Developing algorithms to improve predicting the development of and screening for hyperglycaemia in pregnancy in rural communities
Gestational diabetes mellitus (GDM) is impaired glucose tolerance first detected in pregnancy. GDM is associated with a range of adverse neonatal and maternal outcomes. GDM is the commonest maternal antenatal abnormality in Australia. Screening is conducted in order to detect women at risk of disease, facilitating earlier management and treatment. Currently available evidence indicates that treatment of GDM with dietary modifications, glucose monitoring, and metformin and insulin (if needed) can significantly reduce the risk for adverse birth outcomes.
Current screening recommendations are for all pregnant women who are not known to have diabetes or GDM to have an oral glucose tolerance test (OGTT) at 24-28 weeks gestation. Women need to be fasted for this test and blood samples are taken immediately prior to consumption of a 75g glucose drink, and 1 and 2 hours later. Many women decline screening.
Alternative methods for diagnosing GDM or alternative methods for screening that lead to a reduction in the number of OGTTs required need to be found if we are to improve screening rates. We want to see if levels of glycation products such as HbA1c at first and third trimester antenatal visit predict the risk of developing GDM later in pregnancy or can be used instead of OGTT where an OGTT is difficult to achieve or refused by the patient.
The aims of this project are:
- To determine at baseline the number of 24-28 week OGTTs completed on at least 100 antenatal patients in each study region expected to have had an OGTT.
- To determine the relationship between first trimester antenatal information, including glycation products such as HbA1c, blood sugar levels, family history, obesity, maternal age, ethnic background, and 24-28 week glycation products, with 24-28 week OGTT.
- To determine the proportion of women enrolled in the study requiring an OGTT who complete the OGTT at 24-28 weeks gestation.
- To increase research interest and capacity among health service and RCSWA staff and students, and to build skills in rural and remote health service research.
To ensure that the project findings are generalisable to the broader regional, remote primary health care environment, it will be carried out in a range of health care services across Western Australia: Kimberley, Southwest, Greater South, Midwest and Goldfields.
This project is a collaboration between The Rural Clinical School of WA, KAMS, WA Country Health Services – Kimberley. We thank all partner health services for their significant in-kind contributions. This study is funded through grants from:
Progress to so far:
Many rural and remote Australian women are not tested for GDM. We looked at the antenatal records of 551 pregnant women, 16 years and older and without pre-existing diabetes from across rural and remote WA (Goldfields, Great Southern, Kimberley, Mid West and Southwest) who delivered in 2013. We found that:
- Only half the women were getting the OGTT done. It is meant to be all of them.
- Aboriginal women were less likely to have the OGTT done but more likely to have other blood glucose tests done.
- Some women had other, easier tests done instead of an OGTT.
- One fifth of rural WA women had no testing done.
In women who are tested we estimate 62% of GDM is missed due to OGTT sample instability. We recruited 600 women from across rural and remote WA between 2015 and 2018 who were amenable to having an OGTT; 501 had an OGTT after 24-weeks gestation. During the study we identified problems with OGTT sample stability:
- Cells inside blood samples continue to convert glucose into energy long after collection causing glucose levels to drop.
- In WA, tubes used to measure blood glucose contain fluoride to stop glucose loss, but are slow to work, taking 4-hours to stabilise glucose in the sample.
- The criteria that we use to diagnose GDM are based on the large international Hyperglycaemia and Adverse Pregnancy Outcome (HAPO) study. The HAPO study used a very strict protocol for OGTT collection: blood was collected into fluoride tubes placed immediately on ice (which helped slow down the cells to stop them using glucose) and samples were processed within one hour of test completion. This is not practical in most clinical settings and is not done in WA.
We estimated the loss of glucose in OGTT samples collected into fluoride tubes and corrected glucose results had the HAPO study ice-method or fluoride-citrate (FC) Mix tubes been used. FC Mix tubes are used internationally because they stop glycolysis straight away and keep blood glucose results accurate over time, even at room-temperature. We found:
- Correction for glucose loss using the HAPO study ice-method more than doubled the rate of GDM (from 9.7% to 22.7%).
- FC tube correction gave slightly higher results compared to the HAPO study ice-method (+0.20 mmol/L) and quadrupled the rate of GDM (44.6%).
One in five women who probably had GDM but were not managed had a large baby. This is similar to the rate of women in the HAPO study who had GDM and had a large baby (16.2%, one in six).
- Correction for glucose loss using the HAPO study ice-method improved GDM prediction of risk for a large baby (from 1.1 to 1.8 relative risk compared to women without GDM).
- The higher risk for a large baby remained in women with GDM after accounting for weight, age and smoking.
- When using the FC Mix tube correction we needed to increase the GDM diagnostic criteria +0.20 mmol/L to get similar results to the HAPO study ice-method.
