Are You Remotely Interested... in Prevention? Building a Culture of Safety Conference - Mount Isa, Queensland, Australia: 1-4 August 2012, Mount Isa Queensland, Australia

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Keynote speakers

James Helmkamp
The Challenge of ATV Safety: Risky Business

Over the past 30 years, all-terrain vehicles (ATVs) have grown increasingly popular recreationally in the United States and have become a valuable asset at work as well. With an estimated 11 million in use in 2010 for both recreation and work, ATVs have become a common means of transportation. While most users operate ATVs in a safe and responsible manner, hundreds are killed and tens of thousands more are injured annually - through bad luck, unfortunate circumstances, unsafe behavior, lack of appropriate skills and training, faulty equipment, and a variety of other reasons. From 2001-2010, an average of 659 persons were killed in U.S. ATV crashes at a rate of 8.1 deaths per 100,000 ATVs; the youngest victims had the highest fatality rates. About 86% of the decedents were male, 95% white, and 60% between the ages of 15 and 44. Rolls and overturns were a common event (50-60%). In the work environment, from 2004-2007, there were 38 deaths per year, most in the crop and animal production industries, particularly in workers 65 years of age or older. The mean lifetime cost of each work-related ATV death was approximately $803,000. Over the past decade, many U.S. states have enacted various helmet, training and licensure requirements however, collectively these have not seemed to have made a difference in reducing the number of deaths. In fact, the number of recreational ATV deaths increased 225% from 2,226 between 1990 and 1999 to 7,231 between 2000 and 2007. I believe the failure of these polices is primarily due to lack of enforcement, the casual attitude of many ATV riders to not wear a helmet or take training, and the genuine lack of common sense. I firmly believe that it is an inherent responsibility of ATV manufacturers to make the safest machine possible. It is also equally important for the user to know and understand the risks associated with riding an ATV. ATVs can be fun and safe -- at play and at work - if we identify, understand, and address their inherent dangers. Collectively, we must strive harder to make ATV riding safer-creating stronger collaborations between manufactures, safety advocates, health care professionals, insurers, families, employers, and the riders themselves.

Barbara Lee
Childhood Agricultural Injury Prevention: Global Obligations and Opportunities

Background: Fatal and non-fatal injuries among children living, working and visiting on farms and ranches are a global phenomenon. Injury events have common characteristics and similar prevention strategies despite the diverse issues across geographic regions and socio-economic conditions. Rural/remote living limits options for regulatory oversight. Typically, rural cultures value strenuous work for young people, view injuries as a 'cost' of farming, and set priorities of production over safety. These factors compromise injury prevention efforts. Although non-fatal childhood agricultural injuries in the US have been declining for 11 years, deaths remain constant.
Current efforts: Since 1996 the US has had a national initiative with a formal plan, periodically updated, with the most recent version in 2012. Guidelines for children working on family farms, children playing on farms, and youth hired to work in agriculture were developed by, and endorsed among, safety professionals; but these are not well known in the farming community. A multitude of strategies, e.g. safety day camps, have been employed. Evaluation of interventions reveals mixed results and calls for greater emphasis on influencing the culture of safety at a level higher than the farm or ranch itself.
Future strategies: Efforts for protecting children from agricultural injuries and deaths must look beyond traditional grass-roots educational programs. It is time to capitalize on global trends associated with multinational agriculture-related companies. Farm safety advocates have opportunities to influence the Corporate Social Responsibility programs of companies that respond to consumer demands. Partnerships with trade associations and agribusinesses might address specific needs such as expanded off-farm childcare services. Influencing social norms, such as keeping children off farm vehicles, could include agribusiness-funded campaigns that access their marketing tools and extensive social media outlets. Sharing success stories globally will facilitate a more rapid adoption of evidence-based strategies, with young children as the ultimate benefactors.

Rob Moodie
The Science, Art and Politics of Prevention

This paper outlines some of the major successes of prevention in recent time including HIV/AIDS, tobacco control, road trauma, cardiovascular disease, vaccine preventable diseases and SIDS. Good prevention requires progressive, determined, comprehensive and sustained action over many years. Quick wins and 'silver bullets' don't exist in the complex world of public health. Effective prevention may require a lot of courage, for example in fighting powerful vested interests such as tobacco multinationals, and it certainly requires the three P's - persistence, persistence and persistence!
In the establishment phase the elements of good prevention include convincing evidence (essential, but never sufficient); timely, tactical, courageous and persistent advocacy; understanding, monitoring and building of community support; and building a coalition of organisations, decision makers and political and community 'champions'. Once work is becoming established the elements include an ongoing system of monitoring, evaluation and operational research; establishing overarching policy, appropriate legislation and regulation; communications including mass media, social media and narrowcasting of media; advocacy: getting primary care service involved and other sectors; maintaining bipartisan support and funding.
This paper covers issues such as alcohol, obesity, illicit drugs, sexual and reproductive health and mental health, as well as health inequalities, rural health and indigenous health and asked the question of why aren't we doing well in prevention related to these issues? Responses include the lack of good data defining the problems or good research indicating what works; lack of leadership, unity or critical mass; lack of political champions (as there is no 'waiting list' for prevention); issues that are, or have become very politically partisan; lack of community support, and finally the powerful transnational and national industrial drivers of the tobacco, alcohol and food and drink related epidemics of non-communicable diseases (NCDs).

Gregory Phillips
Cultural Safety and Aboriginal and Torres Strait Islander Health

In Australia, cultural safety is a term used with confusion and interchangeably with terms like cultural awareness, cultural respect and cultural sensitivity. This presentation will explore the origins, uses and meanings of the term in Australia through the example of its application in medical schools, hospitals, non-government organisations and public health policy. Going beyond explanations of 'the other', this presentation will critically examine the power relations implicit in the uses of the word and its implications for health programs, teaching and research. A more nuanced and clearer model is presented.

Presentations in chronological order

Tony Lower
Australian Quad Bike Deaths (2001- 2010)

Introduction: Quad bikes are a leading cause of fatal injury in farm settings. This study examines the pattern of quad bike fatalities based on coronial records between 2001 and 2010.
Method: Data were extracted on all quad bike related fatalities over the study period from the National Coronial Information System.
Results: There were 127 fatalities with 65% of these occurring on a farm. Incidents were classified as either non-rollover events (54%) or rollovers (46%). Almost 90% of rollover incidents occurred on a farm. Overall, 41% of incidents were work-related and occurred on farms. High risk activities for farm work were transportation, weed control and mustering. Non-work related deaths were more likely to involve collisions and loss of control. Children 0-14 years featured in 18.5% of incidents, while those over 45 years made up 42.9% of all cases. Differences in the age patterns of farm and non-farm deaths (X²=24, df=5, p<0.01) and for rollovers and non-rollovers (X²=21.2, df=5, p<0.01), were statistically significant.
Discussion: Given the high number of rollover incidents and their disproportionate burden in the farm setting, improved quad bike design to include safety of the operator in the case of the machine rolling is urgently required.

Geoff McDonald
The Relevance of Quad Bike Rollover Deaths for Safety

Frames were established as effective in reducing tractor rollover deaths by 1964. Many deaths with frameless Australian tractors came from grower resistance and government indecision, despite manufacturer support from 1970. 'Human error' control was advocated. Tractor frames have become widely used and are effective. Quad bikes are now rollover kings on rural properties. Crush protection frames are opposed by manufacturers. Growers are divided and governments indecisive. Lack of veridical (true saying) information, and the presence of non-veridical claims, fuel confusion and indecision. The need to focus on Class I (permanently life altering) personal damage, fatal and non-fatal, and on the significance of impact, crush and shear injury is emphasised. Non-critical evaluation of invalid simulation of 113 (59 UK and 54 USA) quad bike rollovers led to acceptance of the simulators' condemnation of frames. Too many of the UK/USA injuries were Class II (temporary alteration of life) and too few were Class I. Fewer than 50% of the case descriptors necessary to run the simulation were provided. In 104 cases, the simulated injury was to a different part of the body. Crush protection frames must minimise the probability of the weight of the machine coming on the person and minimise increase in the probability of impact injury. Head protection is necessary to reduce both crush and impact injury. Three methods of testing the structural integrity of frames are illustrated: static loadings, inclined ramp and drop from moving vehicles. Inaction is unacceptable and will increase the unnecessary rural rollover tractor/quad bike death toll which, counting from 1964, is still rising. Acceptable structures exist. The Government, Rural Industry and Manufacturers have a part to play. Forget 'human error'. It's technically incorrect and mind limiting.

Sabina M Knight, Kristin E McBain-Rigg, Richard C Franklin
All Terrain Vehicles in North Western Queensland: Use of vehicles in occupational settings and perceptions of safety.

