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BackgroundGlobally, alcohol-related injuries cause millions of deaths and huge economic loss each year . The incidence of facial (jawbone) fractures in the Northern Territory of Australia is second only to Greenland, due to a strong involvement of alcohol in its aetiology, and high levels of alcohol consumption. The highest incidences of alcohol-related trauma in the Territory are observed amongst patients in the Maxillofacial Surgery Unit of the Royal Darwin Hospital. Accordingly, this project aims to introduce screening and brief interventions into this unit, with the aims of changing health service provider practice, improving access to care, and improving patient outcomes. MethodsEstablishment of Project Governance: The project governance team includes a project manager, project leader, an Indigenous Reference Group (IRG) and an Expert Reference Group (ERG). Development of a best practice pathway: PACT project researchers collaborate with clinical staff to develop a best practice pathway suited to the setting of the surgical unit. The pathway provides clear guidelines for screening, assessment, intervention and referral. Implementation: The developed pathway is introduced to the unit through staff training workshops and associate resources and adapted in response to staff feedback. Evaluation: File audits, post workshop questionnaires and semi-structured interviews are administered. DiscussionThis project allows direct transfer of research findings into clinical practice and can inform future hospital-based injury prevention strategies.

BackgroundThe incidence of mandibular fractures in the Northern Territory of Australia is very high, especially among Indigenous people. Alcohol intoxication is implicated in the majority of facial injuries, and substance use is therefore an important target for secondary prevention. The current study tests the efficacy of a brief therapy, Motivational Care Planning, in improving wellbeing and substance misuse in youth and adults hospitalised with alcohol-related facial trauma. Methods and designThe study is a randomised controlled trial with 6 months of follow-up, to examine the effectiveness of a brief and culturally adapted intervention in improving outcomes for trauma patients with at-risk drinking admitted to the Royal Darwin Hospital maxillofacial surgery unit. Potential participants are identified using AUDIT-C questionnaire. Eligible participants are randomised to either Motivational Care Planning (MCP) or Treatment as Usual (TAU). The outcome measures will include quantity and frequency of alcohol and other substance use by Timeline Followback. The recruitment target is 154 participants, which with 20% dropout, is hoped to provide 124 people receiving treatment and follow-up.DiscussionThis project introduces screening and brief interventions for high-risk drinkers admitted to the hospital with facial trauma. It introduces a practical approach to integrating brief interventions in the hospital setting, and has potential to demonstrate significant benefits for at-risk drinkers with facial trauma. Trial RegistrationThe trial has been registered in Australian New Zealand Clinical Trials Registry (ANZCTR) and Trial Registration: ACTRN12611000135910.

High risk drinking is linked with high rates of physical harm. The reported incidence of alcohol - related trauma among Aboriginal and Torres Strait Islander people in the Northern Territory is the highest in the world. Facial fractures are common among young Aboriginal and Torres Strait Islanders. They are often linked with misuse of alcohol in the Northern Territory and are frequently secondary to assault. This review focuses on alcohol-related trauma in the Territory and draws attention to an urgent need for preventative health approach to address this critical issue.

Objective: To test an evaluation framework designed to evaluate implementation of the North Queensland Indigenous communities between August and December 2005. Setting: Both communities are located in Cape York, North Queensland. Community A has an estimated population of around 600 people; Community B has an enumerated population of 750, although health centre records indicate a higher number. Participants: Process evaluation involved health centre staff in both communities; clinical audits used random samples from the adult population (each sample n = 30); ethnographic fieldwork was conducted with resident population. Main outcome measures: Health centre scores and qualitative findings using a System Assessment Tool; clinical audits – extent to which scheduled services recorded; selected primary health performance indicators; qualitative ethnographic findings. Results: On almost all indicators, implementation of NQICDS had progressed further in Community A than in Community B; however, some common issues emerged, especially lack of linkages between health centres and other groups, and lack of support for client self-management. Conclusions: The evaluation framework is an effective and acceptable framework for monitoring implementation of the NQICDS at the primary health centre level.

