farmers, farm workers and their families across Australia and internationally. She leads the implementation of five key strategies, which includes inventive and award-winning service delivery models, farmer research, education and training, the farmer health website (http://www.farmerhealth.org.au) and works with an advisory committee comprised of academics, farmers, health professionals and government representatives in order to achieve the mission of ‘making a difference to farmers’ lives’. Her PhD was on farm work and family health across selected agricultural industries in Australia. In 2014 her team was awarded the Vice-Chancellors Award for Excellence in Teaching. She is an appointed member of the Victorian Rural Advisory Council, which advises the Minister for Agriculture on matters such as rural adjustment, regional issues, training, drought and other matters as requested by the Minister. A graduate of the Australian Rural Leadership Program, Susan has presented and published nationally and internationally.
Background: The sociocultural context of farming in rural Australia—including strong masculinist values, a pragmatic goal-focused outlook, a willingness to offer help but avoid asking for help, and an acclimatisation to risk-taking behaviours—pose a challenge for encouraging female and male farmers to take a proactive role in their health, wellbeing and safety.
The Sustainable Farm Families (SFF) program commenced as a pilot program in Australia in 2003 and took a strengths-based perspective to farmer health promotion working with, rather than against, the normative behaviours present in Australian farmers. Since 2003 over 2600 farm men and women have participated in SFF, with over 6000 personal health, wellbeing and safety actions goals being set. The SFF program’s use of personal goal-setting as a means of de-stigmatising help-seeking and encouraging an action focus on personal wellbeing has now been successfully demonstrated with Australian farmers in other farmer health projects. In 2014 the SFF program was successfully repeated and transferred to farmers in Alberta, Canada to assist them address similar farmer health risks.
Methods: Sustainable Farm Families workshops allow participants to reflect, learn and apply new knowledge in a safe environment among people with shared interests, experiences and cultural context. Templates for personal actions and goals provide opportunity to put new knowledge and improved attitudes into practice in a Specific, Measurable, Achievable, Realistic and Time-based manner. Importantly participants also report back on their actions and achievement using a self behaviourally-anchored rating scale at the following workshop.
Results: Between 2014 and 2018 in Victoria, Australia, 634 farmers attended 39 SFF programs with 1626 personal action goals being set by 83% of participating farmers Since SFF commenced in Alberta, Canada in 2014, 1054 farmers have participated in 51 programs and following the Australian methodology 78% completed action plans and goals setting. The goals are being thematically analysed according to behavioural indicators of stigma reduction and behaviour change evaluated through assessment of self-reported action achievement by both cohorts.
Discussion: This presentation will compare the demographics of attendees, nature of action goals set and their level of action achievement by farmers attending the SFF program in Australia and Canada and discuss differences and similarities. This is the first report to internationally compare farmers action goals for their health, wellbeing and safety. Farmers are interested in improving their health, if opportunities are presented in a format that is cognisant of the normative behaviours common in farming communities.
Robin Bryant is a former senior Commonwealth Public Servant and President of an Olympic and Commonwealth Games Sport in Australia, Oceania and VP of the international body. Now fully engaged at the GP's request with the medical practice to recruit doctors, build the medical practice and improve the range of services and health delivery mechanisms.
In April 2016, our local GP called a public meeting. Over one third of the population came to hear her tell of the difficulties she was facing as the only doctor in a town with a permanent population of roughly 1000 people. What we heard shocked us…the practice was facing closure as she was overworked and yet unable to make ends meet. Mallacoota, whose population explodes to between 6000 and 8000 during the summer and for whom the nearest alternative was over an hour’s drive away, was going to have NO doctor! Hospitals 2 hours away. No aged Care facilities.
4 Drivers got together determined to save the town from this UNTHINKABLE situation. We formed working groups: one tasked with finding more doctors; another to look at longer term solutions to the viability of medical services in Mallacoota.
The ‘Doctor Search’ committee organized attendance at 2016 Rural Medicine Australia conference in Canberra. It was a huge success! We didn’t find another permanent doctor, but we did find doctors who agreed to become rotating locums for us! Networking became part of our raison d’etre.
Determined to work outside the envelope, the ‘viability’ community group went to work. They have worked VERY, VERY hard over many months to form an incorporated DGR charity (CHIRF) and to liaise with both federal and state governments to try and find a solution to the problem of Mallacoota’s Medical Centre survival.
CHIRF is an acronym for Community Health, Infrastructure and Resilience Fund.
2017, in the firm belief that to find a doctor, we must be where the doctors are, CHIRF attended two medical conferences, RMA and GP 17.
Success! CHIRF formed an alliance with RVTS and became the first town in a pilot scheme whose aim is to enable Drs to gain Fellowship in situ, and via remote supervision. We also have a Dr who is contracted to the East Gippsland Rural Training Scheme,
But the story does not end there. Our operation expanded from Dr Search, to health delivery including trying to reintroduce After Hours into the community, a broad scale mental health program and providing a more solid financial base for the Medical Practice. We are building a new medical centre and actively working towards a RACF. This is a story of one GP’s fortitude and determination to turn to the community and her ability to find drivers. A remarkable story.
