Public Health Bulletin SA - Volume 8, Number 1, March 2011

Public HealthBulletin SARural health in the 21st century:challenges and opportunitiesBuilding the Marjorie Jackson-Nelson HospitalVolume 8, Number 1, March 2011Contents1 Editorial3 Why measuring accessibility is important forpublic health: a review from the CardiacARIA project9 Aboriginal family birthing program in ruraland remote South Australia12 Farm injury fatalities: where are we andwhere to from here?15 Resilience in farm families: aconstructivist perspective19 Regional migrant settlement: a healthlens project24 Rural ageing-in-place: communityconnectedness, health and wellbeing—an opportunity for new technologies?30 From tree change to e-change—Willunga becomes a digital village33 Male health: facts, determinants and nationaland South Australian policy responses41 Community participation in the WhyallaIntergenerational Study of Health (WISH):looking back on the possible influences ofknowledge, trust and power49 Screening for colorectal cancer in remote,rural and metropolitan South Australia:analysis of the National Bowel CancerScreening Program data56 RFDS as a preventive health agency in therural and remote setting58 Parenting Eating and Activity for Child Health(PEACH) in the Community: (PEACH IC):translating research to practiceEditorialRobyn McDermottDirector SA NT DataLinkDivision of Health SciencesUniversity of South AustraliaThe second half of the last century has seen unprecedented growth in theworld’s population, massive migration from rural to urban centres and agreater than 50% increase in life expectancy. In 2009, for the first time,more than half of the world’s population lived in cities and there are nowmore than 20 ‘mega-cities’ with populations of more than 20 million people,mostly in developing countries. The pace continues, with the two biggestcountries, China and India, experiencing increased urban drift from ruralareas as millions of people search for a better quality of life, access to jobsand services and better prospects for their children. In the same 50, yearsAustralia has gone from a rural agricultural economy to one dominated byservice industries and where more than two-thirds of us now live in a handfulof coastal cities.In Australia and other OECD countries, our improved life expectancy overthe last half century has been mainly due to a steep decline in cardiovascularmortality in adults, whereas the health transition in most developing countrieshas been dominated by improved child survival. Yet, as we open the 21stcentury, we all share a set of stark common problems that have their genesisin the very success of these past 50 years. Globalisation of fast foods,urbanisation, sedentariness, obesity, diabetes and attendant complications areall linked, and will likely limit further increase in longevity, increase our yearsspent with disability and contribute to escalating healthcare costs.At the same time we document growing disparities in health outcomesbetween the rich and poor, Indigenous and others, and urban and ruralpeople. The contributions from health behaviours (food choices, smoking,physical activity), structural inequities (very low incomes combined withhigh cost of food in remote areas, poor quality of the food supply, foodinsecurity, low educational attainment, poverty and poor housing, loweconomic participation etc.) and access to services (jobs, housing, health care,education) explain many of these differences.62 Communicable Disease Control BranchDisease Surveillance and Investigation Report1 July to 31 December 2010

Public Health BulletinEditorial continued.The challenges faced by rural Australiancommunities are multidimensional and mustgo hand in with policies to improve the basisfor the structural and service inequalities they face.For service providers, epidemiologists, health serviceproviders and social researchers, rural communitiesoffer opportunities for real community engagementthat are not feasible in cities. In rural communities thepopulation is known and it is possible to make a bigdifference in health and other outcomes with relativelysimple measures, in health and other social outcomes.The essays and research reports that are collectedin this Rural Health edition of the South AustralianPublic Health Bulletin, testify to the research and policyinitiatives that seek to address disparities betweenrural and urban populations and in doing so they drawupon the many positive aspects of rural health andcommunity life.Contributors to this edition highlight that while there isan imperative to research the needs of rural populationsand regions, such research can be challenged bydefinitions of key terminology and by communityattitudes. Clark et al. discuss the importance of clearlydelineated definitions of access and remoteness inthe context of the Cardiac ARIA project, arguingthat definitions can impact understandings of theways that distance mediates and limits access togoods and services. From their work on the WhyallaIntergenerational Study of Health (WISH), Haren etal. acknowledge that rural community uptake andinvolvement in research activities could be bolstered byactively seeking and integrating community knowledgeabout public health matters, building trust withcommunities and empowering communities in thegovernance of their futures.The rural population is a diverse group with varyingneeds and opportunities for improved health outcomesand quality of life. Hence, authors in this edition ofthe Public Health Bulletin draw the reader’s attentionto specific policy and research activities linked tosubgroups of the rural population—such as Aboriginalpregnant women, workers in farm industries, rural menand migrants to rural localities. Specifically, Caponiet al. discuss the positive impacts of the AboriginalFamily Birthing Program for rural Aboriginal womenand their children. Lower outlines the evidence-based,well-known and practical solutions that can be usedto reduce injuries and fatalities in the high-risk farmingindustry. Misan et al. comment on the key determinantsof men’s health and existing policy initiatives, and theauthors recommend priorities and additional initiativesto address disparities in men’s health.Finally, Sawford et al. describe the Regional MigrantSettlement health lens project which has exploredmigrants’ experiences of settlement in rural SouthAustralia and the relationship between migrantsettlement and health and wellbeing. The work ofMartini et al. analyses data from the National BowelCancer Screening Program data, and illustrating thatsubgroups of the rural population are vulnerable todisease occurrence due to their particularly poor uptakeof disease screening which is a cornerstone of modernpublic health. In particular cancer screening rates werepoor for older rural and remote residents but also formen, Indigenous people, lower socioeconomic groupsand those living in Far North South Australia.The resilience, adaptation and innovation that havehistorically been part of the rural Australian ethos arealso reflected through articles included in this editionof the Public Health Bulletin. King et al. explore thecontextual, social and personal factors that influencehow rural families maintain their health and wellbeingin the face of adverse climatic conditions such asdrought. In summary, the authors advocate for asystemic across-government approach to buildingcommunity and individual resilience through healthmaintenance. The role of technology such as theinternet in the experiences of rural Australians isconsidered by Feist et al., who highlight its impact infostering and facilitating the relationships betweenpeople and places and in increasing the wellbeing ofolder generations. On the same topic, Bell et al. view ahigh-speed and ubiquitous national internet networkas infrastructure that will enrich all Australians’ livesand allow rural Australians to more readily accesshealth care. The coverage and activities of the RoyalFlying Doctor Service are described by Setchell as aninnovative service that has responded to the needsof rural communities since its establishment in 1928,evolving with these remote populations over 83 yearsof service.This edition of the Public Health Bulletin does notprovide a comprehensive review of the rural healthchallenges to be faced in the 21st century. Rather thisedition provides a snapshot of issues, challenges andresponses faced in the rural health setting. In doingso the Public Health Bulletin seeks to contribute toour joint understandings of the unique challenges ofdistance and accessibility and to aid in our joint searchfor solutions.Note: Due to the large size of Volume 7, Number 3 of thePublic Health Bulletin this edition includes a paper byMagarey et al (pg 58), which responds to the theme Childenand Public Health.page 2

Rural health in the 21st centuryWhy measuring accessibilityis important for public health:a review from the CardiacARIA projectRobyn A ClarkAssociate ProfessorNHMRC Post Doctoral Fellow, School ofNursing and MidwiferyQueensland University of TechnologyAdjunct, Sansom Institute, Universityof South AustraliaNeil CoffeeSenior Research FellowSocial Epidemiology and Evaluation Research, SansomInstitute, University of South AustraliaOn behalf of the Cardiac ARIA projectIntroductionMeasuring accessibility has become more common inthe literature in recent years—indeed, accessibility isoften a ‘variable’ within regression analyses seekingto determine associations between health andoutcomes. The purpose of this paper is to report onthe importance of having a clear definition of accessin public health research, and to demonstrate how ageographic definition was applied in the CardiacARIA project.Accessibility can be defined as ‘the ease of approachfrom one location to another measured in terms ofdistance travelled, the cost of travel, or the time taken’.Remoteness can be defined as ‘distant or far awaygeographically’. 1 These concepts are at the heart ofgeographic models of access and remoteness, theunderlying principle of which is the impact that distanceplays in assisting or hampering access to goods andservices—in this case, access to healthcare services.We acknowledge that these definitions refer to physicalrather than social accessibility, which could include classstructure, income, age, education, gender or ethnicity,and the impact these factors can have in accessingservices. While ‘access’ is a major concern in healthcarepolicy, it is also one of the most frequently used wordsin discussions of the healthcare system. Access is animportant concept in health policy and health servicesresearch, yet it is often not defined or employedprecisely. To some, access refers to entry into or use ofthe healthcare system, while to others it characterisesfactors influencing entry or use. In the pinnacle paperby Penchansky and Thomas, access is defined as ageneral concept that summarises a set of more specificdimensions describing the fit between the patient andthe healthcare system. The specific dimensions areavailability, accessibility, accommodation, affordabilityand acceptability. The Penchansky taxonomy is definedin more detail in Table 1. 2Table 1: Penchansky definition of access in the context of healthcare servicesConceptAvailabilityAccessibilityAccommodationAffordabilityAcceptabilityDefinitionThe relationship of the volume and type of existing services (and resources) to the clients' volume andtypes of needs. It refers to the adequacy of the supply of physicians, dentists and other providers; offacilities such as clinics and hospitals; and of specialised programs and services such as mental health andemergency care.The relationship between the location of supply and the location of clients, taking account of clienttransportation resources and travel time, distance and cost.The relationship between the manner in which the supply resources are organised to accept clients(including appointment systems, hours of operation, walk-in facilities, telephone services) and the clients'ability to accommodate to these factors and their perception of their appropriateness.The relationship of prices of services and providers' insurance or deposit requirements to the clients'income, ability to pay and existing health insurance. The clients’ perception of worth relative to total cost isa concern here, as is their knowledge of prices, total cost and possible credit arrangements.The relationship of clients' attitudes about personal and practice characteristics of providers to the actualcharacteristics of existing providers, as well as to provider attitudes about acceptable personal characteristicsof clients. In the literature the term appears to be used most often to refer to specific consumer reactionto such provider attributes as age, sex, ethnicity, type of facility, neighbourhood of facility, or religiousaffiliation of facility or provider. In turn, providers have attitudes about the preferred attributes of clients ortheir financing mechanisms. Providers either may be unwilling to serve certain types of clients (e.g. welfarepatients) or, through accommodation, may make themselves more or less available.Source: Penchansky R, Thomas JW. The concept of access: definition and relationship to consumer satisfaction. Med Care 1981; 19(2):127–140.Volume 8, Number 1, March 2011 page 3

Public Health BulletinMeasuring accessibility in AustraliaOne of the earlier Australian remoteness classificationswas the Rural, Remote and Metropolitan Areas (RRMA)classification. It was developed in 1994 by the thenDepartments of Primary Industry and Energy andHuman Services and Health in response to concerns inthe Commonwealth Department of Health about thelevel of health service provided to rural and remoteareas. 3 In essence, RRMA defined remoteness in termsof ‘distance’ based on a straight line (Euclidean or ‘asthe crow flies’) between the centroid (or centre-mostpoint) of a statistical local area (SLA) and the centroidof the nearest service centre, coupled with a ‘personaldistance’ factor based on population density. Althoughthe publication of RRMA was significant, a numberof limitations in its application became apparent overtime, for example its use of Euclidean distances ratherthan established road or air networks, its reliance onSLAs, the use of the word ‘rural’, and inclusion of apersonal distance factor. 3 These issues and others, morenotably RRMA’s increasing incompatibility with recentpolicy and analysis (particularly at the town level),provided the impetus for the development in 1997 ofa new geographic remoteness index—the Accessibility/Remoteness Index Australia (ARIA). 4 ARIA replacedRRMA and has been modified to measure all essentialcommunity services (Figure 1). 5In order to systematically tailor services to meet theneeds of Australians living in regional locations, aworkable definition of ‘remoteness’ (identified as alack of accessibility to services regarded as normalin metropolitan areas) was required. 6 In 1996–97the National Key Centre for Social Applications ofGeographical Information Systems (GISCA) at TheUniversity of Adelaide was commissioned to assist theAustralian Bureau of Statistics (ABS) in its review of theAustralian Standard Geographical Classification (ASGC).This review included quantifying the measurement ofremoteness in a more-or-less objective way. GISCArecommended applying geographic information system(GIS) techniques to construct a remoteness measure.The resulting ARIA was designed to be comprehensive,sufficiently detailed, as simple as possible, transparent,defensible and stable over time—and to make senseFigure 1: Accessibility and Remoteness Index of Australia (ARIA)page 4

Rural health in the 21st century‘on the ground.’ 6 ARIA was also designed to be anunambiguously geographical approach to definingremoteness—that is, socioeconomic, urban/rural andpopulation size factors were not incorporated intothe measure. The 2007 version of ARIA (ARIA++)calculated remoteness as accessibility to servicecentres based on road distances. Remoteness valuesfor 20 387 populated localities were derived from theroad distance to service centres in four categories (aweighting factor is applied for islands). Remotenessvalues for each populated locality are then interpolatedto a 1 km grid that covers the whole of Australia andaverages are calculated for larger areas. To create anassociated classification, ARIA values are grouped intothe following five categories using a 0–18 continuousvariable: 61. Highly Accessible (ARIA score 0 to

Public Health BulletinFigure 2: Accessibility to category 1 public hospitals in Australiacardiac rehabilitation, pathology ≤ 1 hour). ForIndigenous people, only 40% had access to a category1 hospital and services to support cardiac rehabilitation,and 12% (56000) resided 3 hours or more from ahospital and only had access to service to support onerehabilitation (Table 2). Disparity in access to category1A cardiac services was demonstrated for 5.8 million(30%) of all Australians, 60% of Indigenous people and32% of people over 65 years of age (Table 2).Implications for practiceOur study has provided a geographic measure ofaccess to cardiac services but does not measure healthsystem performance. Therefore, it reflects ‘what shouldhappen…not what does happen’. The Cardiac ARIAfocuses on community access/support as opposedto medically centred responses. This could allowcommunities to be proactive by taking the lead toimprove access to cardiac services based on the CardiacARIA for their population locality. The Cardiac ARIA willbe iterative as data access improves, and the results canthen be used to identify geographic hotspots wherethere is a mismatch between demand and provisionof cardiac services. Inequities in access in rural areaswill continue without system changes. Public healthresearchers can use the Cardiac ARIA to determinecardiovascular health service delivery against servicerequirements in an objective way.For population localities with limited access to cardiacservices (i.e. high Cardiac ARIA scores), a case couldbe made for innovative practice such as virtual orelectronically supported cardiac care.page 6

Rural health in the 21st centuryTable 2: ABS Census data 2006 key characteristics of Cardiac ARIA categoriesCardiac ARIAcategoryPersonsn (%)Indigenouspersonsn (%)Persons aged≥ 45 yearsn (%)Persons aged≥ 55 yearsn (%)Persons aged≥ 65 yearsn (%)Persons aged≥ 75 yearsn (%)Persons aged≥ 85 yearsn (%)1A 13 983 696(70.58%)180 210(39.74%)5 171 675(68.19%)3 257 449(67.48%)1 784 081(67.56%)882 236(69.47%)229 650(71.19%)2A 1 645 086(8.30%)47 821(10.55%)646 419(8.52%)415 277(8.60%)230 228(8.72%)108 312(8.53%)26 429(8.19%)3A 1 100 338(5.55%)32 252(7.11%)457 016(6.03%)303 527(6.29%)172 781(6.54%)80 687(6.35%)19 495(6.04%)4A 1 127 226(5.69%)39 983(8.82%)487 006(6.42%)323 185(6.70%)181 727(6.88%)84 194(6.63%)20 325(6.30%)4B 7 183(0.04%)78(0.02%)2 848(0.04%)1 787(0.04%)1 058(0.04%)519 (0.04%) 132 (0.04%)4C 89 497(0.45%)2 718(0.60%)37 732(0.50%)24 873(0.52%)14 068(0.53%)6 774(0.53%)1 693(0.52%)5A 669 981(3.38%)27 182(5.99%)295 491(3.90%)196 465(4.07%)107 617(4.08%)48 198(3.80%)11 871(3.68%)5B 101 629(0.51%)8 358(1.84%)44 621(0.59%)30 469(0.63%)17 680(0.67%)8 250(0.65%)2 115(0.66%)5C 223 851(1.13%)23 463(5.17%)88 823(1.17%)56 556(1.17%)29 924(1.1%)13 442(1.06%)3 463(1.07%)5D 102 898(0.52%)17 191(3.79%)31 759(0.42%)17 391(0.36%)7 827(0.30%)3 206(0.25%)739 (0.23%)6A 486 069(2.45%)12 485(2.75%)219 102(2.89%)139 819(2.90%)67 266(2.55%)25 223(1.99%)5 074(1.57%)6B 44 293(0.22%)2 044(0.45%)19 229(0.25%)11 939(0.25%)5 445(0.21%)1 901(0.15%)316 (0.10%)6C 79 455(0.40%)3 103(0.68%)34 157(0.45%)20 800(0.43%)9 294(0.35%)3 091(0.24%)543 (0.17%)6D 40 411(0.20%)10 777(2.38%)13 573(0.18%)7 751(0.16%)3 090(0.12%)966 (0.08%) 157 (0.05%)6E 16 139(0.08%)975 (0.22%) 6 128(0.08%)3 523(0.07%)1 414(0.05%)409 (0.03%) 66(0.02%)7D 40 809(0.21%)34 219(7.55%)8 246(0.11%)4 079(0.08%)1 684(0.06%)595 (0.05%) 129 (0.04%)8C 2 332(0.01%)62(0.01%)1 406(0.02%)1 056(0.02%)486 (0.02%) 141 (0.01%) 16(0.00%)8D 3 757(0.02%)1 987(0.44%)977 (0.01%) 509 (0.01%) 218 (0.01%) 69(0.01%)19(0.01%)8E 29 764(0.15%)NA 18 666(0.09%)8 225(1.81%)9 733(0.13%)296 (0.07%) 7 760(0.10%)5 379(0.11%)5 175(0.11%)2 101(0.08%)2 678(0.10%)661 (0.05%) 132 (0.04%)1 137(0.09%)243 (0.08%)Total 19 813 080 453 429 7 583 701 4 827 009 2 640 667 1 270 011 322 607Volume 8, Number 1, March 2011 page 7

Public Health BulletinRecommendations for further ResearchOutcomes from the Cardiac ARIA project will provideextensive opportunities for further research. We arecurrently awaiting a national mortality dataset fromthe Australian Bureau of Statistics to complete furthermodeling to determine if there is a correlation betweenCardiac ARIA categories and health outcomes. Othersources of data for this project include risk factor dataand outcomes from the North West Adelaide HealthSurvey and the Greater Green Triangle risk Factor Study.LimitationsThe Cardiac ARIA is dependent on the quality of datathat is acquired, and will be iterative as data is updatedand access to key national datasets improves. The indexdemonstrates geographic access to cardiac servicesrather than the performance of the healthcare system.ConclusionOur study has shown that in 2006 the majority ofAustralians were geographically located in communitiesthat have timely access for survival of a cardiac event.The time it takes for systems to mobilise, rather thanthe distance to services, may be more important whendetermining the outcomes for a cardiac event for thisproportion of the population. A key outcome of theCardiac ARIA project was to make a contribution toimprove heart health for all Australian communities.The Cardiac ARIA is a potentially powerful tool forpolicy makers and researchers to both highlight andcombat the burden of cardiovascular disease in urban,rural and remote Australia by classifying access tocardiac services in an objective geographic way thatestablishes a benchmark for practice.References1. Higgs G, Smith DP, Gould MI. Realising 'joined-up'geography in the National Health Service: the role ofgeographical information systems?, Environ Plann C GovPolicy 2003; 21(2):241–258.2. Penchansky R, Thomas JW. The concept of access:definition and relationship to consumer satisfaction. MedCare 1981; 19(2):127–140.3. Department of Primary Industries and Energy andDepartment of Human Services and Health. Rural, Remoteand Metropolitan Areas (RRMA) classification. Canberra,1994.4. Department of Health and Ageing. Review of the Rural,Remote and Metropolitan Areas (RRMA) classification.Discussion Paper. Commonwealth of Australia, Canberra,2005.5. Commonwealth Department of Health and Aged Care.Measuring remoteness: Accessibility/Remoteness Indexof Australia (ARIA), revised edition. Commonwealth ofAustralia, Canberra, 2001.6. Department of Health and Ageing & The University ofAdelaide. Measuring remoteness: Accessibility/RemotenessIndex of Australia (ARIA). Adelaide, 2003. http://www.gisca.adelaide.edu.au/projects/aria/.7. Department of Geography, The University of Adelaide(GISCA). Pharmacy Access/Remoteness Index of Australia(PhARIA). 2004. http://www.gisca.adelaide.edu.au/projects/pharia.html.8. Department of Geography, The University of Adelaide(GISCA). General Practitioner Rural Retention project(GPARIA). 2004. http://www.gisca.adelaide.edu.au/projects/gparia.html.9. Aylward R, Hugo G, Harris K. Accessibility of the agedto residential care facilities and related services in SouthAustralia. Final report to the Office for the Ageing(Department of Human Services). National Key Centre forSocial Applications of Geographical Information Systems(GISCA), Adelaide, 2000.10. Dempsey P, Wilson D, Wilkinson D, Taylor A. Are theremore health problems in rural and remote areas? Acollaborative research project between the SA Centre forRural and Remote Health and the Department of HumanServices. 4th National Regional Australian Conference,11–14 April 2000, Adelaide.11. Aylward R, Bamford E, Hugo G, Taylor D. A comparisonof the ARIA (Accessibility/Remoteness Index of Australia)and RRMA (Rural, Remote and Metropolitan Areasclassification) methodologies for measuring remotenessin Australia. Commonwealth Department of Health andAged Care, Canberra, 2001.12. Australian Institute of Health and Welfare (AIHW). Rural,regional and remote health: a study on mortality. AIHWcat. no. PHE 45 (Rural Health Series No. 2). Canberra,2003.13. Bamford EJ, Dunne L, Taylor DS, Symon BS, Hugo GJ,Wilkinson D. Accessibility to general practitioners in ruralSouth Australia. Med J Aust 2003: 171: 614–616.14. Eckert KA, Taylor AW, Wilkinson DD, Tucker GR. Howdoes mental health status relate to accessibility andremoteness?, Med J Aust 2004; 181(10): 540–543.15. Clark RA, Driscoll A, Nottage J, McLennan S, Coombe DM,Bamford EJ, Wilkinson D, Stewart S. Inequitable provisionof optimal services for patients with chronic heartfailure: a national geo-mapping study. Med J Aust 2007;186(4):169–173.16. Boersma E, Maas ACP, Deckers JW, Simoons ML. Earlythrombolytic treatment in acute myocardial infarction:reappraisal of the golden hour. Lancet 1996; 348:771–775.page 8

Rural health in the 21st centuryAboriginal family birthing programin rural and remote South AustraliaAnna CaponiAboriginal Family Birthing ProjectCountry Health SAVerity PatersonEarly ChildhoodCountry Health SAIntroductionThe purpose of this paper is to outline a model of anteandpostnatal care that meets the holistic needs ofAboriginal women in rural and remote South Australia(SA). It seeks to highlight the importance of buildingrelationships between health services, the communitythey serve and the health professionals involved inbirthing services.Although relationships are a key success factorin providing a comprehensive birthing service toAboriginal women, this paper also outlines otherelements that support a successful service forAboriginal women in rural and remote areas.Program developmentThe Aboriginal Family Birthing Program (AFBP),originally based in Port Augusta and Whyalla, isa culturally appropriate, holistic early interventionprogram aimed at working with ante- and postnatalAboriginal women to improve the health and wellbeingof both mother and baby.Need for the programThe impetus for the program arose from an analysisof the data presented in the Pregnancy Outcome UnitReport South Australia 2003. 1 This showed that:> > The perinatal mortality rate for Aboriginal womenwas 16.9 per 1000 compared with 9.7 in non-Aboriginal women.> > 59% of pregnant Aboriginal women were smokerscompared with 20% of non-Aboriginal women.> > The infant mortality rate of Aboriginal children was12.8% per 1000 compared with 3.5% per 1000 fornon-Aboriginal children.> > Low birth weight continued to be a significantproblem, occurring in 18% in Aboriginal birthscompared with 6.5% in non-Aboriginal births.Based on data presented in this report, 1 it was apparentthat more needed to be done to improve outcomes forAboriginal women and their children, and to ensurethat Aboriginal mothers accessed professional carethrough the birthing process.Birthing is sacred to Aboriginal women and,traditionally, women would have supported each otherthrough this process. Over time, with the pressures ofsociety and poverty, female support mechanisms havebroken down and many young Aboriginal womenstruggle to deal with the immense challenges ofpregnancy and childbirth in isolation.Consultation on the modelThe initial consultation process informing thedevelopment of the AFBP very quickly identified that aprogram was needed that would see Aboriginal womenlooking after Aboriginal women through their birthingprocess. It was also noted that, in order to achievecontinuity of care, each woman needed an individualprimary caregiver throughout her pregnancy.After the initial consultation process, a group of keyhealth service providers met to develop the alternativebirthing program. This program was a partnershipbetween Pika Wiya Health Service, the Port AugustaHospital, Nunyara Health and Wellbeing Service, andthe Whyalla Hospital and Health Service.As part of this process, an Aboriginal women’s advisorygroup was formed to give guidance and to ensure thatthe program was run in a culturally appropriate way. Itcomprised a cross-section of Aboriginal women fromthe communities involved in the project. In particular,members of the group were insistent that only womencould work in the program because in Aboriginalculture birthing is women’s business. Group membersalso strongly supported Aboriginal women caring forAboriginal women as the cornerstone of the program.This key recommendation led to the development ofthe Aboriginal Maternal Infant Care (AMIC) Workerposition.The modelThe operational model of the AFBP was based aroundthe role of women’s AMIC workers, who would lookafter the women in a holistic sense, including providingsome elements of clinical care. Specifically, it wasenvisaged that recruited AMIC workers would alreadybe Aboriginal health workers and that this role wouldbe expanded to provide antenatal care to AboriginalVolume 8, Number 1, March 2011 page 9

Public Health Bulletinclients. They would be the key worker for the women,working alongside midwives (both community andacute) and supporting women to attend appointmentswith their general practitioner and obstetrician. Inaddition, women could request that the AMIC workerbe present during the birth. The AMIC workers wouldform part of the clinical care team involving medicaland midwifery professionals that would support thewomen from early in the pregnancy through to 6 weekspost natal.All Aboriginal women would be targeted for enrolmentin the AFBP, with priority given to those who were atrisk of poor birth outcomes (young women, womenliving in poverty and/or first pregnancy). Due to similarpoor outcomes being experienced by teenage pregnantnon-Aboriginal women in Whyalla, they were alsoincluded in the Whyalla-based program’s prioritytargets.The model outlined here became the basis for thecurrent AFBP that is successfully run in Port Augustaand Whyalla.Key success factorsA number of key success factors were identified asunderpinning the success of the AFBP. These werethe various relationships between AMIC workers andmidwives; among health services; and between healthservices and the community.In order to ensure the success of the program, the keycomponents of these relationships were considered inthe context of mindfulness theory. 2 Snyder and Lopez 2highlighted that, in order to build positive relationships,it is important to :> > seek to understand the other’s point of view> > give others the ‘benefit of the doubt,’ which couldalso be interpreted as developing trust> > accept and respect> > actively participate in the maintenance andenhancement of the relationship.A number of processes were developed to support theprogram by encompassing the key points of positiverelationships outlined by Synder 2 and Lopez, 2 and theseare discussed below.Relationship between AMIC workers and midwivesThe program recognised the need to build partnershipsbetween AMIC workers and midwives as this wouldensure that Aboriginal clients would be morecomfortable in accessing services. As outlined, mutualrespect and learning needed to be developed inareas where this did not already exist. This was partlyachieved through working closely together and havingshared goals for the client, but the main target was theachievement of mutual learning between AMIC workersand midwives. It was recognised that each group wascommitted to their clients and valued learning, but thateach group brought mutually exclusive and importantexpertise to the care of Aboriginal women—AMICworkers contributed cultural expertise and midwivescontributed clinical expertise.To further enhance the process of shared learning andfacilitate delegation of care between the workers, theAFBP project team, in conjunction with the AboriginalHealth Council of South Australia, developed anationally accredited Certificate IV in AboriginalMaternal and Infant Care, including three diploma levelmodules. Two AMIC workers have now completedthis training and a number of others are currently inthe process of gaining their qualification. Similarly, thedevelopment of a cultural learning program targeted atmidwives is nearing completion.Relationship among health servicesIn order to ensure a professional, seamless, qualityhealth service for pregnancy that meets Aboriginalwomen’s clinical, social and cultural needs, it wasrecognised that a strong relationship would be neededamong all the service providers, namely AMIC workers,midwives, Aboriginal health organisations and the localhospitals. As noted, mutual respect and shared goalsfor the client were important to these relationships, butexamination and modification of policies and processeswas also required to ensure that all staff involved in theproject could work across agencies without barriers.The management committee of the AFBP played a keyrole in identifying and addressing any barriers, and thecommittee was also a forum for the resolution of anyconflicts arising between stakeholders.Relationship between health services andthe communityThe AMIC workers play a vital role in the relationshipbetween health services and the community becausethey have both cultural and community knowledge,which are necessary for the success of the program.In addition, community engagement was undertakenduring the consultation phase of the program’spage 10

