Category: Article type

Nine Harkness Fellowships are awarded each year to scholars in Australia, New Zealand and the United Kingdom to allow them to spend up to 12 months in the US. The Fellowships are managed by the Commonwealth Fund, a private foundation that supports independent research on health and social issues. The Fund’s goals are to improve access to health care for disadvantaged groups and to improve quality of care. It aims to build a network of policy-oriented health care researchers and to stimulate innovative thinking on health policy and practice in the United States and other industrialised countries.

Native Americans, like Indigenous Australians, have very high rates of renal disease and receive relatively few transplants, the most effective treatment for ESRD. A successful transplant confers a better quality of life, a longer life expectancy and results in lower costs than does the alternative, long-term dialysis.

Similar factors may well influence transplantation for both Native Americans and Indigenous Australians. Social determinants-poverty, lack of education and other disadvantage-play an important part, but cultural issues also profoundly affect how Indigenous people relate to the health care system.

Dr CASs will use US databases pertaining to dialysis and renal transplantation. He will examine how people have interacted with the system and whether they have had access to transplants. He plans to use the data to document any disparities and then to interview service providers, policy makers and, of course, Native Americans themselves, to discover whether or not there are systemic barriers to access.

The predominant aim of his research is to develop strategies that will help improve equity in access to transplantation for Indigenous Australians.

Alan CASs MBBS FRACP Grad. Dip. Clin. Epidemiology
PhD student, Menzies School of Health Research
Nephrologist, Royal Darwin Hospital

Jenny Darr, Hanni Gennat, Jacinta Elston, Lynore Geia, Adrian Miller, Vicki Saunders.

It has been acknowledged by both community stakeholders and government that Aboriginal and Torres Strait Islander women are in the high-risk group for complications at any stage of pregnancy¹. Infant mortality rates for Aboriginal and Torres Strait Islanders remain unacceptably high, with prematurity and low birth weight still prevalent especially in remote areas².

Earlier recruiting of Aboriginal and Torres Strait Islander pregnant women into antenatal programs is essential, as maternal nutrition, substance abuse, high blood pressure and infections are all important risk factors for low birth weight babies. The anecdotal experience by Aboriginal and Torres Strait Islander women is commonplace.

In order to meet the demand of providing adequate services and programs, the health workforce must be trained. Aboriginal and Torres Strait Islander participation in the workforce is essential and should not be an optional add-on for any Indigenous community. Aboriginal and Torres Strait Islander Health Workers have been recognised through numerous government and community reports as being central to the provision of health services for Indigenous people, and invaluable in the role of cultural and health brokers^{3, 4}. Aboriginal and Torres Strait Islander Health Workers provide culture-specific knowledge, access, and an ability to liaise with Indigenous communities about their interactions with the health care system.

Today, throughout all States and Territories there is an expansive network of Aboriginal and Torres Strait Islander Health Workers, employed in either Aboriginal Medical Services or by State/Territory Health Departments. Their scope of practice and career paths as health professionals within the broader health field has been slow since the creation of the Aboriginal and Torres Strait Islander Health Worker role.

A major objective of this education program offered through James Cook University, School of Public Health and Tropical Medicine, is to increase the number of skilled Aboriginal and Torres Strait Islander Health Workers in maternal health, to help address the unacceptably high levels of Aboriginal and Torres Strait Islander perinatal mortality and morbidity, through improving access to and appropriateness of obstetric services especially in under-serviced rural and remote areas.

The National Centre for Maternal Health Education for Aboriginal and Torres Strait Islander Health Workers has an innovative program entitled ‘Maternal Health for Aboriginal and Torres Strait Islander Health Workers’. The Program provides theoretical knowledge and clinical skills enabling Aboriginal and Torres Strait Islander Health Workers to better manage maternal health care within their communities.