FC tubes are now in used in the Kimberley. We are using FC Mix tubes in Aboriginal Health Service clinics in the Kimberley that give more accurate glucose results, even if the blood sample takes a long time to reach the laboratory. We are monitoring the results of this change.
- Almost three-quarters (71.4%) of Aboriginal women with early HbA1c ≥5.6% went on to have a positive OGTT. We think these women had prediabetes going into pregnancy.
- There were clear differences between Aboriginal and non-Aboriginal women: 16.3% v 5.2% had elevated HbA1c (pre-pregnancy prediabetes) whereas 12.4% v 29.6% developed GDM during pregnancy. This suggests fewer non-Aboriginal women had prediabetes going into pregnancy compared to Aboriginal women.
- The risk of having a large baby was twice as high in women with an early HbA1c ≥5.6% compared to women with an early HbA1c <5.6% and without GDM (21.4% v 10.5%). This suggests that women with prediabetes in early pregnancy have high-risk for a large baby.
In the Kimberley all Aboriginal women have been offered an early HbA1c at their first antenatal visit since 2017. We are currently looking at outcomes for Kimberley Aboriginal women who delivered their babies between 2018 and 2021. This will give us a larger, more representative of group of Kimberley women to test the early HbA1c ≥5.6% threshold.
Current and future work:
- We will continue to lobby for Australian pathology labs to use FC Mix tubes for glucose testing – a national pre-analytical glucose working group was formed in 2020 to progress changes to laboratory practice across Australia.
- We are recruiting an additional 200 women to compare OGTT results from the new FC Mix tubes with other tests that are easier for pregnant women to do, so that less women need to do the OGTT after 20 weeks gestation.
- We are working on updating the Kimberley Diabetes in Pregnancy protocol to add the HbA1c ≥5.6% prediabetes cut-point – this will replace the early OGTT (<20 weeks gestation).
- We are planning on co-designing culturally appropriate management strategies for Aboriginal women with prediabetes in pregnancy.
- Kirke AB, Atkinson D, Moore S, Sterry K, Singleton S, Roxburgh C, Parrish K, Porter C, Marley JV. Diabetes screening in pregnancy failing women in rural Western Australia: An audit of oral glucose tolerance test completion rates. Aust J Rural Health 2019. http://dx.doi.org/10.1111/ajr.12465
- Jamieson E, Spry E, Kirke A, Atkinson D, Marley JV. Real-world gestational diabetes screening: problems with the oral glucose tolerance test in rural and remote Australia. Int J Environ Res Public Health 2019; https://www.mdpi.com/1660-4601/16/22/448888
- Jamieson EL, Spry E, Kirke AB, Roxburgh C, Atkinson D, Marley JV. Underestimation of risk for large babies in rural and remote Australia: Time to change plasma glucose collection protocols. J Clin Transl Endocrin; 2020: 100247.
- Jamieson EL, Spry E, Kirke AB, Roxburgh C, Atkinson D, Marley JV. Variations in the Prevalence of Gestational Diabetes Mellitus With Remote Testing and a Pragmatic Solution to Improve Accuracy. Diabetes Care; 2020: 09: 09.
- Jamieson EL, Spry EP, Kirke AB, Griffiths E, Porter C, Roxburgh C, Singleton S, Sterry K, Atkinson DN, Marley JV. Prediabetes and pregnancy: Early pregnancy HbA1c identifies Australian Aboriginal women with high-risk of gestational diabetes mellitus and adverse perinatal outcomes. Diab Res Clin Prac 2021; https://doi.org/10.1016/j.diabres.2021.108868
Checking for Diabetes in rural communities – plain language summary of the ORCHID study (296 KB)
Audit of OGTT completion in 2013 – plain language report (113 KB)
Failure of the sugar drink test to detect GDM – plain language report for community (222 KB)
Failure of the OGTT to detect GDM in rural WA – plain language report for staff (263 KB)
Failure of the OGTT to detect GDM in rural WA – peer reviewed publication (1.43 MB)
Missing risk for large babies – plain language report for staff
Missing risk for large babies – peer reviewed publication
Early HbA1c detects pre-pregnancy prediabetes – plain language report for community
Early HbA1c detects pre-pregnancy prediabetes – plain language report for staff
Early HbA1c detects pre-pregnancy prediabetes – peer reviewed publication
- Assoc Prof Julia Marley, RCSWA Broome
- Erica Spry, KAMS
- Emma Jamieson, RCSWA Bunbury
- Dr Andrew Kirke, RCSWA Bunbury
- Dr Kylie Sterry, RCSWA Kalgoorlie
- Dr Sarah Moore, RCSWA Bussleton
- Dr Carly Roxburgh, RCSWA Albany
- Dr Sally Singleton
- Dr Emma Griffiths, KAMS
- Dr Cynthia Porter, GRAMS
- Prof David Atkinson, RCSWA Broome
Be Healthy: Implementing culturally secure programs for obesity and chronic disease prevention with remote Aboriginal communities and families
Aboriginal people from several Kimberley communities have requested support for implementing culturally secure lifestyle modification programs that foster internal motivation, enhance health knowledge, and modify health beliefs and risk perception. We codesigned, piloted and refined the ‘Be Healthy’ program with 110 Derby Aboriginal people. The 8-module program involves practical nutrition education, discussion of chronic diseases, cooking, stress management and group physical activity. Content, while consistent with the US Diabetes Prevention Program, is tailored to local culture and younger age (15-40 years), and delivered by Aboriginal facilitators in a culturally secure, supportive and enjoyable atmosphere. The pilot program demonstrated acceptability, positive behaviour changes and proof of concept in a challenging setting.