Rural health in the 21st centurydevelopment, and this contributed to communityownership and understanding of the program. TheAboriginal women’s advisory group’s role in thedevelopment of the AFBP cannot be underestimated,particularly with regard to the ongoing maintenance ofthe relationship with the community.Outcomes of the Aboriginal FamilyBirthing ProgramOver the first 4 years (2004–08) of implementation ofthe AFBP, 164 women were enrolled. Data collectedby the program staff for this period show that, of theenrolled women:> > 42% attended their first antenatal visit at less than14 weeks gestation> > 84% attended seven or more antenatal sessionsthroughout their pregnancy> > 14% delivered low-birthweight babies (statewideaverage is 18%)> > a reduction (albeit small) in smoking duringpregnancy was noted.Feedback from women enrolled in the AFBP indicatedthat, following participation, they:> > were more aware of their health> > were looking forward to the birth as apositive experience> > had improved confidence throughout thebirthing process> > felt more confident in accessing the health systemthroughout their pregnancy.Based on participant feedback, it was also notedthat there was an increase in breastfeeding followingenrollment in the AFBP.One teenage mum stated that:‘This program has really helped me understandwhat changes were happening to my body while Iwas pregnant. [The AMIC workers] supported methrough my pregnancy and also prepared me for mybirth. [AMIC workers] have also supported me aftermy daughter was born, to help me and the baby inthose first few weeks. If it wasn’t for this program Idon’t know what I would have done, but I am reallyenjoying being a mum now.’This young mum came back to the program with hersecond pregnancy and was again very happy with thesupport she received.Program extensionThe success of the AFBP, coupled with the availabilityof increased funding, has led to the program beingextended into other regional areas of SA that havebeen identified as having a high Aboriginal birth rateand an existing positive relationship between theAboriginal health service and other local health services.These communities are in Ceduna, Murray Bridge, LeighCreek, Copley and Coober Pedy.Future expansions of the AFBP will target otheridentified suitable areas pending funding availability.In line with the success factors highlighted in the initialstages of the project, the communities identified forestablishment of the program were consulted regardinghow it should operate in their area—for example,should staff be employed locally or through an outreachservice, and which organisation should employ thestaff? Locally based Aboriginal women’s advisory groupshave also been established to ensure that local culturalaspects are considered and community awarenessof the program is maximised. Local managementcommittees were established to oversee the programand to consider the relationships between agencies,including the examination of policy and processesto enable implementation of the model. Finally, staffwere provided with training to equip them with theknowledge and skills to take on the AFBP model.Although each site is slightly different due to the localenvironment and community resources, the modelof care is ultimately the same across localities, in thatAboriginal women are cared for by Aboriginal womenthroughout their pregnancy. Care is also provided in ateam environment that ensures that the clinical, socialand cultural needs of the women are met, which resultsin a holistic, seamless and safe service.In addition to expansion in rural and remote areas,the success of the AFBP model of care has alsobeen adapted to metropolitan Adelaide, with theChildren’s Youth and Women’s Health Service leadingdevelopment of the program.With regard to evaluation of the program, althoughdata collection has been a continual process, planningis underway for full evaluation across SA during 2012and 2013.Volume 8, Number 1, March 2011 page 11

Public Health BulletinConclusionThe AFBP has improved the birthing experiences ofAboriginal and teenage women through shifting theparadigm of service delivery in rural and remote SA.In summary, the success of the program hasillustrated that the development of good relationshipsbetween key stakeholders can enable the effectiveimplementation of an alternative model of care.Support structures such as local managementcommittees and Aboriginal women’s advisory groups, aswell as training for staff involved in the program, werealso paramount to its success. A service delivery modeldelivered by a skilled clinical team with common goalsfor Aboriginal women needs to underpin a culturallyand clinically safe model of care that has Aboriginalwomen being cared for by Aboriginal women. The endresult is a growing group of Aboriginal women who arestrong, confident mothers due to the care they havereceived through the AFBP.References1. Pregnancy Outcome Unit. Pregnancy Outcome ReportSouth Australia 2003. Department of Health, SouthAustralia, 2005.2. Snyder CR, Lopez SJ. Positive psychology: the scientificand practical explorations of human strengths. SagePublications, Thousand Oaks, California, 2007, pp.297–321.Farm injury fatalities: where are weand where to from here?Tony LowerDirectorAustralian Centre for Agricultural Health and SafetyUniversity of SydneyBackgroundFarming is internationally regarded as a high-riskindustry for injury and fatalities. 1 However, in terms ofthe rates of occupation-related fatalities in Australia, 2the agricultural sector (10.4/100000 employees) ranksonly third to forestry/logging (61.8/100000 employees)and road freight transport (37.6/100000 employees).The Australian Centre for Agricultural Health andSafety (ACAHS) houses the National Farm Injury DataCentre, which draws on fatality data from the NationalCoroners Information System. While the methods usedfor data extraction and quality control are reportedelsewhere, 3 the data indicate that on-farm nonintentionaldeaths have reduced from 587 during theperiod 1989–92 (mean 146 per year) to 353 (mean 88per year) in 2001–04. Furthermore, if assessed on thebasis of annual deaths per 100000 employees, therates dropped from 23.3/100000 in 1989–92 to14.0/100000 in the second period. A similar reductionis also apparent when assessed by annual deaths per10000 agricultural enterprises—from 9.1/10000 farmsto 7.0/10000 farms. 4Despite these significant improvements over the past15 years, agriculture remains a high-risk industryand lags behind progress in other primary industriessuch as mining and construction. This disparity islikely a function of the fact that over 90% of farmingoperations are family owned and operated; hence,institutionalising occupational health and safetypractices is more complex and challenging than in largecorporate enterprises, where significant investmentshave been made to improve health and safety overseveral decades.Agents of fatal injuriesFor the period 2001–04 the four leading causes ofon-farm fatalities, making up almost 48% of all deaths,were tractors (n = 76), quad bikes (n = 51), farm utilities(n = 21) and dams (n = 20). 4 In South Australia theleading causes of the 22 fatalities in this same periodwere tractors (n = 3), farm utilities (n = 3), quad bikes(n = 2), motorbikes (n = 2) and dams (n = 2).page 12

Rural health in the 21st centuryReducing farm fatalitiesFor each of the four main agents of death identifiednationally, there are existing evidence-based, wellknownand practical solutions that can significantlyameliorate the burden of farm deaths. Consequently,the adoption of these solutions will be key to drivingfurther safety improvements in the sector.TractorsApproximately 50% of tractor-related fatalities involverollovers. 4 However, there is strong evidence for theefficacy of rollover protection structures (ROPS) onnew tractors in reducing the number of fatalities. 1Additionally, other international and Australian datasupport the retro-fitment of ROPS to older tractors. 5–7Despite the clear safety advantage of this engineeringsolution, a considerable number of tractors withoutROPS remain in use.Run-overs are the other principle mechanism of tractorrelateddeaths. These can be reasonably expected toincrease as a proportion of all tractor deaths as moreROPS-fitted tractors are purchased in the sector. Toaddress this issue, another engineering solution is toretrofit tractors with safe access steps that have beendeveloped to reduce the risk of serious injuries anddeaths associated with mounting and dismounting. 8There is some evidence to support the use of thisapproach in reducing fatalities from tractor run-overs. 9Quad bikesBoth the use of quad bikes on Australian farms and therelated fatalities have increased rapidly in the past 15years. Safety agencies and manufacturers recommendthat adult-size quad bikes should not be used bychildren under 16 years of age, no passengers shouldbe carried and helmets should be worn by riders.Deaths due to crush or asphyxiation from quad bikerollovers accounted for 47% of the 119 cases during2001–09 where adequate information was availableto define the nature of the incident. 10 There has beensignificant long-term debate about the efficacy ofsystems to protect the rider in the event of a quad bikerollover. Recent reviews of the engineering evidencesuggest that fitment of such devices has the potentialto be beneficial. 11–13 Additionally, the use of suitablehelmets can potentially reduce deaths from headinjuries where riders are thrown from the machine butnot crushed. 14Farm utilitiesTypically, farm utility fatalities result from passengersbeing unrestrained in the cab or riding in the backtray of a ute. It is now illegal to ride in the trays ofutes on public roads in all states of Australia. Whilefarms are not covered under these laws (becausethey are on private property), this practice is notrecommended based on the available data. 15 Globally,the protective advantages of seatbelts for both driversand passengers are well recognised and supported bystrong evidence. 16,17 Therefore, adoption of this simplebehavioural practice will have important preventiveoutcomes.DamsThe majority (over 80%) of drowning deaths in farmdams are of children under 5 years of age, with onethirdbeing visitors to the property. 4 A review of theevidence to prevent drowning on farms indicated thatthe essential approaches are having a safe and secureplay area that provides a barrier between the hazard(the dam or water body) and the child and havingactive supervision. 18 In essence, this works in the samemanner as a swimming pool fence does—however,instead of keeping small children out of an area, itkeeps them within a safe area and separates themfrom hazards in the farm environment such as dams,workshops, moving vehicles and stock. This approachhas been instigated nationally and has illustratedpositive results, 19 and is also supported by the mostrecent review examining the effectiveness of poolfencing. 20Current adoption of solutions inSouth AustraliaA recent study undertaken by ACAHS and theAustralian Bureau of Agricultural and ResearchEconomics–Bureau of Rural Science surveyed 683randomly selected agricultural enterprises acrossAustralia with an estimated value of agricultural outputgreater than $40000. The study examined a rangeof factors including controls for hazard managementin relation to the four leading agents associated withfatal injuries. 21 The South Australian sample consistedof 81 farms, and the results for adoption of solutionscompared with the Australian averages are listed inTable 1.Volume 8, Number 1, March 2011 page 13

Public Health BulletinTable 1: Comparison of hazard controls—South Australian and national dataSolutions South Australia AustraliaTractors witha ROPSFarms withall tractorshaving aROPSUse ofseatbelts infarm vehiclesSecurelyfenced &gated houseyard or safeplay areaUse ofhelmets onquad bikesNotwithstanding the limits to this assessment, includingsample size and representativeness, these data suggestthat the rate of adoption of evidence-based solutionsfor the four leading agents of death are relativelysimilar in South Australia when compared with thenational data. One obvious anomaly appears to be thesignificantly lower rate of seatbelt use when travellingon-farm in vehicles in South Australia compared withthe Australian sample.Although there is a statistically higher rate ofcompliance for presence of safe play areas for youngchildren, approximately 30% of farms do not have asecured area. There are 7% of tractors without a ROPS,with over 20% of South Australian enterprises in thissample having at least one tractor without a ROPS.Additionally, fewer than half of all individuals riding aquad bike reported using a helmet.Where to from here?% (95% CI) % (95% CI)92.8 (89.2–96.3) 90.4 (87.7–93.1)79.1 (67.9–90.3) 78.7 (72.7–84.6)13.9 (8.3–19.5) 36.8 (31.7–41.7) **69.3 (57.2–81.5) ** 48.3 (42.8–53.9)42.0 (23.3–60.7) 45.0 (38.6–51.4)** Significant variation based on 95% confidence intervals.There remain significant gaps in the adoption ofevidence-based solutions, placing those working andliving on farms at increased risk of injury and death.The farm environment is somewhat unique in thatthe lines between home and work are frequentlyblurred, exposing not only those working on the farmto hazards but also those that live on and visit theproperty.Primary producers are well acquainted with drawingon research and evidence to improve their productionsystems (e.g. new crops, crop rotations). Continuedefforts to work with farmer associations and growergroups are required to ensure that health and safetyevidence is supported by them and used in a similarway to improve safety practice. Indeed, this elementof industry ownership and leadership has beenidentified as a key principle to achieve farm safetychange. 7 Practical solutions to reduce the risks fromthe major agents of farm fatalities already exist (Table2)—the challenge remains to ensure their adoption incollaboration with industry leaders.Table 2: Evidence-based solutions to commonhigh-risk hazardsHazardTractors — rolloverSolution(s)Tractor rollover protection1, 5–7structures (ROPS)Tractors — run-over Safe access steps 8,9Quad bikesQuad bike rolloverprotection devices1 1–13Helmets 14Farm utilities Seatbelt use 16,17Farm dams Safe play areas 18-20References1. Rautiainen R, Lehtola M, Day L, Schonstein E, SuutarinenJ, Salminen S et al. Interventions for preventing injuriesin the agricultural industry. Cochrane Database ofSystematic Reviews 2008, Issue 1, art. no. CD006398.DOI: 10.1002/14651858.CD006398.pub22. Safe Work Australia. Work-related traumatic injuryfatalities, Australia 2006–07. Commonwealth ofAustralia, Canberra, 2009.3. Franklin R, Mitchell R, Driscoll T, Fragar L. Farm-relatedfatalities in Australia, 1989–92. Australian Centre forAgricultural Health and Safety and Rural IndustriesResearch and Development Corporation, Moree, NSW,2000.4. Fragar L, Pollock K, Morton, C. The changing profile ofAustralian farm injury deaths. J Occup Health Safety AustNZ 2008; 24(5):425–433.5. Springfeldt S. Rollover of tractors: internationalexperiences. Safety Sci 1996; 24(2):95–110.6. Day L, Rechnitzer G, Lough J. An Australian experiencewith tractor rollover protective structure rebate programs:process, impact and outcome evaluation. Accid Anal Prev2004; 36(5):861–867.page 14

Rural health in the 21st century7. Fragar L, Lower T, Temperley J. Adoption of healthand safety change on Australian farms and fishingenterprises: for industry, governments, service providersand other stakeholders. Rural Industries Research andDevelopment Corporation, Kingston, ACT, 2010.8. Davidson A. National tractor safety project final report.Australian Agricultural Health Unit, Moree, NSW, 1995.9. Day L, Rechnitzer G. Safe tractor access platforms: fromguidance material to implementation. J Agric Saf Health2004; 10(3):197–209.10. Lower T, Fragar L, Herde E. Quad bike rollover deaths inAustralia (2001–09). Brief report prepared for the Trans-Tasman Quad Bike (Engineering) Group, 5–6 October,2010.11. Zellner J et al. An assessment of the effects of theRobertson V-Bar ROPS on the risk of rider injury due tooverturns resulting from ATV misuse. Dynamic ResearchInc., July 2007. (Cited in Australian ATV distributorsposition paper, January 2010).12. McDonald G. Critique of quad bike rollover simulationand evaluation of protective structures. DynamicResearch Inc., November 2010.13. Lambert J. Quad bike computer simulation report (reviewof work by DRI–2nd draft). November 2010.14. Liu B, Ivers R, Norton R, Boufous S, Blows S, Lo S.Helmets for preventing injury in motorcycle riders.Cochrane Database of Systematic Reviews 2008, Issue 1,art. no. CD004333. DOI: 10.1002/14651858.CD004333.pub3.15. Morton C, Fragar L, Pollock K. Vehicle injury associatedwith Australian agriculture: the facts. Australian Centrefor Agricultural Health and Safety, Moree, NSW, 2008.16. Global status report on road safety: time for action.World Health Organization, Geneva, 2009. www.who.int/violence_injury_prevention/road_safety_status/200917. Viano D, Parenteau C. Injury risks in frontal crashes bydelta V and body region with focus on head injuries inlow-speed collisions. Traffic Inj Prev 2010; 11(4):382–390.18. Fragar L, Gibson C, Henderson A, Franklin R. Farmsafefarms for kids: evidence-based solutions for child injuryon Australian farms. Australian Centre for AgriculturalHealth & Safety, Moree, NSW, 2003.19. Depczynski J, Fragar L, Hawkins A, Stiller L. Safe playareas for prevention of young children drowning in farmdams. Aust J Early Childhood 2009; 34(3):50–57.20. Thompson D, Rivara F. Pool fencing for preventingdrowning of children. Cochrane Database of SystematicReviews 1998, Issue 1, art. no. CD001047. DOI:10.1002/14651858.CD001047.21. Lower T, Fragar L, Temperley J. Australian farmsafety baseline survey. Rural Industries Research andDevelopment Corporation, Kingston, ACT, 2010.Resilience in farm families:a constructivist perspectiveDebra KingSenior Research FellowNational institute of Labour StudiesFlinders UniversityAnna LaneResearch AssistantNational institute of Labour StudiesFlinders UniversityColin MacDougallAssociate ProfessorPublic HealthFlinders UniversityJennene GreenhillDirectorRural Clinical SchoolFlinders UniversityIntroductionThe resilience and mental health and wellbeing offarm families experiencing climate variation in SouthAustralia (SA) during the 2006–09 drought washighlighted in research funded through SA Health’sStrategic Health Research Program. 1 We took asalutogenic approach to resilience, exploring howhealth is created in a positive way. We therefore soughtto understand the contextual, social and personalfactors that shaped how participants sustained healthand wellbeing even when facing adversity. The researchdemonstrated that, in achieving the positive outcomeof ‘getting by’ in the domains of livelihood and mentalhealth and wellbeing during drought, farm men andwomen exhibited a stance that informed the way inwhich they negotiated with their personal, social andenvironmental contexts to use particular resourcesand strategies.Mental health and resilience infarm familiesSouth Australia has the highest rate of suicide (14.8per 100000 people in 2000–05) among all themainland states. 2 The rate increases for each categoryof remoteness, with men having higher rates ofsuicide than women. In relation to farm families,studies indicate that the rate of farm male suicide ishigher than that of the non-farm rural populationVolume 8, Number 1, March 2011 page 15

Public Health Bulletinand of the male population more generally. 3,4 Forexample, between 1997 and 2001 in SA, farm menwere approximately 40% more likely than non-farmrural men to commit suicide. 4 Although these statisticsappear alarming, it is important to bear in mind thatthe ‘vast majority of farmers do not commit, norconsider committing, suicide’. 5 However, once farmersdo consider suicide, the pathway seems to be shorterand more intense than for other groups, with morelethal consequences. 5These statistics are serious. Being in a droughtsignificantly increases the likelihood of mental healthproblems for farmers and farm managers. 6–8 Currentresearch highlights the complexity of assessing theimpact of drought on farm families and the relationshipbetween the financial, social and personal impacts.In particular, it demonstrates the importance ofunderstanding the context within which farm familiesexperience drought and that these experiencesdiffer across regions, generations, and farm typesand viabilities.That farm families are deeply affected by drought isnot in question; our research sought to understandthe resilience of farm families rather than their distress.There are many approaches to resilience. In thisresearch resilience was defined as a process wherebyindividuals display positive adaptation behaviour despiteexperiences of significant adversity. 9 We adopted aconstructivist model of resilience as process, 10 whichcontrasts with the more deductive approaches thatattempt to demonstrate clear pathways between causeand effect. In defining resilience as a process ratherthan an outcome or personality trait, we did not viewindividuals as ‘being resilient.’ Instead, resilience wasunderstood as relating to the processes that farm menand women used to achieve a positive outcome (i.e.getting by) in two life domains—livelihood, and mentalhealth and wellbeing.The researchThe constructivist model of resilience as a processunderstands resilience as constructed by the interplayof complex and contextually specific processes.These processes may be individual but also socialand economic. In operationalising the research, weconducted two waves of interviews, 12 monthsapart, with farm families in four regions: Central EyrePeninsula, Lower Lakes and River Murray Corridor, MidNorth, and Upper South East. Of the original 80 farmfamilies (148 participants), 75 families (132 participants)participated in the second wave of interviews.Approximately 48% were women; the mean age ofthe female participants was 47 years and the maleparticipants 50 years; and nearly all participants wereborn in Australia. Participants completed the GeneralHealth Questionnaire–12-item version (GHQ12) andsubjective measures of general and physical health inboth waves, and a broader demographic questionnairein wave one. The GHQ12 is a recognised mental healthmeasure. Scores ranging from 0 to 15 reflect normalfunctioning, from 16 to 20 evidence of distress, andabove 20 severe psychological distress. Additional datawere collected from rural service providers throughholding six focus group consultations in the regions,with policy implications being discussed at a workshopwith selected government and non-governmentagencies in 2009. The interviews and focus groupswere conducted in 2008–09. We drew conclusionsabout social capital by analysing data about individualsand communities and looking for social capital buildingblocks such as trust and reciprocity. 11Resilience as processOur sample comprised participants who had selfselectedon the basis that they were ‘getting by’ duringdrought. It included people who had a diagnosedmental illness and those who were considering leavingfarm life. The resilience of farm families was thereforenot about the absence of psychological distress, butabout how such distress was managed; nor was itabout the capacity to stay on farm, but about thecapacity of farm families to maintain a source oflivelihood.Over the 12-month period between the twointerviews, an increased number of participants ratedthemselves as having fair to poor general health,although the proportion was similar to that of theAustralian population at that time. 12 However, therewere differences between regions and age groups. Incontrast, the mental health of participants improvedover this time, with the proportion scoring >15 in theGHQ12 decreasing from 20.2% in 2008 to 15.2% in2009. Older participants (over 60 years of age) had thehighest rates of distress and the least recovery fromstress over time.Information was sought as to the participants’ capacityto get by (emotionally and financially) over time—47.2% indicated that their capacity had increased inthe 12 months since the first interview, with a further32.8% staying the same. Two main reasons were givenpage 16

Rural health in the 21st centuryfor this outcome. On a personal level, participantsdiscussed finding useful strategies for dealing withstress and realising that, having been through somuch, their threshold was higher than they thought.On a business level, participants discussed the waysin which their drought-related business strategies hadworked out, and that they were now more familiarwith the situation and had greater confidence in theirbusiness decision-making. To understand how farmfamilies managed to not only get by during droughtbut to improve their capacity to get by, we developeda conceptual framework of resilience as a process inwhich three elements were critical: stance, context andprocesses (resources and strategies).StanceA stance is reflective of a person’s identity, sociallocation and social roles, and is the position that isassumed when making decisions, non-decisions andtaking action. We identified four aspects of participants’stances that influenced their approach to getting by: acommitment to farming as a business lifestyle, having apositive sense of self, having contingent optimism, andengaging in active decision-making.The stances of farm men and farm women weredifferent. While that of farm men was strongly relatedto their primary role in the farm business, the stanceof farm women was more diverse. Depending on theirlevel of involvement in the farm business, their familyresponsibilities and their off-farm roles, it was evidentthat family relationships strongly influenced women’sdecisions and actions. Farm women and farm menhad different bases of power that influenced how theypositioned both themselves and each other within thefarm family.Although a stance is relatively stable, it was apparentfrom the interviews that participants constructed andreconstructed it as circumstances changed. There wereseveral ‘key events’ that could alter a stance, including:moving on-farm, taking off-farm work (or moving offfarm),intergenerational transitions, having children andfinancial pressure. This fluidity in a stance means that itis likely that aspects of it can be learned, and a stancecan be shaped to enhance an individual’s capacityto successfully negotiate with their environment forresources and strategies that could help them get byduring adversity.ContextContext was the second of the three elements ofresilience identified in this project. Three spheres ofinfluence directly or indirectly affected the wellbeingof farm families as they dealt with drought. The microsphere of the farm and family was important on aday-to-day basis as they worked through competingdemands on their time and their financial, emotionaland relational resources. The meso sphere comprisedthe geographical region in which the farm family waslocated. Within the region the environment, communityand industry provided opportunities and constraints forengaging in resilience processes. Regional differenceswere evident among the four areas selected for thisresearch and, in some areas, intra-regional differenceswere also noted. Differences were especially noticeablein levels of social capital in both communitiesand agricultural industries. The macro sphere ofgovernment, the economy and society were particularlyinfluential on the livelihood of farm families. Serviceprovision and social norms, which cross macro andmeso spheres and attitudes, were also important.The three spheres of influence were embedded in oneanother and inherently linked. Changes in one spherecould trigger changes in another. For example, changesin the global financial sector influenced the profitabilityof regional industries and businesses, services andemployment. This, in turn, affected the farm family’sability to secure off-farm work or draw on investmentincome, while also impacting on their profit marginby raising the cost of inputs. However, the changeswere not all one way, with changes in the farm family(e.g. decreased involvement in community activities)also influencing levels of social capital and/or serviceprovision, especially in smaller communities where thewithdrawal of relatively few volunteers can make a bigdifference to the sustainability of community services.While such ‘bottom-up’ changes would have only aminor impact at an individual level, when undertakenen-masse in response to widespread drought-relatedfinancial stress, the impact on elements of the mesoand macro spheres would be significant.Resources and strategiesFarm families used a range of resilience resourcesand strategies to help get by during the drought. Inthe mental health and wellbeing domain, strategiesassociated with the development and maintenanceof social capital and significant relationships wereidentified as being important, as was the ability toVolume 8, Number 1, March 2011 page 17

Public Health Bulletindisengage from the farm business and place theirsituation in perspective. Most participants hadstrategies for managing their physical and mentalhealth, with 74% having regular check-ups with aprimary healthcare provider. Women identified a lack ofrecognition of their role in mental health maintenance,with several women suggesting that the focus on men’shealth made their own issues invisible and difficult todiscuss openly. However, both men and women in thestudy had good levels of awareness about the resourcesavailable for health maintenance. While women oftentook the primary role in monitoring family health andorganising services if required, men were also activeparticipants, using strategies such as checking onfriends they thought might be at risk, going along toinformation sessions, incorporating exercise into theirdaily program, and eating healthily.In the livelihood domain, participants used a rangeof strategies to sustain their income and minimisetheir expenses. Their preparedness for droughtwas important, as was their confidence as businessmanagers. The availability of options, particularly inrelation to work, also provided farm families with asense of security and a ‘fallback’ position when theywere under financial pressure.Implications for policyResilience, as with health, is affected by social,economic, political, environmental and culturaldeterminants. 13 In this research we identifieddeterminants that were specifically mentioned byparticipants as being relevant to the ways in which theyengaged in resilience processes during the drought.In the consultations about policy and service provisionit was suggested that enhancing resilience requiresa systemic across-government approach thatfocuses on health maintenance rather than illnessprevention or treatment. This requires recognisingthe social contexts—the family, business (industry)and community—within which people negotiate forthe appropriate resources to achieve wellbeing, andpresents challenges to the current ways of thinkingabout mental health, wellbeing and resilience.It is worth noting some of the main points made byservice providers and policy practitioners. Enhancingresilience among farm families would requirecoordination between four policy areas: health,families and communities, regional development andagriculture, and climate change. Across and withinthese areas, workshop participants indicated a need for:> > Continuity of services at a base level outside adverseevents to reduce the lag and reliance on crisis-drivenresponses. Service providers and policy practitionerswere critical of the ‘crisis’ model of service deliveryin which communities were inundated with servicesduring a crisis, only to have them withdrawn whenthe crisis was perceived to be over. Instead, theyargued that a salutogenic approach to communitydevelopment and rural health required the provisionof a better base-level of continuous services in ruralcommunities. This would help to create resiliencein community structures, providing a buffer andresource for individuals against adversity.> > Community capacity building, including leadershipdevelopment in rural communities, which can, inturn, increase social capital. For example, enhancingcommunity resilience through developing socialinfrastructure and strengthening social capital,including finding mechanisms for generatingcollective optimism, will, in turn, increase therelevance and effectiveness of services provided toindividuals.> > A gendered approach to policy to ensure thatservices are able to meet both the common anddistinctive needs of rural men and women.> > Greater acknowledgment of the contribution of farmfamilies to the community and to agricultural andnon-agricultural industries.> > Improving service delivery, shifting it toward astrengths-based, client-centred model with bettercoordination and integration. It was recognised thatservice providers would need capacity building tomake this transition effectively> > Creating opportunities for learning and employmentfor farm familiesThis project was funded on the basis that resilienceresearch might well hold the keys to better preventivepolicies and services. The strengths-based, processfocusedapproach used in our research opened upopportunities for shifting the discussion about mentalhealth and wellbeing to one that acknowledges thepersonal, social and environmental contexts withinwhich farm families achieve wellbeing, even whenfacing adversity.page 18

