Sean Taylor

Getting better at chronic care in remote communities: study protocol for a pragmatic cluster randomised controlled of community based management

BackgroundPrevalence and incidence of diabetes and other common comorbid conditions (hypertension, coronary heart disease, renal disease and chronic lung disease) are extremely high among Indigenous Australians. Recent measures to improve quality of preventive care in Indigenous community settings, while apparently successful at increasing screening and routine check-up rates, have shown only modest or little improvements in appropriate care such as the introduction of insulin and other scaled-up drug regimens in line with evidence-based guidelines, together with support for risk factor reduction. A new strategy is required to ensure high quality integrated family-centred care is available locally, with continuity and cultural safety, by community-based care coordinators with appropriate system supports.Methods/designThe trial design is open parallel cluster randomised controlled trial. The objective of this pragmatic trial is to test the effectiveness of a model of health service delivery that facilitates integrated community-based, intensive chronic condition management, compared with usual care, in rural and remote Indigenous primary health care services in north Queensland. Participants are Indigenous adults (aged 18–65 years) with poorly controlled diabetes (HbA1c>=8.5) and at least one other chronic condition. The intervention is to employ an Indigenous Health Worker to case manage the care of a maximum caseload of 30 participants. The Indigenous Health Workers receive intensive clinical training initially, and throughout the study, to ensure they are competent to coordinate care for people with chronic conditions. The Indigenous Health Workers, supported by the local primary health care (PHC) team and an Indigenous Clinical Support Team, will manage care, including coordinating access to multidisciplinary team care based on best practice standards. Allocation by cluster to the intervention and control groups is by simple randomisation after participant enrolment. Participants in the control group will receive usual care, and will be wait-listed to receive a revised model of the intervention informed by the data analysis. The primary outcome is reduction in HbA1c measured at 18 months. Implementation fidelity will be monitored and a qualitative investigation (methods to be determined) will aim to identify elements of the model which may influence health outcomes for Indigenous people with chronic conditions.DiscussionThis pragmatic trial will test a culturally-sound family-centred model of care with supported case management by IHWs to improve outcomes for people with complex chronic care needs. This trial is now in the intervention phase.Trial registrationAustralian New Zealand Clinical Trials Registry ACTR12610000812099

Depression and diabetes in the remote Torres Strait Islands

Issue addressed Diabetes is associated with significant depression, which can result in poorer clinical outcomes, including increased mortality. Little is known about the prevalence of depression among Torres Strait Islander adults with diabetes. Methods Self-reported depression was measured using the Patient Health Questionnaire (PHQ)-9 translated into Torres Strait Creole, and associations with socioeconomic, behavioural and clinical indicators in Torres Strait Islander adults with diabetes in five remote Torres Strait Islands were examined. Results Seventy-three men and 115 women completed interviews. The median PHQ-9 score was 5.5 (IQR 0-7); 42% of respondents scored 0-4 (none-minimal), 46% scored 5-9 (mild) and 12% scored 10+ (moderate-severe). Mean HbA1c was 8.3% (67.4mmol). HbA1c was not related to PHQ-9 scores (β=0.20, P=0.323), however exercise in hours (β=-0.34, P<0.001) and screen time in hours (β=0.11, P<0.001) were significant predictors of depression after adjusting for other study variables. Conclusions This sample of remote living Torres Strait Islanders reported relatively low rates of depression compared with national samples, and depression was not related to glycaemic control. Exercise and screen time were the strongest predictors of depression based on PHQ-9 scores. This represents an opportunity for health promotion. So what? These findings provide an indication of the health impact of physical activity in rural and remote communities. Local health and education services, councils and sporting bodies should work collaboratively to promote sustainable physical activity programs.

We are everything to everyone: a systematic review of factors influencing the accountability relationships of Aboriginal and Torres Strait Islander health workers (AHWs) in the Australian health system

BackgroundHealth policy in Australia positions Aboriginal and Torres Strait Islander Health Workers (AHWs) as central to improving Aboriginal and Torres Strait Islander peoples’ health, with high expectations of their contribution to closing the gap between Indigenous and non-Indigenous health outcomes. Understanding how AHWs’ governance and accountability relationships influence their ability to address such health inequities has policy, programme and ethical significance. We sought to map the evidence of AHWs’ experiences of accountability in the Australian health system.MethodsWe followed an adapted qualitative systematic review process to map evidence on accountability relations in the published literature. We sought empirical studies or first-person accounts describing AHWs’ experiences of working in government or Aboriginal community-controlled services anywhere in Australia. Findings were organised according to van Belle and Mayhew’s four dimensions of accountability – social, political, provider and organisational.ResultsOf 27 included studies, none had a primary focus on AHW governance or AHWs’ accountability relationships. Nonetheless, selected articles provided some insight into AHWs’ experiences of accountability across van Belle and Mayhew’s four dimensions. In the social dimension, AHWs’ sense of connection and belonging to community was reflected in the importance placed on AHWs’ cultural brokerage and advocacy functions. But social and cultural obligations overlapped and sometimes clashed with organisational and provider-related accountabilities. AHWs described having to straddle cultural obligations (e.g. related to gender, age and kinship) alongside the expectations of non-Indigenous colleagues and supervisors which were underpinned by ‘Western’ models of clinical governance and management. Lack of role-clarity stemming from weakly constituted (state-based) career structures was linked to a system-wide misunderstanding of AHWs’ roles and responsibilities – particularly the cultural components – acting as a barrier to AHWs working to their full capacity for the benefit of patients, broader society and their own professional satisfaction.ConclusionsIn literature spanning different geographies, service domains and several decades, this review found evidence of complexity in AHWs’ accountability relationships that both affects individual and team performance. However, theoretically informed and systematic investigation of accountability relationships and related issues, including the power dynamics that underpin AHW governance and performance in often diverse settings, remains limited and more work in this area is required.