The number of and variety of uses for All Terrain Vehicles (ATVs, or quad bikes as they are more commonly known,) has increased over the past decade (Fragar et al. 2007, Krauss et al. 2010, Lord et al. 2010). While the increase in use in overseas markets has been recreational, in Australia it has largely increased in occupational uses (Fragar et al. 2007). Research on the risks of utilising these vehicles in occupational settings and information regarding use in occupational settings is minimal in Australia. There is also a paucity of research regarding the decision process for ATV purchase and use, and the impact of injury from ATV on enterprises and communities. Recent discussions in Outback Queensland revealed that ATVs are becoming more popular in pastoral and agricultural industries as alternatives or adjuncts to horses, motorcycles or other four wheel drive vehicles. However, further enquiry was needed to establish how and why this change in use is occurring. This paper will discuss exploratory studies being undertaken in North West Queensland regarding ATV use in occupational settings. This research explores the attitudes and perceptions of various owner and user groups, as well as service and health care providers in the North West region of Queensland. Preliminary results of the first phase of research will be presented.

Aaron James Pym, Belinda Wallis, Richard Franklin, Roy Kimble
Unregulated and unsafe: the impact of motorcycle trauma on Queensland Children

Introduction: Across Australia, motorcycle use by children on private property is popular but unregulated, i.e. no training, vehicle safety, protective equipment or supervision standards. As children under 16 years are unlicensed and unable to ride on public roads, their injury pattern differs from on-road adult riders.
Aims: To describe paediatric (0-15 years) motorcycle incidents in Queensland, inform safety/policy initiatives and identify opportunities to improve data.
Methods: Population-based retrospective descriptive study of motorcycle-related child (0-15yrs) trauma, causing fatality or hospital admission > 24hrs to any Queensland public hospital (2007-2009). Data compiled from hospital and coronial records.
Results: Ten child fatalities (male=10) occurred; all were the primary rider. Nine fatalities were related to head injury; head protection was inadequate in five of these. The coroner identified rider-factors contributing (excessive speed, age or substance abuse) in seven cases. Motorcycle-related incidents (619 incidents;1,225 injuries) were the second most-common cause of paediatric trauma (N=9,141)(bicycles=752 incidents). Patients were older (13yrs vs 10yrs) and more frequently male (85% vs 67%) compared with the all-trauma population. Children from outer-regional/remote areas (31% of patients) were over-represented (approximately 10.5% of population). Most incurred >1 injury (mean=2.01 injuries); fractures (45%) and open wounds (17%) were most common. Lower limb (44%), upper limb (26%) or head/neck (16%) were frequently injured.
Discussion: Motorcycle-riding is probably the most dangerous activity for children. In absence of exposure data, it seems likely that many more children have access to bicycles and that the rate of serious injury is significantly greater for motorcycle-riding. Over-represented outer-regional/remote communities may benefit from prevention efforts in this area. Current trauma systems contain limited environment or protection data; improvements would contribute to child safety policy. Protective equipment, especially helmets should be worn to reduce injury risk. Providing and enforcing safety standards for child riders may reduce the rate and severity of injury.

Paul Vardon, John Pearn
Priorities in Injury Prevention: Perspectives, Competing Domains and Challenges

The domain of injury prevention has evolved into a discipline in its own right. The epidemiology of injury patterns, the analysis of causes, research into potential preventative stratagems and the implementation of primary preventive approaches (education, ergonomic design and legislation) today comprise the themes which enjoin those who strive for a safe personal, workplace and community environment. Each of these themes competes for resources, both in terms of money and in demands on human endeavour. Priority setting is thus an underlying theme which is one imperative for all who work in safety promotion. Priority setting involves prior ranking of the impact of injury; listing imperatives to which the process of injury prevention are subject; and making judgements about the allocation of both material and non-material resources. The first step - ranking injury - necessitates ranking by one or more disparate indices. Such may include (a) crude incident statistics; (b) syndrome-specific statistics involving injury patterns classified by age, gender, site and wounding agent; (c) rate assessments where denominators can be generated; and (d) cost of injuries both in terms of the victim themselves and the healthcare and community systems which care for them. Imperatives which influence ranking range from political imposts and directives to local community assessments of perceived priority needs. This paper discusses these themes in the context of the work of the Queensland Injury Prevention Council; and its stewardship of a significant corpus of resources directed to the promotion of injury prevention in all its forms.

Emily Herde, Tony Lower
A decade of tragedy - an update on farming fatalities in Australia

Introduction: Farms in Australia continue to hold the notorious reputation of being dangerous environments to live, work and play. In the Year of the Farmer it proves timely to look back on 10 years of data collection to see in fact whether this reputation is justifiable. This study was conducted to examine farm fatality rates and to describe patterns of fatal agricultural injury on Australian farms from 2001 to 2010.
Method: Data were extracted from the National Coronial Information System on all non-intentional fatal injury events occurring on farms in Australia for the study period.
Results: There were over 780 on-farm fatalities for the period 2001 to 2010. Children (<15 years of age) featured in approximately 18% of incidents, while those over the age of 55 years made up 40% of all deaths. The majority of incidents occurred when work related activities were being undertaken on the farm. Tractors, quad bikes and dams continue to be leading causes of on-farm death. A downward trend in the overall number of on-farm injury deaths is apparent however the picture is not so positive when individual agents causing death are explored.
Discussion: This study highlights a decade of tragedy that has been experienced by the Australian farming community. In doing so it identifies scope for continued reductions in the number and rates of non-intentional farm injury fatalities. Given the limited resources that are available for farm injury prevention efforts, priority should be given to addressing those leading agents identified in this study through the adoption of evidence-based solutions and promotion by relevant agricultural, government, health and safety agencies.

Kylie Maras
Injury trends and management in the Agriculture Industry - a WorkCover Queensland perspective

WorkCover Queensland is a statutory authority that provides insurance to employers for compensation of wages and medical expenses when an employee is injured. The needs of both the worker and employer are balanced to achieve a cost effective return to work.
WorkCover Queensland support AFOEM of the Royal Australasian College of Physicians position statement, 'Realising the health benefits of work' and encourages a 'Stay at Work' approach where possible following a workplace injury. Assistance can be provided to employers and workers to identify appropriate alternate tasks within medical restrictions, locate resources to help and educate employers on best practise that can be applied to their industry.
The Agriculture industry has seen a gradual increase in the number of work injuries over the last five years with average paid days, including partial and total incapacity for work, being thirty-five compared to twenty seven days for all other industries. Final return to work in the Agriculture industry is significantly lower than that of all other industries.
WorkCover Queensland is educating employers with trends in injuries and rehabilitation strategies, in particular in the Banana Growing and Beef Cattle farming industries. WorkCover Queensland is also currently working with Q-COMP, the regulatory body for workers compensation in Queensland, and Workplace Health and Safety Queensland on joint projects and strategies to identify risks and prevention of injuries, improve injury frequency and promote safer workplaces and durable return to work outcomes.

Janice Mills
Future Farmers: Strategies for farm injury prevention

Introduction: Despite a reduction of 60% in the number of on-farm fatalities since the early 1990's, agriculture remains one of the most hazardous industries in Australia with a total of 326 non-intentional deaths on farms from 2003-2006 identified by the Australian Centre for Agriculture Health and Safe (2011). Children continue to be involved in farm fatalities. The leading cause of all children and youth fatalities continues to be quad bikes, tractors and farm utilities.
Method: Education remains the strategy of choice of the agricultural industry to improve health and safety to all who work, live or visit farms. A Future Farmers strategy involving Year 9/10 students has been developed based upon PDHP curriculum requirements. Students attend a Future Farmers Field Day rotating through a number of workshops conducted by accredited trainers with follow up classroom activities. Evaluations have mostly focused upon process and impact of the program. Evaluation of the program using a pre and post test method for intervention and control groups has been conducted. The intervention group received the information between the pre and post test whereas the control group received the intervention after completing both the pre and post test.
Results: There were no significant difference in the perception of farm risk factors between the intervention and control groups at the pre test: p<0.307. A significant difference was observed between the intervention and control groups following the farm safety intervention (H=4.928; p<0.026). This was further reinforced by qualitative data in responses contained in open ended questions.
Discussion: The objective of the project was to evaluate the short term effectiveness of the farm safety education program. The project did identify significant differences between the intervention and control groups. Whilst this study had limitations in design and practice it did provide evidence of the effectiveness of the strategy.