Rural health in the 21st centuryReferences1. King D, Lane A, MacDougall C, Greenhill J. The resilienceand mental health and wellbeing of farm familiesexperiencing climate variation in South Australia. SAHealth, Adelaide, 2009. http://nils.flinders.edu.au/publications.php?pid=12548786822. Australian Government Department of Health andAgeing. Living Is For Everyone (LIFE) Framework: researchand evidence in suicide prevention. Commonwealth ofAustralia, Canberra, 2008.3. Judd F, Cooper A-M, Fraser C, Davis J. Rural suicide:people or place effects? Aust and N Z J Psychiatry 2006;40:208–216.4. Miller K, Burns C. Suicides on farms in South Australia,1997–2001. Aust J Rural Health 2008; 16:327–331.5. Judd F, Jackson H, Fraser C, Murray G, Robins G, KomitiA. Understanding suicide in Australian farmers. SocPsychiatry Psychiatr Epidemiol 2006; 41:1–10.6. Edwards B, Gray M, Hunter B. Impact of drought onmental health and alcohol use. Unpublished paperpresented at the Social Policy and Research CentreConference, Sydney, July 2009.7. Gunn K. 2008. Farmers’ stress and coping in a time ofdrought. Unpublished Honours thesis, The University ofAdelaide, South Australia.8. Stehlik D, Gray I, Lawrence G. Drought in the 1990s:Australian farm families' experiences. Rural Social andEconomic Research Centre, Queensland, and Centre forRural Social Research, New South Wales, 1999.9. Luthar SS, Cicchetti D. The construct of resilience:implications for interventions and social policies. DevPsychopathol 2000; 12:857–885.10. Ungar M. A constructionist discourse on resilience:multiple contexts, multiple realities among at-risk childrenand youth. Youth Society 2004; 35:341–365.11. Ziersch A, Baum F, MacDougall C, Putland C.Neighbourhood life and social capital: the implications forhealth. Soc Sci Med 2005; 60:71–88.12. South Australia Department of Health. South Australia:our health and health services. South AustralianGovernment, Adelaide, 2008.13. Keleher H, McDougall C. Understanding the determinantsof health. Pp. 41–58 in H Keleher and C MacDougall(eds), ‘Understanding health: a determinants approach’.Oxford University Press, Melbourne, 2009.Regional migrant settlement:a health lens projectAmy SawfordProject Officer, Health in All PoliciesSA HealthDeborah WildgooseSenior Project Officer, Health in All PoliciesSA HealthTyson MillerPolicy Officer, Population and Migration PolicyDepartment of Trade and Economic DevelopmentIntroductionRegional South Australia (SA) faces the challenges oflow population growth (particularly in comparisonto the state average), a rapidly ageing populationand young South Australians leaving their localareas to pursue career paths in Adelaide, interstateand overseas. A key role for the South AustralianGovernment is to promote population growth inthe regions of the state through overseas migrationprograms. 1 The Australian Government has supportedthe state’s desire for population growth throughmigration by developing policies promoting statespecificand regional migration. 2 As a result, migrationto SA, particularly into regional areas, has increasedsignificantly in recent years, with a particular focus onskilled migration to counter persistent skill shortages.Migration provides a significant contribution to theeconomic growth, prosperity and cultural diversity ofSA. However, as both the literature and the findingsof this project reflect, many migrants face challengesduring settlement. These may include languagebarriers, cultural differences, unfamiliarity with how toengage with and access the Australian service system,and the loss of familiar support structures. 3 Thesechallenges can be described as ‘settlement needs’. Inany given location, the level and type of settlementneeds encountered by new arrivals are based on arange of factors, including overall numbers of arrivals;the characteristics, specific needs and pre-arrivalexperiences of those arrivals; the capacity of localservices to respond to those needs; the amount offamily or community support available on arrival; andcommunity attitudes.There are many benefits associated with living inregional and rural areas, including the strong sense ofVolume 8, Number 1, March 2011 page 19

Public Health Bulletincommunity often found, resulting in better communitycohesion and personal resilience. In their 2001 study,Onyx and Bullen found that “social capital wasgenerally higher in the rural communities… comparedwith the urban centres, particularly in relation tocommunity connections, feelings of trust and safetyand neighbourhood ties”. 4 However, in some cases, thechallenges faced by migrants can often be magnifiedin regional and rural areas because of languagedifficulties, cultural or religious differences, limitedaccess to extended family or cultural networks anddifficulties in navigating or accessing potential supportsand services (i.e. health services, Centrelink, trainingopportunities). In addition, differing community andmigrant expectations of what the settlement experiencewill be like, verses the reality of settlement.It is critical that future policies, programs and servicesare effective in meeting the challenges of migration inorder to continue to attract and retain migrants inthese areas.Collaborative health lens projectIn order to more fully understand the range ofchallenges faced by migrants and the potentialmechanisms for addressing these challenges, theDepartment of Trade and Economic Development(DTED), the Department of Health (DH) andMulticultural SA undertook a collaborative Health in AllPolicies (HiAP) ‘health lens analysis’ project.The health lens analysis is part of the broader HiAPapproach, a primary recommendation of 2007 AdelaideThinker in Residence Professor Ilona Kickbusch, whichwas adopted by the South Australian Government in2008. A health lens is a collaborative process betweenSA Health and other government agencies thatassesses and analyses the links between health andwellbeing and the partner agencies’ policy areas. Itaims to identify opportunities to optimise the partneragencies’ (in this case DTED and Multicultural SA) goalsin a way that supports improved population healthand wellbeing. Both of these outcomes are equallyimportant, and HiAP aims for outcomes that aremutually beneficial.The aim of the Regional Migrant Settlement HealthLens Project (the project) was to develop a deeperunderstanding of the relationship between settlementand health and wellbeing for migrants in regional areasof SA. Applying a health lens to settlement services,programs and processes helped identify the complexinterplay between the social, economic and healthfactors impacting on migrant settlement and theassociated health outcomes.The project comprised three stages.Stage 1—Project Development—explored thegeneral issues of migrant settlement through aliterature scan and development of a MigrantSettlement Wellbeing Framework. The findings fromthis stage suggested that the four key areas forsuccessful settlement are:> > employment> > social support> > access to services> > English language proficiency.Stage 2—Preliminary Investigation—includedbaseline data collection (including location data), thedevelopment of settlement pathways for both skilledand humanitarian migrants, and the development ofdetailed profiles of two regional areas of SA—Whyallaand the Limestone Coast.Developing a clear picture of the current location ofrecently arrived migrants was challenging. While datais collected by a number of agencies for a varietyof administrative purposes, there is no requirementby any agency to provide a picture of either initialsettlement location or movement of either skilled orhumanitarian migrants to support policy-making andservice planning decisions. However, the Departmentof Education and Children’s Services (DECS) collectscountry-of-origin data for public school students. Aspatial mapping exercise was undertaken by researchersfrom the University of Adelaide using DECS data, andwas supplemented by data from the Australian Bureauof Statistics (ABS) to identify the clustering of migrantpopulations across SA.The DECS data provided a picture of the location ofmigrants but only captured migrants in family units;however, in the South Australian context this is stilla significant proportion of recently arrived migrants.Census data from 2006 supplemented the DECSenrolment data to provide a more comprehensivepicture. This information was then used to inform theselection of regions on which to focus the remainder ofthe project.Workshops were undertaken with service providers inboth of the chosen regions. The outcomes providedpage 20

Rural health in the 21st centurythe service providers with an overview of the projectand identified what they perceived as the key issuesimpacting on migrants. Their assistance was thensought in shaping the approach that would beincorporated into stage 3 of the project.The preliminary investigation stage suggested thatin-depth qualitative research needed to be conductedto form a more comprehensive and complete pictureof migrant settlement that could inform policyrecommendations.Stage 3—Regional Research—consisted of undertakingqualitative research with community members,employers and recently arrived migrants (primarilyin the previous 5 years). A total of 111 migrants,community members and employers from Whyallaand the Limestone Coast each participated in eightfocus groups and three interviews. This stage of theproject built on earlier findings to explore more-specificinteraction between migrant settlement experiencesand outcomes and health/wellbeing in regional SA.Migrant groups represented in the research were:> > skilled migrants—Indian, Fijian-Indian, Fijian,Zimbabwean, South African, Dutch, French, Eritrean,Sudanese and Pakistani> > humanitarian migrants—Burmese.Key project findingsWhile settlement experiences varied (Table 1), migrantscommonly faced a challenging period in the first 3–6months following arrival. Many participants reportedsettling well after overcoming the initial hurdles offinding jobs, adequate housing and social support.Some participants found the settlement processuneasy due to communication and social engagementdifficulties, and lack of access to services and toeducation and training opportunities.Most participants intended or hoped to stay in SA andindicated strong commitment to their local area. Incases where participants planned to move elsewhere,it was predominantly within Australia, and theprimary reasons given were the need to find suitableemployment or to access further education and trainingfor themselves or their family. Factors such as lifestyleand cheaper living costs were important in people’slonger term commitment to regional SA.Overall, migrants, employers and community memberspresented a largely positive picture of migrants’integration into regional communities. Nonetheless,participants from all three perspectives agreed thatthere were ‘pockets’ of negativity and discrimination.Migrants and community members felt that localcommunities had improved over time in their opennessto new migrants, and also acknowledged that it tooktime for new migrants to settle and integrate.Both community members and employers noted thatmigrants contributed positively to local communities.They felt that greater cultural diversity was afundamental contribution that had become part of thelocal identity, especially in Whyalla and Bordertown.Another common contribution from migrants,according to community members and employers, wasfilling crucial employment roles and financially investingin regional and rural towns.Table 1: Key settlement facilitators and barriersSettlement facilitatorsSocial supportEmployment opportunitiesSupport from other servicesLifestyleSettlement barriersLack of Englishlanguage skillsNegative employmentexperiencesLack of access to interpretersBureaucratic red tapeProblems accessing servicesSocial isolationUnmet expectationsEffects of settlement on migrantwellbeingHumanitarian migrants in particular, experiencedimproved wellbeing as a result of relocation to a placewhere they did not fear for their safety or that of theirfamilies.In contrast, other participants experienced difficultsettlement circumstances that had adverse impact ontheir mental health and wellbeing. For instance, onerecent skilled migrant commented that the experienceof being unable to find suitable employment diminishedtheir self-esteem. Another participant, whose partner(a skilled migrant) had experienced difficulties withtheir sponsoring employer, reported that their partnerwas experiencing depression linked to their workproblems. Several other participants spoke about theirown experiences of depression and hardship when theyfirst arrived. For many migrants these problems hadVolume 8, Number 1, March 2011 page 21

Public Health Bulletinlessened over time as they became more settled andfinancial problems eased.Migrants in several focus groups talked about a gapbetween their pre-arrival expectations and the reality ofthe new location, which impacted on their wellbeingin the initial settlement period. Participants felt thatthere were issues with representatives from Australiangovernment agencies (both state and federal) oremployers giving unrealistic information before theyarrived, especially about job opportunities.Another participant said that she would have delayedher migration to Australia by at least a year if she hadknown beforehand how hard it was going to be. Shefelt her settlement experience would have been betterif she had stayed longer in her home country to savemore money, as her initial period in SA was marked bysubstantial financial hardship and difficulties in findingwork.DiscussionThe project identified regional variability in theapproach to settlement, based on numbers of migrantsand visa streams. The different approaches werepartly driven by the government funding provided fordifferent visa classes. In addition, while one region hadbeen involved with intensive migrant support for a fewyears, another location, although having a significanthistory of migration, had only recently implemented acoordinated approach. However, all the approaches hada common desire to reduce the difficulties experiencedby migrants as they settle in a particular location. Theproject found that the approaches could be enhancedby strategies that help migrants become part of acommunity while also meeting their individual needswhen they arrive, regardless of their visa class.The project provided a unique opportunity for theagencies involved to obtain, first-hand, current androbust qualitative research through the focus groupand interview process. The existing relationship of theservice providers and community leaders with DTED andMulticultural SA through regional networks was integralto the success of the project, and played a pivotal rolein allowing the researchers access to the communitymembers and migrant groups.Direct engagement with migrants, employers andcommunity groups through the research enabled adifferent and richer perspective of the impact of existingpolicies. It highlighted the differences between thestate government agencies’ perspectives of prioritiesand the regional priorities. For example, supporting thedevelopment of a reasonable level of English proficiencyin the spouses of skilled migrants and humanitarianmigrants was recognised as a key issue at a regionallevel by all three groups.The important role of members of the local communitybecame evident throughout the process, particularly inrelation to supporting the integration of newly arrivedmigrants into the community. Regional communitiesin SA have historically been built on the migration ofpeople from overseas, and are proud of the mutuallyinclusive role that migration has had with the futureprospects and growth of their towns.Community members included in the focus groupresearch expressed empathy towards the new arrivalsand sought to support them where they could.However, they also felt that they, as the community,required support to be able to meet the needs of themigrants.Additionally, direct involvement of agency staff (DTEDand DH) in the research was particularly valuable asit provided them with a deeper understanding of theissues raised by the participants and of the researchprocess, which in turn helped with development of therecommendations.The recent trend of population movement has beenaway from regions to other states and metropolitanareas. This has resulted in some significant challenges:> > Population decline makes it difficult to attract andretain rural and remote populations.> > The sustainability of small rural and remote localgovernments becomes uncertain and impactsnegatively on service delivery.> > Economic restructuring and industry adjustment ismore difficult without access to people with thenecessary or desired skills.Positive settlement of new waves of migrants istherefore important in assisting regional communities toattract and retain population, which helps them meettheir economic, social and environmental goals.Key outcomesA key outcome of this project was a series ofpolicy recommendations for each of the agenciesinvolved, which have been signed off by the ChiefExecutives of DTED, DH and Multicultural SA. Theserecommendations will inform future decisions by DTEDpage 22

Rural health in the 21st centuryand potentially other government departments on waysto improve policies and programs in order to achievepositive settlement outcomes for migrants and theregional communities that they settle in.Importantly, the process of developing therecommendations drew strongly on the outcomes ofthe research—paying particular attention to the directmessages from the migrants, community members andservice providers.Recommendations which related to the broadcategories of settlement identified previously include:> > Employment: Exploring ways to improve training andfurther education opportunities for migrants.> > Access to services: Improving awareness ofinterpreting and translating services, particularly inthe health portfolio.> > English Language Proficiency: Exploring opportunitiesfor improved English language learning of migrants.> > Social Support: Increasing community awareness ofthe value of migration in regional areas.An evaluation of this project has been undertaken byresearchers from the South Australian CommunityHealth Research Unit, Flinders University of SouthAustralia. Their report will be made publicly availablethrough the HiAP website once it has been finalised.Early indications show that the project has had positiveoutcomes, including project partners developing abetter understanding of other government agenciesand the people within them, demonstrated success incollaborating across government and the potential forworking collaboratively on other issues. Evidence hasalso shown that some of the recommendations andfindings from the project have begun to be addressedat both state and community levels, including theorganisation of cultural activities to help strengthenlinks between migrants and their communities.ConclusionThe settlement barriers that migrants face arenumerous, complex and variable, based on both theindividual and the host community they are settling in.However, there are also positive impacts of migrantssettling in regional areas of SA, including theircontributions to the community and the economicfunctioning of the region.‘Settlement’ a is a process that can take years, or evendecades, to occur. Enhancing the current approachand supporting communities to receive migrants willimprove societal, economic and individual wellbeingand reduce costs to society in the future.The project presented a valuable opportunity to visit theregions and see how migration operated in practice.From the government perspective, it was critical tounderstand the issues, for example how migrants weresettling in, their impressions of life in regional SA, whatthey expected from government, how communities andemployers received migrants and whether migrants’aspirations of life in a new country were being met.The project also reinforced the critical aspectsof settlement and identified those areas wheregovernment has the opportunity to have an influence.This is important in a process such as HiAP, where thefocus is on the actions that government can implementto better deliver outcomes for the community andthe state.The project has provided an opportunity for furtherpolicy and program development in regional migrationsettlement to be undertaken in the future. Broad areasof focus for DTED will be:> > working closely with the appropriate migrationgroups within government to investigate optionsto improve access to services essential to migrantsettlement, notably English language learning, andfurther education and training opportunities> > increasing the level of advocacy and informationexchange with the Commonwealth on regionalsettlement and visa issues> > increasing community awareness of the value ofmigration in regional communities as an importantcomponent of supporting migration settlement> > developing employer awareness to understandthe implications of different visas and promote thebenefits of migration.For more information on this project and the HiAPapproach, please visit:http://www.sahealth.sa.gov.au/healthinallpoliciesaDiscussions of ‘good settlement’ often refer to ‘integration’of migrants and refugees. Integration can be defined as: “…the ability to participate fully in economic, social, cultural andpolitical activities, without having to relinquish one’s owndistinct ethno-cultural identity and culture. It is at the sametime a process by which settling persons become part of thesocial, institutional and cultural fabric of a society”. 5 Individual,community and economic wellbeing all play an important rolein the outcomes of the settlement process.Volume 8, Number 1, March 2011 page 23

Public Health BulletinReferences1. Government of South Australia. Prosperity throughpeople: a population policy for South Australia. Adelaide,2003.2. South Australia’s Strategic Plan. South AustralianGovernment, 2007.3. Commonwealth Department of Health and Aged Care.Mental health promotion and prevention national actionplan. Commonwealth of Australia, Canberra, 1998.4. Onyx J, Bullen P. The different faces of social capital inNSW Australia. Pp. 45–58 in P Dekker and EM Uslaner(eds), ‘Social capital and participation in everyday life’.Routledge, London, 2001.5. Valtonen, K., From the Margin to the Mainstream:Conceptualising Refugee Resettlement Processes. Journalof Refugee Studies, 2004. 17: 1.Rural ageing-in-place: communityconnectedness, health andwellbeing—an opportunity fornew technologies?Helen FeistSenior Research AssociateNational Centre for Social Applications of GeographicInformation Systems (GISCA) The University of AdelaideKelly ParkerResearch AssociateGISCA, The University of AdelaideNatasha HowardResearch FellowUniversity of South AustraliaGraeme HugoDirector of GISCA, ARC Professorial FellowThe University of AdelaideIntroductionThe Linking Rural Older People to Community throughTechnology project (the project) aims to improve accessand connection to the wider community for olderAustralians in rural and remote locations through theuse of new communication technologies. The focuson community connectedness is framed within ademographic and geographical perspective, particularlyunderstanding the influence of rural spaces and placeson ageing-in-place and social connections. 1–3 The studyregion for the project is the Murray Lands StatisticalDivision, South Australia. This 3-year, multiphase projectis funded by the Australian Government Departmentof Health and Ageing and managed by the MurrayMallee Aged Care Group Inc., a community serviceprovider based in Murray Bridge. Researchers from theNational Centre for Social Applications of GeographicInformation Systems (GISCA) at the University ofAdelaide are carrying out the research.The first two phases of this project involved a paperbasedsurvey and follow-up in-person interviews withpeople aged 55 years and older living in the region. Awide range of data was collected including informationabout participants’ connections to their communitiesand how the size, composition and proximity ofdifferent aspects of community were related toparticipant variables including self-reported health.Self-reported health assessed by a simple single-itemmeasure has been shown to be a robust predictor ofpage 24

Rural health in the 21st centuryhealth and wellbeing. 4–6 There is evidence in Australiathat the proportion of people rating their health as‘fair’ or ‘poor’ increases as they age. 4,5 Communityparticipation (in the form of voluntary work andinvolvement in sporting and recreational groups) is alsopositively associated with self-reported ‘very good’ and‘excellent’ health. 4BackgroundOver 90% of Australians aged 65 years and olderare living in the community or ‘ageing-in-place’. 7Consideration of ‘place’ in this context is particularlyimportant in rural environments. 1,8,9 Australian ruralplaces often have low population densities; smaller,more dispersed social groups; and an increasedlikelihood of family and friends being located at greaterdistances from the older person. 10 There are also usuallypoorer transportation options in rural areas and greaterregionalisation of services. In terms of socioculturaldimensions, rural people may have limited localisedsocial opportunities, different value sets and personalbiographies compared with their urban counterparts.The challenges involved in ageing-in-place in a ruralenvironment may vary widely depending on the olderperson’s ‘place in the lifecourse, on the communitysettings in which they live, and on the ways theyconstruct their relationships to people and place’. 8,p.129There is often an assumption that rural communitieshave strong, localised kinship and friendship networkswithout any real knowledge of the actual social tiesand patterns of connection. In order to understandthe importance of these networks in rural regions, it isnecessary to understand how community is defined byolder people.Community connectedness and social networks, whichhave established links to positive ageing, health andwellbeing, 4,11,12 provide opportunities for support,engagement, and access to assistance and informationand community resources. 13 ‘Social integration is amajor element in wellbeing and strongly influencesother aspects of life such as health’. 14,p.60MethodThe first two phases of this project involved a paperbasedsurvey and follow-up in-person interviews withpeople aged 55 and over living in the region. A widerange of data were collected including informationabout participants’ connections to their communitiesand how the size, composition and proximity ofdifferent aspects of community were related toparticipant variables including self-reported health.The project survey (n = 858) and follow-up interviews(n = 191) explored a number of factors related tocommunity connectedness, including the type ofcommunity networks participants have, how satisfiedthey are with their level of community involvement andthe length of residence at their current address. Thesevariables are explored here by participants’ self-ratedhealth responses to the survey. Using the SF1, the firstquestion in the Short Form 36 (SF-36), 15 as a measureof subjective health.The project used a spatial approach to study, and bothgeneral community members and community agedcare service users were sampled. Nearly 20 % of thetotal Murray Lands population aged 55 and over, wereapproached to be surveyed and the survey responserate was 22.6 %. A detailed explanation of thesampling approach is available in previous publications16, 17. An overview of the socio-demographiccharacteristics of survey respondents are presented inTable 1.ResultsThe majority of survey participants (over 86%) feltsatisfied with their level of community involvement.Generally, those who were older, living in more remoteareas and who have been living at the same address fora longer period of time were more likely to be satisfiedwith their level of community involvement. Familyappeared to be the most important social networklink for many older people. The State of Ageing inSouth Australia report 14,p.60 highlights that 80% ofolder people stated that support in a time of crisiscame from family, while friends and neighbours wereonly nominated by about half this proportion. Table2 shows that self-rated health was much lower forrespondents who nominated having no contact withfamily, with 61% of this group rating their health asfair or poor. It did not appear to matter if family wereliving close or far away—having some form of familycontact was better for self-rated health. Satisfactionwith community involvement was also clearly related tofamily network type. Those respondents who reportedhaving no family or no contact with family were alsoless likely to be satisfied with their current level ofcommunity involvement (62% compared with 87% oftotal respondents).Volume 8, Number 1, March 2011 page 25

Public Health BulletinTable 1: Socio-Demographic Characteristics of SurveyRespondents (n = 858)*Socio-Demographic Characteristics n %Age (years)55 - 64 138 16.165 - 79 433 50.580+ 285 33.2GenderMale 308 35.9Female 543 63.3Household TypeLive Alone 382 44.5Live with Others 474 55.2EducationLess than High School 522 60.8Completed High School 145 16.9Trade Certificate/ApprenticeDiploma147 17.1University Degree or higher 36 4.2Gross Household IncomeUp to $10000 96 11.2$10001 - $20000 342 39.9$20001 - $50000 275 32.1$50001 - $100000 45 5.2Over $100000 7 0.8* Missing data excluded from analysisTable 2: Self-rated health by type offamily network aSelf-ratedhealthExcellent /very goodFamilynearby(n =268)%Scatteredfamily(n =474)%No familycontact(n =105)%TOTAL(n =858)%22.8 29.5 15.0 25.5Good 36.9 36.9 23.0 35.0Fair/poor 38.8 32.9 61.0 38.6Not stated 1.5 0.6 1.0 0.9Total 100.0 99.9 b 100.0 100.0PercentageFigure 1 shows that more than half of all surveyrespondents said they had friends living nearby andregular contact with neighbours. The propensity to havenetworks with friends and neighbours varied based onself-reported health. Those reporting better health weremore likely to have friends nearby, regular contact withneighbours, scattered friends or a large circle of friendscompared with respondents who reported fair or poorhealth. Respondents reporting fair or poor health moreoften nominated having one or two friends that theyrely on.70.060.050.040.030.020.010.00.0FriendsnearbyRegularcontactwithneighboursamultiple response variablesExcellent/veryGood (n=219)Good (n=300)Scatteredfriends, alwaysin touchOne ortwo friendsI rely onFigure 1: Type of networks with friends andneighbours a by self-rated healthFair/poor(n=331)TOTAL (n=858)Large circleof friendsIn the second phase of the project, interviews wereconducted with a subset of survey participants (n =191) from the first phase. Participants were asked tolist all the ‘people and activities’ that were importantto them. On average, they listed a total of 15 socialnetwork ties; however, the overall size of networkswas found to vary across a range of characteristics,including self-reported health at the time of the survey.Figure 2 shows that participants who reported theirhealth as excellent or very good were much more likelyto have a large social network compared with thosewith fair/poor self-reported health, and participantswith fair/poor self-reported health were more likely tohave a small-sized social network.asingle response variablebtotal does not sum to 100.0 % due to rounding.page 26

Rural health in the 21st centuryLarge network(>17 ties)Average network(12 –17 ties)Small network(

Public Health BulletinOnline BankingTelephone BankingInternetPersonal ComputerEFTPOS to pay thingsATMCar SatelliteNavigationMobile PhoneDVD PlayerMicrowaveCD PlayerTelephoneVideo Player (VCR)RadioTelevisionSource: Feist et al. 2010 16Figure 4: Percentage of respondents moderately tovery comfortable with using various technologies byageConclusion0 20 40 60 80 100% Moderately to VeryComfortable Using Technology80+65-7955-64TOTALRESPONDENTSThe role that new technologies can play in connectingolder people to other people within their existingnetworks and to wider community and interestnetworks needs to be explored further, as theseconnections are associated with subjective healthand wellbeing. New technologies represent an idealmedium to foster and strengthen both localised,place-based community connections and dispersedsocial network ties. They also offer improved access torelevant information and services for older people livingin rural communities and the potential for increasedautonomy in decision-making about their own health.Myths that older people are disengaged from the widerworld and unable to embrace new technologies shouldbe dispelled. We need to enable access and understandthe needs and preferences of older people for learningand using new technologies, and incorporate these intodaily life and service provision.In the past decade the number of international studiesinvestigating older people and their use of newtechnologies such as personal computers, the internetand mobile phones has increased, although it is stillan emerging field of interest. 26,28–30 There is very littleresearch in this field in Australia and none in ruralareas with this age cohort. There is a need to examinethe applicability of even newer technologies, such astouch screen computers, web-based mobile phones anddevices such as Apple iPads®, to older generations inAustralia, in particular within the diverse geographiesand populations of rural places.The next phase of this project will engage 48 studyparticipants with their choice of a laptop or AppleiPad®, 3G internet connection and individualisedtraining and support in order to enhance communityconnections. Changes to participants’ communityengagement, access to information, and contact withboth existing and new social networks after using thesetechnologies will be measured through pre- and posttestsand ongoing weekly activity log sheets. Preliminarypilot phase results suggest that older people are keento embrace new technologies and that newer, userfriendlytechnologies combined with reliable, faster 3Ginternet connections will enhance access to generalinformation, services and local connections withincommunities. It is anticipated that relationships withwider social networks, in particular communication withdispersed family and friends, will improve. Participantshave expressed interest in accessing email and VOIPapplications such as Skype® to maintain these socialconnections. There is potential for subjective healthand wellbeing to be improved by facilitating these newmodes of connection within this older, rural population.References1. Peace S, Holland C, Kellaher L. Environment and identityin later life. In: Walker A (ed.), 'Understanding qualityof life in old age: growing older series'. Open UniversityPress, Maidenhead, UK, 2006.2. Rowles G. Evolving images of place in ageing and 'ageingin place'. Generations 1993; 17(2):65–71.3. Wahl H-W, Lang F. Aging in context across the adult lifecourse: integrating physical and social environmentalresearch perspectives. In: Wahl H-W, Scheidt R, WindleyP (eds), 'Aging in context: socio-physical environments'.Springer, New York, USA, 2004, p.1–33.4. Australian Bureau of Statistics (ABS). Self-assessed healthin Australia: a snapshot, 2004–05. ABS, Canberra, ACT,2007.5. Avery J, Noack H, Gill T, Taylor A. Overall health statusof South Australians: as measured by the single item SF1general health status question. Population Research andOutcomes Study Unit, South Australian Department ofHealth, 2006.page 28