The Royal Australian College of Obstetrics and Gynaecology (RACOG, now RANZCOG) established a pilot program in 1990 with funding from the Federal Government (DEETYA) to provide a Skills Transfer (Maternal Health Education) Program for 12 Aboriginal Health Workers, in Broome, Western Australia. The Aboriginal and Torres Strait Islander Health Studies unit in the School of Public Health and Tropical Medicine (SPHTM) at James Cook University taught the skills transfer program.

This early collaboration developed into the current partnership between RANZCOG, the SPHTM at James Cook University, Kimberly Aboriginal Medical Service Corporation (KAMSC) and the teaching hospitals involved in the program. A Commonwealth grant in 1997 saw an injection of financial resources enabling the partners to increase the numbers of courses on offer each year and the number of sites where teaching occurs. This improved access for Aboriginal and Torres Strait Islander Health Workers whose ability to study was limited by family, community and work commitments.

The Maternal Health Education Program is aimed at transferring both practical skills and knowledge to female Aboriginal and Torres Strait Islander Health Workers, allowing them to practically contribute to the obstetric care of Aboriginal and Torres Strait Islander women during their antenatal, labour and post natal terms. The course has been designed to provide the experienced health worker with a solid foundation in both theoretical background and clinical experience. It aims to optimise the management of normal pregnancy and the early identification of at-risk pregnancy. It is now offered to both experienced and non-experienced health workers.

The Maternal Health Education Program is delivered in block mode comprising a two-week theoretical component with face-to-face delivery of lectures and a clinical placement, consisting of an additional two weeks within an appropriate tertiary level maternity hospital.

The program examines current maternal health epidemiological patterns and includes an examination of various maternal health programs and their comparative impact. The curriculum includes a basic knowledge of female anatomy and obstetric anatomy and physiology; the principles of normal pregnancy and antenatal care, the recognition and management of high risk and abnormal pregnancy, and management of the puerperium. Other topics include: the recognition of onset of labour, management of out-of-hospital deliveries, communicating effectively with hospital staff, abnormal palpation and the use of foetal Doppler and stethoscope.

A variety of teaching techniques are used to achieve these learning objectives. These include small group learning sessions and clinical skill laboratories using mannequins and case studies. Teaching aids such as videos and mock case studies help reinforce the theoretical content. Nutrition, sexual health, breast feeding, risk factors for high-risk pregnancy, and post-natal care at home and hospital, are subjects delivered by guest lecturers with particular expertise in these topics. During each block guest lecturers who work or reside in the community where the block is being delivered are identified and invited to lecture on specific subjects. This enables a local community perspective and flavour to be fostered within particular sessions inclusive of the objectives that have been outlined in curriculum.

The content is delivered in such a way that it aims to contextualise Indigenous worldviews and experiences within the western medical setting, as appropriate for maternal health. Consequently, the students participate more effectively in the learning process.

The structural design of the program content enables students to follow a logical pathway in basic maternal health care. It exposes students to technical terminology and practices of maternal medicine whilst being delivered in the context of Indigenous learning. The topics are sequenced from pre-conception to antenatal care and then on to postnatal care and are delivered in the context of the physiological processes that would occur in a normal pattern of pregnancy. Additionally, the course structure is designed to address those factors such as nutrition, sexually transmitted infections, substance misuse, and other factors that contribute to high-risk pregnancies which are prevalent amongst Aboriginal and Torres Strait Islander mothers.

The clinical component of the course is designed to cement the knowledge acquired during the theoretical component by immersing health workers in a clinical hospital setting. This ensures student learning by hands-on, practical experience within a major tertiary (teaching) maternity hospital. This is further reinforced by the clinical assessment, which requires the student to attain specific skills while on placement. During clinical placement, students are exposed to a variety of ward areas within the hospital to experience and attain a wide range of skills. The students are required to complete a Clinical Experience Record that demonstrates they have observed and conducted a range of appropriate clinical and program activities whilst on placement.