Tony Lower
Crush Protection Devices on Quad Bikes - What Farmers Think

Introduction: Quad bikes are the leading cause of fatal injury in farm settings, with 46% of cases involving rollovers. However, there is significant resistance by manufacturers to fitting some kind of crush protection device (CPD). This exploratory study examines the attitudes and experiences of a small sample of Australian dairy farmers that have fitted a CPD.
Method: Subjects completed a pre-intervention self-report survey that included rider experience, injury history and typical farm usage patterns. The quad bikes of 11 dairy farmers were fitted with CPD's for a 14-day period. A post-intervention survey was completed considering any positive or negative impacts that the users had experienced. Two focus groups and interviews were conducted with the subjects in the weeks following completion of the post-intervention survey.
Results: Respondents reported the CPD had only negligible impacts on bike operation (going under hot tapes and towing) and the conduct of farming activities. There were perceived personal safety benefits and those that employed staff, felt they were meeting legal obligations. The major impediment to fitting CPDs was the lack of consistent information regarding their effectiveness. Respondents preferred self-regulation, but were not staunchly opposed to mandatory fitting if required. Additionally, there was a move by some farmers to alternate (and safer) vehicles.
Discussion: The results suggest that CPDs will be generally viewed positively by farmers and do not interfere in any substantive way with current operation of quad bikes. This is contrary to manufacturers stated claims that these devices impact on stability and normal operations of the vehicles. Furthermore, there are steps that can be taken to increase the uptake of CPD's by dairy farmers.

William Atkinson
Agriculture Sector Action Plan: a New Zealand innovation for rural injury prevention

In 2012 the New Zealand Government launched an innovative 'Agriculture Sector Action Plan' (ASAP). This has its origins in the 'Workplace Health and Safety Strategy for New Zealand to 2015' (WHSS) established in 2006. The Department of Labour is the lead agency. This Strategy aims to lift workplace health and safety performance and reduce the work injury toll to achieve healthy people in safe and productive workplaces. From this evolved a National Action Agenda focusing on the five sectors where the most harm is occurring: construction, agriculture, manufacturing, forestry and fishing.
A 2009 review found that clearer direction was needed to engage stakeholders in the workplace. More focused, achievable actions were needed between the high-level strategy and activity on the ground. Sector Action Plans resulted. Priorities included a focus on occupational health issues and improved workplace capability, guidance and standards, especially for small businesses.
In April 2012 the Minister for Labour launched the Agriculture Sector Action Plan (ASAP). Unlike many previous Government programs that concentrated on single issue topics, the ASAP can claim to be an innovation. The Department is to provide leadership and communication and promote integration between sector stakeholders including government agencies, institutions and businesses across four priority areas: agricultural vehicles, physical and mental health, slips, trips and falls and animal handling.
This paper will provide a brief outline of some previous injury prevention initiatives. It will cover the aims and methods proposed in the new ASAP, explore some examples and comment on how the future for injury prevention in New Zealand agriculture may be influenced by this scheme.

Amber Thornburrow
Point of View (POV) cameras: an innovative approach to remote assessment of vocational trainee health professionals

Formative assessment of remote vocational trainee doctors in remote and rural Australia is a process which requires the trainee to travel to metropolitan areas to be assessed on their skills. Currently, the assessment is limited to post-hoc discussion and simulation of skills with an educator/assessor at the training facility of choice.
An exciting trial involving point of view (POV) cameras, assessing their validity and reliability as an adjunct to formative assessment of these doctors, is being undertaken at the Mount Isa Centre for Rural and Remote Health. Previous limitations to using POV technology included poor definition of footage, not allowing the participant to capture the clinical skill with sufficient clarity. Improvement in technology has seen POV cameras able to capture high definition footage in often harsh environments. The cameras used are shock and weather resistant as well as being able to capture footage in poor light and dusty conditions. These improvements have opened up new opportunities to engage in assessment at a suitably equipped remote site, significantly reducing the need to travel to major urban centres.
Aim: The aim of this project was to demonstrate that POV cameras are a reliable and viable adjunct tool to formative assessment in rural and remote areas.
Design: Quasi Experimental
Method: 10 assessments took place at the Simulation Lab and around the Mount Isa Centre for Rural and Remote Health. An onsite medical assessor/educator, assessed each doctor in a series of 4 clinical skills using a modified standardised assessment tool using a score of 1 through to 4 (fail, borderline, pass, excellent), across six domains: communication skills, systematic approach, clinical management and judgement, rural context, overall performance.
Results: Data collection is underway at time of abstract submission, and will be discussed at the time of presenting.
Discussion: How might the findings of this study have application to the formative assessment of other health professionals in rural and remote areas? Further research and validation of this technology for professions such as Remote Area Nurses, Nurse Practitioners, Paramedics and Allied Health professionals is clearly needed.

Jo Symons
How can new funding initiatives affect recruitment and retention rates of Allied Health Professionals and Nurses in rural and remote Australia?

The recruitment and retention of nurses and allied health practitioners (AHPs) in rural and remote areas of Australia is problematic. Policy-makers face significant challenges trying to meet the health needs of rural and remote Australia by providing access to trained health workers. A shortage of qualified health workers in remote and rural areas impedes access to health-care services for a significant percentage and often disadvantaged section of the population.
In 2012, the Rural Workforce Agencies received funding from Health Workforce Australia under the Rural Health Professionals Program (RHPP). The RHPP program is designed to affect recruitment and retention rates by 'Growing and supporting an allied health and nursing workforce for Rural Australia'. The RHPP supports Australia's rural and remote health workforce by recruiting new international and Australian-trained allied health professionals and nurses into rural and remote areas of Australia, and into Aboriginal Community Controlled Health Services. Significantly, it then provides them with appropriate support services over a two-year period to improve retention rates.
There has been a plethora of research investigating the factors associated with recruitment and retention of nurses and allied health professionals, and there is now evidence for AHPs specifically in rural and remote areas including a workforce retention framework. It is paramount that the research, evaluation of existing service providers, and current frameworks and tools are considered so that a raft of strategies required to enhance the recruitment and retention of nurses and allied health professionals in rural and remote areas can be designed. The choice of interventions to be included as part of the RHPP roll out in Queensland will be informed by an in-depth understanding of the health workforce and an analysis of the factors that influence the decisions of AHPs and nurses to relocate to, stay in or leave rural and remote areas. Giving due consideration to this will help to ensure the choice of services provided to AHPs and nurses are anchored in and tailored to the specific needs of the individual, their profession and their location.
This presentation aims to summarize the available evidence on factors that influence recruitment and retention of allied health practitioners and nurses in rural and remote Australia, and strategies that have been developed to address them. It will then outline the criteria of the RHPP program and articulate how the program will be implemented in Queensland in accordance with recommendations in the literature for real recruitment and retention rates for these professionals to be affected.

Janindu Goonawardena
Case Study - Student Session

Mr J, 63-year-old Aboriginal male presented to Cairns Base Hospital (CBH) with two day history of sharp right upper quadrant pain with associated low grade fever, nausea and vomiting. This led to the diagnosis of acute cholecystitis and a cholecystectomy was recommended as the best treatment approach. It was uncertain if the best method of approach would be laparoscopic or open given the patient's risk factors such as demographics, clinical factors and previous abdominal surgery. It was decided to perform a laparoscopic cholecystectomy (LC) and as a medical student I was involved in the care for the patient. Mid way through the surgery, due to complications it was decided to convert the surgery to open cholecystectomy (OC), which resulted in a longer operation time. Patient developed sepsis on day 2 post operatively and multiple organ failure despite all medical intervention.
As the medical student involved in the care for this patient it was a dreadful tragedy and a life changing moment. It is known that the major complication rate is higher in patients who are converted from LC to OC. This implies that some of the higher risk patients approached laparoscopically, who are likely to have a higher probability of conversion be better served with a straight open approach. Given the high rate of conversion at CBH (8.5% compared to 1.3% nationwide) I had to think of a way to prevent this from happening and came up with the idea which is the basis for my honours project to develop a probability nomogram to predict the rate of conversion from LC to OC pre-operatively based on patient risk factors. (i.e. gender, age, obesity, aboriginal status, previous upper abdominal surgery etc.) This will allow the surgeons to chose the best planned method of approach (LC vs OC) based on the probability of conversion to minimize such dreadful complications.

Sara Fraser
Case Study - Student Session

Michelle is a 39 year old lady brought in by ambulance to a rural hospital with sudden onset of severe suprapubic pain. She described it as a sharp pain with 12/10 intensity. Her last menstrual period was 2 weeks previous. She has was diagnosed with Mittelschmerz. She was ready to be discharged after the initial pain resolved with recommendations of over-the-counter analgesia for mid-cycle pain relief. My friend and I thought Michelle would be a good case study so before she left, we gained consent and took a detailed history and performed a comprehensive examination. To our surprise we learned a lot about Michelle's health that had not initially surfaced. This included that she is a regular smoker of pot and has struggled with depression for 20 years after her children were taken off her. She was suicidal only one month previously and has been trying to conceive another child for 7 years. She does not have a regular GP and is getting no mental health assistance. Additionally on examination, we found Michelle has an unstable gait with patella subluxation during knee flexion. She had bilateral knee realignment surgery in 2009, although is still experiencing pain and instability. She states she did not follow-up with the orthopaedic surgeons. We documented our findings in her chart and passed this information on to our doctors who proceeded to contact the orthopods and a social worker.
Lessons Learnt: This experience stressed to me the importance of taking a good history and doing a good examination. A lot of people will not volunteer their ailments and it is our responsibility as health professionals to seek out this information. The value of students in rural hospitals to do this should be utilised as it is an effective and efficient way of learning.