Rural health in the 21st century6. Mavaddat N, Kinmonth A, Sanderson S, Surtees P,Bingham S, Tee Khaw K. What determines self-ratedhealth (SRH)? A cross-sectional study of SF-36 healthdomains in the EPIC-Norfolk cohort. J EpidemiolCommunity Health 2010. doi:10.1136/jech.2009.0908457. Australian Institute of Health and Welfare (AIHW). Agedcare packages in the community 2006–07: a statisticaloverview. Care Statistics Series no. 27, cat. no. AGE 57.AIHW, Canberra, 2008.8. Keating N (ed.). Rural ageing. a good place to grow old?The Policy Press, Bristol, UK, 2008.9. Rowles G, Watkins J. History, habit, heart and hearth:on making spaces into places. In: Warner Schaie K,Werner-Wahl H, Mollenkopf H, Oswald F (eds), 'Agingindependently: living arrangements and mobility'.Springer Publishing, New York, 2003, p.77–96.10. Hugo G, Smailes P. The Gilbert Valley in South Australia.In: Cocklin C, Alston M (eds), 'Community sustainabilityin rural Australia: a question of capital?' Centre for RuralSocial Research, Wagga Wagga, NSW, 2003.11. Andrews G, Phillips D (eds). Ageing and place:perspectives, policy, practice (1st edn). Routledge, Oxon,2005.12. Phillipson C, Allan G, Morgan D (eds). Social networksand social exclusion: sociological and policy perspectives.Ashgate, London, 2004.13. Luszcz M, Giles L, Eckermann S, Edwards P, Browne-Yung K, Hayles C et al. The Australian LongitudinalStudy of Ageing: 15 years of ageing in South Australia.Government of South Australia, Department for Familiesand Communities, 2006.14. Hugo G, Luszcz M, Carson E, Hinsliff J, Edwards P, BartonC et al. State of ageing in South Australia. Governmentof South Australia, Adelaide, 2009.15. Ware J, Donald-Sherbourne C. The MOS 36-Item Short-Form Health Survey (SF-36). Med Care 1992; 30(6):473–483.16. Feist H, Parker K, Howard N, Hugo G. New technologies:their potential role in linking rural older people tocommunity. Int J Emerging Technol Soc 2010; 8(2):68–84.17. Hugo G, Feist H, Parker K, Howard N. Linking RuralOlder People to Community through Technology: PhaseOne Report, Community Members. Canberra, ACT: TheUniversity of Adelaide and the Department of Health andAgeing, 2010.18. Bauman Z. The individualized society. Polity, Cambridge,2001.19. Rheingold H. Social networks and the natureof communities. In: Purcell P (ed.), 'Networkedneighbourhoods: the connected community in context'.Springer, London, UK, 2006, p.47–75.20. Wellman B, Hogan B. Connected lives: the project.In: Purcell P (ed.), 'Networked neighbourhoods: theconnected community in context'. Springer, London, UK,2006, p.161–216.21. Pretty G, Chipuer H, Bramston P. Sense of place amongstadolescents and adults in two rural Australian towns:the discriminating features of place attachment, senseof community and place dependence in relation to placeidentity. J Environ Psychol 2003; 23:273–287.22. Cody M, Dunn D, Hoppin S, Wendt P. Silver surfers:training and evaluating internet use among older adultlearners. Commun Educ 1999; 48(4):269–286.23. Danowski JA, Sacks W. Computer communication andthe elderly. Exp Aging Res 1980; 6(2):125–135.24. McConatha D, McConatha J, Dermigny R. The use ofinteractive computer services to enhance the quality oflife for long-term care residents. Gerontologist 1994;34:553–556.25. Australian Bureau of Statistics (ABS). Household use ofinformation technology, Australia 2008–09. Cat. no.8146.0. ABS, Canberra, 2009.26. Czaja S, Schulz R. Innovations in technology and aging.Generations 2006; 30(2):6–8.27. Lenhart A. Adults and social network websites: Internet &American Life Project. Pew Research Center, 2009.28. Eisma R, Dickinson A, Goodman J, Syme A, Tiwari L,Newell A. Early user involvement in the developmentof information technology-related products for olderpeople. Universal Access in the Information Society 2004;3:131–140.29. Magnusson L, Hanson E. Ethical issues arising from aresearch, technology and development project to supportfrail older people and their family carers at home. HealthSoc Care Community 2003; 11(5):431–439.30. Segrist K. Attitudes of older adults toward a computertraining program. Educ Gerontol 2004; 30:563–571.Volume 8, Number 1, March 2011 page 29

Public Health BulletinFrom tree change to e-change—Willunga becomes a digital villageGenevieve BellDirectorInteraction and Experience Research, Intel Labsat Intel CorporationSouth Australian Thinker in Residence 2008–10Contributing authorsCarolyn AndersonDirectorScience and Information EconomyDepartment of Further Education, Employment, Scienceand TechnologyGovernment of South AustraliaAlison KershawSenior Policy OfficerScience and Information EconomyDepartment of Further Education, Employment, Scienceand TechnologyGovernment of South AustraliaIntroductionOver the last three years the Federal Labor Governmenthas articulated an ambitious set of reforms gearedat transforming healthcare delivery, education,productivity and innovation. In order to make suchreforms a reality, Australia must also embrace newforms of infrastructure and new technology platforms.In April 2008, the government introduced a newplan for a National Broadband Network (NBN) to theAustralian public. While Australia was an early adopterof dial-up internet, we have significantly slipped in ourposition on the current internet league tables. The NBNseeks to connect all Australian homes, businesses andpublic sector institutions to high-speed broadband—the transformative infrastructure of the 21st century.Through a combination of fibre-optics, satellite andfixed wireless broadband, Australians will enjoy a muchricher set of experiences, applications and services.Disappointingly, the NBN is currently being promoted tobusinesses, citizens and consumers on the speed of thenetwork and that it is the only broadband solution, thusignoring some of the NBN’s more powerful implications.First, broadband via 3G or 4G phone networksprovides the mobility that people demand and willbe complementary to rather than a replacementfor high-speed broadband to premises. Second, theNBN offers the promise of ubiquity, connecting up allpremises, schools, hospitals, businesses and communitycentres—all Australians can have access to the networkand its benefits. Last, the NBN offers more than justenhanced web content on computers. It will also delivera greater density of devices, applications and serviceswith an internet connection, including mobile phones,televisions, consumer electronic devices and evenelectrical meters.The NBN might well be the largest infrastructureproject in Australia’s history, but it is not the technicaldetails that will interest and excite Australians as thefuture users of the network. Clearly, a high-speednetwork that delivers robust connectivity to dwellings,social institutions and organisations through anincreasing density of smart, interconnected devices hasimplications for a range of different sectors, experiencesand activities. Indeed, all Australians—the tech-savvy,existing non-users, occasional users and naïve users—must be encouraged and supported to get interestedand get connected. In so doing, this 21st centuryinfrastructure will become a reality and a practical partof our daily lives.The NBN and South AustraliaOver the last two years, I (Genevieve Bell) have spenta great deal of time in South Australia (SA). As thestate’s 15th Thinker in Residence, I was tasked withexploring how South Australians used new informationand communication technologies (ICTs), and thenhelping the state think about how to benefit from thesetechnologies. I travelled 13 000 km to 45 differentcommunities and had almost 500 conversations andinterviews across schools, communities, governmentand businesses. I also participated in formal interviewsand meetings, day-in-the-life activities, formalcommunity conversations, the SA Stories Project and anOffice for Youth A-Team (in the Riverland).In my time travelling through the state, it rapidlybecame clear that talking about technology with SouthAustralia’s citizens also meant talking about everythingelse. Conversations about technology were also aboutkids, community, education, citizenship, democracy,work, leisure time, holidays, privacy, health care, water,farms and the future. In those conversations it alsobecame very clear that people are NOT looking totechnology to solve everything. They see technology asa tool—it must work in a way that meets a need, solvesa problem or adds value; otherwise, it is just anotherpage 30

Rural health in the 21st centurydevice that gathers dust. These attitudes, of course,have significant implications for the NBN as it rolls outin SA.My report as Thinker in Residence is divided into fourareas that are critical to SA’s future:1. Broadbanding the state. It is critical to ensure that allSouth Australians get access to the best broadbandservices available, and that regional and remotecommunities are not further disenfranchised.2. Switching on the state. In order to make the mostof the NBN, the public and private sectors will haveto undertake a significant investment in SA. Wewill need to train and empower everyone to beconfident and successful online citizens, and thisincludes digital literacy and cyber engagement.3. Strong communities. While the NBN will havea strong impact on individual lives, it also hasthe chance to drive new forms of communityengagement, supporting and enhancing existingcommunity activities.4. SA’s future. The NBN rollout will take nearly adecade to complete, which means that now is thetime to start investing in new areas of research,development and innovation, including aroundenvironment and sustainability, new urbanisation,transportation and ageing.The advent of the NBN has provided a focal pointaround which many of my recommendations canbe contextualised and developed. My final report isavailable at www.thinkers.sa.gov.au.The NBN and health careThe impending NBN can do much to promote thehealth and wellbeing of citizens through enablingaccess to vital health professionals, services andproducts. As Kevin Buckett, Director, Public Health,SA Health, writes: ‘Our health is mostly determinedby factors outside the operational sphere of thehealth sector, so the health sector must move beyondmanaging the healthcare system and seriously addressthose determinants of health in other spheres—education, housing, transport, employment, income,welfare etc.—where they impact on health.’ 1 ICTs willact as enablers across all the sectors listed above andallow individuals to affect their own health outcomes.Clearly, a high-speed and ubiquitous internet hassignificant implications for the delivery of health carein Australia. E-health, as it is sometimes called, is muchmore than online patient healthcare records—much,much more. Until now, health services have beenbased very much on location—patients are requiredto be co-present in surgeries, pharmacies etc. E-healthbreaks the co-presence nexus and allows in-homeand remote access to key services such as digitalmedical imaging, consultation, health monitoring anddiagnostics. ICTs and the internet enable provisionof service and support, as well as access to andsharing of information, and are a means of furtheringconnections, both personal and professional.The opportunity, for both the healthcare system andindividual healthcare workers, to take full advantageof the potential of the NBN is too good to miss. Forhealthcare workers there will be opportunities todevelop new skills to support and guide patientsto become well and maintain wellness through theapplication of the new high-speed broadband. Thisis likely to be through use of a combination of bothoffline and online resources; for example, a patientliving in a regional area may be given a brochure butalso referred to an online support group and givenan appointment for an online consultation with anAdelaide-based specialist. This blend of offline andonline healthcare is likely to become the norm.Technology will be a tool that healthcare workers willhave in their ‘bag of tricks’, but how the tool is used isyet to be fully explored. For example, there are currentlyat least two iPhone applications that enable healthcareworkers to access a range of pain managementassessment tools and information.E-health will potentially also allow patients to bemore active and involved in the management of theirown health, which will mean that patients will needto be digitally literate to take full advantage of thenew opportunities. Healthcare workers will also needto develop their own digital literacy so that they canprofessionally support patients using new modes ofe-health services and information.We can also make the argument that these newtechnologies and infrastructures will help individualsand the public health system find solutions to complexissues regarding the wider concept of wellbeingrather than simply health. There will be opportunitiesfor exploration and innovation to develop solutionsto specific problems and to address very specificneeds. New models of health practice are likely to bedeveloped alongside new business models.Volume 8, Number 1, March 2011 page 31

Public Health BulletinThe implications of the NBN go beyond service delivery.New models of funding, billing and payment forthose delivering and receiving services will need to bedeveloped. Governments must provide funding fornew hardware, software and training for all healthcareworkers. This will potentially have huge implicationsfor hospitals and other healthcare providers as theywill need to reallocate resources to new services, newtechnologies and training for staff and patients. Theinfrastructure that supports the healthcare system willalso need to adapt and change. Medicare and theprivate health insurance providers will need to developpricing and funding models for new modes of servicedelivery. Will an online consultation cost the same as aface-to-face consultation? Will a patient be bulk billed?These and many other questions will need tobe answered.Patients and consumers of healthcare services liveand operate in complex offline and online networks,accessing information and support from a range ofsources. Health care in the 21st century will be aboutholistic responses to health and wellbeing problemsrather than just pills. This has already been clearlydemonstrated in the work of Professor Ilona Kickbuschand Health in All Policies.A call to action: Willunga—SouthAustralia’s first digital villageWillunga is 46 km south of Adelaide’s CBD. With apopulation of 2104, its main industries are viticulture,tourism, horticulture and agriculture, and associatedindustries. In 2011 Willunga will be the first release sitefor the NBN in SA. What might be done in Willungawith and around the NBN is an important challenge forlocal, state and federal agencies.providers to engage the community in the developmentof skills in digital literacy, and provide an opportunityfor a seamless pathway with multiple access pointsthrough to accredited training and higher levelqualifications.But I think we can take the e-change in Willunga onestep further. Willunga has a large number of ancillaryhealth services that could form the backbone of awellbeing network that would include healthcareservices and providers, organic produce shops,churches, service groups, a recreation centre, B andBs etc. There is, however, no aged care facility inWillunga, although there are facilities in the adjacenttowns. Research shows that it is the aspiration of mostpeople to remain living in their own home for as longas possible before transitioning to aged care facilities.This places pressure on families and the health systemto support this, which can be very difficult if familyor health care is not situated in close proximity. As anexample of the potential of the NBN, it could be usedto provide in-home tele-presence videoconferencing toconnect elderly people currently living in their homeswith a local health and wellbeing network comprisinglocal doctors’ surgeries, pharmacies, physios,chiropractors, library, community centre and serviceproviders.Clearly, first-release sites such as Willunga provide aunique opportunity to explore new ways of providinghealth and wellness services using high-speedbroadband. And this is an opportunity we should take!References1. Buckett I. Editorial. Public Health Bulletin SA, Health inAll Policies, July 2010. http://www.health.sa.gov.au/pehs/publications/publichealthbulletin-pehs-sahealth-1007.pdfFirst, we need to work to ensure that all residents areequipped to get online and take advantage of therange of experiences, applications and services thatthe NBN will make possible. Creating a digitally literatecommunity will enable more Australians to share inand explore the opportunities provided by ICTs and theNBN. Furthermore, being digitally literate can have animpact on a person’s sense of wellbeing, their sense ofconnection to communities, both local and global, andtheir ability to access information and services.With this in mind, a digital literacy frameworkdeveloped by the South Australian Government, inresponse to my report, will be trialled and tested inWillunga. It will enable non-accredited and accreditedpage 32

Rural health in the 21st centuryMale health: facts, determinantsand national and South Australianpolicy responsesGary MisanAssociate Research ProfessorCentre for Rural Health and Community DevelopmentUniversity of South AustraliaJohn AshfieldDirectorEducation and Clinical PracticeAustralian Institute of Male Health and StudiesIntroduction2010 was a watershed year for the health of Australianmales with the release of Australia’s first ever NationalMale Health Policy (NMHP). 1 Until then, men’s healthin Australia had attracted little meaningful policyattention at the national level. In contrast, Australiahas had a National Women’s Health Policy since 1989as well as Offices for Women at the federal level andin every state and territory of Australia—there are noCommonwealth or state equivalents for Australianmales.That such a policy is overdue is not because data onmale health has not been available until now. In fact,in1988 the Health for all Australians report noted that:‘Men in Australia die from nearly all non-sexspecificleading causes at much higher rates than dowomen…’ and that ‘… These differences in healthstatus largely reflect the prevalence of preventablefactors.’ 2In macro terms, nothing much has changed in over30 years. Thus, the aim of this paper is to offer asummary of male health status in Australia and SouthAustralia (SA), and a brief critique of the NMHP andthe South Australian Men’s Health Strategic Framework2008–2012. The purpose is to highlight current issuesfor male health in Australia by drawing on state andnational morbidity, mortality and health utilisation data,as well as local and international literature regardingthe likely determinants that impact on male healthoutcomes. The paper then explores in what publichealth framework they are positioned, what they sayabout the key determinants of male health, whetherrecommendations address special needs and specialgroups of men, what current gaps exist and whatopportunities exist for South Australian health systemsto respond.Males account for almost half of both our state’sand the national population. They have specific andspecial needs that deserve specific national and statepolicy responses as well as an equitable distributionof national and state health resources to meetthose needs. This paper, as much as possible, avoidscomparisons with the health status of women becauseto do so implies that it is non-problematic. It alsoinappropriately sets a benchmark for men’s health andimmediately places male health policy in an adversarialand deficit context. Similarly, comparisons betweenmale and female health determinants are avoided, as iscomment on the effectiveness or otherwise of women’shealth policy and related initiatives.Male healthMale health extends beyond the purely biologicalaspects and encompasses a range of issues affectingthe health and wellbeing of men and boys. Whileconcepts of masculinity, gender and societalexpectations play a part in how males understand andexperience health, socioeconomic, cultural, ethnic,educational, environmental, occupational, social andother factors are key determinants of the health statusof the Australian male. 3At the outset, disparities in national and state mortalitystatistics for males and females call for better targetingof male health policy. Statistics indicate that, over thelast 20 years, death rates for both males and femaleshave declined but males still die more often thanfemales in all age groups. 4 At both state and nationallevels, average male life expectancy is 79.3 years,compared with 83.9 years for females. 5 In remoteand very remote areas average male life expectancy isabout 4 years less again. For Aboriginal males averagelife expectancy is 59 years, 6 years less than forAboriginal females. The national and South Australianstandardised death rate for males is 2.2 deaths perthousand higher than for females. 6 These figures, whenextrapolated by population, represent approximately22400 national and 1765 South Australian additionalmale deaths per year compared with female deaths—compelling enough reason for concern about the healthof Australian males.Life expectancy aside, mortality rates for males formost non-sex-specific causes of death are higher thanfor females across all age ranges. These figures areVolume 8, Number 1, March 2011 page 33

Public Health Bulletincorroborated by other measures including years of lifelost, potentially avoidable deaths and calculations ofexcess mortality, 7 the details of which provide clearindicators for male health policy.The leading causes of male death nationally areischaemic heart disease (IHD), trachea and lung cancer,stroke, chronic lower respiratory disease, prostatecancer, dementia and Alzheimer’s disease, colorectalcancer, blood and lymph cancer (including leukaemia),diabetes, suicide and prostate cancer. 8 These causesaccount for approximately 60% of all male deaths andpoint to potential priority areas for male health policy.In SA the leading causes of male death are IHD,lung cancer, suicide and self-inflicted injuries, stroke,colorectal cancer, road traffic accidents, chronicobstructive pulmonary disease, prostate cancer,pneumonia, cirrhosis of the liver and type 2 diabetes. 9Males in this state die from avoidable causes 85%more often than females, highlighting a need for moremale-specific disease prevention and early interventionstrategies as key components of male health policy. 3Morbidity measures suggest further opportunities toimprove male health outcomes. In SA male rates fordiabetes are 27% higher than for women, and 10%higher for heart, stroke and vascular disease. 3Men in the 15–29 years age group have higherdeath rates from injury than in other age groups.Males are also three times more likely to die fromvehicle accidents than females, with 60% of deathsoccurring in younger men. The incidence of suicideis also higher in younger males. 7 This suggests thatstrategies specifically engaging and targeting youngmales are required over and above the public healthmessages cautioning young drivers in general aboutrisks associated with driving, including when under theinfluence of alcohol or other drugs.Nationally, males are at least three times more likelythan females to die from suicide. This has been apersistent trend since 1999, with males in remoteregions being more likely than their urban counterpartsto commit suicide. 10, 11 Farmers are more likely thannon-farmers to commit suicide, highlighting the needto address the additional risk of this subgroup. 12, 13 SAhas the highest rate of suicide among the mainlandstates, with rates increasing with remoteness. 14Determinants of healthWhile mortality, morbidity, disease burden, risk factorattribution and other measures of health are useful inprofiling male health and potential priorities for policydevelopment, they don’t provide an overarching insightof the causality of ill health. What then are the keydeterminants of male health?The common dogma of ‘males behaving badly’—oftencited as the reason for poor male health—has little basisin evidence 15 . This paradigm considers that being maleis of itself a pathological state calling for personal andbehavioural change. In this view men are deficient inhelp-seeking and health care, and inclined to gratuitousrisk taking—all factors leading to poor health. Theseviews have been challenged in recent times 16,17,18,19,20,21since they ignore critical sociocultural determinants ofmale health and male health-seeking behaviour. Thereis also notable absence of evidence supporting a directcorrelation between gender attributes and health. 15Contrary to this notion is clear evidence that muchmale death and burden of disease is attributable tohistorical, social, economic, geographic, environmentaland cultural factors, 3, 7, 22, 23, 24, 25 which are mostdemonstrable in Australia in Aboriginal and TorresStrait Islander populations. 7, 26 Research suggests thatill health is the result of a combination of influences,including socioeconomic disadvantage, low income,low levels of education and working in blue-collaroccupations, that result in persistent and adversechanges to physical and biological functioning. Thesechanges are triggered by psychosocial processes andhealth behaviours that, in turn, are a result of exposureto adverse social, physical, economic and environmentalcircumstances. The latter are influenced by macro-levelfactors including government policy, the economy, civicsociety and broader global forces. There is also a directlink between social factors and morbidity resultingfrom accidents, injury and violence. 22 These findingsindicate that coordination of policy across a number ofjurisdictions is required if we are to comprehensivelyaddress male health issues.In addition to health determinants, many of the riskfactors common to both fatal and non-fatal disease arepreventable, including smoking (cancer, cardiovasculardisease; (CVD); high blood pressure (CVD); overweightand obesity (CVD, diabetes, cancer); low levelsof physical activity (CVD, diabetes, cancer); highcholesterol (CVD); alcohol (injury, mental illness, cancer,CVD); diet (CVD, cancer); and occupational exposurepage 34

Rural health in the 21st centuryand hazards (injury, cancer, CVD). 27 In light of thesedata, male-specific prevention strategies, including forspecial subgroups of males, should be key components3, 27of male health policy.In practical terms, the most likely determinantof a man’s health is where he is situated on thesocial gradient. 28 Although the social gradient hasimplications for both males and females, males appearmore adversely affected by lower socioeconomicstatus (SES) than females. 3, 22 Males from low-incomehouseholds living in disadvantaged areas with lowerlevels of education and employed in blue-collar jobsgenerally report the poorest health. Data shows thatpremature mortality for males in the most sociallyadvantaged group of the population is higher thanthat for females in the most socially disadvantagedgroup, and the rate for males from the lowest SESgroup is nearly double that of the most sociallydisadvantaged females. 3 Men with lower SES are morelikely to make poorer lifestyle choices 3, 22 and to workin dangerous, health-damaging occupations. 22 Maleblue-collar workers experience significantly higherdeath rates for all causes and for most specific causes. 22Socioeconomically disadvantaged men are more likelyto report chronic disease or adverse health indicators orassociated risk factors, 7, 15, 22, 29 and are less likely to beable to access health services. 22Where people live (social geography) is anotherdeterminant of health, including the prevalence ofselected diseases, injury (greatest in the 25–64 yearsage group) and diminished mental health. Comparedwith those in major cities, males in regional andremote areas are less likely to report very good orexcellent health and more likely to report fair orpoor health. 30 Prevalence for chronic disease andinjury is generally higher for males who live outsidemetropolitan areas, and increases with remoteness. 30Of note are increased self-report prevalence ratesof diabetes, bronchitis, arthritis and some cancers,compared with city counterparts. Males in regionaland remote areas are more likely to show high to veryhigh levels of psychological distress, and males livingoutside major cities are significantly more likely toexperience depression (greatest in the 45–64 years agegroup). Prevalence rates are generally higher again forAboriginal males. 30Increased remoteness is also associated with increasedprevalence of poor health behaviours. For example,country males are more likely to drink alcohol inharmful quantities, smoke, exhibit sedentary behaviour,be overweight or obese, and consume a poor diet.They are also more likely to demonstrate alcoholrelatedpersonal risky behaviour and consume cannabisand other illicit drugs. 30 Exposure to hazardousmachinery and chemicals, combined with the long andstrenuous hours of many rural occupations, can also bedetrimental to men's health. 3 Access to health servicesmay be limited because of lesser numbers of healthprofessionals in rural areas, the need to travel or taketime away from work, or limited operating hours ofhealth services. 3South Australian statistics generally correspond withnational figures although SA has a higher proportion ofmales who live outside major urban centres comparedwith the national average (72.4% versus about 66.6%,respectively). 31 All-cause death rates are significantlyhigher for males living in remote and very remote SA,in part due to the disproportionate concentration ofAboriginal people. 22 The difference is noted mostlyamong adolescent and young adult males. 7SA males disadvantaged by poverty or geographicalremoteness are at higher risk of ill health. SA malesmost at risk of premature death include Aboriginalmales, those with low education levels, the un- orunderemployed, the homeless, those with low SESand those living in rural and remote areas. 32,33 Theprevalence of males with at least one chronic conditionand who report good or better health generallydecreases with decreasing socioeconomic status, aswell as with increasing remoteness. 34 Death rates fromboth premature and avoidable causes are stronglycorrelated with socioeconomic disadvantage. Similarcorrelations exist for high unemployment rates, dentalill health, presentations to accident and emergency(A&E) departments, and hospital admissions for mentaland behavioural problems. 3 Male cancer rates aresubstantially higher than for women in the 55 yearsand older age group, although there is little differenceacross SES or remoteness indexes.Males in SA access general practitioner, medicalspecialist and community health services (exceptcommunity mental health) less often than women. 32Potentially avoidable rates of hospital admission arehigher for males than for females and increase withremoteness, possibly resulting from lesser availabilityof primary healthcare services in these areas. Rates ofutilisation of mental health services are inversely relatedto South Australian patterns of SES, being higher withVolume 8, Number 1, March 2011 page 35

Public Health Bulletinlower SES. 3 The inference arising from these findingsis that male health policy in SA should include specificstrategies that target males from socioeconomicallydisadvantaged, younger, Aboriginal, and rural andremote area groups.In general, male experience of social inclusion, 33,34, 35, 36as well as social control and cohesiveness, 37are important determinants of social and emotionalwellbeing, health and longevity. Research has shownindependent causal association between the prognosisof coronary heart disease and social isolation, lack ofquality social support and depression. 37, 38 Other studiesdemonstrate that risk of death due to the absenceof meaningful social relationships is comparable tothe well-known risk factors of smoking, alcohol, high33, 34, 35, 36,cholesterol, poor diet and lack of exercise.38Lack of control over work and life decisions, whichis more common among low SES groups and thosein lower paying jobs, also adversely impacts health. 37Thus, strategies to improve social support, control andinclusion are crucial in policy considerations.Occupational health and safety (OH&S) remains a keyarea of concern. The most dangerous, deadly andhealth-diminishing work in Australia is performedoverwhelmingly by men, and males experience 70% ofthe burden of disease related to injury. 39 Nationally, 15serious workplace injuries occur every hour and at leastone work-related death occurs every day, with males24, 40accounting for 94% of all work-related fatalities.Around 2000 deaths related to occupational exposureto hazardous substances occur each year, again mostlyin men. 41 Even though statistics have improved over thelast decade or more, they are clearly still unacceptable. 42Since 2002 the incidence of work-related fatalitieshas decreased by 25% and those of serious injuriesby 22%, but Australia still lags behind comparablecountries. 43 Continuing, serious and coordinatedeffort by government and industry to achieve targetedreductions is still required.Requisite features of male health policyMost of the above determinants are the result ofmodifiable factors, so it seems rational to expectthat strategies to address them should form the keytenets for male health policy. 3 A reasonable premise isthat reduction of excess risk to health from whatevercause should be acknowledged as a guiding principlethat underpins all public health policy. However,some factors that impact on health are outside thejurisdiction of health departments and other agencies.In order to affect a holistic approach to health andbetter coordinate a whole-of-government approach,health policy should articulate with policy thataffects macro-level social and economic conditions,improves living and working conditions, empowersindividuals, strengthens social and family networks,and improves health system equity. 44, 45 Such policyincludes economic, health, welfare, housing, transport,taxation, OH&S, law and order, family law, land rights,environment, social inclusion and others. Not to do soundermines the key tenets of the ‘new public health’paradigm, which promotes the need to address theinterplay between health, socioeconomic and culturalfactors, education, environment and social capital, andmandates a whole-of-government approach to healthcombined with intersectoral cooperation betweengovernment and non-government organisations (NGOs)34, 46and communities.Local data suggests that male health policy shouldtarget several broad areas: prevention, early detectionand treatment, service delivery and research. Theconditions that account for the majority of the burdenof chronic disease are deserved priority targets. Thepolicy should also be aimed at subgroups of maleswho are most at risk, giving particular attention tosocioeconomic determinants of health and affordableaccess to health services. For the more general malepopulation, policy should focus on strategies thatpromote service access, increase numbers of malehealth workers, provide additional male-specificservices, and make existing services significantly moremale friendly. 16, 47 Social marketing strategies thatimprove health literacy and promote effective use ofprimary care, community health and specialist servicesshould also be incorporated. 48 Policy should reflectmale-specific strategies that aim to reduce exposureto modifiable risk factors, facilitate healthy lifestylechoices, target young male drivers and improve overall15, 28work safety.Due regard should be given to biological factors thatdetermine differential health outcomes for malescompared with females, including increased incidenceof foetal complications, congenital malformationsand chromosomal abnormalities in males at birth, anddeaths from prostate cancer in older men. 22There should also be emphasis on education initiativesto up-skill service providers in working effectively withmen. 48 Finally, an equitable approach is required tofunding that augments research into more-effectivepage 36