Many factors impact on the ability of the graduates to successfully apply the skills and knowledge attained during the course. There is some anecdotal evidence that the program is contributing to increased antenatal attendance and at an earlier stage in pregnancy at several sites around Australia⁵. This experience includes several Aboriginal Community Controlled Health Organisations who have established dedicated Maternal and Child health programs utilising the skills and knowledge of staff that have successfully completed the program.

The course has had national uptake. There has also been an increase in hospital sites participating in the clinical phase of the program to accommodate the increased number of students in the course. The hospitals include: The Townsville Hospital (Townsville, QLD), Royal Darwin Hospital (Darwin, NT), King Edward Hospital (Perth, WA), Nepean Hospital (Penrith, NSW), and King George V Memorial Hospital for Mothers and Babies (Sydney, NSW). A range of tertiary hospital sites are utilised to expose Aboriginal and Torres Strait Islander Health Workers to the treatment and care that the majority of high-risk Indigenous mothers and babies experience in these hospital settings.

The Maternal Health Education program featured as part of the recommendation in a report to the Victorian Aboriginal Community Controlled Health Organisation (VACCHO) and the Victorian Department of Human Services⁶. The report recommended that the James Cook University Maternal Health Education Program be made available to all female Aboriginal and Torres Strait Islander Health Workers involved in maternal and child health care. VACCHO emphasised that the course is Aboriginal owned and recommended that Aboriginal and Torres Strait Islander Health Workers who are employed to provide maternity services, undertake this training.

In 1997, a new course, Basic Ultrasound Skills for Indigenous Health Workers in Remote Locations was written as a partnership between SPHTM, RANZCOG and the Australasian Society of Ultrasound Medicine. The course was designed to provide female Aboriginal Health Worker in rural and remote settings with limited access to sonographers, skills in maternal ultrasonography. The ultrasound course is skill specific and is only intended to assist Health Workers to identify a normal pregnancy via ultrasonography. The course emphasises that any abnormal findings should be referred to a doctor. Since the commencement of this course a total of nine students have been trained in maternal ultrasound skills. All of the ultrasound students are currently based in rural or remote communities. Indigenous women appear already to be attending the antenatal clinic earlier often in the hope of having an ultrasound examination. It has also become apparent that the partners of the pregnant women are also attending the ultrasound examination, which was previously unheard of in this community⁷.

Health Worker Profile

Heather Lee successfully undertook her Health Worker training at Townsville TAFE, and the Maternal Health Education Program in 1999, also in Townsville. Heather completed the clinical component of the course at Kirwan Hospital for Women (now The Townsville Hospital) and stated that this experience was good. She has since been working at Townsville Aboriginal and Islander Health Service (TAIHS) as the Coordinator/Health Worker of Mum’s and Babies Clinic. Heather has always had an interest in the medical field and her experiences as a birthing partner for friends and family led her to pursue studies so that she could formally provide health assistance to the Indigenous population.

In the Mum’s and Babies Clinic Heather finds that she utilises her maternal health training on a daily basis and the program has grown successfully since her employment in this position. Heather says that being able to provide holistic and culturally appropriate care to Aboriginal and Torres Strait Islander women has improved their health and wellbeing and she enjoys being part of this important team.

When asked whether she thought her training had been of benefit to her employer, Heather said she thought her training had helped to generate an increasing client base to the Mum’s and Babies clinic, which has an atmosphere where everyone feels comfortable and safe to attend. Heather feels that her maternal health training has improved the quality of the service that she provides as she is able to discuss women’s issues with clients in a safe environment and feels confident about giving them information that they can easily understand.

Heather believes that all of the Townsville community, particularly those who attend the clinic (and their families and partners) have benefited from her training and has helped to break down barriers between non-indigenous and indigenous people. This unique Mum’s and Babies clinic has been funded for a two-year period by Rio Tinto, and provides an important service. Unfortunately at this point in time, TAIHS has been unable to secure future funding for this successful program.