Osmo Hautaniemi
Mapping dental decay before water fluoridation amongst children in a remote Cape York Community.

Information about the extent of dental decay in children who live in remote Cape York communities is scarce. The oral health of these children is not included in the National Child Dental Health Survey or the Queensland Child Dental Health Survey. It is important that baseline data is collected to inform decisions about public health initiatives, such as water fluoridation. The introduction of water fluoridation to Queensland communities with populations of greater than 1000 people is planned by the State Government to occur by 2013. However, there is no data regarding the current decay rates of children in remote communities that currently have low water fluoridation levels. Without the collection of such data any improvements to oral health will not be measurable. The aim of this child dental health project is to document the number of decayed missing and filled deciduous teeth (dfmt) and permanent teeth (DFMT) so as to develop a baseline set of oral health data before water fluoridation is introduced. This will enable a comparison with children's oral health after fluoridation has been established. The baseline data will be compared to national and state child dental health surveys. This is a retrospective, cross-sectional, quantitative survey. The research project will utilise Queensland Health, School Dental Service records from children ages 4-15yrs in a remote Cape York town. The research team will catalogue dmft/DMFT data, which will be analysed using SPSS, also noting child age, sex and Aboriginal or Torres Strait Islander status. By contributing to a baseline set of data, comparisons can be made between the caries experience of a remote Cape York community to national and state data, as well as the future effects of water fluoridation. This research will provide valuable data that will potentially inform other public health measures and community initiatives.

Marisa Blackley
Case Study - Student Session

In the student session, I would like to share an experience I had when observing a consultation dealing with a suspected child abuse case, whilst doing my GP placement at an Indigenous community. An intern who did not get as many patient folders in their box often picked up patients from other more experienced permanent GPs' boxes. When this intern asked the mother and child if they were comfortable seeing them instead, I could see from the mother's body language they felt obliged to see this doctor rather than the one they requested because they did not want to shame this doctor by saying no. Unfortunately, the intern did not pick this up. In the consult, when the mother stated that she was concerned her primary school aged daughter was being sexually abused, I thought the intern would respect the patient's wish to see the GP they had requested, but instead decided to go ahead with the consult themselves and left the room to get advice from the GP the mother wanted to see in the first place. Although I have not had a lot of professional experience working with suspected child sexual abuse cases, I remember clearly from my social work training the importance of not (further) traumatising children (or adults for that matter) with unnecessary intimate physical examinations. In the Student Session, I would like to share how the intern dealt with the case, including the way the intern dealt with addressing the mandatory reporting aspect with the mother.

Jerry Abraham
Case Study - Student Session

Introduction: This study looks at the role of a clinical mentor (in programs like the John Flynn Scholarship placement, or university based rural placements) in being able to address the workforce shortage by attracting more medical students to work in regional, rural and remote areas.
Method: Literature keyword searches of medical student, mentor, and rural workforce shortage were conducted, and several articles were reviewed. Anecdotal evidence of students on the John Flynn Scholarship Placement program, and several students who had done placements in very rural and remote areas were also taken into account, while compiling the PowerPoint presentation.
Results: The studies and literature suggest that the positive influence of a clinical mentor during a rural placement is highly indicative of the medical student pursuing a career in rural and remote medicine. While various other factors may also play a role in the students' decision to work in a rural or remote area, the biggest factor was the need for a clinical mentor and the influence that the relationship had in moulding the students thinking.
Discussion: Discussions therefore centre on the need for more clinical mentoring in Queensland and other larger states that have a dire shortage of medical workforce. Various models of mentoring are considered, and recommendations of a possible (structured) model through RDAQ and local hospitals and clinics are suggested. If implemented in an appropriate manner, it may be instrumental in witnessing a surge in medical students' willingness to work in a rural or remote area and thereby, overcome the rural medical workforce shortage in years to come.

Chris Braithwaite
Medication management as a prevention tool

Spending two months on student placement in remote areas really opened my eyes to the logistical issues both health professionals and consumers face. Being involved in this kind of problem solving, in both Mount Isa and Katherine, has fostered my passion for rural and remote health. One individual can make a large difference to a community and this is something every student should have the pleasure to witness.
An increasing role of pharmacists in 'building a culture of safety,' is through ensuring appropriate medication management. There are currently government-funded medication review programs that can be implemented by accredited pharmacists. Continued GP referral and patient utilisation of these will help prevent the growing number of medication-related hospital admissions, which was recently estimated at 190,000/year¹.
This case study is a Home Medicines Review (HMR) that occurred in a remote location with a 56-year-old gentleman, who was one-month post-CABG. The issues to be discussed include polypharmacy, non-compliance and confusion around medication administration and scheduling. As well as the obvious physiological problems, there are also psychological and logistical issues to work through. Simple interventions from the HMR process drastically improve the patient's understanding of treatment and are critical in preventing further medication-related problems. Collaboration with other health professionals in a team-based approach contributes to the holistic management of the patient. This provides an opportunity to learn about other professions and increase our capacity for interdisciplinary teamwork, which is vital in remote locations.
This review highlights the importance of simple interventions and support in small communities. The fact that follow-up coincidently occurred during my time in the community pharmacy also illustrated how rewarding remote practice can be; and as a pharmacy student, this experience is invaluable.
¹Kardachi, G 2012, 'Pharmacist intervention and counselling', Australian Pharmacist, vol. 31, no. 03, pp. 161.

Kristy McGregor
Preventing Burnout By Building Strong Networks Among University Health Students

Isolation and burnout represent key challenges when it comes to recruiting and retaining health professionals to rural and remote Australia. Health graduates today want to stay connected to their peers and are less likely to pursue a rural and remote career if it means vast separation from their existing personal and professional networks, or a high risk of becoming overworked due to local workforce shortages.
The National Rural Health Students' Network (NRHSN) is a unique network working to help address these issues and prevent them from turning health students away from rural or remote careers. The Network comprises over 9 000 health student members studying medical, nursing and allied health courses at universities across the country.
The NRHSN builds strong personal and professional networks among university health students as they embark on a journey of practice in rural and remote Australia. The Network fosters strong networks among students through its unique platform of events and initiatives for members to meet and develop useful connections with like-minded peers who share a passion for rural health.
This platform includes events which expose students to the realities of rural and remote living on road trips to regional areas. Interdisciplinary initiatives run by the NRHSN also help bring students together in a multi-disciplinary team environment as commonly exists in remote practice, and contribute positively to rural and remote communities they may potentially become a part of. The NRHSN mental health guide 'When the Cowpat Hits the Windmill' written by students for students is another initiative helping to nurture an emerging generation of more resilient rural and remote practitioners.
This presentation will outline these ways in which the NRHSN is actively building strong networks among future rural and remote health professionals to prevent practitioner burnout and benefit the health of communities in remote Australia.

John Temperley, Tony Lower, Emily Herde, John Curtis
Safety on Small Australian Farms

Introduction: It has been estimated that there could be as many as 600,000 small area farms who do not meet the threshold value to be classified as a primary producer. This study examined to determine injury risks and patterns in this group of lifestyle (hobby) and small area/ scale farmers.
Methods: Information from coronial records was assessed for cases likely to involve small area farms. Seven small farm safety workshops were held in Qld, NSW, Vic and Tasmania where participants completed a formative farm health and safety assessment and discussed relevant issues. Data were also collected from small area farmers at agricultural field days.
Results: Coronial information indicated that just over 10% of cases (n=57) were on a small farm. Workshop data illustrated a range of factors including: that there were few barriers to safety in terms of cost, time and the complexity of actions; there was a general acceptance of risk, to get the job done; only one-third conducted regular hazard inspections; and, few had a farm safety plan. Safety information was most commonly attained from field days and agricultural newspapers.
Discussion: Small area farmers face similar hazards to that of larger scale farming operations. However, the level of knowledge within small area farmers regarding their OHS obligations in law and on a practical level in taking necessary action to control hazards, requires attention. In providing this type of information it was seen as important that it was short, written in plain English and had pictures illustrating practical controls.