David Buckley graduated with honours in veterinary science in 1992 and worked in a range of roles in agriculture, from government veterinary officer, to veterinary research scientist, climatology, academia and for the last eight years has been a health statistician in the Clinical Governance Unit at Murrumbidgee Local Health District. Along the journey he has collected a Masters in Veterinary Science, researching decision making in response to climate forecasts, and a Masters in Applied Science (Statistics).
In rural areas the human inhabitants tend to come into more frequent contact with a more diverse range of fauna than the residents of metropolitan environs. Besides the endemic fauna animals serve as companions, a source of recreation, working animals as well as being used for commercial production. With this contact comes the potential for zoonotic disease, or the transmission of disease between animal species and humans. Similarly, contact with animals is also accompanied by the risk of trauma associated with bites, kicks, scratches, envenomation, allergic sensitisation and falls from ridden animals. Super-imposed on these risks are climate changes that have been demonstrated to be altering the range of many the zoonotic diseases. Historically, the management of zoonotic diseases has largely been the domain of government veterinary services. Whilst the treatment of these disease is funded by universal healthcare the prevention and management of zoonotic is somewhat of an externality. In response the One Health Initiative arose. The One Health Initiative is dedicated to improving the lives of all species—human and animal—through the integration of human medicine, veterinary medicine and environmental science. Whilst this movement has been strongly driven by veterinary scientists the impact in healthcare has been limited. This paper examines starts by describing the prevalence of zoonotic disease, analyses the absolute and relative burden on the healthcare system and then evaluates the likely shifts with climate changes and asks whether zoonotic disease is really a substantial issue in modern rural Australia and do we need One Health?
Jodi Burnstein holds Bachelor degrees in Arts and Laws, a Postgraduate Diploma in Social Science and is currently enrolled in a Specialist Certificate in Implementation Science. Jodi has worked with Barnardos for 18 years, is based in Orange, NSW and oversees management of a range of early intervention, safety and prevention child and family welfare programs. The Barnardos Western NSW Centre covers a large geographic area of regional rural and remote NSW. Prior to the move to Western NSW Jodi spent ten years working as a solicitor with NSW Legal Aid Commission working with asylum seekers, Family Law mediations and Civil Law class actions.
High rates of Indigenous imprisonment have extended the disadvantages parents have experienced to the lives of their children (Weatherburn, 2014). Most Aboriginal women offenders are the primary carers of their children at the time of incarceration. Incarceration is a major disruption to family and kin relationships as the children either go in to statutory care or voluntary family care while their mother is incarcerated.
The Beyond Barbed Wire program seeks to improve health and wellbeing outcomes for women with children in contact with the criminal justice system address the rates of re-incarceration and recidivism of women with children, and in particular Aboriginal women, in Western NSW. The service model aims to reduce the rates of re-offending and re-entry into correctional centres, support mothers to build parenting skills and maintain connections with their children, prevent removal of further children and restoration of their children who have been removed back into their care. It is made up of a suite of programs including evidence informed parenting skills and knowledge, practical skills, training and work experience, short term accommodation, referral to a casework service and matching with a volunteer mentor for up to two years.
The presentation highlights key policy and practice insights from an independent economic evaluation of the service was undertaken by Western Research Institute. The evaluation indicates that for every dollar spent there is a return on investment of $2.15 to the community. The study included a program logic, a literature review, economic analysis, and in depth interviews with program participants and the staff working in the service. The presenter will analyse practice components that support service outcomes and highlight areas for further development and evaluation, including assessing the wellbeing outcomes for the volunteer mentors.
The presentation is of relevance to those who are interested in cost effective approaches to achieving positive outcomes for the health, wellbeing and safety of Aboriginal women and their children and improving the intergenerational outcomes related to justice and closing the gap on incarceration rates of Aboriginal people. On the basis of the findings, it will draw out the implications for improving evidence informed health and welfare practices for effectively supporting Aboriginal women who are in contact with criminal justice system in rural settings.
Dr Sally Butchers FRACS completed her fellowship in general surgery and followed this up with two years of work in Glasgow and Portsmouth. Sally commenced her career as a visiting medical officer with the North Coast Area Health Service (now Northern NSW Local Health District) in March 2008 and has enjoyed helping to care for patients from all over the north coast ever since. Sally is the Chairperson of the Rural Surgery Section of the Royal Australasian College of Surgeons (RACS) and member of the RACS NSW Committee where she is involved in promoting rural surgical services. She is an instructor on the RACS Early Management of Severe Trauma and MOSES courses and enjoys sharing her specialist knowledge with GPs and registrars in these important areas of medical care and training. On a local level, Sally is a member of the Lismore Base Hospital Theatre Management Committee and the Trauma Committee and is involved with the local breast screening unit. Recognising that a balanced life is important in being able to give the best to your profession, Sally likes to keep fit, plays hockey, nurtures her creative side through mosaics and loves a stroll through the many colourful local markets.