Ms Heather Lee – Coordinator of Mum’s and Babies Clinic at TAIHS

References

1. 1. NHMRC. (2000). Standards of Antenatal Care.

1. 1. Commonwealth of Australia. (May 2000). Health is life: Report on the Inquiry into Indigenous Health House of Representatives Standing Committee on Family and Community Affairs. Canberra. Family and Community Affairs. pp 4.

1. 1. Commonwealth of Australia. (May 2000). Health is life: Report on the Inquiry into Indigenous Health House of Representatives Standing Committee on Family and Community Affairs. Canberra. Family and Community Affairs. pp 97-98.

1. 1. William, A. and Cadet-James, Y. (2000). The role of tertiary education in strengthening Indigenous health. Brisbane. Centre for Indigenous Health Education and Research, University of Queensland.

1. 1. Aboriginal and Torres Strait Islander Health Studies. (May 2001). Internal Report on the Maternal Health Education Program for Aboriginal and Torres Strait Islander Workers. Townsville. School of Public Health and Tropical Medicine, James Cook University. pp 44.

1. 1. Campbell, S. (2000). From Her to Maternity. A report to the VACCHO members and the Victorian Department of Human Services about maternity services for the Aboriginal women of Victoria. Melbourne. Department of Human Services, Victorian Government. pp 33.

1. Kohlenberg, C. (1998). Report on the review of the pilot scheme. Penrith. Ultrasound skills transfer project, Nepean Hospital

About OATSIH

The Office for Aboriginal and Torres Strait Islander Health (OATSIH) was established in the mid 1990s when responsibility for Aboriginal and Torres Strait Islander health at a Commonwealth level moved from the Aboriginal affairs to the Health portfolio (OATSIH is located in the Department of Health and Ageing).

Since its beginning, the Office has developed its vision to reduce the gap in health status between Indigenous and non-Indigenous Australians through strengthening primary health care for all Aboriginal and Torres Strait Islander people. Support for Indigenous specific community-controlled services and the improvement of functional access to general health services are priorities. The Office supports strategies to reform existing health systems and improve the infrastructure, workforce and information systems on which comprehensive primary health care rests. It aims to address specific health issues and to enhance the evidence base that underpins health interventions. In addition, OATSIH seeks ways to maximise whole-of-government responses across all levels of government and jurisdictions to achieve improvements in Aboriginal and Torres Strait Islander health.

The Office is organised around three broad streams of activity: health and community strategies, program planning and development, and workforce, information and policy. Within these streams, current activities include:

• the primary health care access program (PHCAP) directed at improving access to primary health care through supporting mechanisms to increase community-control, reforming existing health system structures, and increasing the available resources within selected PHCAP sites;
• initiatives directed at improving access of Aboriginal and Torres Strait Islander peoples to general health programs (for example, the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme);
• consultation on a draft National Strategic Framework for the Aboriginal and Torres Strait Islander health workforce
• assisting the Minister’s National Aboriginal and Torres Strait Islander Health Council in its task to consult on and finalise a second National Aboriginal and Torres Strait Islander Health Strategy;
• the development of policy frameworks in the areas of chronic disease and maternal and child health; and
• support for the work of the Research Agenda Working Group in its task to develop a strategic ‘roadmap’ to facilitate and guide initiatives, nationally, in Aboriginal and Torres Strait Islander health research.

The breadth and depth of activity is impressive.

The role of SMA at the Office

The senior medical advisor (SMA) position is important in linking the Office and other areas of the Department of Health and Ageing, in particular those areas concerned with medical professional activity. The SMA facilitates liaison with outside organisations (such as medical schools, universities and research institutions) and maintains communication with medical and other health professionals and organisations in the Indigenous health field. Within the Office, and in collaboration with other staff, the SMA provides clinical and public health expertise, and guidance for policy development work. There is considerable room to move within the position, with scope to take on projects of interest and to allow one’s particular experience and talents to be utilised.