Kristy McGregor
'Far from Help - Yet Closer to Self Discovery: The Realities of Life in a Remote Outback Community'

Living permanently in a remote outback community presents many personal and professional challenges. Living and working on a cattle station in Western Queensland, I am witness to the realities of remote life and the importance of the services of the Royal Flying Doctor. This presentation draws on my lived personal experience to personally engage with other students. Through 'true yarns' from the bush, I will share my story and foster discussion of the challenges, and beauties, of isolation.
Working in a remote community requires responding to the challenges with a team approach. We are continually faced with a lack of services, and without the contemporary conveniences of suburban life. Here, one learns independence and self-reliance, and the ability to get along with people from all walks of life - chatting with a truckie at breakfast, and hosting a company CEO and his group of shareholders for lunch.
Life in a small community of twenty people lacks the professional and personal boundaries one would expect. In a remote community you socialise on weekends with your superiors, who become good mates, as hierarchical boundaries are broken by the small group interaction. Personal lives are rarely private, as the weekend's happenings become the subject of smoko's humour and entertainment.
Living in an isolated setting, it can be difficult to develop networks and remain aware of contemporary issues in the rural health context. Email and teleconference therefore become essential lines to communication and networking with other interested students and professionals. When you are studying by distance education with lack of peer interaction, conferences and workshops become crucial means of sharing ideas and imparting knowledge.
While the physical and geographical isolation of remote communities present many obstacles, they offer a beauty in allowing one to discover the richness of humanity. Remote communities are the context for much self-discovery.

Margaret Stebbing
What motivates older allied health professionals in rural areas to stay in the health workforce? - The Retention of Allied Health Professionals at Retirement Age in Rural Victoria (RETAINR) Project.

Government and public attitudes to work and retirement are changing and existing strategies may not be effective in meeting the needs and challenges of a sustainable health workforce. The current rural health workforce is ageing and the 'baby boomer' generation is now approaching retirement age. Many will choose to settle for retirement in a rural area, and some will be health professionals. This subset of the health workforce represents an untapped resource as they are already seeking to live in a rural area, are highly skilled and experienced, and their support needs are low.
The Retention of Allied Health Professionals at Retirement Age in Rural Victoria (RETAINR) study team is working with local stakeholders in the Gippsland region of Victoria to develop a communication strategy and recruitment and retention strategy that focuses particularly on the beliefs and attitudes of allied health professionals towards work and retirement. In a research and action process framed on the 'Reasoned Action Approach' the study utilises both quantitative and qualitative research methods to tap into the skills, beliefs and motivations of retiring age allied health professionals in Victoria who are rural residents and also those who intend to relocate from the city to a rural area in retirement. The broad research question is - What would it take to increase the likelihood that an allied health professional will remain in the rural health workforce (at least part time) for two more years after retirement age?
The results of this project are expected to have some applicability to rural regions across Australia. The project is based in the Monash University Department of Rural and Indigenous Health, and is fully funded by a grant from the Victorian Department of Health - Workforce Innovation Grants Program.

Aidan Hobbs
Pursuing a best practice approach to Podiatry in Remote Primary Health Care

Allied Health Practitioners face a number of significant challenges in providing Primary Health Care to remote Indigenous communities. Recognising the social causes of high chronic disease incidence, cultural challenges in providing a bridge between traditional and mainstream services and the logistical challenges of extreme remoteness require an holistic approach to providing an effective allied health primary health care service which is not detailed in National Evidence Based Guidelines of practice.
In a bid to alleviate some of the aforementioned barriers, a qualitative and quantitative evaluation of the North West Queensland Primary Health Care (NWQPHC) Podiatry service in Mornington Island was undertaken. The appraisal established the current role of the Podiatry service and its demand. Based on the fundamental Primary Health Care principle for ensuring equity of service access, this study revealed that Podiatry service provision is currently insufficient to meet the demands for Indigenous populations in Mornington Island.
The results presented in this paper indicated that the capability of the Podiatry service may be improved by the implementation of a reliable diabetic foot triaging system with the assistance of community Health Workers and creating patient transportation agreements with local agencies. Details of the study are summarised in this paper and recommendations to reduce the demand and better target Podiatry services in Mornington Island outlined.

Dennis Pashen
'Brave Decisions'? Australian health workforce reform ; rewards and risks towards 2025.

Introduction : The Australian Health Reform Agenda has progressed over the past 2 years. A number of papers have been published and the author has sat upon a number of the strategic and expert reference groups. Whilst there is much more to complete, there have been significant shortfalls and risks identified by the working groups and papers produced.
Methodology: This is a descriptive summary of the Health Workforce Australia progress to date and how it relates to potential reform directions. It also relates to the benefits and risks of proposed reform packages and the failure of government to implement recommendations.
Results: Approaching 2025, whilst the medical workforce appears to be reaching parity between demand and supply, the nursing workforce is approaching a shortfall of between 110,000 to 125,000. A number of papers on workforce innovation have been completed and been presented to AHMAC and COAG, including publications from Health Workforce New Zealand. Many of these remain unavailable to the public to date, however they deal with debated models such as Rural Generalism, Physicians' Assistants, Nurse Practitioners, Paramedics and scope of practice.
Discussion: The risks of implementing or failing to implement reform packages are discussed with reference to the current published workforce data projections, the political environment, and the health demands of the Australian community.

Louise Roufeil
What's a psychologist? Challenges in growing the remote psychology workforce

There are approximately 5,300 fully registered psychologists working in regional, rural and remote Australia, representing 21.5 per cent of the fully registered psychologist workforce (APS, 2012). Although there is limited recent data on the distribution of psychologists in Australia, the 2008 Australian Psychology Workforce Study indicates that of the RRR workforce, only 0.8% work in remote regions. Moreover, about half of the remote psychology workforce is relatively inexperienced with less than 5 years experience as a psychologist. The impact of this shortage of psychologists, especially experienced and specialist psychologists, is widespread in terms of consequences for individuals, families, service providers and communities. Across remote Australia, there are long waiting lists for assessments (e.g., children, medico-legal) and inequities in access to evidence-based interventions. This paper will describe the barriers to growing the remote psychology workforce and identify windows of opportunity to address this workforce issue.

Kym Thomas et al.
The Aboriginal Staff Alliance of the University Departments of Rural Health Network

The Aboriginal Staff Alliance (ASA) was formed in 2000 in recognition of a need for Aboriginal and Torres Islander staff to have collegial support, at a time when there was only a few such staff. Each ATSI staff member employed by a UDRH is an ASA member. Our members hold differing positions within the UDRHs that reflect a diversity of backgrounds. Positions held include some of the following, associate professors, lecturers, educators, researchers, staff support, cultural program design and delivery coordinators, advocates, resource agents. Our network aims to be inclusive of ATSI people across rural and remote Australia and strives to assist and support our communities towards self-determination of local health priorities. The network also provides support to our members, thereby reducing the feeling of working in cultural isolation. The ASA works towards ensuring that non-Indigenous health workers, professionals and academics are equipped with cultural awareness, safety and security protocols when addressing Indigenous health. To facilitate this process the network has developed a set of cultural protocols and procedures for use within the UDRHs covering such areas as research, community involvement, cultural safety, student placements and the delivery of cultural awareness ,safety, and security training. By providing a mechanism for partnerships and alliances the ASA ensures that representation on Indigenous health issues is presented as a collaborative voice. As Aboriginal and Torres Strait Islander workers we are governed by our local cultural protocols and principles as well as the policies and procedures of the UDRH. While this may at times create conflicting interests overall the ASA works towards achieving positive outcomes relating to Indigenous health, well-being and education. Working in Aboriginal communities and with Aboriginal people is a privilege. What must be realised is that history, health and consequence are all inter related, and the ASA advocates this constantly.

Lorraine Muller
The theoretical framework used by Aboriginal and Torres Strait Islander Social Health professionals: Indigenous Australian Social-Health Theory - and beyond.

This presentation outlines the theoretical framework used by Aboriginal and Torres Strait Islander Social Health professionals, Indigenous Australian Social-Health Theory, the result of my first PhD. I follow with my 2nd PhD research, Shifting the Lens: Indigenous Research into Mainstream Australian Culture, that emerged as a result of the first research. There is a significant body of knowledge that runs parallel to, independent of, but selectively informed by, Western academic knowledge. Social-Health Theory is the established theoretical framework, used by 'our' Social Health professionals; those for whom the social, emotional (including Spiritual), and physical, wellbeing of our people is central to their practice. Researching and translating this, until now, oral theory into an academic format was the project of my first PhD. Documenting 'our' theory allows Indigenous students and health/welfare professionals to benefit from the collective knowledge shared in this project and our non-Indigenous colleagues may gain insight into the sound theoretical framework that informs their Indigenous colleagues work practices. Decolonisation provided the theoretical framework for research, and the uniquely Australian consensus-based research methodology Aboriginal Grounded Research (AGR) provided the methodology. An expert panel was central to this methodology, as they ensured the accuracy, cultural integrity, and appropriateness of the knowledge shared in this project. Shifting the Lens, my 2nd PhD research, turns the research lens onto aspects of mainstream Australian culture that were identified in my first research as needing explanations. This new research will use the same framework and methodology as the first. The focus of this research is adult non-Indigenous Australians from the health professions, who are able to reflect on and articulate aspects of their cultural norms. The aim of this current research aims to gain a greater understanding of mainstream culture and protocols to enhance working relationships with Indigenous Australians.