Managing Aboriginal and Torres Strait Islander data for public health research

Good quality data on Aboriginal and Torres Strait Islander peoples are needed to assess the effectiveness of programs and interventions, and to evaluate policies that are designed to improve the status of, and service delivery to, Aboriginal and Torres Strait Islander peoples. Due to the lack of longitudinal data it is difficult to gain knowledge on the specific causes or consequences of changes in indigenous outcomes. Variables such as name, date of birth and address for Aboriginal and Torres Strait Islanders may be subject to more variation and be less consistently reported than other Australians. Improving the collection and management of key identifying variables for Aboriginal and Torres Strait Islanders are key to providing more quality information on this population group.

High glycaemia and low uptake of insulin treatment among remote Torres Strait Islanders with diabetes: Implications for service delivery

[Extract] Torres Strait Islanders have the highest prevalence of Type 2 Diabetes in Australia.[1] Between 2005/06 and 2009/10, there were on average 123 diabetes separations per year in the Torres Strait and Northern Peninsula Hospital and Health Service. A review in 2005 noted that newer diabetes cases were younger, more obese and had poorer glycaemic control compared to 6 years previously.[2] Here we briefly report all diabetes cases in five of the most remote outer islands of the Torres Strait conducted in 2013 who were recruited into a cohort study. These very remote islands are serviced by local primary care workers, nurses and only intermittently visited by specialist outreach teams and general practitioners.

Barriers to insulin treatment among Australian Torres Strait Islanders with poorly controlled diabetes

Abstract Objective To explore self reported knowledge and attitudes to insulin treatment among a group of adults with poorly controlled diabetes in the Torres Strait islands. Design Cross‐sectional survey in 2014, interviews with 29 adults with HbA1c ≥ 8.5% (69 mmol mol−1) and not taking insulin, using Insulin Treatment Appraisal Scale (ITAS) and Barriers to Insulin Treatment Questionnaire (BITQ) scores. Setting Five remote Torres Strait Island communities in the Torres Strait region. Participants Poorly controlled insulin‐naïve type 2 diabetics. Main outcome measures BITQ and ITAS scores on items related to knowledge and attitudes to insulin treatment, clinical and demographic measures. Results Overall, 34% of the cohort had poor glycaemic control. Compared to those with HbA1c ≥ 8.5% and taking insulin (n = 37), the 29 insulin‐naïve participants were more obese, more likely to smoke and drink alcohol, have lower mean HbA1c and fewer years with diabetes. Among the insulin‐naïve group, those reporting higher ‘barriers’ (BITQ scores) were older and with lower formal education than those reporting fewer barriers. Torres participants consistently scored low on ‘knowledge’ items in the ITAS, especially those which would guide insulin initiation (insulin improves glucose control and prevents complications). Conclusion Compared to other published studies, the Torres participants had higher scores for BITQ ‘barrier’ items and lower ‘knowledge’ scores. This suggests better education around glycaemic control with medication and discussion of perceptions and exchange of experiences with peers who are taking insulin might improve the uptake of insulin in this high‐risk group.

Diabetes in Torres Strait Islanders: Challenges and opportunities for remote area nurses

Abstract Torres Strait Islanders living in the Torres Strait region have the highest prevalence of Type 2 diabetes in Australia; more than three times the rate of other Australians. Abdominal obesity and insulin resistance are the main causes for these high rates of the disorder. Further, Aboriginal and Torres Strait Islanders diagnosed with diabetes have poorer glycaemic control and much lower rates of insulin use than non-Indigenous Australians diagnosed with Type 2 diabetes alongside extremely high rates of renal failure and other comorbidities. Interventions have been instigated in order to overcome these issues. Previously a simple recall system managed by local health workers achieved significant improvements in diabetes care, reduced diabetes-related hospitalisations by 40% and led to the implementation of a chronic disease register and recall system throughout the Torres Strait region. Nurses, Indigenous health workers and other health professionals play important roles in ensuring these interventions continue.