Rural health in the 21st centurydetection and screening of male-specific afflictions,and more-effective ways of respectfully engaging malesin the pursuit of better health. As a notable example,prostate cancer, the second leading cause of cancerdeath after lung cancer, kills more men each year thanbreast cancer in women. Yet, NHMRC expenditurefor prostate research during 2000–10 fell far short(by 56%) of funding for breast cancer for the sameperiod. 33National and South Australian men’shealth ‘policy’The National Male Health Policy 2010On the above requisites the NHMP scores reasonablywell. The policy is framed within a context of positiveacknowledgment of: the role of males in society; thedisparity in health status between males and females,which goes beyond sex or gender differences; thespecial needs of males in general and of subgroupsof males (e.g. living in rural and remote areas) inparticular; and the need for collaboration betweengovernment, health services, communities andindividuals to effect change.The NMHP exhorts gender equity in health—in whichmales and females have equal opportunity to achievegood health. 49 The policy acknowledges that healthand wellbeing are contingent upon making positivechanges in economic and social health-minimisingconditions. However, rather than identifying key,specific strategies to achieve this for disadvantagedmales, the NMHP appears to defer to the government’ssocial inclusion agenda as a panacea, potentiallyjeopardising the focus on specific male health issues,including those of Aboriginal and Torres Strait Islanderand socially disadvantaged males. 50 Coordinatedactions—specifically targeting men and boys—betweenfederal and state government departments and otheragencies will be required if real and meaningful changeis to occur.A number of priority areas for action are identifiedby the policy, including: calling for the developmentof improved service delivery models and changesto language used in health promotion programs;acknowledging groups of males who are at risk ofpoorer health; recognising transition points across thelife course that require special interventions, services orinformation; valuing the important role that older maleshave in mentoring and caring for younger generations;and recognising that, to effectively engage males,prevention programs need to be tailored and targeted,taking into account the strategies and environmentsthat are most likely to reach at-risk groups.The policy is unfortunately diminished by repeatedreference to the ‘men behaving badly’ paradigm,emphasising the need for men to change a range ofso-called ‘risky’ behaviours, and to be more vigilant inattending health education sessions and seeking morefrequent medical advice. While acknowledging thatmany men work in dangerous or health-diminishingoccupations and are exposed to toxic substances inthe workplace, the policy suggests only the need forcontinued monitoring and safety awareness rather thanmaking a serious attempt to address key risks. Finally,the policy makes no reference to the need to trainhealth workers in better understanding men’s healthneeds or how to effectively engage with men.The NMHP allocates small tranches of funding forspecific initiatives, for example to support the AustralianMen’s Sheds Association; to develop health promotionresources for men’s sheds; to provide fatherhoodsupport and services to Aboriginal and Torres StraitIslander males; to build an evidence-base in malehealth including establishing a national longitudinalstudy; and to commission regular statistical bulletinson male health. The need for additional research isalso acknowledged. While the policy outlines potentialactions for each of its six health priority areas, onlythe small tranches of funding already mentionedappear likely to be forthcoming. It appears thatexisting programs will be expected to give effect to theunfunded emphases and principles of the policy. Historyand experience suggest that this reflects unfoundedoptimism.The South Australian Men’s Health StrategicFramework 2008–2012The South Australian response to male healthwas framed by the release of the South AustralianMen’s Health Strategic Framework 2008–2012 (theFramework). 9 This document took a positive view ofthe increasing concern of men to health issues andthe corresponding positive changes in their healthhealth-seeking behaviour. The framework describes theinfluence of both biological as well social determinantson male health. At risk sub-groups of males, includingAboriginal males are identified. The Framework exhortsa primary health care and population health approach,a coordinated response across sectors, together withhealth service initiatives appropriate to the health needsVolume 8, Number 1, March 2011 page 37

Public Health Bulletinof different populations of SA men, including those inrural and remote areas and Aboriginal males.The framework comprises 3 main objectives supportedby 17 key directions. The directions, as they stand,are laudable but do not outline specific men’s healthinitiatives. The challenge remains to translate theframework into policy supported by centrally coordinatedplanning and funding for male-specificinitiatives.Where to for male health in SA?Beyond dispute are the significant health issuesfor males across the age spectrum in SA. The atriskgroups identified by the Framework deserveadditional consideration. Improving access to healthservices, particularly in country SA, should be apriority. Considerations include easily accessible afterhourshealth care, male-friendly primary healthcareenvironments, male-friendly general practitioners,services that target Aboriginal males, provisionof primary healthcare services in non-traditionalenvironments (e.g. workplaces, men’s sheds, clubsand pubs) and increased numbers of male primaryhealthcare workers in general.There are few dedicated men’s health workers andno formal training programs for health service staffwho want or need to work with men. Yet, there areseveral men’s health groups based in SA able to providetraining and education, together with professionaldevelopment, in cooperation with government and51, 52tertiary institutions.Similarly, even though SA has the oldest network of‘men’s sheds’ in the country, 53 there is no infrastructureor other state support for them. With a few exceptions,this leaves what ought to be vibrant communities thatprovide important social and other supports for oldermen, 54 barely sustainable.More state-supported research is needed to addresspriority issues for men’s health in SA and to identifybetter ways to engage men with the health system.Research and preventive health initiatives thatspecifically target the physical and mental health needsof men in predominantly male industries such as miningand related services is also required. The royalty streamfrom the ‘mining boom’, together with the growingnumber of men working in mining, petrochemicaland other hazardous industries, presents a leadershipopportunity for partnership between government andindustry in safeguarding male health and wellbeing.While there are a number of short-term male healthprograms being delivered at the individual agencylevel, there is no statewide coordination or allocationfrom state budgets. Mapping, evaluating and thencoordinating implementation of the most effective ofthe current strategies would seem a worthwhile andlow-cost research objective.There are a number of male health initiativesthroughout Australia that, although notcomprehensively evaluated, are examples of programsshown to improve men’s health outcomes and these aresummarised in Text Box 1. They may serve as modelsfor South Australian health service policymakers,planners and providers. In sum, with relatively modesttargeted funding, significant gains could be made inaddressing male health issues, beginning by modellingprograms shown to be successful elsewhere, addressinggaps in existing policy and sensibly augmentingCommonwealth programs.Text Box 1: Examples of programs shown toimprove men’s health outcomes> Toll Holdings Second Step Program (secondstep@toll.com.au)> Men’s Resource Centre (Albany, Western Australia;WA)> Bendigo Men’s Health Clinic,> Pit Stop Men’s Health Check (http://www.acrrm.com.au/pit-stop-caring-rural-men%E2%80%99shealth)> "Less Gut" Wonders (Port Pirie Health Service, SA)> Men's Health - No More Secrets (http://www.lava.com.au/samples/menshealth/about.asp)> Diabetes Management along the Mallee Track 55> Men's Health Nights (Victoria) 56> 'Three in One' men's project (Wollongong, NewSouth Wales (NSW) 57> Diabetes Education Project (WA)58, 59There are also a number of programs forIndigenous males—Yura Yulang Men’s Program,(Campbelltown, NSW), Aboriginal Men’s Group(Redfern, NSW), MiB (Males in Black; Port Augusta,SA)—to name a few.page 38

Rural health in the 21st centurySummaryThere is a growing interest in and concern aboutmale health, both in Australia and overseas. Therewill be increasing prompting of government and NGOhealth policy and planning authorities to take up thechallenge of making an appreciable difference to malehealth outcomes. Essential to this must be a genderappreciative approach (which has proven successfulfor women’s health), an approach that appropriatelyaddresses the crucial determinants and particularneeds of male health. This will require little more thanmodest funding along with the creative utilisation andadjustment of existing resources. However, perhapsthe most fundamental prerequisite for progress inmale health is that we actually value males and theirindispensable contribution to the Australian community.References1. Commonwealth of Australia. National Male Health Policy- Building on the strengths of Australian Males. Canberra,ACT, Australia2010.2 . The Health Targets and Implementation (Health for All)Committee. Health for all Australians : report to theAustralian Health Ministers' Advisory Council and theAustralian Health Ministers' Conference. AustralianGovernment Publishing Service, Canberra, ACT; 1988.3 . Leahy K, Glover J, Hetzel D. Men’s health and wellbeing inSouth Australia: an analysis of service use and outcomesby socioeconomic status. PHIDU, University of Adelaide;2009.4 . Australian Bureau of Statistics. 3302.0 - Deaths, Australia,2009. [cited 2011 Jan 15]; Available from: http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/3302.02009?OpenDocument.5 . Australian Bureau of Statistics. 3302.0 - Deaths, Australia,2009 2010; Available from: http://www.abs.gov.au/ausstats/abs@.nsf/mf/3302.0.6. Pink B, Allbon P. The Health and Welfare of Australia'sAboriginal and Torres Strait Islander Peoples 2008. ABSCatalogue No. 4704.0, AIHW Catalogue No. IHW 21.Australian Bureau of Statistics, Australian Institute ofHealth and Welfare, Canberra, ACT; 2008.7. Draper G, Turrell G, Oldenburg B. Health Inequalities inAustralia: Mortality. Health Inequalities Monitoring SeriesNo. 1 AIHW Cat No. PHE 55, Canberra: QueenslandUniversity of Technology and the Australian Institute ofHealth and Welfare; 2004.8. Australian Bureau of Statistics. 3303.0 - Causes of death,Australia, 2008. Canberra: Australian Government; 2008[cited 2011 Jan 15]; Available from: http://www.abs.gov.au/ausstats/abs@.nsf/mf/3303.0.9. South Australia Department of Health. South AustralianMen’s Health Strategic Framework 2008-2012. SouthAustralian Government, Adelaide, SA, Australia2008.10. Australian Institute of Health and Welfare. Rural, regionaland remote health—Indicators of health. AIHW Cat.No. PHE 59: Canberra: AIHW (Rural Health Series no. 5);2005.11. Australian Institute of Health and Welfare. Rural, regionaland remote health: a study on mortality (2nd edition).Rural Health Series no. 8 Cat. no. PHE 95: Canberra:AIHW; 2007.12. Judd F, Cooper A, Fraser C, Davis J. Rural suicide - peopleor place effects? Australian and New Zealand Journal ofPsychiatry. 2006;40:208-16.13. Miller K, Burns C. Suicides on farms in South Australia,1997-2001. Australian Journal of Rural Health.2008;16:327-31.14. Australian Government Department of Health andAgeing. Living Is For Everyone (LIFE) Framework: Researchand Evidence in Suicide Prevention. Commonwealth ofAustralia: Canberra, ACT; 2008.15. Woods M. Dying for a Policy – Men’s & Boys' Health inAustralia. Men's Health Information & Resource CentreUniversity of Western Sydney; 2005.16. Macdonald JJ. Shifting paradigms: a social-determinantsapproach to solving problems in men's health policyand practice. Medical Journal of Australia. 2006200610;185(8):456-8.17. Robertson S. Men's health promotion in the UK: a hiddenproblem. Br J Nurs 1995 Apr 13-26;4(7):382, 99-401.18. Smith JA. Beyond masculine stereotypes: moving men'shealth promotion forward in Australia. Health promotionjournal of Australia. 2007;18(1):20-5.19. Smith J, Braunack-Mayer A, Wittert G, Warin M. It's sortof like being a detective: Understanding how Australianmen self-monitor their health prior to seeking help. BMCHealth Services Research. 2008;8(56).20. De Kretser D, Cock M, Holden C. The Men In AustraliaTelephone Survey (Mates) - Lessons For All. MedicalJournal of Australia. 2006;185:412-13.21. Robertson S, Williamson P. Men And Health Promotion InThe Uk: Ten Years Further On? Health Education Journal.2005;64(293-301).22. Turrell G, Stanley L, de Looper M, Oldenburg B. HealthInequalities in Australia: Morbidity, health behaviours,risk factors and health service use. Health InequalitiesMonitoring Series No. 2. AIHW Cat. No. PHE 72.Canberra: Queensland University of Technology and theAustralian Institute of Health and Welfare; 2006.23. Harvey PW. Social determinants of health - why wecontinue to ignore them in the search for improvedpopulation health outcomes! Aust Health Rev. 2006Nov;30(4):419-23.24. Linacre S. Australian Social Trends 2007: Work-relatedinjuries. Australian Bureau of Statistics, Canberra, ACT;2007.Volume 8, Number 1, March 2011 page 39

Public Health Bulletin25. Marmot M. Social determinants of health inequalities.Lancet. 2005;365(9464):1009-104.26. Wenitong M. Indigenous Male Health: A report forIndigenous males, their families and communities, andthose committed to improving Indigenous male health:The Office for Aboriginal and Torres Strait Islander HealthCommonwealth Department of Health and Ageing2002.27. Begg S, Vos T, Barker B, Stevenson C, Stanley L, LopezA. The burden of disease and injury in Australia 2003.PHE 82, Australian Institute of Health and Welfare,Canberra2007.28. Ashfield J. Men The Disposable Gender. Available from:http://www.menshealthaustralia.net/~mhirc//files/JA23MenDisposableGender.pdf.29. Lohan M. How might we understand men’s healthbetter? Integrating explanations from critical studies onmen and inequalities in health. Social Science & Medicine.2007;65 493-504.30. Australian Institute of Health and Welfare. Rural,regional and remote health: indicators of health statusand determinants of health. AIHW Cat. No. PHE 97:Canberra: AIHW (Rural Health Series no. 9); 2008.31. Australian Bureau of Statistics. 3235.0 - Populationby Age and Sex, Regions of Australia, 2009. [cited2011 Jan 15]; Available from: http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/3235.02009?OpenDocument#Data.32. Australian Government, Department of Health andAgeing. National Male Health Policy SupportingDocument: Access to health services. Canberra, ACT,Australia 2010.33. National and Medical Research Council. NHMRC CancerDataset. 2010 [cited 2011 March 10]; Available from:http://www.nhmrc.gov.au/_files_nhmrc/file/grants/dataset/cancer(1).xls.34. Baum F. The New Public Health. 3 ed. Melbourne,Victoria, Australia: Oxford University Press; 2008.35. Holt-Lunstad J, Smith TB, Layton JB. Social Relationshipsand Mortality Risk: A Meta-analytic Review. PLoS Med.2010;7(7):e1000316.36. Seeman TE, Lusignolo TM, Albert M, Berkman L.Social relationships, social support, and patterns ofcognitive aging in healthy, high-functioning olderadults: MacArthur Studies of Successful Aging. HealthPsychology. 2001;20(4):243-55.37. Marmot M. Inequalities in Health. The New EnglandJournal of Medicine 2001;345(2):134-638. Bunker SJ, Colquhoun DM, Murray D Esler, Hickie IB,Hunt D, Jelinek M, et al. “Stress" and coronary heartdisease: psychosocial risk factors. Medical Journal ofAustralia.178(6):272-76.39. Australian Bureau of Statistics. Causes of death, 3303.0.Canberra: Australian Government2006 2006. Report No.:3303.0.40. Australian Bureau of Statistics. Work related Injuries2005-6. Cat No. 6324, ABS, Canberra, ACT; 2006.41. Fritschi L, Driscoll T. Cancer due to occupation inAustralia. Australian and New Zealand Journal of PublicHealth. 2006;30(3):213-19.42. Safe Work Australia. Work Health and Safety Statistics,Australia. 2011; Available from: http://nosi.ascc.gov.au/Default.aspx.43. Safe Work Australia. Key Work Health and SafetyStatistics, Australia - 2011. Commonwealth Governmentof Australia, Canbera, ACT, Australia; 2011.44. Oldenburg B, McGuffog I, Turrell G. Socioeconomicdeterminants of health in Australia: policy responsesand intervention options. Medical Journal of Australia.2000;172(10):489-9245. Dixon J, Douglas R, Eckersley R. Making a difference tosocioeconomic determinants of health in Australia: aresearch and development strategy. Medical Journal ofAustralia. 2000;172(11):541-4.46. Leeder SR. The new public health. James CookUniversity, Townsville; 2005; Available from: http://www.menzieshealthpolicy.edu.au/media/doc/nphtnvl070305.pdf.47. Australian Medical Association. Men’s Health - 2005.Available from: http://www.ama.com.au/web.nsf/doc/WEEN-6B56JJ.48. Men’s Health Information & Resource Centre. Submissionto the Senate Select Committee on Men's Health:University of Western Sydney 2009.49. World Health Organization. Madrid Statement:Mainstreaming Gender Equity in Health: The Need toMove Forward. WHO; 2001.50. Australian Government, Department of Health andAgeing. National Male Health Policy SupportingDocument: Social determinants and key actions.Canberra, ACT, Australia 2010.51. Australian Institute of Male Health and Studies. Availablefrom: http://aimhs.com.au/cms/.52. Men's Heath SA. Available from: http://www.menshealthsa.com.au/.53. Golding B. A profile of men's sheds in Australia: patterns,purposes, profiles and experiences of participants: someimplications for ACE and VET about engaging older menWollongong, N.S.W.: [Nowra, N.S.W.]: AVETRA2006.54. Misan G, Sergeant P. Men's Sheds - a strategy to improvemen's health. 10th National Rural Health Conference;Cairns, Queensland, Australia May 17-20, 2009.page 40

Rural health in the 21st century55. Shephard MDea. The impact of point of care testingon diabetes services along Victoria's Mallee Track:results of a community-based diabetes risk assessmentand management program. Rural and Remote Health.2005;5(371).56. Verrinder A, Denner BJ. The success of men's healthnights and health sessions. Australian Journal of RuralHealth. 2000;8(2):81-6.57. Fildes D. The Three in One Men's Project: An EvaluationMethodology. Centre for Health Service Development(CHSD); 2005; Available from: http://ro.uow.edu.au/cgi/viewcontent.cgi?article=1002&context=chsd.58. Aoun S, Johnson L. Men's health promotion by generalpractitioners in a workplace setting. Australian Journal ofRural Health. 2002 2002 Dec;10(6):268-72.59. Aoun S, Johnson L. Diabetes education and screening inworksites in rural Western Australia. Health PromotionJournal of Australia. 2002;13(1):65.Community participation in theWhyalla Intergenerational Study ofHealth (WISH): looking back on thepossible influences of knowledge,trust and powerMatthew T HarenNHMRC Post-doctoral FellowSansom Institute for Health Research and Centre forRural Health and Community Development, Universityof South Australia;Spencer Gulf Rural Health SchoolUniversity of South Australia andThe University of AdelaideAngie StokesManager SustainabilityOneSteel Whyalla;Chair, WISH Community Advisory GroupJudy TaylorSenior Research FellowCentre for Rural Health and Community DevelopmentUniversity of South Australia;Spencer Gulf Rural Health SchoolUniversity of South Australia and The University ofAdelaideRobyn A McDermottNHMRC Practitioner FellowSansom Institute for Health ResearchUniversity of South AustraliaOn behalf of the WISH Investigators and the WISHCommunity Advisory GroupIntroductionLay knowledge is developed through what can beseen, touched and smelled (i.e. tangible evidence)and the prevailing community viewpoint (i.e. what isregarded as ‘common sense’). Thus, it is grounded inthe experience of everyday life in the community. 1 Incontrast, scientific knowledge is grounded in theory andmethodological principles, and is developed by qualifiedindividuals and academic institutions. In communityresearch, there is potential for conflict between theseforms of knowledge, and this can influence communitytrust and confidence in the study. 2In the North American context, Scammell et al. (2009)reported the existence of distrust in different elementsof research that appeared socially, contextuallyVolume 8, Number 1, March 2011 page 41

Public Health Bulletinand experientially derived, and which influence theacceptance of study findings. 3 They suggest that layknowledge, trust and power are the lens throughwhich a community views and judges health research.This paper retrospectively examines the potential forthese factors to influence community participationin an observational health study in a regionalcommunity. Participation is defined and examinedas: (1) participation in the research process throughcommunity consultation; and (2) participation throughinformed consent to the provision of data as a subjectin the healthy study.Research context, design and methodsBroad research contextIn 2006 collaboration was conceived betweenthree existing adult cohort studies with a focuson the biological, psychosocial and environmentaldeterminants of chronic health conditions in Adelaide,South Australia (SA). 4–6 The goals were to harmoniseprotocols across cohorts, collect a new wave of data,initiate a regional cohort and recruit dependent childrenof participating adults. The existing research capabilitiesof the Spencer Gulf Rural Health School (SGRHS) inWhyalla made the city a pragmatic choice for theregional site.The Whyalla research contextWhyalla is an industrial, outer regional city in SA withsocial, economic, political and physical environs thatmay pose excess health risk. Internal and externalperceptions of health in Whyalla may be dominatedby the visible issue of ‘red dust’ from the processes ofiron ore transport, crushing and screening by the majorindustry—an iron ore miner and steel manufacturer.This company employs, directly and indirectly, 3000 ofthe city’s 15000 working-age adults, and was the mainsource of income for 35% of the population in 2000. 7This was reflected by a greater than 20% enrichment ofblue-collar workers in the city in 2006. 8Previous research has suggested higher than expectedlevels of obesity, 7 asthma, 7,9 chronic lung disease, 7,9and chronic liver disease and lung cancer 9 in Whyalla.In 2006 a study suggested that smoking and alcoholconsumption alone were unable to explain the poorerrespiratory and hepatic health in the population, andinconclusive suggestions about a link with fugitive dustfrom industrial sites were made. 9 Due to the ecologicaldesign of the study, behavioural, sociodemographic andco-morbidity explanations cannot be excluded.Within this context, WISH was designed to:1. estimate the population prevalence and socialdistribution of: (a) cardiovascular disease; (b)diabetes and cardiometabolic risk; (c) asthma andchronic obstructive pulmonary diseases (COPD); and(d) anxiety, depression and psychological distress2. compare prevalences with state and nationalpopulation data and with collaborating metropolitancohorts3. examine parent–child dyad and individual-levelvariation in chronic conditions and intermediatephenotypes4. engage in knowledge translation with thecommunity and explore opportunities for bothongoing longitudinal research and communityinterventions.Community consultation processesInvolvement of community residents throughoutthe research process has been promoted by the USInstitute of Medicine as a way of achieving mutualexchange between lay and scientifically derived formsof knowledge. In theory, this should build trust in theresearch, moderate positions of power and result inmore complete and policy-relevant interpretations offindings. 10 Consultations with key local government,industry and regional development leaders in Whyallain 2007 aimed to inform and gain support for theproposed health study. The project had alreadybeen conceptualised, partly designed and fundedprior to consultation with these groups. In 2008 acommunity advisory group (CAG) was establishedusing stakeholder databases of SGRHS. Representativesfrom local government; industry; the health, economicdevelopment and education sectors; and communityorganisations were invited, and the first meeting washeld 4 months after study recruitment began.Sampling frame, contact strategiesand recruitmentRecruitment occurred between February 2008 andJuly 2009. Due to the commonality of mobile-phoneonlyhouseholds, 12 the residential housing database ofPlanning SA for Whyalla was preferred as the samplingframe over the Electronic White Pages. 11 The strengthof this sampling frame is its completeness; however,information was limited to residential addresses andpage 42

Rural health in the 21st centurytherefore household contact and recruitment was amultistage process (Figure 1). Invitations to participate,addressed to ‘The Householder’, were mailed to2500 randomly selected households and coordinatedwith a community-wide media campaign informedby individual consultations and later by the CAG.Householders were invited to register online or byphone, providing their telephone number and basicdemographic information.In stage two, sample addresses were matched to WhitePages® listings using SENSIS services. Direct matcheswere made for 1183 households, for which contact bytelephone could then be made. Unmatched householdswere contacted by doorknocking. Calling cards wereleft if nobody was found at home, and householdswere visited at least twice.Computer assisted telephone interviews (CATI I andII) were conducted by trained interviewers usingestablished protocols 13,14 to recruit one adult and,where present, one dependent child aged 0–17years from each household. Where multiple adults orchildren resided in the household, those who last hadtheir birthday were selected. 13 Households withouttelephones, or those who preferred face-to-facecontact, were interviewed in-home. Appointments forclinical assessments were made, and information andquestionnaire packs were mailed or hand delivered.Data collectionParticipation in consultation and advisory groupmeetings was obtained from meeting notes.Sociodemographic data of participants, and age group,sex and reason for refusal from non-participants,were collected where possible via CATI. Comparativesociodemographic data were extracted for Whyalladefinedsuburbs from the 2006 Census 8 to analyserepresentativeness of the cohort. Notes fromconsultation and CAG meetings were scanned forreferences to knowledge, trust and power, or relatedconcepts, and used to interpret the quantitativeparticipation findings. Meetings were neitherestablished with this intent nor designed specificallyto elicit such information, and notes were not subjectto thematic analysis. Findings from this exercise aretherefore hypothesis generating and should be testedby subsequent research.Self-report and objectively measured health outcomeand exposure data were collected using a combinationof telephone interviews, paper and electronicquestionnaires, and clinical assessments, but are notreported in this paper. A full list of data collected isavailable on the study website (http://sgrhs.unisa.edu.au/SGRHSProjects/project.asp?Project=271). Allparticipants provided written informed consent (and/or consent from legal guardians). All procedures andprotocols were approved by the Human Research EthicsCommittee of the University of South Australia and theAboriginal Health Research Ethics Committee of SouthAustralia.Data management and analysesData are stored on secure servers at SGRHS andUniSA. Where indicated, data were weighted to theage and sex distribution of the Whyalla population in2007 15 and the inverse likelihood of being recruited.Analysis was performed using STATA 10.1 for Windows(StataCorp, College Station TX USA).ResultsCommunity participation in the research processCommunity consultations in 2007 achievedsupport from local government, industry andregional development. Distrust in and perceiveddisempowerment by previous health research 9 waspresent in these sectors due to lack of communicationand involvement. The subsequent formation of theCAG was championed by stakeholders. Three meetingswere held in 2008 and one in 2009. Chaired bythe study manager, the meetings focused on publicawareness and recruitment, and attendances were:15/16 invitees (representing 10 different organisations)in April; 10/11 (7) in June and 10/10 (7) in September;and 21/27 (8) in August 2009. Local government andhospital and health services were represented at allmeetings; local industry at three; and the AboriginalHealth Service at one; while the education and socialwelfare sectors and the Division of General Practice didnot attend any meetings.Recruitment trends, participation andresponse ratesTemporal trends in the completion of CATI (blue bars)and clinical assessment (red bars) are shown in Figure1 (bottom panel) by contact mode (CATI I/II). The peakin CATI II completion from April to June 2008 identifiesthe response to SENSIS matching. The recruitmentvia CATI I from August to December 2008 and againin March 2009 largely identifies the response todoorknocking.Volume 8, Number 1, March 2011 page 43

Public Health BulletinThe participant flow from household sampling to CATIand clinic attendance is shown in Figure 2. The CATIresponse rate was 51% and the adult clinic responserate was 32.4%. Of the adults who attended clinics,30.9% had eligible children residing in their household,and from 55% of these a randomly selected child wasenrolled in the study. Non-participation in CATI didnot appear to be related to age or sex, and the mostfrequent reasons for non-participation were: ‘just don’twant to participate’ (33%); ‘too busy’ (29%); ‘toosick’ (8%); or ‘information discarded/not received/notunderstood’ (6%).Population representativeness and demographiccharacteristics of the cohortSociodemographic characteristics of participatingadults are summarised in Table 1. Married peoplewere over-represented by approximately 20%, whilenever-married people were under-represented byapproximately 10%. The sample was 10% underrepresentedby state housing administration renters.There was a 5% over-representation of UK/Ireland-bornadults.DiscussionCommunity participation—integrationof knowledgeThe two participation routes examined in this paperwere: (1) community consultation and advisory groupmeetings; and (2) recruitment as a subject in the healthstudy. WISH experienced a high level of communityparticipation in the research process through CAGmeetings in 2008–09; however, not all relevant sectorswere represented. The level of community advisoryparticipation did not translate to high participationlevels among residents randomly sampled forrecruitment into the study. The final response ratesto both CATI (51%) and clinical assessments (32.2%)were approximately 15–20% lower than what hadbeen achieved in the hands of the recruitment teamin similar suburban metropolitan studies in previousyears. 14,16 The cohort displayed some differences to theWhyalla population in social characteristics, for examplemarital status and residential tenure type, suggestinga social pattern to participation. Non-participation,however, did not appear to relate to age or sex, andthe majority of non-participants cited ‘just don’t wantto [participate]’ or ‘too busy’ as reasons for nonparticipation.Lay knowledge (through the CAG) was sought toinform strategies to maximise recruitment. In June2008 open recruitment to volunteers outside of therandom sample was suggested. This was rejectedby investigators due to potential selection bias butremained a point of discussion in CAG meetingsafter recruitment was completed, demonstrating thedifficulty in integrating both forms of knowledge.A solution may have been to maintain a randomlyselected cohort (for representativeness), supplementedwith a self-selected cohort (to maximise absolutenumbers), and this approach could be reviewed as anoption in future studies. Other strategies that wereimplemented included: ‘talking up’ WISH with familyand friends; organisational newsletters and meetings;approaching randomly selected households in person;community television; and Whyalla Show and shoppingcentre booths (Figure 1, media campaign panel).The high level of non-attendance at clinic appointmentspresented scientific and management challenges.Inconvenience was identified as a potential barrier bythe CAG, and strategies to make clinic attendancemore convenient included splitting appointments,home visits and provision of transportation. Despiteimplementation of all strategies, 22% of adultsscheduled for appointments subsequently withdrew.Analysis of CATI refusal data showed that only ninepeople (

Rural health in the 21st century1st meetingswith stakeholder(18 Jul 2007)Communityconsultation meeting(18 Apr 2008)Community consultation1st meeting of WISHCommunity Advisory group(25 Jun 2008)2nd meeting of WISHCommunity Advisory group(16 Sep 2008)3rd meeting of WISHCommunity Advisory group(13 Aug 2009)Community advisory groupmeeting are ongoing and occurquarterlyMedia campaignABC radiointerview(Dec 2007)ABC radiointerview(29 Feb 2008)Central t.v.news storyBooth at Whyalla Show(16-17 Aug 2008)Booth at shoppingprecinctABC Stateline story(14 Nov 2008)Local newspaper advertorials Central t.v. cash classifieds Organisation newsletter/email promotionHousehold approach strategiesMail out/selfregistration(6 Feb 2008)SENSIS matching/coldcalling (4 Mar 2008)Booth atWhyalla Show(16-17 Aug 2008)Booth at shoppingprecinct (Nov)Doorknocking (began 22 Jul 2008, intensified Nov/Dec)10 10 20 300 10 20 30201 Jan 08 01 Apr 08 01 Jul 08 01 Oct 08 01 Jan 09 01 Apr 09dateCATI’s completedClinic appointments attendedGraphs by participant completed WISH CATI I or WISH CATI IIFigure 1: Contact and recruitment strategy and timeline for Whyalla Intergenerational Study of HealthVolume 8, Number 1, March 2011 page 45