Glenda Duffy, Simone Ross, Torres Woolley, Sundram Sivamalai, Donald Whaleboat
A case study of a successful collaboration between the JCU Medical School and the Mount Isa Indigenous Community

Introduction: This case study presents the methodology behind a successful Indigenous community engagement project in North Queensland (NQ). The reasons why the project was successful are discussed in light of previous consumer participation literature, and also in relation to what the participating Indigenous community reported to be good Indigenous engagement practices.
Methodology: The methodology used in the project is a participatory action research design., The James Cook University (JCU) School of Medicine & Dentistry (SMD) established an Indigenous Reference Group in the remote NQ city of Mount Isa - MIATSIRG., MIATSIRG included Elders, community members and health service staff active in the local community. Yarning circles were conducted to develop the Terms of Reference for MIATSIRG, and gather information about good and bad community engagement strategies. Data clustering was used to identify main themes in the data.
Results and Discussion: Curriculum improvement outcomes for JCU from the project include providing an avenue for an Indigenous community to have input into the SMD Indigenous Health curriculum, undergraduate rural placement program, and Indigenous Health Experience program. A specific resource developed during the project and incorporated into the curriculum to assist medical students learn more culturally appropriate ways of engaging with Indigenous patients and health professionals was a 'black engagement' pamphlet listing desired strategies for non-Indigenous people to engage with the Indigenous people of Mount Isa. As a reciprocal benefit, MIATSIRG members were assisted by the SMD to: (1) improve their media and leadership skills, and (2) developed and conducted a community health activity healing weekend based on priority community health issues.
Conclusion: This project has directly resulted in MIATSIRG members now having the skills and confidence to advocate for improving Indigenous health and social issues in Mount Isa, both with external organisations such as the media and local government, and also internally within the local Indigenous community.

Adrian Hepi
The Aboriginal and Torres Strait Islander Perspective

Evidence indicates that Aboriginal and Torres Strait Islander People's find accessing mainstream services difficult and traumatic experience due to possible past engagement of health care provision, with removal of children or with discriminatory treatment from government agencies in general.
One of the key features of consideration that needs to be taken into account is that for Aboriginal and Torres Strait Islander People, the manifestation of mental health disorders can take forms that are distinctive to their culture and experience and are known as 'culture bound syndromes'. This ought to be taken into account by the clinical team with assistance from Aboriginal and Torres Strait Islander staff or clinicians, this is vital for interpretation and advice regarding care planning and interventions that are appropriate for the client and their situation.
The recent Evolve therapeutic outcomes report states that Aboriginal and Torres Strait Islander representation is on average 35% of the cases in Evolve Therapeutic Services across Queensland. For this reason many Evolve Therapeutic Service Sites have Indigenous Program Coordinators to assist in building competency of service.
This presentation aims to highlight how Aboriginal and Torres Strait Islander conceptualisation of mental health differs from the western views and other cultural groups. It will examine the ways in which Indigenous Program Coordinators can support engagement, assessment and subsequent intervention with clients identified as Aboriginal and or Torres Strait Islander heritage.

Bernadette Rogerson, Alan Clough
Cannabis withdrawal among Indigenous offenders

Studies in the Northern Territory have demonstrated emergent problematic cannabis use in some remote communities. Anecdotal evidence in Cape York and Torres Straits and preliminary data collected in three Cape York communities also raise concerns about widespread cannabis use. Cannabis use amongst inmates and police detainees is elevated compared to the general population, with a demonstrated link between illicit drug use and contact with the criminal justice system. When cannabis use is curtailed, many users suffer symptoms which can lead to violence, threats, intimidation, anxiety, sleep disturbances and heighten risk factors of self-harming behaviours. The DSM-5 has proposed to include cannabis withdrawal syndrome however, there are no studies of inmate, nor Indigenous populations. Despite patterns of high cannabis use, dependence and demonstrated risk factors, whether these cohorts experience withdrawal differently has not been considered. A study to investigate if there are differences will recruit participants who identify Indigenous (Aboriginal and/or Torres Strait Island) from two far north Queensland Correctional Centres to ascertain symptomology of cannabis withdrawal over a 28 day period. This study will document the onset and severity of withdrawal symptoms and devise culturally-acceptable, low-cost resources and support to assist new inmates to manage withdrawal. Findings will also inform the 'Cannabis Withdrawal Syndrome' for cultural variations and considerations to the proposed criteria. This information will be utilised to improve assessment and for timely treatment of cannabis withdrawal within custodial settings. Pilot data of 101 retrospective interviews with Indigenous males will be presented along with preliminary findings of the current study will be presented.

Dympna Leonard, Danielle Aquino
The Fred Hollows Foundation Early Childhood Nutrition and Anaemia Prevention Project and potential relevance to the issue of lead in Mt Isa.

The Fred Hollows Foundation (FHF) in recent years has taken the lead role in a project to prevent early childhood anaemia, in a collaboration which includes various health organisations and eight remote Aboriginal communities across the top of Australia. The project combined nutrition promotion with the use of a multi-micronutrient powder (Sprinkles Plus ©) which is designed to be added to solid food for babies between six months and 24 months of age. Using Sprinkles increases the nutrient density of food for small children without changing the taste, smell or appearance of the food and without increasing bulk, which is an important consideration for small tummies.
The project evaluation is still ongoing but it is anticipated that the project methodology will be useful in other locations where early childhood anaemia is prevalent. In addition the project methodology may provide an innovative approach to preventing or reducing the absorption of lead by mothers and young children in settings such as Mt Isa where this is also an issue of concern.

Ruth Stewart
The impact of Quality Assurance activities within an Australian rural maternity managed clinical network

Introduction: In Queensland between 1990 and 2012, forty-seven rural maternity services closed, leaving forty-two maternity services in the state. This pattern of rural maternity service closure is echoed around Australia. For various reasons small rural maternity services have difficulty performing quality assurance activities. Models of care which enable quality assurance are needed. In the Corangamite Shire in rural Victoria a managed clinical network was formed between three hospital maternity services. Managed Clinical networks support quality assurance, workforce modelling and professional development. This presentation will focus on the impact of the quality assurance activities.
Methods: Two series of interviews with key stakeholders were performed and analysed using grounded theory to identify themes and participant observation methodology was used to provide a narrative of the development, activity and impact of the CMCN.
Results: Within the Corangamite Managed Clinical Network (CMCN) comprehensive quality assurance activities were developed and the clinical effectiveness cycle was implemented. There were significant barriers experienced in the implementation of the locally adapted evidence based clinical guidelines due to lack of alignment between regional hospital and network governance. The engagement with clinicians was very good and there was a strong ownership of the guidelines. Clinicians found the guidelines very helpful. Clinical Audit against the guidelines informed locally delivered professional development and led to significant changes in clinical practice. Clinical Audit meetings improved team members understanding of each others' skills, and team morale and there changes in clinical practice were observed.
Discussion: The Managed Clinical Network organisational structure enabled the development of a learning organisation and improvement in clinical outcomes in the three small low volume rural maternity services in the Corangamite Shire, but the Macro-system of the regional health service failed to support this innovative microsystem.

Jilpia Nappaljari Jones
Traditional Aboriginal mothers and their birthing practices in rural and remote Australia: Rectifying the current injustices

In my mother's time, birthing was carried out in one's country and was completed with complex rituals that were seen as beneficial to not only mother and baby but also affected the father too. The advent of western medical technology changed all this. On the one hand, evacuation of my people to tertiary centres ensured that the complications of labour were competently managed. On the other hand such a strategy destroyed the traditional rituals surrounding child birth. I argue that this represents two sides of the coin: on the one hand life saving medical intervention in the few, on the other where women not only had more delayed labour, requiring greater intervention. However, the community from which they were sent was unable to compensate for the disruption of those ceremonies that could not be carried out in the absence of the pregnant woman. I see this as an important factor in the breakdown of traditional values in many communities, which in turn leads to an increase in risk factors for girls and women during pregnancy and labour. I argue that more health resources, particularly midwives, must be available in rural and remote areas, to ensure continuity of care, development of trust and professional confidence, birthing risk assessment, and very importantly, inclusion of designated traditional women, usually relatives, in women's business. I also argue that Aboriginal babies born to mothers who must be evacuated from their traditional country for delivery for complex medical reasons, should have the name of their country entered on their birth certificate.