My background in Indigenous health

With Queensland Health in far north Queensland

I arrived in the Office from far north Queensland (FNQ) in October 2001, having worked for some years for Queensland Health as a community women’s health program manager. I established an outreach women’s general practitioner service for remote area Aboriginal and Torres Strait Islander women (now operating under the auspices of the Royal Flying Doctor Service (Qld) as the Rural and Remote Women’s Health Program). In FNQ, this service is supported by visiting district mobile women’s health teams (comprising registered nurse and health worker), an accredited training program, comprehensive information systems, and access to specialist services. This well-women’s program has increased women’s access to a skilled women’s health practitioner and to appropriate reproductive health and well-women’s screening services. It has resulted in 200-300 per cent improvement in cervical screening participation rates over the course of the 1990s (albeit from a very low base). Importantly, all elements of this program continue today.

Other activities during my time in FNQ included:

• the establishment of the breast screening service in Cairns;
• overseeing the feasibility study that explored options for the provision of breast screening to remote area women in FNQ; and
• the development of the medical aspects of a sexual assault service. Since1993, the Cairns-based sexual assault service has provided a female medical officer to attend adult women immediately following sexual assault.

I worked also for ‘The Well Person’s Health Check’ project as the sexual health physician for the first 18 months of its operation, and was involved in the implementation of an important initiative that has introduced screening for domestic violence in Queensland Health facilities (the Queensland Domestic Violence Initiative). I was a member also of the FNQ Community Corrections (Parole) Board up to October 2001, building on an early interest in Indigenous prison health that arose from clinical visits to prisons in Sydney during the 1980s.

With the Redfern Aboriginal Medical Service in Sydney

Prior to my time in Queensland, I was privileged to work in Sydney at the Aboriginal Medical Service (AMS) in Redfern for nine years. I started work at Redfern as a young(ish!!) medical officer having recently returned from post-graduate clinical training (with an emphasis on women’s and children’s health) in England. I returned to Australia in order to work at the Redfern AMS and, indeed, I had to wait six months (for the departure of Dr Archie Kalokerinos) before they could take me on. Working at Redfern was grand – a great clinical experience within a pretty cohesive community.

It was a tremendously steep learning curve:

• interacting across cultures (with bemused and tolerant teachers);
• operating in a multidisciplinary health care team;
• participating in intersectoral action in health service provision; and
• working in an organisational structure that fostered community-control and made community development a reality for many individuals and satellite communities.

After five years as a full-time general practitioner within the AMS I took on a more public health role, working only part-time in the clinic. Over the following few years, I completed a Master of Public Health and was involved in much project work at Redfern. These projects included writing submissions (such as: Far West Children’s Home at Manly, asbestos mining at Baryulgil, drug and alcohol treatment programs in the inner city, prison health, etc.), development of health promotion programs (HIV, breast-feeding, diabetes, immunisation), and the conduct of research (mental health problems presenting to Indigenous primary health care services in NSW – the subject of my masters thesis).

How I hope to contribute to OATSIH’s vision

The OATSIH has come far since its establishment. There have been gains – but the strengthening of primary health care remains a continuing challenge and core business for a department of health. At a broader level (than health alone can achieve), it is critical to improve the environment into which many Aboriginal and Torres Strait Islander children are born. I hope to contribute to this vision during my time in OATSIH, in particular through:

• strengthening OATSIH’s links across the Department and with medical professionals/organisations involved in Indigenous health; and
• the carriage of projects that will benefit from my medical and public health experience (across a diverse range of Aboriginal and Torres Strait Islander health settings – in urban and remote locations, and within both the community-controlled and government health sectors).

Dr Patricia Fagan FAFPHM, DCH, DRCOG
Senior Medical Advisor
The Office for Aboriginal and Torres Strait Islander Health
Department of Health and Ageing
Patricia.Fagan@health.gov.au