Public Health BulletinUnoccupied 99Address non-existent 11Original Samplen=2498Couldn't enter household 2Vacant block 2Sample loss a 12Eligible Samplen=2245Completed CATIn=1146 (Response rate 1 c : 51%)Made clinic appointmentn=923Completed clinical protocolsn=722 (Response rate 2 d : 32.2%)Households with children n=223 (30.9%)Adult only households n=499 (69.1%)Unable to be contacted b 126Via CATI 32Via doorknocking 94Refusals 1072 47.8%No info obtained 373Demographicinfo obtained 699Incapable/too ill 27 1.2%Refused clinic 223 19.5%Withdrew/repeatedlymissed appointment201 21.8%Completed post-CATIquestionnaires/consented to datalinkage 4 0.04%Notes:aSample loss includes from deaths,foreign language/no interpreter, hearingimpairment.bAfter a minimum of 6 attempts for CATIand 2 attempts for doorknocking.cCompleted CATI divided by ELIGIBLESAMPLEdCompleted clinical protocols divided byELIGIBLE SAMPLEeChild participants divided by COMPLETEDCLINICAL PROTOCOLS: HOUSEHOLDSWITH CHILDRENChild participantsn=131 (Response rate 3 e : 58.7%)Figure 2: Flowchart of adult and child participation in Whyalla Intergenerational Study of Health, February2008 to June 2009was related to strong doubt about the success ofcommunity participation in health studies. 3 A cultureof apathy implies impact across a range of communityhappenings. It is unknown how widespread thisperceived culture is, what subgroups of the populationit exists in or how it has been acquired. This barrier tocommunity participation deserves further study, bothgenerally and as it relates to health.Applications and extensions of the research—integrating knowledge, building trust,sharing powerThe first report from WISH is due for public releasein early 2011 and will be available from the studywebsite. The report was reviewed by the CAG, which isresponsible for development of the public disseminationstrategy and application of the findings to the WhyallaHealth Service Plan 17 and the Whyalla CommunityPlan. 18 Improving recognition of the way in whichinformation about health is obtained (‘research literacy’)may foster better acceptance and understanding ofresearch, and the CAG has highlighted this as a spinoffbenefit of WISH. Future goals of the CAG are tobroaden stakeholder engagement; inform analysis andinterpretation of baseline data; and contribute to futureresearch with the cohort and application of findingsthrough policy advocacy, service provision and practice,and intervention design and implementation.ConclusionWISH has built on previous health studies in theWhyalla population, with a primary focus on theprevalence and social distribution of cardiometabolic,respiratory and psychological ill-health. The studyhas fostered community participation but did notinitiate it from study conception, and some sectorsremain disengaged. Community participation in theresearch process has been high despite some previousexperiences leading to distrust and disempowerment.Recruitment to the health study, however, did appearto have social barriers that may relate to a ‘culture ofapathy’, but this hypothesis requires further exploration.page 46

Occupation d,f Manager 0.049 21 0.018 0.019 14 0.019 0.018Rural health in the 21st centuryWhyalla WISH CATI a WISH clinical assessment(2006,ABS) sample (n=1143) sample (n=726)Census n crude weighted n crude weightedn (aged ≥18 years) 15621 1143 726Age (years) b 18 to 24 0.116 89 0.078 0.125 49 0.067 0.12525 to 34 0.162 172 0.150 0.164 90 0.124 0.16435 to 44 0.208 241 0.211 0.206 157 0.216 0.20645 to 54 0.177 205 0.179 0.177 140 0.193 0.17755 to 64 0.150 212 0.185 0.147 150 0.207 0.14865 to 74 0.108 144 0.126 0.107 90 0.124 0.10775 + 0.079 80 0.070 0.075 50 0.069 0.075Sex, male b 0.501 474 0.415 0.511 310 0.427 0.512Dwelling ownership bOwn/purchasing 0.577 745 0.652 0.677 484 0.668 0.687Rent (Housing Trust) 0.241 237 0.207 0.182 135 0.186 0.159Rent (private/company) 0.059 153 0.134 0.132 103 0.142 0.149Refused 0.031 8 0.007 0.009 3 0.004 0.006Country of birth cAustralia 0.730 809 0.708 0.718 498 0.689 0.692UK/Ireland 0.132 223 0.195 0.181 147 0.203 0.187Other 0.138 109 0.095 0.101 78 0.108 0.121Australian Aboriginalor Torres StraitIslander, yes0.036 28 0.025 0.022 16 0.022 0.019Marital status dMarried/live-in partner 0.498 661 0.578 0.668 436 0.601 0.685Widowed 0.079 113 0.099 0.070 63 0.087 0.061Divorced/separated 0.143 167 0.146 0.081 103 0.142 0.072Household size,medianNever married 0.280 196 0.171 0.176 120 0.166 0.1762.400 1143 2.000 2.000 1143 2.000 2.000Unemployed e , yes 0.050 41 0.036 0.036 24 0.033 0.025Table 1:Sociodemographicrepresentativenessof computerassisted telephoneinterview and clinicalsamples of WhyallaIntergenerationalStudy of Health withrespect to overall adultpopulation of WhyallaNotes:WISH: WhyallaIntergenerationalStudy of Health;CATI: computer assistedtelephone.aProportions for WISHare of the total study orweighted sample aged18 years and over.bProportions for census areof the population aged18 years and over.cProportions for census areof the total population.dProportions for census areof the population aged20 years and over.cProportions for census areof the population aged15 years and over.fOccupation in WISHis primary lifetimeoccupation, whereasCensus data is currentoccupation.Professional 0.075 140 0.122 0.117 103 0.142 0.136Technician/trade 0.092 196 0.171 0.195 138 0.190 0.216Community or personalservice occupation0.052 77 0.067 0.062 53 0.073 0.066Clerical/administrative 0.059 137 0.120 0.111 93 0.128 0.121Sales worker 0.042 155 0.136 0.132 97 0.134 0.136Machine operator/driver0.065 47 0.041 0.044 29 0.040 0.037Labourer 0.071 289 0.253 0.254 155 0.213 0.209Never worked/unable/undefinedn/a 37 0.032 0.035 20 0.028 0.038Home duties n/a 44 0.038 0.031 23 0.032 0.024Volume 8, Number 1, March 2011 page 47

Public Health BulletinThrough the CAG, it is anticipated that equality ofpower will be achieved across sectors and the researchteam, establishing confidence in the research andinvestment in the direction and utility of this communityhealth project.AcknowledgmentsThe WISH Investigators would like to acknowledge thegenerous contribution of time, effort and informationsharing by all Whyalla residents involved in the studyas participants, advisory group members, consultantsand staff. The WISH Investigators, staff, CAG membersand SAPHIRe members are listed on the study website(www.wishwhyalla.info). We gratefully acknowledgethe contribution of the North-west Adelaide HealthStudy team.Funding was provided by the South Australian Premier’sScience Research Fund (RAM). Matthew T Haren issupported by a Post-doctoral Training Fellowship (PublicHealth) from the National Health and Medical ResearchCouncil (NHMRC) of Australia (# 511345).References1. Schutz A. Common-sense and scientific interpretation ofhuman action. Philos Phenomenol Res 1953; 14(1):1–382. Brown P. Popular epidemiology challenges the system:citizen action in stopping toxic waste and pollution ofwater supply. Environment 1993; 35:16–31.3. Scammell MK, Senier L, Darrah-Okike J, Brown P, Santos S.Tangible evidence, trust and power: public perceptions ofcommunity health studies. Soc Sci Med 2009; 68:143–153.4. Grant JF, Taylor AW, Ruffin RE, Wilson DH, Phillips PJ,Adams RJ et al. Cohort profile: the North West AdelaideHealth Study (NWAHS). Int J Epidemiol 2009; 38(6):1479–1486.5. Martin S, Haren M, Taylor A, Middleton M, Wittert G,Members of the Florey Adelaide Male Ageing Study(FAMAS). IJE Cohort Profile: the Florey Adelaide MaleAgeing Study (FAMAS). Int J Epidemiol 2007; 36(2):302–306.6. Crotty M, Miller M, Giles L, Daniels L, Bannerman E,Whitehead C et al. Australian Longitudinal Study ofAgeing: prospective evaluation of anthropometric indicesin terms of four year mortality in community-living olderadults. J Nutr Health Aging 2002; 6(1):20–23.7. Dal Grande E, Dempsey P et al. Whyalla Health Survey.South Australian Department of Human Service, Adelaide,2000.8. Australian Bureau of Statistics (ABS). Population andHousing Census: Basic Community Profile. Cat. no.2001.0. 2006.9. Department of Health. Whyalla Health Impact StudyReport. Government of South Australia, Adelaide,2006.10. US Institute of Medicine (ed.). Towards environmentaljustice: research, education, and health policy needs.National Academy Press, Washington DC,1999.11. Grant JF, Chittleborough CR, Taylor AW, Dal GrandeE, Wilson DH, Phillips PJ et al. The North WestAdelaide Health Study: detailed methods and baselinesegmentation of a cohort for selected chronic diseases.Epidemiol Perspect Innov 2006; 12:3–4.12. Dal Grande E, Taylor AW. Sampling and coverage issues oftelephone surveys used for collecting health information inAustralia: results from a face-to-face survey from 1999 to2008. BMC Med Res Methodol 2010; 26:10–77.13. Dillman DA. Mail and telephone surveys: the total designmethod. Wiley-Interscience (Wiley & Sons), New York,1978.14. Grant JF, Chittleborough CR, Taylor AW, Dal GrandeE, Wilson DH, Phillips PJ et al. The North WestAdelaide Health Study: detailed methods and baselinesegmentation of a cohort for selected chronic diseases.Epidemiol Perspect Innov 2006; 12:3–4.15. Australian Bureau of Statistics (ABS). Population by ageand sex, South Australia, 2007. ABS, Canberra, 2008.16. Martin S, Haren M, Taylor A, Middleton M, Wittert G,Members of the Florey Adelaide Male Ageing Study(FAMAS). The Florey Adelaide Male Ageing Study(FAMAS): design, procedures & participants. BMC PublicHealth 2007; 7(1):126.17. Whyalla Health Advisory Council. Whyalla: 10 yearlocal health service plan. SA Health, 2011. http://www.countryhealthsa.sa.gov.au18. Whyalla City Council. The Whyalla community plan:Whyalla towards 2022 vision. 2009. http://www.whyalla.sa.gov.aupage 48

Rural health in the 21st centuryScreening for colorectal cancer inremote, rural and metropolitanSouth Australia: analysis of theNational Bowel Cancer ScreeningProgram dataAngelita Martini *Sara Javanparast *Paul R Ward *Stephen Cole *Paul Aylward †Genevieve Baratiny *†Tiffany Gill †George Tsourtos *Gary Misan †Carlene Wilson *OGraeme Young **Flinders University†The University of AdelaideOCancer Council SAContext and backgroundThe early detection of colorectal cancer (CRC) is a majorclinical and public health concern. CRC is now thesecond most commonly diagnosed cancer in Australiaand has the second highest cancer mortality rate. 1Around 1 in 19 men and 1 in 28 Australian womenwill develop the disease before 75 years of age. 1 In2005 there were 4165 deaths from CRC in Australia,accounting for almost 11% of all cancer deaths. 1Cancer mortality rates vary according to the remotenessof a person’s place of residence. 2 The average annualdeath rate for CRC during 1998–2001 in Australiawas highest in inner and outer regional areas (13.4%and 13.3%), followed by major cities (12.8%), remoteareas (12.4%) and very remote areas (7.7%). 2 Survivalis inversely related to the degree of cancer progression,and up to 90% of all deaths from CRC may bepreventable with early detection. 3A number of randomised controlled trials havedemonstrated the effectiveness of CRC screening forreducing its incidence and mortality. However, thesebenefits have been limited by a number of factorsincluding the accuracy of screening technology, 7 thewillingness of eligible populations to participate, 8access to CRC screening 4,5 and primary healthcarepractitioners, 9 geographical location, 10 Indigenousstatus, and a range of social, demographic andeconomic factors. 14,15The Australian CRC population-based screeningprogram, the National Bowel Cancer Screening Program(NBCSP), was implemented in South Australia (SA) inJanuary 2007. The NBCSP aims to facilitate Australiawideaccess to CRC screening services. Phase oneof the program (August 2006 – June 2008) offeredfree screening by faecal occult blood test (FOBT) topeople recorded on the Medicare and Department ofVeterans Affairs registers who turned 55 or 65 yearsof age between 1 May 2006 and 30 June 2008 (theNBCSP Register). The FOBT screening kits were alsooffered to people who had been invited to screen inthe 2003 NBCSP and who were aged between 55 and74 years on 1 January 2003. Eligible participants weresent invitation packages by Medicare that included animmunological FOBT kit, and were requested to mailtheir FOBT sample to a central pathology service foranalysis. Participants who returned a positive resultwere advised by mail to visit a general practitioner (GP)to arrange further examination.However, provision of the NBCSP to all populationsubgroups does not result in equity in screeninguptake. In SA disparities exist in bowel cancer screeningparticipation. People of male gender, in lower agegroups, of lower socioeconomic status, from culturallyand linguistically diverse (CALD) groups, and Indigenouspeople have lower rates of participation. This resultis consistent with the national statistics on NBCSPparticipation rates.Aim of studyThis study aimed to explore the association betweenscreening participation and different sociodemographicindicators in SA. This was part of a broader study thatincluded a qualitative exploration of the barriers toand facilitators of NBCSP participation among selectedethnic groups, Indigenous Australians and people whospeak English at home. This paper also drawson these qualitative findings in discussing the uptakeof screening in rural, remote and metropolitan areasof SA.Study design and methodologyThe project was conducted over three stages,employing a mixed methodology approach includinga literature review and quantitative and qualitativemethods.In stage 1, de-identified data for the South Australianpopulation invited to participate in phase one of theNBCSP (between January 2007 and July 2008) wereprovided by Medicare Australia. The dataset includedVolume 8, Number 1, March 2011 page 49

Public Health Bulletinthe age, sex and postcode of those people sent theFOBT (i.e. invitees—the denominator in participationrates) and the age, sex, postcode, Indigenousstatus and language spoken at home of those whocompleted the FOBT (i.e. participants—the numeratorin participation rates). Ethics committee approval wasgranted by the Departmental Ethics Committee of theCommonwealth Department for Health and Ageingand by the Social and Behavioural Research EthicsCommittee of Flinders University.The postcode variable was converted into two newseparate variables for use in the analysis. First, eachpostcode was coded according to the Index of RelativeSocial Disadvantage (IRSD), 16 a composite measurebased on selected Census variables such as income,educational attainment and employment status. TheIRSD scores for each postcode were then groupedinto quintiles for analysis, where the highest quintilecomprised the 20% of postcodes with the highestIRSD scores (the most advantaged areas). Second,each postcode was converted into a measure of‘remoteness’ using the Accessibility/Remoteness Indexof Australia (ARIA). 17 This is an index of the accessibilityof postcodes to service centers or, conversely, ofremoteness of postcodes. The ARIA has both a 5-pointand a 3-point scale. We chose to use the 3-point scale,which includes the categories of metropolitan, rural andremote areas.Stage 2 of the study employed a qualitative methodto explore barriers to, enablers of and culturalappropriateness of bowel cancer screening in SA.In-depth interviews were conducted with threepopulation subgroups. Group 1 included SouthAustralians from three ethnic groups: Greek,Vietnamese and Iranian. Criteria for selection of ethnicgroups were based on population size in SA, averagepopulation age, average length of stay in Australia,resources available to ensure study feasibility, andwhether the community had already been studiedon this question. The second group included Anglo-Australian residents who were native English speakers.Based on our postcode mapping in stage 1, weselected locations with the highest and lowest rates ofparticipation and advertised in local papers in selectedareas to recruit study participants. Group 3 includedIndigenous Australians living in SA. Participants wereselected from males and females aged between 50 and75 years.Data analysisStatistical data were analysed using the StatisticalPackage for the Social Sciences version 15.0. In totalthere were 92279 invitees during phase one of theNBCSP (January 2007 to July 2008 in SA), including the17497 who had been involved in the pilot phases of theNBCSP. The pilot invitees were removed from the dataanalysis because their prior exposure to CRC screeningmay have had a confounding effect on NBCSPparticipation. Therefore, our final dataset for analysisincluded 74782 South Australians who had beeninvited to undertake CRC screening for the first timeby the NBCSP. It was not possible to ascertain if thesepeople had previously been offered, or participated in,CRC screening.Mapping and analysis of the NBCSP data wasperformed by placing Australian Bureau of Statistics(ABS) Census of Population and Housing data andNBCSP data for Adelaide into a geographic informationsystem (GIS) using ESRI ArcGIS software, MapInfo,Microsoft Access and Microsoft Excel. Data wasaggregated to postcode and participation was thenmapped according to overall participation rates, sexand age. Postcodes with less than 20 participants (9in the Adelaide Metropolitan area and 48 in rural andremote SA) were considered to have insufficient datafor mapping.Bivariate analysis using chi-square (c 2 ) tests wasundertaken to analyse the associations betweenparticipation in the NBCSP and sociodemographicvariables (age, sex, Indigenous status, language spokenat home, IRSD and ARIA). All variables associatedwith NBCSP participation rate at the p

Rural health in the 21st centuryfrom the research questions—perceptions aboutdisease prevention, perceptions about cancer andcancer prevention, knowledge and experience aboutbowel cancer, participation in bowel cancer screening,barriers and enablers for screening test uptake, culturalissues and recommendations. In addition to thesedeductively derived codes, the team also generatedcodes inductively to capture unexpected concepts inparticipants’ accounts. This combined coding structurewas used to code all of the data, and the samestructure was applied across all study groups to enablecomparisons between groups.ResultsStage I: Epidemiological analysis of the NBCSP inSouth AustraliaBased on the findings of stage I, 46.9% of invitees ofthe SA NBCSP agreed to participate in the program bycompleting and returning their FOBT and participantdetails form. Our findings revealed that rates ofparticipation varied according to place of residence,gender, age, socioeconomic status, ethnicity andIndigenous status. Table 1 profiles the South AustralianNBCSP participants within these categories.Figures 1 shows the overall participation rates in ruraland remote SA for phase a one of the NBCSP, plotted foreach postcode region.PostcodeIn the Adelaide Metropolitan region there weregenerally higher participation rates in the south andeast, and lower participation rates in the centre, westand outer north. Geographical variation in participationrates was also revealed in rural and remote SA, withhigher participation in the south-east. The highestparticipation rate in rural SA was 70%, compared with79% in the metropolitan area (Figures 1). However,in the north, east and west of regional SA, therewere large areas excluded from analysis because ofinsufficient invitees per postcode.ARIAOverall participation rates were similar in metropolitanand remote areas (45.6% and 46.0% respectively) andrates were slightly higher in rural areas (48.6%). Therural and remote SA participation rates were statisticallysignificantly different (p

Public Health BulletinGenderThe participation rate was higher for women (49.9%)than men (43.9%). In the Adelaide Metropolitan areathere were generally higher participation rates in thesouth-east and lower rates in the centre, north andnorth-west. Similar patterns of gender disparity inscreening participation were found in rural and remoteareas, with significantly more postcodes recording highfemale participation rates of 60–100% compared withmale rates.IRSD / SEIFAParticipation rates varied significantly (p

Rural health in the 21st centuryFigure 1: NBCSP participation rates in rural and remote South Australia by postcodeData Source: Australian Bureau of Statistics 2006 Census Boundaries and SA Bowel screening data.Map prepared by Deborah Nankervis, Augusts 2009.bowel cancer or the national screening program.Suggestions to overcome the lack of awareness aboutbowel cancer included public education using nationaland local media, culturally friendly sessions and nationalcampaigns.Facilitators to screeningFactors that were considered to be facilitators ofscreening uptake were peace of mind, the chance todetect cancer in the early stages, no cost for the test,having a personal history of cancer, being able to dothe test privately, having done other screening tests,Volume 8, Number 1, March 2011 page 53

Public Health Bulletindoctors’ recommendations, obligation and respect towhat is offered for peoples’ health, reminder letters andbeing encouraged by family and friends.Barriers to screeningBased on the barriers identified by different groups ofparticipants, a few remedial actions were recommendedto improve the rate of participation in the NBCSP.Overcoming language barriers was commonlyrecommended by people with different ethnicbackgrounds. The engagement of medical practitionersin the program was the most effective action suggestedby many of the Anglo-Australian people. The mostfrequent barriers to bowel cancer screening cited bythe study participants were embarrassment, doubtabout test accuracy, difficulty in dealing with faeces andsending the sample via mail, lack of knowledge aboutthe screening test, a fatalist view about cancer andunwillingness to know the result, fear of doing furtherinvasive tests, inability to read English and following theinstructions, and lack of a physician’s recommendation.Discussion and conclusionIn this study we examined the association betweensociodemographic characteristics and screeningparticipation among those aged 55 and 65 yearsin metropolitan Adelaide and rural and remote SAwho had received a written invitation to participatethrough the NBCSP. In order to gain a deeperunderstanding of the barriers and facilitators ofscreening participation, we also conducted qualitativeinterviews with Indigenous people and other culturalgroups who speak a language other than English athome (Greek, Vietnamese and Iranian people), asthese are known to have lower participation rates. Forcomparative purposes Anglo-Australian people werealso interviewed.Overall, our analysis revealed lower NBCSP participationrates for men compared with women, for populationsresiding in areas of relative disadvantage, for 65 yearolds compared with the 55 year old group, and forpeople from metropolitan and remote areas comparedwith those from rural areas. In addition, comparisonwith the most recent Census data indicated that SouthAustralian participants in the NBCSP who reportedspeaking a language other than English at home, andthose who reported an Indigenous background, wereunder-represented. These differences in screeningparticipation rates, while potentially explainable inpart by other factors, highlight the high likelihood ofinequity for CRC screening in SA. These findings areconsistent with results from other cancer screeningprograms, which suggest that inequitable patternsof participation may arise from a variety of factorsincluding those associated with gender, 20,21 ethnicity, 22,23socioeconomic status 24,25 and Indigenous status. 26,27 Theuptake of cancer screening is particularly poor for olderrural and remote residents, men, Indigenous people,lower socioeconomic groups and those living in FarNorth SA.Our findings are also consistent with the national dataon CRC screening participation for metropolitan, ruraland remote areas, with people of male gender, in theyounger of the two age groups (i.e. aged 55 yearsat the time of screening), living in areas of relativedisadvantage, who do not speak English at home, andIndigenous people having lower rates of participation.While there are common and group-specific barriersand enablers that prevent or facilitate screening uptakenationally, this study revealed that group-specificinequalities also exist within NBCSP participation in SA.While being preventive oriented, identifying cancer asa treatable disease was less evident among the ethnicgroups and Indigenous people interviewed. A sense ofdreading the disease combined with poor awareness ofscreening and language difficulties may also contributeto explaining inequities in screening uptake.This study did not address the inequity in opportunityto participate for some population subgroups, forexample people who do not appear on the NBCSPinvitee Medicare register, prisoners, those withoutregular mail service or the homeless. The overallparticipation rates also obscure the differences in ratesshown on various maps.Variation between regions in the rates of CRC screeningof different subpopulations is conveniently visualisedin the participation maps subdivided by postcode. Theutility of such maps is to assist in planning servicesand interventions aimed at maximising participationin FOBT-based CRC screening. The maps also serveas baseline data for visualising the effectiveness offuture interventions aimed at increasing participation,particularly in subpopulations.page 54

Rural health in the 21st centuryReferences1. Australian Institute of Health and Welfare (AIHW),Australasian Association of Cancer Registries (AACR).Cancer in Australia: an overview, 2008. Cancer Series.AIHW and AACR, Canberra, 2008.2. Australian Institute of Health and Welfare (AIHW). Cancerin Australia 2001. AIHW, Canberra, 2004.3. Smith R, von Eschenback A, Wender R, Levin B, ByersT, Rothenberger D, Brooks D, Creasman W, Cohen C,Runowicz C, Saslow D, Cokkinides V, Eyre H. AmericanCancer Society guidelines for the early detection ofcancer: update of early detection guidelines for prostate,colorectal, and endometrial cancers. CA Cancer J Clin2001; 51:38–75.4. Kronborg O, Fenger C, Olsen J, Jorgensen OD,Sondergaard O. Randomised study of screening forcolorectal cancer with faecal-occult-blood test. Lancet1996; 348:1467–1471.5. Hardcastle JD, Chamberlain JO, Robinsonk MH, MossSM. Randomised controlled trial of faecal-occult-bloodscreening for colorectal cancer. Lancet 1996; 348:1474–1477.6. Mandel J, Church T, Bond J. The effect of fecal occultbloodscreening on the incidence of colorectal cancer, NEngl J Med 2000; 343:1603–1607.7. Whitlock E, Lin J, Liles E, Beil T, Fu R. Screening forcolorectal cancer: a targeted, updated systematic reviewfor the US Preventive Services Task Force. Ann Intern Med2008; 149:638–658.8. Ford J, Howerton M, Lai G, Gary T, Bolen S, Gibbons M,Tilburt J, Baffi C, Tanpitukpongse T, Wilson R, Powe N,Bass E. Barriers to recruiting underrepresented populationsto cancer clinical trials: a systematic review. Cancer 2008;112:228–242.9. Hamilton W. Five misconceptions in cancer diagnosis. Br JGen Prac 2009; 59:441–447.10. Javanparast S, Ward P, Cole S, Gill T, Ah Matt M, AylwardP, Baratiny G, Jiwa M. Martini A, Mison G, TsourtosG, Wilson C, Young G. A cross-sectional analysis ofparticipation in National Bowel Cancer Screening Programin Adelaide by age, gender and geographical location ofresidence. Australasian Med J 2010; 1:141–146.11. Condon JR, Armstrong BK, Barnes A, Cunningham J.Cancer in Indigenous Australians: a review. Cancer CausesControl 2003; 14:109–121.12. Condon JR, Armstrong BK, Barnes T, Zhao Y. Cancerincidence and survival for indigenous Australians inthe Northern Territory. Aust N Z J Public Health 2005;29:123–128.13. Condon JR, Barnes T, Armstrong BK, Selva-Nayagam S,Elwood JM. Stage at diagnosis and cancer survival forIndigenous Australians in the Northern Territory. Med JAust 2005; 182:277–280.14. Whynes DK, Frew EJ, Manghan CM, Scholefield JH,Hardcastle JD. Colorectal cancer, screening and survival:the influence of socio-economic deprivation. Public Health2003; 117:389–395.15. Javanparast S, Ward P, Young G, Wilson C, Carter S, MisonG, Cole S, Jiwa M, Tsourtos G, Martini A, Gill T, Baratiny G,Ah Matt M. How equitable are colorectal cancer screeningprograms which include FOBTs? A review of qualitativeand quantitative studies. Prev Med 2010; 50:165–172.16. Australian Bureau of Statistics (ABS). Census of populationand housing: Socio-Economic Indexes for Areas (SEIFA).Technical Paper. ABS, Canberra, 2004.17. Australian Institute of Health and Welfare (AIHW). Rural,regional and remote health: a guide to remotenessclassifications. AIHW, Canberra, 2004.18. Hosmer D, Lemeshow S. Applied logistic regression (2ndedn). John Wiley & Sons, New York, 2000.19. Australian Bureau of Statistics. Census CommunityProfile Series: South Australia, 2006. http://www.censusdata.abs.gov.au/ABSNavigation/prenav/PopularAreas?collection=census/period=200620. Friedemann-Sanchez G, Griffin JM, Partin MR. Genderdifferences in colorectal cancer screening barriers andinformation needs. Health Expect 2007; 10:148–160.21. Beeker C, Kraft JM, Southwell BG, Jorgensen CM.Colorectal cancer screening in older men and women:qualitative research findings and implications forintervention. J Community Health 2000; 25:263–278.22. Wong S, Gildengorin G, Nguyen T, Mock J. Disparities incolorectal cancer screening rates among Asian Americansand non-Latino Whites. Cancer 2005; 104:2940–2947.23. Walsh J, Kaplin C, Nguyen B, Gildengorin G, McpheeS, Perez-stable E. Barriers to colorectal cancer screeningin Latino and Vietnamese Americans compared withnon-Latino White Americans. J Gen Intern Med 2004;19:156–166.24. McCaffery K, Wardle J, Nadel M, Atkin W. Socioeconomicvariation in participation in colorectal cancer screening. JMedl Screen 2002; 9:104–108.25. Wardle J, McCaffery K, Nadel M, Atkin W. Socioeconomicdifferences in cancer screening participation: comparingcognitive and psychosocial explanation. Soc Sci Med 2004;59:249–261.26. Ward PR, Kelly B, Tucker G, Luke C. Theoretical andconceptual issues around equity in health care: applicationto cervical cancer screening in South Australia. PublicHealth Bull 2006; 5:9–14.27. Binns PL, Condon JR. Participation in cervical screeningby Indigenous women in the Northern Territory: alongitudinal study. Med J Aust 2006; 185:490–494.Volume 8, Number 1, March 2011 page 55