Priscilla Page
Building Aboriginal & Torres Strait Islander Primary Health Care Capacity

There is a gap in health between Indigenous and non-Indigenous Australians. The gap is at least partly the result of fewer health professionals coming from Indigenous backgrounds. Creating an interest in Indigenous high school students who will soon be making career choices is one way to improve the number of Indigenous health professionals.
This presentation will describe the journey to create health career interest in Indigenous high school students at St. Theresa's Abergowrie College in North Queensland. Indigenous students from this college are under-represented at tertiary and technical level. Therefore, a project was undertaken to increase Indigenous student enrolment in the Indigenous Health Worker Certificate II program.
This project involved the development of a learning outcomes curriculum devised specifically for Indigenous students that focussed their ways of learning. Strategies included:

• Healing sessions to assist in the removal of emotional 'baggage' (before health education was possible),
• Giving ownership to student learning direction,
• Student-directed active learning, and
• Culturally-appropriate practical activities.

Project outcomes include:

• Student enrolment in the Certificate II program rising from 8 to 25 within 12 months,
• More positive student perceptions towards higher education and a health career,
• Having another career option for Indigenous students at Abergowrie College,
• Encouragement and support of student growth, and
• The curriculum is now a permanent education option for Indigenous students at Abergowrie College.
• All Year 10's to complete the course
• Year 11 & 12 elective

The Program: Continual networking was also conducted to implement the learning outcomes curriculum into two other high schools having high numbers of underrepresented Indigenous students.
The program has now been extended to Shalom Christian College, Townsville and Mount St Bernard College, Herberton with a view potentially to go into the North West Queensland regions.

Norelle Ryan
Monit: Your Occupational Health and Safety Protection.

Introduction: Monit is a Safety Management System that has comprehensive computer software backed by a high level of service.
By law all Persons Conducting a Business or Undertaking (PCBU) have an obligation to take reasonably practicable steps in their business to reduce unnecessary risks and are required to have a dynamic approach to health and safety in their workplace.
Monit:

• Is fully compliant with every State's Workplace Health and Safety laws and with the new National Work Health and Safety Act and Regulations 2011 which came into effect on the 1^st January this year.
• Appoints a professionally trained 'Monitor' to every client to tell you what to do each month to comply with your legal requirements.
• Comes to your premises to verify the setup of your system, which includes questions specifically drawn from the Acts relating to each individual business and a 'walk around' of the premises to verify the answers to those questions.
• Identifies unnecessary risks in your workplace and calculates a risk percentage.
• Develops an action plan to systematically remove risks.
• Provides a live OH&S process through your Monitor.
• Provides regular reminders designed to assist you in meeting your obligations.
• Gathers, stores and produces evidence to prove you are doing the right thing.

Conclusion: Northern Gulf Resource Management Group Ltd is a not-for-profit community driven organisation covering an area of 196,000 km2 which includes the centres of Kowanyama, Chillagoe, Georgetown, Croydon, Normanton and Karumba.
In 2009 Northern Gulf became a client of Monit and liked it so much that we decided to work with Monit in developing a template specifically for the rural and farming industries. The Northern Gulf region includes a very high percentage of grazing and farming properties and it was because we know how dangerous this industry is that we wanted to help out. The way Monit operates is ideal for rural industry people because it gives them someone to manage and constantly remind them of their obligations without them having to do everything themselves. We have made it a priority to provide safety awareness and a safe working culture to the rural industry.

Sharon Dennis
A University Cultural Shift towards Aboriginal Inclusion

The evolution of Aboriginal programs comes and goes. Like a tidal surge some work leaves a wonderful trail of more things to explore. Others don't work and leave a tainted stain. So when the question is asked 'How do we encourage Aboriginal people to apply to University?' it requires careful consideration. I began contemplating the question with the review of all the past tidal waves of programs.
The program had to fit the requirements of the funding bodies and the reporting indicators of the University, as well as the Aboriginal participants and wider Aboriginal community. Background work required investigating what is actually already offered to Aboriginal students and what is missed. With indicators identified, the next question was 'What has the Aboriginal Community been asking for in the past that has not been heard?'
Combining all the information and my own experiences as an Aboriginal staff member and the valuable experience of my colleague, a program began to develop. There were many existing programs in the Aboriginal community, education and employment services. Consideration was also given to the issue of Aboriginal identity and the Tasmanian Aboriginal history. By linking all these different programs, choices emerged about a variety of pathways to University that could be mapped out. The pathways were formatted to deliver a University presentation called Bunguna (Leadership) Pathways aimed at year 9 and 10 Aboriginal students. The objective is to provide Aboriginal high school students with the information with cultural considerations to make an informed choice towards University.
Bunguna Pathways has only had one delivery and the results are positive with Aboriginal students and high school Pathway Officers already requesting to be included.

Margaret Stebbing
Practising Prevention - Adapting high quality evidence in the design of interventions for action at the local community or settings level.

This one hour interactive workshop briefly introduces the key concepts of Evidence Informed Population Health Practice and then focuses on the last part of this process - using high quality evidence to inform innovation in practice in a population setting. Participants will use an evidence based health promotion resource to consider the tasks of: applying knowledge to the local context, assessing barriers to knowledge translation, selecting, tailoring and implementing interventions, monitoring knowledge use, evaluating knowledge applications and sustaining successful practice over time. Participants will then apply this knowledge to prepare an outline plan for action to address a selected population health problem for which there is an established evidence base.

Selina Taylor, Amanda Sanburg
Medication Safety through Home Medicine Reviews

Home Medicine Reviews (HMR's) are relatively new to Mount Isa. They provide opportunities for review of medicines by an accredited pharmacist within the home environment identifying opportunities for better and safer use of medicines. The process of HMR's will be presented with their benefits around safe medication use highlighted. These include issues around safe storage of medicines, medication reconciliation, identification of side effects and provision of patient education. This occurs in an environment where the patient is relaxed and time allows for greater discussion around medicines. Problems identified by the HMR are reported and discussed with the GP for further action. Over 150 HMR's, approximately a third with indigenous clients, have been performed in Mount Isa to date. Patient feedback has been positive and the reports are being well received by the referring doctors. Examples of some successful pharmacist interventions specifically relating to medication safety issues will be highlighted. Medication reviews benefit patient health outcomes and provision of this service will continue in Mount Isa and hopefully into the broader region.

Katherine Galligan
North West Community Rehabilitation Project

North West Community Rehab (NWCR) is an innovative teaching neurological rehabilitation project being implemented in North Western Queensland (NWQ) from 2012 - 2014. Prior to this project there were no specialised rehabilitation services available in NWQ despite the region having an ageing population and an increasing number of people with neurological conditions. The project aims to provide innovative evidence-based services for prevention, early intervention, post-discharge and long term follow up for people with neurological and ageing conditions; vertically integrated education to build the capacity of the current and future workforce; and continuous improvement through high quality research.
Ten weeks of service delivery, comprising 2 consecutive 5 week blocks were undertaken in March - May 2012. Physiotherapy students, local and specialist allied health staff and a rehabilitation assistant were involved. Four different programs were offered, all with an underlying focus on learning for self-management and in which participants were central to their rehabilitation. Thirty four participants were involved in programs which were delivered in community settings in Mt Isa and Cloncurry, with an additional acute program at Mt Isa Hospital. Standardised clinical outcome measures were taken pre and post each program, in addition to participant, student and staff placement evaluations.
Preliminary analysis of clinical outcome measures and evaluation forms indicate an improvement across measures including 6 minute walk distances, timed up and go and functional reach measures. Self- rated measures including goal attainment and self -efficacy to manage their condition also showed improvements across the board. Overall, evaluation responses were positive.
Overall, the 2012 NWCR program was considered a success by those involved. Recommendations for future programs are being developed with respect to service delivery, education and workforce and research.

Sarah Larkins, Caroline Harvey, Paula Matich, Priscilla Page, Clare Jukka, Jane Hollins
Keeping young people safe: what are the issues for rural and regional young people in accessing SRH services?

Introduction: Young people in rural areas have trouble accessing health services, including sexual and reproductive health (SRH) services. This project investigates how access to SRH services can be improved for young people in rural and regional areas through studying the acceptability and accessibility of SRH services in rural Queensland, and markers of quality in SRH service delivery as defined by young people and service providers.
Methods: Initially a systematic review of the literature on access to SRH services for young people was performed. Data collection involves descriptive mixed methods using multiple purposively-selected case studies. Four pilot sites are currently underway. Data collected includes service mapping and usage data, electronic survey (online or face-to-face on Ipads) and focus group discussions with young people, and interviews with service providers. Young people's reference groups have been formed at each site.
Results: Pilot data has been collected from four sites. Over 170 responses have been received for the survey to date (more than 10% Indigenous) and five focus groups held. Although the majority of respondents reported needing SRH care, large numbers did not seek professional help, rather relying heavily on friends, family and the internet; not always reliable sources of information and advice. The most important factors for young people when accessing SRH services were the presence of friendly and non-judgemental staff members. This paper will report on the literature review and results to date, with a particular focus on differences according to rurality.
Discussion: Rural, remote and Indigenous young people are particularly disadvantaged in terms of accessing SRH services. This project will assist in understanding issues involved in optimising sexual health care for these young people, using methods to optimise both the participation of young people and the translation into policy and practice of the results.