The objective of this study was to assess the potential for reducing the harm resulting from tobacco use through health promotion programmes run in community stores in remote Aboriginal communities. The Tobacco Project utilised data from 111 stakeholder interviews (72 at baseline and 71 at follow-up after 12 months) assessing presence of sales to minors, tobacco advertising, labelling and pricing. It also involved the assessment of observational data from community stores and comments obtained from 29 tobacco vendors derived from community surveys. Sales of tobacco to minors were not reported in community stores and all stores complied with requirements to display the legislated signage. However, tobacco was accessible to minors through a vending machine and through independent vendors. Only one store displayed tobacco advertising; all stores had displayed anti-tobacco health promotion posters or pamphlets. Pricing policies in two stores may have meant that food items effectively subsidised the cost of tobacco. All stores had unofficial no-smoking policies in accessible parts of the store. Remote community stores complied with existing legislation, aside from allowing access of minors to vending machines. There may still be potential for proactive tobacco education campaigns run through community stores and for a trial assessing the effect of changes in tobacco prices on tobacco consumption.

ISSUE ADDRESSED: To assess the effect of anti-tobacco television advertising in comparison to other anti-tobacco interventions for Aboriginal people in remote communities in the Northern Territory. METHOD: This research was carried out as part of a large study evaluating the effect of multi-component, evidence-based tobacco interventions developed in three remote communities. Community surveys (assessing changes in smoking behaviour and exposure to tobacco interventions) were used to assess exposure to and effect of television advertising, relative to other interventions over the intervention year. RESULTS: 351 community members were interviewed. Exposure to anti-tobacco television advertising was high among both smokers and non-smokers (86% vs. 85%, p = 0.78). However, those who recalled seeing anti-tobacco advertising were no more likely to have quit than those who had not (11 exposed (6%) vs. 3 non-exposed (10%), Fisher's Exact Test p = 0.42). Logistic regression showed that exposure to individual tobacco interventions was not associated with an increased chance of cessation during the intervention year. CONCLUSION: Recall of anti-tobacco television advertising was high in these remote Aboriginal communities; more Aboriginal people recalled exposure to anti-tobacco television advertising than to any other cessation intervention. Although the overall cessation rate was low, a small number of smokers had given up as a result of seeing these television advertisements.

A recent rise in cannabis use in Indigenous communities in northern Australia may have compounded existing patterns of other substance use. This paper describes these patterns in Arnhem Land in the 'Top End' of the Northern Territory (NT). Economic impacts of the cannabis trade are also described. In a descriptive cross-sectional study, random samples included 336 people (169 males, 167 females) aged 13 - 36 years. Consensus classification of lifetime and current use of cannabis, alcohol, tobacco, kava, inhalants (petrol) and other drugs was derived based on health workers' proxy assessments. A sample (n = 180, aged 13 - 36) was recruited opportunistically for interview. Lifetime cannabis users among those interviewed (n = 131, 81 males, 50 females) described their current cannabis use, usual quantities purchased and consumed, frequency and duration of cannabis use and other substance use. In the random samples, 69% (63 - 75%) of males and 26% (20 - 31%) of females were lifetime cannabis users (OR = 7.4, 4.5 - 12.1, p < 0.001). The proportion of males currently using cannabis was 67% (60 - 73%) while the proportion of females currently using cannabis was 22% (16 - 27%) (OR = 7.9, 4.8 - 13.1, p < 0.001). Current cannabis users were more likely than non-users to be also using alcohol (OR = 10.4, 4.7 - 23.3, p < 0.001), tobacco (OR = 19.0, 7.9 - 45.8, p < 0.001) and to have sniffed petrol (OR = 9.1, 4.6 - 18.0, p < 0.001) but were less likely to be using kava (OR = 0.4, 0.2 - 0.9, p < 0.001). Among those interviewed, higher tobacco consumption in current users and greater alcohol use in lifetime users was associated with increased cannabis use. Action is required to reduce cannabis use, especially in combination with other substances.

Objective: To examine the trends in processes of diabetes care and in participant outcomes after an intervention in two remote regions of Australia.Design: Follow-up study over 3 years.Setting: Seven health centres in the Tiwi Islands and the Katherine West region of the Northern Territory.Participants: 137 Aboriginal people with type 2 diabetes.Intervention: Implementation of a multifaceted trial, including transfer of purchasing and planning responsibility to local health boards, the development and dissemination of clinical guidelines supported by electronic registers, recall and reminder systems and associated staff training, and audit and feedback.Main outcome measures: Trends in the proportion of Aboriginal people receiving services in accordance with clinical guidelines and in the proportion for whom specified levels of blood pressure and glycosylated haemoglobin (HbA1c) were achieved; health staff perceptions of barriers to effective service delivery.Results: An initial improvement in overall service levels from 40% to 49% was not fully sustained over the 3-year period. The overall proportion of services delivered varied from 22% to 64% between communities and over time. The proportion of participants whose most recent HbA1c level was less than 7% improved from 19% to 32%, but there was little change in blood pressure control. Perceived barriers to service delivery included discontinuities in staffing, lack of work-practice support and patients’ acceptance of services.Conclusions: Multifaceted interventions can improve quality of care in this environment, but achieving sustainable, high-quality care in a range of services and local conditions presents particular challenges. Developing and testing strategies for consistent and sustained improvement should be a priority for service providers and researchers.