Public Health BulletinRFDS as a preventive health agencyin the rural and remote settingJohn SetchellGeneral Manager - Health ServicesRoyal Flying Doctor ServiceThe purpose of this paper is to outline the variouspreventive primary healthcare programs conductedby the Royal Flying Doctor Service (RFDS) throughoutAustralia, and to demonstrate the extensive role thatthe organisation has in this area of health care.HistoryThe RFDS was established by the Reverend JohnFlynn in 1928; he envisaged that a ‘mantle of safety’would be provided to those people who workedand lived in the remote and outer rural areas of thecontinent. The initial services related to a doctor, pilotand aircraft travelling to an injured or unwell patientand transporting them back to a hospital setting formedical care. In 1928, 225 patients were transportedand 30000 km flown. Over time the services grew andflight nurses were added to the crew mix, such thatin the 2009–10 financial year 38852 patients weretransported and 25592455 km were flown.For many Australians their perception of the role of theRFDS continues to be only that of teams of doctors,nurses and pilots travelling to remote locations to treatand transport injured and unwell patients. However,for many years the RFDS has also provided primarycare services to residents of remote Australia. In 1995it produced a strategic plan—The Best for the Bush a—that clearly articulated a significant role for the RFDSin the broadest range of health-service delivery basedaround comprehensive primary care principles. Sincethe publication of this document, the following types ofpreventive health programs have been developed:> > general practitioner (GP) and community healthnurse (CHN) remote clinics> > rural women’s GP services (RWGPS)> > mental health programs> > health promotion programs> > healthy living programs> > Aboriginal and Torres Strait Islander health programsIn 2009–10146014 patients were treated throughoutAustralia at numerous locations serviced by RFDSprimary care clinics, 91623 patients were treated byRFDS doctors via our remote telephone consultationservice, and 7305 immunisations were given by ourcommunity health nurses.General practitioner and communityhealth nurse traditional remote clinicsFor many years the RFDS has provided visiting GP andCommunity Health Nurse clinics to remote locationsthroughout the country. These clinics are conductedat a range of locations including remote area nursingposts, Aboriginal community health centres, pastoralproperties and remote roadhouses. The clinics providepatients with regular GP consultation and treatmentservices, and data demonstrate that reason for visitpatterns and diagnoses given to patients’ conditionsare comparable with those found in suburbangeneral practice—hypertension, diabetes, obesity,injuries and poisoning, and respiratory conditionsbeing the most common diagnoses. One of themost important preventive health functions of theseclinics is the provision of immunisation services inlocations that would otherwise not have immediateand local access—7305 immunisations were providedin 2009–10. An important aspect of both the GP andCHN work at the various locations is the provision ofhealth education / health promotion services throughindividual patient consultations and as part of grouppresentations to communities.Maps showing the locations of traditional RFDSclinics can be found at http://www.flyingdoctor.org.au/ignitionsuite/uploads/docs/Images%20for%20SA%20Public%20Health%20Bulletin.pdf?129472998242117500Rural women’s GP servicesIn the late 1990s the difficulties confronted by womenliving in rural and remote locations in being able toconsult a female GP were identified as a major barrierto effective preventive women’s health services inthese locations. Low pap smear screening and breastscreening rates were two key elements identified.In order to address this shortcoming, the RFDS wasawarded a contract by the Commonwealth Departmentof Health to establish and deliver a program of visitingaThe Best for the Bush – Report of the National HealthStrategy Working Group of November 1993 to the AustralianCouncil of the Royal Flying Doctor Service of Australia.Available from Mr Robert Williams, RFDS National Office –02 8259 8100.page 56

Rural health in the 21st centuryfemale GPs to areas where male GP services wereavailable but not female GP services. This programcommenced in 1999 and has become an exemplar ofgood practice, addressing gender choice of practitioner,but is not a solution to workforce shortages. In the firstfull year of operation of this program (2000–01), 1877patient consultations were conducted at 164 clinics;and in 2009–10, 18977 patient consultations wereconducted at 1565 clinics. The main reasons for visits in2009–10 were Pap smears, depressive disorders, breastchecks, contraception and menopause, demonstratinga significant preventive health focus. In addition, a totalof 487 women attended specific health promotionactivities conducted by the RWGPS doctors on matterssuch as menopause, osteoporosis management, breastscreening procedures, mental health wellbeing andcancer screening.Mental health programsThe identification of mental health as an area of needwithin the RFDS network was noted in the Best for theBush document—in particular, the need to developpreventive mental health strategies for rural and remoteresidents in times of drought, other natural disastersand local traumatic events. The Queensland Sectionof the RFDS pioneered this work with the writing ofa mental health ‘first aid’ program, presented via CD-ROM b covering matters such as how to identify a friendor work colleague who may be suffering from a mentalhealth condition, how to understand the language ofmental health, and how to work out the best approachto mental health care. The program has been accessedby several hundred health professionals in the rural andremote regions and used by comparable numbers ofresidents. With the advent of web-based technologies,the intent is for this program to be transferred to thenational RFDS website (www.flyingdoctor.org.au/), itselfa valuable health education resource.Psychologists, mental health nurses and allied healthworkers have been employed in Queensland to supportthis program, and these teams have been active in theprovision of preventive services through the WellbeingCentres in Aboriginal and Torres Strait Islandercommunities in Far North Queensland. Additionalpreventive mental health services are provided from ourbases in Alice Springs and Broken Hill as a componentof the Department of Health and Ageing’s MentalHealth Services in Rural and Remote Areas (Stage 2)program. In these two locations teams of mental healthnurses provide community development and mentalhealth outreach services to remote communities. Amental health nurse works from our Port Augusta baseproviding mental health consultation and educationservices to patients in the remote areas of SouthAustralia.Health promotion programsThe Best for the Bush strategic document establisheda direction within RFDS health services to address thepaucity of health promotion and health educationprograms that were available within the remote areasof Australia. The document endorsed the benefitthat such programs could deliver. Consequently, overthe last 10 years a wide range of health promotionprograms have been implemented by the fouroperating sections of the RFDS. These include theHealthy Living Program in South Australia, funded byan international philanthropic organisation (the Li KaShing Foundation), which provides on-site practicaleducation and support on healthy eating and exerciseto residents in remote locations; the On the Roadprogram in Western Australia (WA), sponsored by BHPBilliton Iron Ore, which provides a road-based vehiclethat delivers health screening and health educationprograms throughout remote areas of WA; the FarNorth Queensland Wellbeing Centres located withina number of Aboriginal communities, which provide,among a range of services, mental health and drugand alcohol education; and the dental screening andtreatment program delivered by the RFDS South EasternSection from Broken Hill.SummaryFrom this high-level overview of the services providedby the RFDS across Australia, it is clear that our workis much more than aeromedical evacuation of thesick and injured. Programs that provide primary care,screening, health education and health promotion, andthat underpin the provision of preventive health care torural and remote Australia, are a core element of thework of the RFDS.bAvailable from Mr Robert Williams, RFDS National Office –02 8259 8100Volume 8, Number 1, March 2011 page 57

Public Health BulletinParenting Eating and Activityfor Child Health (PEACH) inthe Community: (PEACH IC):translating research to practiceAnthea MagareySenior Research Associate, Nutrition and DieteticsFlinders UniversityJo HartleyResearch Associate, Nutrition and DieteticsFlinders UniversityRebecca PerryResearch Associate, Nutrition and DieteticsFlinders UniversityRebecca GolleyPostdoctoral Fellow, Public Health, SansomInstitute of Health ResearchUniversity of South AustraliaIntroductionRecent national data indicate that over one in fivechildren and adolescents are overweight or obese. 1 Thehealth consequences of excess weight in childhoodare well documented, 2 as is the persistence intoadolescence and adulthood and the additional healthburden this conveys. 3,4 Effective treatment of childhoodoverweight is an important secondary preventionstrategy. 5 The key elements of intervention in childweight management are moderation of energy intake,increased physical activity and decreased sedentaryactivity, achieved through behaviour modification withparental involvement and support. 6,7The Parenting, Eating and Activity for Child Health(PEACH TM ) program is a group-based family-focusedweight management program for overweight childrenaged 4–10 years. 8 It incorporates the cornerstonesof child weight management described above.Additionally, parenting skills training is included toenhance parent capacity to undertake changes inthe family diet and lifestyle to support child weightmanagement. Parents attend the 6-month program,comprising 13 fortnightly sessions (10 x 90-minutegroup sessions and 3 individual phone calls). A NationalHealth and Medical Research Council (NHMRC)-fundedtrial (ACTR 00001104) conducted in Adelaide andSydney with 169 families of 4–9 year olds showedthat a reduction of 10% in relative weight loss (childbody mass index and waist circumference z scores)was achieved at the end of the intervention (6 monthsfrom baseline), and was maintained in the following18 months without further program contact. 9,10 Whilethe initial weight loss is similar to that reported in otherchild weight management trials, 11,12 the long-termmaintenance of this loss is better than published adultoutcomes. 6,13It is recognised that research settings are unique,and therefore it is important to understand whetherachievements in a research setting are transferable toreal-life community practice settings—PEACH TM in theCommunity (PEACH TM IC). PEACH TM IC complementsSA Health’s Obesity Prevention and Lifestyle (OPAL)program, which targets environmental change byproviding an effective intervention for those alreadyoverweight. This paper describes the process oftranslation and presents data on the evaluation ofthis process.Steps towards translationThree years of funding a has supported:> > modification of the PEACH TM program based onfacilitator and participant feedback in the originaltrial, and addition of graphic design to the parenthandbook, resulting in a 96-page spiral-bound colourbook 14> > development of a 2-day facilitator training workshopand facilitator materials for implementation (programslides with notes and checklist, recruitment materials)> > creation of a website (www.peach.net.au), throughwhich interested practitioners can register theirinterest in facilitator training and families can registertheir interest in attending a PEACH TM program> > Flinders University (FU) staff time to supportfacilitators as they implement the program (training,recruitment, program delivery, evaluation).Ethics approval was sought and it stipulated thatinformation sheets and consent forms had to beprovided to all participants (facilitators and families),a process that is not usual practice for communityhealth programs.aFunding was provided by SA Health (2008-11) to implementthe PEACH TM program in a practice setting, with additionalsupport (2008) from Mazda Foundation (via FlindersFoundation).page 58

Rural health in the 21st centuryFacilitator trainingThe free 2-day facilitator training provides healthprofessionals with knowledge, skills and confidence toimplement the PEACH TM family weight managementprogram. The objective is to enhance their capacity tosupport families of overweight children. The trainingincludes:> > the background rationale and theoreticalunderpinnings of the PEACH TM program> > an overview of the program content> > role-play activities to develop confidence in deliveryof the parenting and problem-solving componentsof the program.Considerable effort was required to attract facilitators,despite the PEACH TM program being listed as a priorityprogram by SA Health. Recruitment also occurredthrough email notices, attendance at professionalnetwork meetings and personal approaches. Initially,training was limited to those practitioners in aposition to implement the program in their workplace,but it was expanded to any interested person. Sixworkshops have been held since April 2009. Of the40 professionals (50% dietitians) who attended,the majority were females working in metropolitanAdelaide with less than 3 years of experience in weightmanagement.EvaluationEvaluation of the facilitator training (process andeffectiveness) and program satisfaction providesimportant data on the effectiveness of the translationprocess. The former entails three questionnaires: preand post training, and post-program delivery. Anadditional questionnaire was incorporated early in 2010aimed at those who had completed training but hadnot implemented the program in their workplace within6 months. Evaluation of program effectiveness entailspre- and post-program measurement of child height,weight and waist circumference; parent completion ofchild diet and activity behaviours; pre-program parentcompletedfamily background questionnaire; andpost-program parent-completed program satisfactionquestionnaire. All data collection tools are provided byFU and de-identified data is returned to FU for dataentry and analysis.Facilitator training evaluation (n = 40)Pre- and post-training questionnaires were completedby all 40 participants, with the majority expressingsatisfaction with the pace of the training, coursestructure, activities, and usefulness of the resources andtraining modules. Suggestions for change were made,which are being actioned for future training sessions.Participants were asked to rank their knowledge,skills and confidence in three key areas of childweight management on a 5-point Likert scale of high,medium–high, medium, medium–low, low. Datapresented in Table 1 of pre- and post-training rankingsindicate that training has made a positive contributionto workforce development.Table 1: Number of workshop participants ratingeach content area medium–high/high pre- and posttraining(n = 40)FamilyfocusedweightmanagementLifestylesupportBehaviourmodificationPre Post Pre Post Pre PostKnowledge 2 31 9 34 1 28Skill 3 21 6 28 1 21Confidence 4 28 7 31 2 25Previous studies with dietitians have reported lowconfidence and perceived skills in facilitating behaviourchange, 15 and anecdotally reported low confidence inworking with families to manage children’s weight. Ourtraining has increased practitioner knowledge, skills andconfidence, which are important aspects of workforcedevelopment in the area of best practice child weightmanagement.Program implementationTwo groups, with a total of 13 families, havecompleted training. However, it is too early to presentany evaluation data of pre- and post-training childanthropometrics, child dietary and activity behaviours,and parent program satisfaction.Barriers to the translation processA number of barriers have been encountered in theprocess of translating this effective research programinto the real-life setting of community practice. First,with respect to training, there has been difficulty inengaging practitioners to attend training and embracethe program. This may be due to a lack of commitmentby workplaces as a result of the changing and/orVolume 8, Number 1, March 2011 page 59

Public Health Bulletinuncertain roles of staff, the instability of staff due toshort-term contracts, the relatively new funding modelsin community health, the fact that obesity managementis not a high priority at the primary care level, or thatPEACH TM is perceived by some as not relevant to theirtarget population, who have varying levels of need andliteracy. Further, the nature of PEACH TM (family-focused,group sessions, 6-month length) challenges existingpractice, which is typically one-to-one counselling orno service.Second, with respect to implementation of theprogram, there have been varied levels of commitmentby workplaces. For example, despite their post-trainingenthusiasm, practitioners have experienced competingdemands as PEACH TM is one of a range of availableprograms and not a priority in some locations. Staffmovements—changing roles or maternity leave (7 ofthose trained)—have limited opportunities for some.Workplaces may not have suitable rooms for groups,and the program format of 10 fortnightly sessionsdoes not match the usual service delivery model ofweekly sessions over a single school term. Contributingfactors to the difficulty in recruiting families to attendthe program have been problems with respect toadvertising, the fact that many families are not awarethat their child has a weight problem and so are notactively seeking help, the lack of defined referralpathways, the nature of the program for families (groupbased versus 1:1 with the dietitian or health worker,and the 6-month length), and the challenge of findinga suitable session time for all families in their busyschedules.The final barrier identified relates to programevaluation. It can be challenging for practitionersto collect data beyond routine process evaluation.Repeated phone calls and/or appointments maybe required to have families attend the follow-upassessment, which requires anthropometric measuresas well as distribution and collection of questionnaires.In the case of the participating families, most lackexperience of being involved in the formal evaluationof a service and may lack an understanding of theimportance of the collection of evaluation data.Additionally, they may find the text required byethics committees in patient information sheetsoverwhelming.Understanding the translation processThe limited but expanding literature on translatingresearch to everyday practice provides understandingas to why implementation in the community settingis low. Interestingly, there is a paucity of successfulhealth promotion interventions being implemented inapplied settings. 16 The difficulty of translating researchto practice and the potential challenges are welldescribed in the literature, which identifies the needfor a staged approach, time and patience to effectchange. Theories such as the diffusion of innovationtheory, 17 staged approach 18 and the RE-AIM (Reach,Efficacy or Effectiveness, Adoption, Implementation,Maintenance and Cost) framework 19 help describe thedissemination process and identify potential barriersand likely challenges. We have applied such theories tothe PEACH IC experience to assist in conceptualisingand modelling the processes involved, and to provideunderstanding for the gap between research andpractice to enhance the process in the future.ConclusionThe PEACH TM family weight management program is anevidence-based program for children aged 4–10 yearsthat results in relative weight loss of approximately10% after 6 months and is maintained in the longerterm. The PEACH TM in the Community project aimsto translate this effective program from the researchto the practice setting. The specific 2-day facilitatortraining has had a positive effect on practitionerknowledge, skills and confidence. However, the limitedimplementation of the program is concerning. Anumber of barriers that may explain this low activityhave been identified; while many have been addressedand modifications made, many challenges remain. Wewill continue to address these obstacles and train andsupport facilitators as they implement PEACH TM in theircommunity settings.page 60

Rural health in the 21st centuryReferences1. Department of Health and Ageing. Australian NationalChildren’s Nutrition and Physical Activity Survey: mainfindings. Australian Government, Canberra, 2007.2. Reilly JJ, Methven E, McDowell ZC et al. Healthconsequences of obesity. Arch Dis Child 2003; 88:748–752.3. Whitaker RC, Wright JA, Pape MS, Seidel KD, Dietz WH.Predicting obesity in young adulthood from childhood andparental obesity. New Engl J Med 1997; 337:869–873.4. Guh DP, Zhang W, Bansback N, Amarsi Z, Birmingham CL,Anis AH. The incidence of co-morbidities related to obesityand overweight: a systematic review and meta-analysis.BMC Public Health 2009; 9:88.5. World Health Organization (WHO). Obesity: preventingand managing the global epidemic. Report of a WHOconsultation on obesity. WHO, Geneva, 1998.6. National Health and Medical Research Council (NHMRC).Clinical practice guidelines for the management ofoverweight and obesity in children and adolescents.Commonwealth of Australia, Canberra, 2003.7. National Institute for Health and Clinical Excellence (NICE).Obesity: guidance on the prevention, identification,assessment and management of overweight and obesity inadults and children. NICE, London, 2006.8. Golley RK, Perry RA, Magarey AM, Daniels LA. Familyfocusedweight management program for five- tonine-year olds incorporating parenting skills trainingwith healthy lifestyle information to support behaviourmodification. Nutr Diet 2007; 64:144–150.9. Magarey A, Perry R, Baur LA, Daniels L, Steinbeck KS, HillsAP. Effectiveness of the PEACH RCT: a family focussedweight management program for 5 to 9-year-olds: 6month outcomes. Obesity Rev 2006; 7(suppl 2):99–117(114).10. Daniels L, Perry R, Baur LA, Steinbeck KS, Magarey A.Maintenance of relative weight loss 12 and 18 monthspost-intervention: outcomes of the PEACH RCT, a familyfocussed weight management program for 5-9 year olds.IJO 2008; 32(Suppl 1): S20.11. Wilfley DE, Tibbs TL, Van Buren DJ, Reach KP, WalkerMS, Epstein LH. Lifestyle interventions in the treatmentof childhood overweight: a meta-analytical review ofrandomized controlled trials. Health Psychol 2007;26(5):521–532.12. Oude Luttikhuis H, Baur L, Jansen H, Shrewsbury VA,O'Malley C, Stolk RP, Summerbell CD. Interventionsfor treating obesity in children. Cochrane Databaseof Syst Rev 2009, Issue 1. Art. No. CD001872. DOI:10.1002/14651858.CD001872.pub2.13. Wing RR, Hill JO. Successful weight loss maintenance. AnnRev Nutr 2001; 21:323–241.14. Nutrition and Dietetics, Flinders University. PEACH ParentHandbook. Flinders University, South Australia, 2009.15. Collins C. Survey of dietetic management of overweightand obesity and comparison with best practice criteria.Nutr Diet 2003; 60:177–184.16. Glasgow RE, Emmons KM. How can we increasetranslation of research into practice? Types of evidenceneeded. Annu Rev Public Health 2007; 28:413–433.17. Greenhalgh T, Robert G, Macfarlane F, Bate P, KyriakidouO. Diffusion of innovations in service organisations:systematic review and recommendations. The MilbankQuarterly 2004; 82:561–629.18. Brownson RC, Kreuter MW, Arrington BA, True WR.Translating scientific discoveries into public health action:how can schools of public health move us forward. PubHealth Reports 2006; 121:97–103.19. Glasgow RE, Lichtenstein E, Marcus AC. Why don’t we seemore translation of health promotion research to practice?Rethinking the efficacy-to-effectiveness transition. Am JPublic Health 2003; 93:1261–1271.Volume 8, Number 1, March 2011 page 61

Public Health BulletinCommunicable DiseaseControl BranchDisease Surveillance andInvestigation Report 1 July to31 December 2010Compiled by Louise Flood, public health registrar,Communicable Disease Control BranchThe Communicable Disease Control Branch (CDCB)conducts statewide surveillance for notifiable diseasesenabling analysis of health data and initiation ofspecific public health actions to prevent further spreadof disease. Specified data are provided regularly to theNational Notifiable Diseases Surveillance System.Weekly summaries of notifiable diseases inSouth Australia (SA), as defined in the Public andEnvironmental Health Act 1987, are published on theSA Health website. Included are counts of notifiedinfections, information about current cluster andoutbreak investigations, in addition to historical data.Some investigation and control activities are conductedin conjunction with partner agencies that provideadditional expertise and authorities under other Actsin SA. These agencies include OzFoodNet Australia, SAPathology, Biosecurity SA (previously Primary Industriesand Resources SA), and Environmental Health Officers(EHO) from local government. Partners in SA Healthinclude Food Policy and Programs, Health ProtectionPrograms and Scientific Services.SummaryBetween 1 July and 31 December 2010, 12585notifications were collected by the CDCB.In the second half of 2010, 2782 cases of sexuallytransmitted diseases (STDs) and blood borne viruseswere notified to STD surveillance section. Thirty-onecases of tuberculosis and 46 cases of non-tuberculousmycobacterial infection were notified to SA TuberculosisServices. These data are not further analysed in thisreport, but are included in the summary of notifiablediseases (Table 2).There were 10745 notifications of vaccine preventabledisease including 4886 cases of pertussis and 4227cases of influenza; 1595 notifications of enteric disease;202 notifications due to vector borne disease and 9notifications due to zoonotic infections.Investigation and control activities included:> > 15 cases of Shiga-toxin producing Escherichia coliinfection> > 13 cases of invasive meningococcal disease> > 1 case of hepatitis A> > 4 cases of typhoid fever> > 5 cases of Q fever> > 1 case of leptospirosis> > 1 case of brucellosis> > 4 cases of Legionella pneumophila serogroup 1Four possible foodborne outbreaks with the causativeagent Campylobacter, Salmonella Typhimurium phagetype 9, norovirus and pathogen unknown wereinvestigated. There were 10 cluster investigations withthe causative agent Salmonella in nine clusters andCampylobacter in one cluster. There were 33 nonfoodborneclusters of gastrointestinal disease, all butthree occurring in aged care facilities.Vectorborne DiseaseThe endemic arboviruses, Ross River virus and BarmahForest virus, are both spread by the bite of an infectedmosquito. Both infections usually demonstrate cyclicpatterns of disease, with a peak in summer. SA Healthreleases an annual health alert in early summer to raiseawareness of these infections. A prevention program,the Fight the Bite campaign, has operated in SA sinceDecember 2004.Ross River infection and Barmah Forest infectionSymptoms of infection with Ross River virus andBarmah Forest virus include arthralgia, rash, flu-likesymptoms and swollen glands. Blood tests confirmthe diagnosis usually by demonstration of specificantibodies in acute-phase sera.Between 1 July and 31 December 2010, 158 casesof Ross River virus infection were notified, comparedto 199 in the second half of 2009. Cases comprised56 males and 102 females with an age range fromthree to 89 years. Since the epidemic of 2005–2006,the background level of Ross River virus infection hasbeen higher than previous inter-epidemic periods.This may partly reflect increased testing due toincreased awareness of the disease (Figure 1). Reportedgeographical location of infection acquisition waspage 62

Communicable Disease Control BranchNumber of notified cases454035302520151050widespread, with the Murray Mallee region the mostcommon (42 cases, 27%) (Table 1).Ross River virus infectionBarmah Forest virus infection2005 2006 2007 2008 2009 2010Year & Week of NotificationFigure 1: Notified cases of Barmah Forest virusinfection and Ross River virus infection by yearand week of notification, 1 January 2005 to31 December 2010There were 23 cases of Barmah Forest virus infectionnotified in the July to December period, compared with16 in the same period of 2009. Cases comprised 10males and 13 females, with an age range of five to 89years and mean age of 50 years. The Murray Malleeregion was the most common reported location ofinfection acquisition (10 cases, 43%) (Table 1).Dengue feverDengue fever is transmitted by the bite of an infectedmosquito (usually Aedes aegypti). Dengue fever ischaracterised by fever, headaches, myalgias, arthralgias,nausea, vomiting and rash. Dengue diagnosed in SA isacquired either in Northern Australia or overseas.During the second half of 2010, 18 cases of denguefever were notified, compared to seven cases in thesame period of 2009. Cases included 11 males andseven females with an age range of 18 to 64 years. Allcases reported recent travel to Asia.MalariaMalaria is a parasitic disease transmitted by mosquitoesinfected with Plasmodium species. Malaria is endemicin many tropical and subtropical countries. Malaria ischaracterised by fevers, myalgias, headache, diarrhoeaand vomiting. Many complications may ensue includingacute encephalopathy, anaemia, renal failure andcoagulation defects, and malaria remains a significantcause of mortality worldwide.Table 1: Reported geographical location of infectionacquisition for cases of Barmah Forest virus and RossRiver virus 1 July to 31 December 2010GeographicalAreasBarmah Forrestvirus infectionRoss RivervirusinfectionMetropolitanAdelaide3 (13%) 24 (15%)Adelaide Hills 0 (0%) 1 (1%)Barossa, Lightand Lower 1 (4%) 2 (1%)NorthFleurieu andKangaroo 0 (0%) 11 (7%)IslandMurray Mallee 10 (43%) 42 (27%)LimestoneCoast0 (0%) 2 (1%)Yorke and MidNorth1 (4%) 19 (12%)Far North 1 (4%) 7 (4%)Eyre andWestern1 (4%) 19 (12%)South Australianot otherwise 0 (0%) 4 (3%)specifiedInterstate 0 (0%) 9 (6%)Overseas 0 (0%) 1 (1%)Unknown 6 (26%) 17 (11%)Total 23 (100%) 158 (100%)The three cases of malaria notified in the second half of2010 were all acquired overseas. Cases comprised onemale and two females, aged from 14 to 48 years. Twocases, caused by Plasmodium vivax, reported exposurein Papua New Guinea and one case, caused by P.falciparum, reported exposure in Africa. Nineteen casesoccurred in the same period of 2009.ZoonosesHydatid diseaseHydatid disease is caused by the larvae of thetapeworm Echinococcus granulosus and usually occursvia contact with dogs which have eaten infected offalfrom sheep and other herbivores. The parasite formsslowly enlarging cysts that can occur in any organ butare most common in the liver or lungs.Volume 8, Number 1, March 2011 page 63

Public Health BulletinHydatid infection is frequently asymptomatic and isnow rare in SA. In the second half of 2010, one caseof hydatid disease was reported in a 68 year-old femalefrom metropolitan Adelaide, whose medical historysuggested past rather than recent infection.Q feverQ fever is a zoonotic disease caused by Coxiellaburnetii. Cases often have direct exposure to animals,commonly sheep, cattle or goats, which are naturalreservoirs for this infection. Typically, cases are workingagepersons who have occupational exposure toanimals in the meat and livestock industries. Q feverinfection is asymptomatic in approximately half ofinfected persons. Symptoms may include: fever,headache, fatigue, muscle aches, confusion, cough,vomiting and diarrhoea, and longer term complicationsinclude endocarditis.During the second half of 2010 five cases of Q feverwere recorded, compared with eight cases in the sameperiod of 2009 (Figure 2). Cases comprised two malesand three females aged between 21 and 51 years. Fourcases reported plausible occupational exposures forthis infection. None of the cases were vaccinated for Qfever. Q fever vaccination is recommended for personswith possible occupational exposure to C.burnetti (seehttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-qfever).LeptospirosisLeptospirosis is a bacterial zoonotic disease caused byspecies of Leptospira. Many wild and domestic animalsare reservoirs of Leptospira serovars due to chronicrenal infection. Leptospires can remain viable in theenvironment for many weeks; hence, transmission canoccur through contact with soil, vegetation or watercontaminated by animal urine, in addition to directanimal exposure. Leptospirosis has a wide spectrum ofseverity from asymptomatic disease to a mild febrileillness to fatal disease.One case of leptospirosis was notifed in the secondhalf of 2010. The case was a 64 year old male whohad recent travel to South East Asia. No cases ofleptospirosis were notified in SA during 2009.BrucellosisBrucellosis is a zoonotic disease caused by Brucellabacteria. It is characterised by fever, headache,weakness and joint pains. Untreated, the illness can lastmany months, with long-term complications common.Transmission is through close contact with infectedanimals or ingestion of contaminated unpasteuriseddairy products.One case of brucellosis (caused by Brucella suis) wasnotified in the second half of 2010. The case was a 33year old man from metropolitan Adelaide who reportedoccupational exposure to feral pigs and goats. This wasthe fourth case of brucellosis and the only case of B.suis infection notified since 1 January 2005.4Ornithosis (Psittacosis)Number of notified cases32102005 2006 2007 2008 2009 2010Year & Week of NotificationFigure 2: Notified cases of Q fever in SA by yearand week of notification, 1 January 2005 to31 December 2010Ornithosis is a bacterial disease caused by infection withChlamydophila psittaci. The clinical picture is usuallyatypical pneumonia and complications may includeencephalitis and myocarditis. Parrots and other birds arereservoirs for C. psittaci and apparently healthy birdsmay be infected.In the July to December 2010 period there was onenotified case of ornithosis. The case was a 44 year oldman who had pet parrots. There were two cases in thesame period in 2009.Vaccine Preventable DiseasesInfluenzaInfluenza is a potentially fatal illness characterisedby fever, headache, myalgias, cough, fatigue andpage 64