Sandra Downing, Arun Menon, Therese Howard, Angela Cooper, Patricia Fagan
An outbreak of infectious syphilis amongst young Aboriginal and Torres Strait Islander people in north west Queensland

Background: Infectious syphilis notifications in the Aboriginal and Torres Strait Islander population have fallen over the last decade with only 123 Indigenous notifications nationally in 2009. During 2010 increasing notifications in the Mt Isa Health Service District (MIHSD) were observed and by early 2011 an outbreak of infectious syphilis affecting young Indigenous people was established. We describe the outbreak and the response measures.
Methods: A Syphilis Incident Management Team was formed. A communication and engagement plan was developed, additional sexual health staff were deployed and screening activities conducted. Data was extracted from the Syphilis Surveillance System to describe the epidemiology and selected management outcomes.
Results: Between 01/01/2011 and 31/05/2012, 134 infectious syphilis and 3 congenital syphilis cases were notified from the MIHSD. A further 19 cases notified elsewhere are directly linked to MIHSD. Of the 153 cases, 82% are less than 25 years old, 62% are female and 99% are Indigenous. 39 of 70 (56%) cases presenting with symptoms and/or as a contact were correctly treated presumptively. Median time from test date to treatment date for the 83 screened cases was 7 days (mean:14 days, standard deviation:29). In May 2012 intensive screening events targetting15-24 year olds in two MIHSD settings identified 17 cases.
Discussion: Ongoing control measures include continuing improvement in sexual health service delivery, development of innovative approaches to engage youth, and longer term sexual health promotion efforts to reduce risk for Indigenous youth in the region.

Ian Wronski
Queensland Regional Training Networks

On 22 April 2010 the Australian Health Ministers Council (AHMC) endorsed the establishment of Integrated Regional Clinical Training Networks (IRCTNs), by the newly formed Health Workforce Australia (HWA), as the mechanism to coordinate and facilitate clinical placements across all types of service providers at a regional level. The approved functions include:

• Promoting access to clinical placements through engaging underused settings and facilitating increased capacity;
• Facilitating systematic reporting of clinical training activity;
• Building education and clinical training provider relationships;
• Facilitating planning of placement requirements and opportunities;
• Matching supply and demand for placements;
• Supporting the management of clinical placements and workforce issues.

Queensland's model for RTNs includes:

• The state-wide Queensland Clinical Education and Training Council (QCETC);
• The Northern Queensland Regional Training Network (NQRTN);
• The Southern Queensland Regional Training Network (SQRTN); and
• The Greater Northern Australia Regional Training Network (GNARTN).

The geographical boundary-split for the NQRTN and SQRTN runs just below Rockhampton. The QCETC has overall authority for decision-making and setting directions within Queensland-based RTNs.
The GNARTN is currently in establishment phase. In principle the Greater Northern Australia (GNA) will broadly be defined as north of the Tropic of Capricorn. Its primary functional domains include:

• Addressing Obstacles to Inter-jurisdictional Clinical Placements;
• Aboriginal and Torres Strait Islander Health Workforce Development; and
• Development of the Rural Generalist and General Specialist Workforce.

This model allows the geographic needs of different regions of Queensland to be addressed and acknowledges the unique needs of the disparate participants of the clinical education and training continuum, from pre-entry to multi-disciplinary specialist learners. This model also allows region-specific issues to be addressed without establishing multiple structures and assigning the required funds to support these structures before a definite need is shown.

Posters and alternative format presentations

Julaine Allan
Drug and alcohol use by farming and fishing workers: Key findings for industry

This study collected qualitative and quantitative data to describe farm and fishing workers' use of drugs and alcohol, their understanding of drug and alcohol related harms and the influence of workplace culture on drug and alcohol use.
Research sites in NSW and Victoria, Australia with either farming or fishing as the key industry were identified for the study via consultation with primary industry leaders. Farm worker and partner participants were identified through local industry groups and networks by snowball sampling. One hundred and forty five farm and fishing workers/contractors, partners of workers and community leaders across six research sites completed interviews and surveys between November 2010 and May 2011.
It was found that alcohol is the major drug of concern for workplaces, while tobacco causes most concern for the participants. Farm and fishing employees consume significantly higher amounts of alcohol than the general Australian population. Alcohol is used at moderate to high risk or dependent levels by around 44% of study participants. The proportion of farming participants (18.2%) reporting high risk/dependent alcohol use was more than double that reported by fishing participants (8%). Many participants described examples of working while affected by alcohol including being drunk or hung-over. There is strong resistance to change hazardous drinking behaviour. Illicit drugs were used by some people in the industry. Cannabis was the most common (12.7%) followed by amphetamines (8.5%). 20% of participants reported working under the influence of illicit drugs during the past 12 months.
Problematic substance use, especially alcohol, goes to the heart of industry productivity even though most people do not connect out of work substance use with workplace health and safety. Drug and alcohol interventions such as screening and workplace policies, are effective when accessible to the population. Challenges include making them fit with the industry context and work practices. Employers may need advice and support to address substance use, particularly alcohol, directly with employees. Farm and fishing workers need ready access to information and support to reduce harmful alcohol and tobacco use.

Julaine Allan, Michele Campbell
Cultural safety in drug and alcohol services: one way to do it

Providing drug and alcohol services to Aboriginal communities in rural areas is challenging, particularly when those services employ non-Indigenous workers. This paper describes the soft entry approach applied across western NSW by Lyndon Community Outreach workers. The fundamental aim of the approach is to shift the power balance from worker to community in when and how to access services. The method and skills required are described and experiences of Aboriginal community members used to illustrate the benefits. The organisational commitment required to implement this approach is explained.

Tony Lower
Cancer in farmers: An international review

Introduction: Previous research has shown that Australian farmers have elevated rates of death due to certain types of cancers. However, it is unknown if this is due to variations in the incidence, stage of diagnosis, treatment or medical outcomes between farmers and non-farmers; or how rural-urban factors might influence these. This review examines the international research on this issue.
Method: A systematic search of abstracts listed within 8 electronic databases was undertaken (eg. Medline, Scopus, Web of Science). Full text articles of studies meeting specific selection criteria were obtained and appraised using a tool based on 'STROBE' and Cochrane Collaboration recommendations.
Results: Over 1300 studies were identified with 500+ meeting the selection criteria. Moderate evidence for a lower incidence and mortality for 'all-cancers' and lung cancers in farmers exist. There are consistent findings for an excess in lip, prostate and haemo-lymphopoietic cancers. Less data is available on cancers amongst farm women and there is a paucity of data on differentials between farmers and others related to health service factors (eg. screening, stage of diagnosis, treatment, outcome, rurality). The role of environmental risk factors, such as pesticides, sun exposure, micro-organisms and concurrent lifestyle/socio-economic factors have been explored, with evidence for associations with cancer being mixed or inconclusive.
Discussion: It appears that previous Australian research on cancer mortality in farmers is consistent with international findings; and that more needs to be learnt about cancer in farm women and the contribution of health service factors to cancer. Whilst conclusive evidence of cancer causation based on epidemiological studies alone cannot be expected, consistent findings can point the way forward in the development of appropriate cause-and-effect clinical studies.

Mark Andrew Morgan
TrueBlue collaborative care for managing depression, diabetes and heart disease

Introduction The aim of this project was to determine the effectiveness of practice nurse led collaborative care for depressed patients with type 2 diabetes or coronary heart disease. In these chronic diseases, depression is both under-recognised and under-treated despite being a risk factor for poor outcomes. General practice care of these chronic diseases falls short of best practice. TrueBlue is a model of service delivery within existing workforce that could better manage chronic diseases with a focus on co-morbid depression.
Methods: Cluster randomised trial involving eleven Australian general practices (404 patients). Intervention: TrueBlue was a newly introduced system care with enhanced roles for the practice nurse to review: chronic disease parameters; depression using PHQ9; lifestyle risk factors; and patients' goals. Patients saw the nurse for 45 minutes and then GP on a three-monthly cycle. Control: Usual care
Results After six months, the mean depression score decreased 10.8 to 6.9 in the intervention which was a significantly greater improvement than controls. Compared to controls, intervention practices demonstrated an intensification of treatment for depression and increased exercise rates. After 12 months of intervention there was a significant decrease in 10-year cardiovascular risk from 27.4 to 24.8. Adherence to diabetes and heart disease guidelines was much closer than Australian norms.
Discussion Practice nurse led collaborative care has been shown in this study to be an effective intervention to better manage co-morbid depression, diabetes and coronary heart disease. Nurses became the case-manager, coach and educator. After training (2 days) they confidently used PHQ9 and handled suicidal patients according to study protocols. As TrueBlue was implemented in large, small, rural and urban practices, it could provide, with the help of local expertise, a model for the management of chronic disease and co-morbid depression in remote areas.