We evaluate a method to describe changing substance use patterns in northern Australia's remote Aboriginal communities (Arnhem Land, Northern Territory). Substance use was assessed in random samples in two communities A (n = 194) and B (n = 176). Five Aboriginal health workers made assessments independently of each other in community A. A different group of three health workers made independent assessments in community B. Sub-samples were opportunistically recruited for interview (community A, n = 77; community B, n = 55). In community C, 10 1 people were interviewed and were also assessed by four local health workers working together. Proportional agreements (kappa-kappa statistic) among health workers for a history of substance use and current use, varied from kappa=0.207 for petrol sniffing (P=0.006) up to kappa=0.749 for cannabis use (P<0.001), all better than would be expected by chance. In communities A and 13, agreement between health workers' consensus and self-reported substance use was weaker (0.103

Australian Aborigines have much higher rates of illness and life expectancy, up to 20 years lower than the Australian population as a whole. Community based primary healthcare to Aborigines in the Northern Territory of Australia has, historically, been under-resourced, in part due to distinctive characteristics of the Australian healthcare funding system which has disadvantaged rural and remote regions. From 1998, the Northern Territory was the site of two Coordinated Care Trials (CCTs) which sought to achieve three main objectives: to significantly increase funding available to health services; to implement a system of clinical best practice; and to improve Aboriginal participation in health service delivery through the establishment of Aboriginal community health boards to act as funds managers and providers of health services to the trial populations. The paper outlines general CCT outcomes according to the findings of the commissioned evaluation studies and examines the possibilities and constraints encountered in improving Aboriginal participation in complex health service developments.

Background: Interventions to improve delivery of preventive medical services have been shown to be effective in North America and the UK. However, there are few studies of the extent to which the impact of such interventions has been sustained, or of the impact of such interventions in disadvantaged populations or remote settings. This paper describes the trends in delivery of preventive medical services following a multifaceted intervention in remote community health centres in the Northern Territory of Australia.Methods: The intervention comprised the development and dissemination of best practice guidelines supported by an electronic client register, recall and reminder systems and associated staff training, and audit and feedback. Clinical records in seven community health centres were audited at regular intervals against best practice guidelines over a period of three years, with feedback of audit findings to health centre staff and management.Results: Levels of service delivery varied between services and between communities. There was an initial improvement in service levels for most services following the intervention, but improvements were in general not fully sustained over the three year period.Conclusions: Improvements in service delivery are consistent with the international experience, although baseline and follow-up levels are in many cases higher than reported for comparable studies in North America and the UK. Sustainability of improvements may be achieved by institutionalisation of relevant work practices and enhanced health centre capacity.

OBJECTIVE: To identify barriers faced by Aboriginal people from remote communities in the Northern Territory (NT) when accessing hospital-based specialist medical services, and to evaluate the impact of the Specialist Outreach Service (SOS) on these barriers.DESIGN: Combined quantitative and qualitative study.SETTING: Remote Aboriginal communities in the "Top End" of the NT, 1993-1999 (spanning the introduction of the SOS in 1997).PARTICIPANTS: 25 remote health practitioners, patients and SOS specialists.MAIN OUTCOME MEASURES: Numbers of consultations with specialists; average cost per consultation; perceived barriers to accessing hospital-based outpatient care; and perceived impact of specialist outreach on these barriers.RESULTS: Perceived barriers included geographic remoteness, poor doctor-patient communication, poverty, cultural differences, and the structure of the health service. Between 1993 and 1999, there were 5,184 SOS and non-SOS outreach consultations in surgical specialties. Intensive outreach practice (as in gynaecology and ophthalmology) increased total consultations by up to 441% and significantly reduced the number of transfers to hospital outpatient clinics (P< 0.001). Average cost per consultation was $277 for SOS consultations, compared with $450 at Royal Darwin Hospital and $357 at the closest regional hospital. Outreach has reduced barriers relating to distance, communication and cultural differences, and potentially bolsters existing primary healthcare services.CONCLUSIONS: When compared with hospital-based outpatient services alone, outreach is a more accessible, appropriate and efficient method of providing specialist medical services to remote Aboriginal communities in the NT.