Communicable Disease Control BranchFrequencyrhinorrhoea. Transmission of influenza virus is byairborne droplets or fomites. There is increased riskof complications in persons under two years of age,persons over 64 years and persons with certain medicalconditions. Annual vaccination is recommended forpersons at high risk of severe disease (see http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/immunise-influenza).In May 2008 influenza became a notifiable diseasefor laboratories and doctors in SA. CDCB undertakessyndromic surveillance by collating datasets from SApathology and clinical sources. Clinical diagnoses of‘influenza-like illness’ are collected from two sources:Royal Australian College of General Practitionersmembers participating in the Australian SentinelPractice Research Network (ASPREN) and emergencydepartments of several public hospitals. Together, thesedata provide a weekly picture of confirmed influenzainfections and influenza-like illness activity state wide.A prominent spike of influenza and influenza-likeillness is noted in winter and spring in 2010; althoughlower than the spike of 2009 associated with the H1N1pandemic, it is significantly higher than other winter/spring increases in the 2006 to 2008 period (Figure 3).14001300120011001000900800700600500400300200Influenza A laboratory diagnosesSentinel general practitioner diagnosesInfluenza B laboratory diagnosesEmergency Department diagnosesPercent of notified cases100%90%80%70%60%50%40%30%20%10%0%

Public Health BulletinNumber of notified casesInvasive pneumococcal diseaseStreptococcus pneumoniae is carried asymptomaticallyand harmlessly in the upper respiratory tract of manyindividuals; however, invasive pneumococcal disease,e.g. pneumonia or meningitis, occurs when organismsinvade beyond the upper respiratory tract. Two vaccineshelp protect against some of the 90 identified serotypesof S. pneumoniae. A 23-valent vaccine is commonlyused for adults; and a 7-valent vaccine for infants andchildren.Between 1 July and 31 December 2010, 86 cases ofinvasive pneumococcal disease were notified. Therewere 93 cases for the same period in 2009. Casescomprised 54 males and 32 females, with an age rangefrom less than one year to 92 years and mean age of42 years. Fifteen cases (17%) were aged less than fiveyears. Thirteen of the notified cases were in AboriginalAustralians (mean age 29 years), in two cases theIndigenous status was unknown and 71 cases were notIndigenous (mean age 44 years). There were six deathsdue to invasive pneumococcal disease, all occurring innon-Indigenous persons with medical co-morbidities(age range less than one year to 86 years).There has been a significant decrease in the number ofnotifications of invasive pneumococcal disease since thepeaks of 2002 and 2004, with the decrease particularlypronounced in the less than five years old age groupand the 65 years and over age group (Figure 5).250200150100500

Communicable Disease Control Branch0-45-910-1415-19202012002402201000200180Number of notified cases800600400Number of notified cases160140120100806040202000J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D01996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010Year and month of notificationFigure 6: Notified cases of pertussis by year andmonth of notification and age group, 1 January1996 to 31 December 20102008 2009 2010Year and month of notificationFigure 7: Notified cases of rotavirus infection in SA byyear and month of notification and age group (years),1 May 2008 to 31 December 2010Rotavirus infection became a notifiable infection in SA on1 May 2008.RotavirusRotavirus infection causes a wide spectrum of illnessfrom asymptomatic infection to fatal gastroenteritisassociated with watery diarrhoea, vomiting, fever andsevere dehydration. It is a major cause of hospitalisationfor children under five years. Vaccination wasintroduced in July 2007 and notification of rotavirusinfection commenced in May 2008 in SA.In temperate regions there is usually a seasonal peakin winter. In the second half of 2010, 570 cases ofrotavirus infection were notified, compared with 148for the same period in 2009 (Figure 7). A seasonalwinter peak is demonstrated. The increased cases in2010 compared with 2009 may reflect a true increasein disease, increased testing rate, increased notificationrate or a combination. Cases comprised 269 males and301 females aged from less than one year to 101 years,with 124 notifications (22%) in persons less than twoyears of age and 153 notifications (27%) in personsaged two to four years.Of the cases aged less than two years of age atnotification, 22 (18%) were unvaccinated (of which 11(9%) were too young for vaccination), 86 (69%) hadreceived at least one vaccination and vaccination statuswas unknown for 16 (13%).Varicella-zoster virus infectionVaricella-zoster virus infection is manifested as chickenpox and shingles. Chicken pox is usually characterisedby a febrile illness with vesicular rash. Complicationsof chicken pox occur in approximately one per cent ofcases. Shingles is characterised by a painful blisteringrash that may occur upon reactivation of latentvaricella-zoster virus.A monovalent varicella vaccine became available inAustralia in 2000 and was included in the NationalImmunisation Program Schedule from November 2005.Although not on the National Immunisation ProgramSchedule, a zoster vaccine (Zostavax) is recommendedfor persons 60 years and over (although multiplecontraindications exist, see http://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbookzoster).During the second half of 2010, 966 cases of varicellainfection were reported, compared to 972 casesreported for the same period of 2009 (Figure 8). Casescomprised 442 males and 524 females and were agedfrom less than one year to 99 years.Number of notified cases250200150100500ChickenpoxZoster (Shingles)2005 2006 2007 2008 2009 2010Year and month of notificationVaricella virus infection not further classifiedFigure 8: Notified cases of varicella-zoster virusinfection by clinical syndrome (chicken pox, shinglesand varicella virus not further classified) and by yearand month of notification, 1 January 2005 to 31December 2010Classification of varicella-zoster virus infection as either shinglesor chickenpox is obtained from medical notification.Volume 8, Number 1, March 2011 page 67

Public Health BulletinMedical notification characterised 210 (22%) varicellazosterinfections as chickenpox and 602 (62%) aszoster (Figure 8). Cases notified as chicken pox had anage range of less than one year to 90 years with 86per cent of cases aged less than 30 years (mean age 14years). Cases notified as shingles ranged in age from ofless than one year to 99 years with 87 per cent aged 20years or more (mean age 51 years).MumpsMumps is an acute viral illness characterised by feverand swelling of the salivary glands. It can be associatedwith respiratory symptoms, orchitis, pancreatitis andhearing loss. Prior to vaccination becoming available,mumps was a childhood disease with peak incidencein the five to nine year age group. Children are nowroutinely offered two mumps vaccinations as part ofthe National Immunisation Program Schedule. Manyaged adults aged approximately 30 to 45 years receiveda single mumps vaccination, hence, may be susceptibleto mumps infection. Adults in this age group areencouraged to seek revaccination with MMR vaccine(see http://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-mumps).During the second half of 2010, there was one case ofmumps. This was in a male aged 30 to 39 years whoreported childhood mumps and childhood mumpsvaccination. There were two cases of mumps in thesecond half of 2009.MeaslesMeasles is a highly infectious viral disease characterisedby fever, malaise, cough, coryza and conjunctivitis.Complications may include otitis media, pneumoniaand encephalitis. Measles is no longer endemic inAustralia.There was one case of measles in the second half of2010 in a 29 year old unvaccinated female who hadrecently travelled to Germany. Two close contactsrequired post exposure prophylaxis with normal humanimmunoglobulin.Enteric DiseasesIn the second half of 2010 there were 1595notifications of enteric infection which accounted for13 per cent of all disease notifications to CDCB.Foodborne disease investigationsThe CDCB investigated an outbreak of Campylobacterinfection associated with a hotel with six confirmed and12 presumptive cases identified. The suspect vehiclewas steak served with chicken liver pate. Appropriatepublic health action was taken.A suspected foodborne outbreak that occurred inattendees at a training function was investigated inAugust 2010. Eight of 11 attendees became unwellwith vomiting and diarrhoea of short duration,however, the causative agent was not identified.In September the CDCB investigated a communitybased outbreak of Salmonella Typhimurium phagetype 9 (STM 9) infection with 10 cases notified withina fortnight. Hypothesis generating interviews revealedthat four of the 10 cases had dined at a commonrestaurant. No food samples from the restaurant werepositive for STM 9. Three of the 10 cases comprised asocial cluster involving two siblings and a neighbour.An outbreak of norovirus infection occurred in arestaurant in December 2010 involving one confirmedand 18 presumptive cases. Illness was characterisedby diarrhoea and vomiting of rapid onset and shortduration. Investigation revealed that a food-handler hadbeen symptomatic whilst preparing food.There were 10 cluster investigations with single clusterscaused by: Salmonella Typhimurium (STM) phagetype 12A, STM phage type 135, STM phage type193, STM phage type 44, STM untypable, SalmonellaMontevideo, Salmonella Infantis, Campylobacter andtwo clusters caused by STM 9.Non foodborne outbreaksIn the second half of 2010, 33 clusters ofgastrointestinal infectious disease were notified to theCDCB: 29 within aged care facilities, three in personswho attended restaurant based functions and one ata training centre. The causative agent was rotavirus innine clusters, norovirus in 14 clusters, adenovirus in onecluster, likely adenovirus in one cluster and unknownin eight clusters. In clusters occurring in aged carefacilities a total of 725 persons were reported as ill. Onenorovirus infection outbreak in an aged care facilityinvolved 169 persons.The CDCB liaises with the aged care facility involved toensure resolution of the outbreak with key elementspage 68

Communicable Disease Control Branchof management outlined in the publication ‘A PracticalGuide to the Management of Gastroenteritis Outbreaksin Residential Environments in South Australia’ which isavailable from http://www.health.sa.gov.au/pehs/PDFfiles/SAGastroGuidelinesResidentialEnv-CDC-100106.pdf.CampylobacteriosisCampylobacter species causes gastroenteritis frequentlyaccompanied by fever. Complications may include:reactive arthritis and Guillian-Barré syndrome. Manyanimals including poultry and cattle are reservoirs ofCampylobacter species.Campylobacter infection accounted for 71 per cent ofenteric notifications in the second half of 2010 (1135cases), compared to 872 cases during the same periodof 2009 (Figure 9). Cases comprised 623 males and 512females, with an age range of less than one year to 93years and a mean age of 39 years. Fifteen per cent ofcases were aged less than 10 years at diagnosis.SalmonellosisSalmonella species infection is usually characterisedby gastroenteritis with symptoms including diarrhoea,fever, abdominal pain, headache, nausea andsometimes vomiting. Complications may include:septic arthritis, endocarditis, cholecystitis, menigititis,pericarditis, pyelonephritis and pneumonia. Salmonellaspecies are found in many animals including poultryand domestic pets.Salmonella infection is generally the second mostcommonly notified enteric infection in SA. BetweenJuly and December 2010 there were 343 notificationsof Salmonella infection, which was consistent with the301 cases notified in the second half of 2009 (Figure9). In the second half of 2010, Salmonella infectioncomprised 22 per cent of enteric disease notifications.Cases comprised 161 males and 182 females, with anage range from less than one year to 94 years. Casesresided in a range of rural and metropolitan locationsin SA.Laboratory tests characterise Salmonella isolates byserotype and phage type. Between July and December2010, STM 9 was the commonest serotype (54%).Among the 185 cases attributed to infection by theSTM serotype were isolates classified into 20 differentphage types. STM caused 59 infections; STM 135acaused 18 infections, STM 135 caused 13 infections,STM phage type 108 caused 31 infections and STM 193caused 14 infections.Number of notified casesNumber of notified cases140120100Figure 9: Notified cases of Campylobacter andSalmonella infections by year and week ofnotification, 1 January 2005 to 31 December 20106050403020100806040200Salmonella infectionCampylobacter infection2005 2006 2007 2008 2009 2010Year and week of notificationCryptosporidiosisCryptosporidiosis is a parasitic infection caused by theprotozoa Cryptosporidium hominis and C. parvum.Infection is characterised by watery diarrhoea withabdominal pain although fever, malaise and vomitingmay occur. Asymptomatic infections are common.Cryptosporidium parasites can be found in a rangeof vertebrates as well as humans. Transmission is viathe faecal-oral route including through ingestion ofcontaminated food or water. Accidental ingestion canoccur whilst swimming, hence, persons diagnosed withcryptosporidiosis should be excluded from swimmingfor 14 days after symptoms disappear.Twelve sporadic cases of cryptosporidiosis werereported in the second half of 2010 compared to 33 forthe same period in 2009 (Figure 10). Cases comprisedseven males and five females, with an age range of oneyear to 42 years and a mean age of 14 years. Residentsfrom both metropolitan and rural areas of SA wereamong the cases.2005 2006 2007 2008 2009 2010Year and week of notificationFigure 10: Notified cases of cryptosporidiosis by yearand week of notification, 1 January 2005 to31 December 2010Volume 8, Number 1, March 2011 page 69

Public Health BulletinCryptosporidiosis cases with reported risks potentiallyrequiring public health action are referred to localgovernment EHOs, as well as the Water Quality Sectionof SA Health’s Scientific Services Branch.Hepatitis AHepatitis A virus causes illness of varying clinicalseverity, ranging from asymptomatic infection toprolonged relapsing hepatitis. Prior to the onset ofjaundice, prodromal symptoms may include fever,nausea, anorexia, malaise and abdominal discomfort.Hepatitis A has a prolonged incubation period of 15to 50 days, hence, the source of exposure is frequentlydifficult to identify. Most cases in SA are imported fromcountries where hepatitis A is endemic. Outbreaks dueto contaminated food or water have been reported inAustralia including the 2009 Australia wide outbreakassociated with semi-dried tomatoes (Figure 11).One case of hepatitis A was reported during the thirdquarter of 2010, compared with eight cases for thesame period of 2009. The case was a 44 year old malewho reported recent overseas travel to countries wherehepatitis A infection is endemic. Contact tracing isundertaken for all cases of hepatitis A infection andvaccine or immunoglobulin is recommended for closecontacts.Number of notified cases765432102005 2006 2007 2008 2009 2010Year and week of notificationFigure 11: Notified cases of hepatitis A byyear and week of notification, 1 January 2005to 31 December 2010Paratyphoid feverThe bacterium Salmonella Paratyphi causes an acuteillness characterised by fever, headache, anorexia,malaise, cough, rash and change in bowel habit(constipation is more common than diarrhoea).There is a spectrum of clinical severity ranging fromasymptomatic to severe disease; however, paratyphoidfever is usually less severe than typhoid fever.There was one case of paratyphoid fever notified in thesecond half of 2010 compared with no cases in thesecond half of 2009. The case was a female less thanone year of age who usually resided in Indonesia.Typhoid feverTyphoid fever is characterised by sustained high fever,headache, malaise, anorexia, abdominal discomfort,cough, rash and change in bowel habit. Untreatedtyphoid fever has significant mortality. Typhoid feveris caused by Salmonella Typhi which is spread byingestion of food or water contaminated by faeces orurine of persons infected with S. Typhi. Unlike otherSalmonella infections, up to 10 per cent of infectedpersons become asymptomatic carriers of the infection.S. Typhi infections notified in SA are generally acquiredoverseas.Four cases of S. Typhi infection were notified in thesecond half of 2010 compared to one case in the sameperiod of 2009. Cases comprised three males and onefemale aged from one year to 62 years. All reportedrecent travel to Asia. Contact tracing was undertakencovering the period of infectiousness in Australia. Nocontacts became infected.Shiga-toxin producing Escherichia coli (STEC)Escherichia coli is usually carried harmlessly in the colonof many animals including humans. Some strains ofE. coli may produce Shiga-toxin. Infection with Shigatoxinproducing Escherichia coli (STEC) is associatedwith a broad clinical spectrum from asymptomaticinfection to bloody diarrhoea with abdominal cramping.In a small proportion of cases infection progresses toShiga toxin mediated haemolytic uraemic syndrome(HUS) that is characterised by haemolytic anaemia,thrombocytopenia and acute renal impairment. InSA, all faecal specimens from patients with bloodydiarrhoea are screened in a central SA pathologylaboratory for genes encoding the STEC toxins,enabling prompt notification of such infections.Between 1 July and 31 December 2010, 15 cases ofSTEC infection were reported (no deaths), comparedto 30 for the corresponding period in 2009. Casescomprised five males and ten females aged one yearto 82 years (mean 36 years). Laboratory testing by SApathology further characterised isolates as positive forShiga toxin 1 gene (three cases), Shiga toxin 2 gene(two cases), both Shiga toxin 1 and Shiga toxin 2 genes(eight cases) and in one case the carriage of Shiga toxingene 1 or 2 was unknown. Cases resided in a rangepage 70

Communicable Disease Control BranchNumber of notified casesof rural and metropolitan locations. All cases wereinterviewed with a standard risk questionnaire to collectcomprehensive food and environmental data. No linkswere found between cases.ShigellosisShigella is a bacterium that can cause gastrointestinaldisease with typical symptoms including fever,bloody diarrhoea, vomiting and stomach cramps.However, infection with Shigella also may be mild orasymptomatic. Transmission is via direct or indirectfaecal-oral spread through person-to-person contact oringestion of contaminated food or water. Few Shigellabacteria are needed to cause infection and humansare the only significant reservoir. Appropriate antibiotictreatment shortens the illness and reduces the risk oftransmission.In the second half of 2010 there were 36 notificationsof shigellosis compared to 24 cases in the second halfof 2009 (Figure 12). The agent was characterised asShigella sonnei in 15 cases (14 cases biotype g and onecase biotype a), S. flexneri in 18 cases, S. boydii in twocases and S. dysenteriae in one case. Cases comprised16 males and 20 females with an age range of oneyear to 64 years and mean age of 29 years. Of the36 cases, seven identified as Aboriginal and in ninethe Indigenous status was unknown. All the cases inpersons known to be Aboriginal were caused by S.flexneri. Twenty-four cases had recently migrated ortravelled overseas.98765432102005 2006 2007 2008 2009 2010Year and week of notificationFigure 12: Notified cases of shigellosis byyear and week of notification, 1 January 2005to 31 December 2010YersiniosisYersiniosis is an uncommon acute illness caused byYersinia species. Symptoms may include: diarrhoea,fever and abdominal pain. Spread is by ingestion ofcontaminated food or water, or occasionally by bloodtransfusion.Four cases of Yersinia enterocolitica infection werenotified between July and December 2010, comparedwith 12 cases in the corresponding period of 2009.Cases comprised three males and one female, agedless than one year to 37 years. All cases were locallyacquired.Other DiseasesInvasive meningococcal diseaseNeisseria meningitidis is carried harmlessly in thenose and throat of approximately 10 per cent of thepopulation, with transmission via close prolongedcontact. Septicaemia and meningitis are the two mostcommon forms of notified invasive meningococcaldisease. In Australia, approximately 5-10 per centof persons with invasive meningococcal disease die.Invasive meningococcal disease is most common inpersons aged less than five years and aged between15 and 24 years, although it can occur at any age.Routine meningococcal C vaccination was implementedin 2003 with a resultant decrease in cases associatedwith serogroup C infection (Figure 13). In SA, thepredominant serogroup of N. meningitidis responsiblefor disease remains serogroup B, for which no vaccineis available.Thirteen cases (no deaths) of invasive meningococcaldisease were reported in the second half of 2010,compared with eight for the corresponding period in2009 (Figure 13).Twelve infections were due to N. meningitidisserogroup B and one due to N. meningitidis serogroupC. Cases comprised seven males and six females, withan age range of less than one year to 51 years. Inaccordance with national guidelines, prompt contacttracing occurred with all cases. Information, clearanceantibiotics and vaccination were recommended asappropriate.LegionellosisInfection with the environmental bacterium Legionellaclassically causes atypical pneumonia. L. longbeachae isfound in potting mix and compost and L. pneumophilacan colonise water sources. Persons with impairedimmunity e.g. due to smoking, respiratory orcardiovascular disease, have increased susceptibilityto disease.Volume 8, Number 1, March 2011 page 71

Public Health Bulletin454035ABCYOther/UntypeableW-135Non-groupablewere without underlying chronic illness or obvioushigh risk exposure. There was one death due to L.longbeachae in an elderly man with underlying medicalco-morbidities.Number of notified cases3025201510502000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010Year of notificationFigure 13: Notified cases of invasive meningococcaldisease, by year of notification and serogroup,1 January 2010 to 31 December 2010Nineteen cases of Legionellosis were reported duringthe second half of 2010, from both metropolitan andrural SA. No links were identified between any cases.Laboratory tests attributed three cases to Legionellapneumophila serogroup 1, one case to L. pneumophilaserogroup 6 and 15 cases to L. longbeachae (Figure 14).All cases of L. pneumophila serogroup 1 are referredto Health Protection Programs for environmentalinvestigation.Creutzfeldt-Jakob diseaseClassical Creutzfeldt-Jakob disease is a rareprogressively fatal prion disease manifested usuallyby dementia, confusion and motor dysfunction withusual onset in persons over 40 years. The majorityof cases are sporadic although cases may be familialor iatrogenic (e.g. associated with administration ofhuman pituitary hormones). The diagnosis is confirmedon autopsy. Variant Creutzfeldt-Jakob disease usuallyaffects a younger age group and frequently begins withpsychiatric and sensory disturbances.In the second half of 2010 there were two notifiedcases of fatal sporadic Creutzfeldt-Jakob disease, ina female and a male both aged in their fifties.These data are provisional and subjectto further revision.The L. pneumophila serogroup 1 infection notificationsoccurred in two males and two females with an agerange of 61 to 69 years. Environmental swabs identifiedL. pneumophila serogroup 1 at the home of one caseand the workplace of another case.Of the 15 cases due to L. longbeachae, ten weremale and five were female, with ages ranging from42 to 86 years and mean age of 67 years. Two cases12L. longbeachae L. pneumophila 1 L. pneumophila 210Number of notified cases864202005 2006 2007 2008 2009 2010Year and month of notificationFigure 14: Notified cases of Legionella longbeachae,Legionella pneumophila serogroup 1 and 2 infectionby year and month of notification, 1 January 2005 to31 December 2010page 72

Communicable Disease Control BranchTable 1: Notifiable diseases in South Australia: 1 July to 31 December 2010 and annual comparisons 2005–2010.Disease2005 2006 2007 2008 2009 2010Jul-Dec Total Jul-Dec Total Jul-Dec Total Jul-Dec Total Jul-Dec Total Jul-Dec TotalAnthrax 0 0 0 0 0 0 0 0 0 0 0 0Barmah Forest virus infection 15 27 50 188 29 60 22 38 16 37 23 43Botulism 0 0 0 0 0 0 0 0 0 0 0 0Brucellosis 0 0 0 0 1 1 0 0 0 2 1 1Campylobacteriosis 1226 2089 1549 2449 1127 2714 945 1984 872 1778 1135 1760Chikungunya 3 - - - - - - 1 1 0 0 0 2Chlamydia (genital) 1 1331 2751 1524 3189 1625 3529 1765 3701 1816 3840 2124 4392Cholera 1 2 0 0 1 1 0 1 0 0 0 0Creutzfeldt-Jakob disease 0 0 0 0 1 3 2 4 1 3 2 4Crimean-Congo Haemorrhagic Fever 0 0 0 0 0 0 0 0 0 0 0 0Cryptosporidiosis 61 160 46 191 23 459 23 160 33 105 12 47Dengue Fever 3 5 3 10 15 23 13 31 7 18 18 23Diphtheria 0 0 0 0 0 0 0 0 0 0 0 0Donovanosis 1 0 0 0 0 0 0 0 0 0 0 0 0Ebola Fever 0 0 0 0 0 0 0 0 0 0 0 0Gonorrhoea 1 169 410 171 505 161 462 204 487 133 372 212 470Haemophilus influenzae infection 8 13 6 8 12 18 3 11 6 12 9 18Hepatitis A 7 9 2 9 2 5 6 19 17 59 1 4Hepatitis B 1 120 276 136 262 157 328 152 280 140 305 138 282Hepatitis C 1 347 697 343 665 313 600 297 575 300 545 267 523Hepatitis D 1 1 4 6 4 8 1 6 4 11 5 6HIV 1 20 50 30 60 21 55 25 47 29 54 22 48Hydatid disease 2 2 1 2 3 8 9 13 4 5 1 3Influenza 3 215 273 76 87 263 279 475 489 9588 10742 4227 4307Lassa Fever 0 0 0 0 0 0 0 0 0 0 0 0Legionellosis 30 57 41 62 8 20 11 18 24 44 19 30Leprosy 0 0 1 1 2 2 0 0 0 0 0 1Leptospirosis 2 3 1 1 0 0 0 0 0 0 1 1Listeriosis 5 6 3 4 6 7 0 1 0 4 0 1Lyssavirus infection 0 0 0 0 0 0 0 0 0 0 0 0Malaria 19 43 20 34 11 24 10 17 19 32 3 8Marburg Disease 0 0 0 0 0 0 0 0 0 0 0 0Measles 0 0 0 9 1 1 1 2 0 3 1 2Meningococcal disease 21 26 9 18 12 16 14 20 8 22 13 25Mumps 5 8 15 20 15 22 9 18 2 12 1 1Mycobacterial Disease (non-Tuberculous) 2 33 69 27 53 38 69 34 56 45 83 46 77Ornithosis 1 1 0 0 1 3 0 0 2 3 1 1Paratyphoid Fever 2 6 0 4 3 4 3 5 0 2 1 2Pertussis 755 1409 1332 2152 204 382 1061 1340 3484 5246 4886 7525Plague 0 0 0 0 0 0 0 0 0 0 0 0Pneumococcal disease 75 134 64 104 53 91 78 117 93 146 86 140Poliomyelitis 0 0 0 0 0 0 0 0 0 0 0 0Q Fever 6 20 7 16 13 24 5 16 8 10 5 10Ross River virus infection 64 92 78 361 103 214 94 181 199 331 158 349Rotavirus infection 3 - - - - - - 110 132 148 434 570 836Rubella 0 0 1 2 0 1 0 1 2 3 0 0Salmonellosis 292 576 211 547 316 864 277 645 301 684 343 667Severe Acute Respiratory Syndrome (SARS) 0 0 0 0 0 0 0 0 0 0 0 0Shigellosis 25 41 17 28 43 59 51 143 24 52 36 53Smallpox 0 0 0 0 0 0 0 0 0 0 0 0Shiga toxin producing E. coli / HUS / TTP 13 38 16 38 12 42 17 39 30 68 15 32Suspected Food Poisoning 48 66 188 514 409 446 47 62 3 6 17 24Syphilis 1 8 13 17 44 22 50 21 48 15 28 14 21Tetanus 0 0 0 0 0 0 0 0 0 0 0 0Tuberculosis 2 21 46 42 72 36 61 42 63 28 58 31 73Typhoid Fever 1 2 1 2 1 5 1 3 1 2 4 5Varicella infection 1080 1741 782 1231 759 1585 1080 1741 972 1827 966 1868Yellow Fever 0 0 0 0 0 0 0 0 0 0 0 0Yersiniosis 2 7 4 11 12 17 11 20 12 17 4 91Data collected by Sexually Transmitted Diseases Services2Data collected by SA Tuberculosis Services3notifiable since 1 May 2008Volume 8, Number 1, March 2011 page 73

Public Health Bulletin SAThe Public Health Bulletin South Australia is a publication of SA Health. The Bulletinaims to provide current data and information to practitioners and policy makersemphasising the value of orienting services towards prevention, promotion andearly intervention and to support effective public health interventions.Editorial correspondenceThe editorial team welcomes correspondence and suggestions for public health themes for future issues of thePublic Health Bulletin. Comments and reports should be 500-600 words. Guidelines for authors are availablefrom the managing editor. Please address all correspondence to:The Managing EditorPublic Health Bulletin South AustraliaPublic HealthSA HealthPO Box 6 Rundle Mall SA 5000Fax (08) 8226 7102Email phbsa@health.sa.gov.auEditorial Group members:Robyn McDermott (Guest Editor)Matt HarenGary MisanChris LeaseJeanette BrownAgnes MaddockRachel EarlDanny BroderickDistributionTo add your name to the electronic distribution list for the Public Health Bulletin South Australia please email:phbsa@health.sa.gov.auThe Public Health Bulletin can also be accessed in PDF format athttp://www.dh.sa.gov.au/pehs/publications/public-health-bulletin.htmDisclaimerThe articles appearing in this publication represent the views of the authors and not necessarily those of theMinister for Health or the Department of Health. No responsibility is accepted by the Minister for Health or theDepartment of Health for any errors or omissions contained within this publication. The information containedwithin the publication is for general information only. Readers should always seek independent, professionaladvice where appropriate and no liability will be accepted for any loss or damage arising from reliance upon anyinformation in this publication.For more informationwww.health.sa.gov.auphbsa@health.sa.gov.auDepartment of HealthPO Box 6, Rundle Mall, SA 5000Fax: 8226 7102http://www.gilf.gov.au/© Department of Health, Government of South Australia.All rights reserved. ISSN: 1449-485X Printed July 2011. DH-PH 11112.1