Supporting and enhancing the contribution of surgeons to the broader community is a pillar of RACS strategy. At present approximately 30% of Australian’s live in rural and remote locations, 34% of RACS Fellows live/work in metropolitan and visit rural locations and 14% of RACS Fellows live and work rurally in Australia.
Developing formal rural training pathways is a strategic priority for RACS to ensure it is training and supporting surgeons with the desire and confidence to work in rural and regional areas.
This paper will outline RACS initiatives and advocacy efforts toward formalising rural surgery training pathways including:
- The development of rural training centres (or hubs) as a mechanism to facilitate training with a rural focus utilising existing SET accredited posts. A rural training centre shifts the focus from metropolitan areas to training in rural and regional locations and rotating trainees through metropolitan centres as relevant.
- The establishment of post training metropolitan based hub and spoke models to provide support and attract surgeons interested in working in rural and regional areas through providing links and opportunities for regular short term rotations in metropolitan centres, backfilling roles, developing professional and referral networks and ensuring opportunities for ongoing career and skill development.
- Support for rural and regional surgical generalism focused on cross-specialty collaboration and training to ensure surgeons operating in rural and regional areas have the skills to provide an extended scope of surgical practice within their local communities. To be successful this requires developing a framework that ensures the availability of cross-specialty collaboration and training for surgeons working in rural and regional locations.
- The adoption of trainee selection criteria that rewards applicants with a rural and regional background and/or work history could facilitate an increase in surgeons with a desire to work in rural and regional areas. Bonding and financial incentives in isolation have been demonstrated to be ineffective.
- Promotion of clear pathways to employment post-Fellowship through mentoring and negotiating with hospital administration would provide a powerful incentive for surgical trainees considering a rural and regional career in surgery.
Lucy Byrne is an experienced community and health professional and a leader in her field. After growing up on a farm in Tasmania, Lucy graduated in 2000 with a Bachelor of Arts (Recreation Management) from Victoria University. She jumped straight into the industry, finding roles within local government, sports organisations, youth justice and adventure tourism. Lucy spent nine years with the University of Tasmania, where she founded, developed and managed the multi-award winning, project called Active Launceston. Following this success Lucy then created Active Tasmania, which delivered primary health projects across Tasmania. Lucy has been involved in high-level policy development and strategic planning, presented her research at international conferences and has been published in peer-reviewed literature. Lucy has a demonstrated ability to engage people of influence to gain support and funding for her projects. Lucy contributes to numerous community boards and organisations, and in 2015 Lucy established a company with her sister Penny Terry. Healthy Tasmania, works on a wide range of projects to improve the individual, social and economic health of our communities. Lucy is a graduate of the Australian Institute of Company Directors and the University of Tasmania with a Master of Biomedical Science (Research).
Launceston is a regional community in northern Tasmania.
Active Launceston is a community driven project with the vision of improving the health and wellbeing of the Launceston community through physical activity.
Active Launceston’s mission is to mobilise the community to increase their participation in physical activity by; filling gaps in provision, creating pathways, reducing barriers and targeting those with the highest need.
Between 2008 and 2017 Active Launceston delivered 223 community programs, engaged 12, 661 attendees, attending 32, 857 sessions, amounting to 40, 787 hours of physical activity.
Active Launceston has been the subject of higher degree research, published in peer reviewed literature, presented at two international conferences, provided leadership opportunities and placements for 93 students, won multiple community awards and attracted close to two million dollars in funding with a return of investment of $416 for every dollar spent. Active Launceston has developed a strong community profile, an excellent reputation, and a highly-recognisable brand and community identity. The projects events, programs, website, organisational structure, partnerships and levels of community engagement have gained accolades at a state, national and international level.
An interrupted time-series process and impact mixed-methods evaluation of Active Launceston between 2008 and 2015 consisted of participation statistics, focus groups, stakeholder interviews, a serial online survey and a randomised cross-sectional serial population telephone survey of Launceston residents. Amongst numerous societal impacts, the key finding of this research was a significant increase in sufficient physical activity for health (defined as 150 min per week) in the Launceston community.
Active Launceston is delivered under a well-established evidence based framework which enables the successful delivery of a complex community-wide health promotion project. The project was initiated as an 18 month pilot partnership in June 2008 but according to the Federal Government Department of Health, Active Launceston is the last remaining project across the country that was funded through the original Active and Healthy Communities grants program back in 2008.
Rather than simply presenting the research findings, this service report will tell the story of Active Launceston. Delegates will meet some of the characters and hear how the project impacted their lives. Delegates will come to understand some of the challenges faced by project managers and the key elements of the project that continue to make it a success today.