This project will empower Aboriginal people to increase exercise levels, improve nutrition and reduce obesity. It combines the power of research to drive evidence-based positive behaviour change with the wisdom, knowledge and cultural strength of Aboriginal communities, integrated with the major Kimberley healthcare providers. This community-led initiative will be adapted using a similar codesign process with other Aboriginal communities, implemented on a large scale over 5 years and evaluated. While the program will be open to all Aboriginal residents, we will particularly encourage participation of people who are 1) obese, 2) pregnant (improve outcomes for baby/child), and 3) parents (intergenerational transfer of health regarding behaviour). Through partnerships between Aboriginal organisations and academic researchers, the program will be culturally relevant, rigorously evaluated and embedded within the community for sustainability and will deliver short, medium and long-term health benefits.
- Assoc Professor Julia Marley
- Erica Spry
- Prof Lynette Henderson-Yates, DAHS
- Prof David Atkinson
- Jamilah Bin Omar
- Dr Kimberley Seear
- Ms Emma Carlin
- Dr Sarah Straw
Progression to diabetes among Aboriginal people in the Kimberley: Identifying opportunities to enhance intervention for prevention within primary health care
Regular screening for T2D is standard in the Kimberley and this process can also detect people at high risk for diabetes; that is, people with “pre-diabetes”. Large studies have demonstrated that interventions supporting healthy lifestyle behaviours for people with pre-diabetes can prevent or delay T2D. The recently-published position statement on screening and management of pre-diabetes in primary care in Australia recommended the HbA1c range 6.0–6.4% for pre-diabetes. Identified individuals should be provided with healthy lifestyle education, strategies and support within primary care, including consideration of psychosocial factors. This is particularly important in the Kimberley, where there are limited referral options and few structured prevention programs.
This study will improve understanding of the quality of screening for diabetes in the Kimberley region, and the factors influencing progression to T2D. This will enable the development and implementation of clinical guidelines for best practice for pre-diabetes in remote Aboriginal settings that emphasise both physical and psychosocial factors. The Kimberley Lead Clinicians Forum and Kimberley Aboriginal Community Controlled Health Services recognise and support the need to investigate progression to T2D regionally with a view to improved interventions for diabetes prevention and more timely diagnoses to minimise complications. Findings will also be highly relevant to other settings with a high T2D burden in Australia and internationally.
- Assoc Prof Julia Marley, RCSWA Broome / KAMS
- Prof David Atkinson, RCSWA Broome
- Dr Kim Seear, KAMS
- Erica Spry, KAMS / RCSWA Broome
- Dr Caitlyn White, KAMS
Young-onset diabetes refers to type 2 diabetes mellitus (T2DM) that is first diagnosed at a young age (less than 25 years old). The number of people being diagnosed with young onset diabetes is increasing around Australia, particularly in Aboriginal or Torres Strait Islander youth. This is concerning because young-onset diabetes has been shown to be a more aggressive version of diabetes than the later-onset type, and is associated with earlier progression to complications. These complications can include damage to the eyes (retinopathy), kidneys (nephropathy), nerves (neuropathy) and the heart and brain (cardiovascular disease). Importantly, there are things that can be done, which can prevent or slow down the onset of these complications.
We are concerned at some of the preventable early complications that we are seeing in young people with diabetes in the Region. We would like to be able to work out the best way to support young people with young-onset diabetes across the Kimberley.
What will this evaluation project involve?:
- Describing the current situation of young-onset diabetes in the Kimberley
- Identifying best practice screening guidelines for young-onset diabetes in our region
Progress so far:
We piloted a locally developed evidence-based screening algorithm in a remote Western Australian Kimberley town for 6-month. A retrospective audit of electronic health records for the pilot period and a 6-month period before the screening algorithm was introduced was conducted. Interviews were held with 30 PHC staff at participating services, an Aboriginal Community Controlled Health Service (ACCHS) and a hospital-based general practice service.
During the pilot, significantly more patients received an initial T2D screening test at the ACCHS (22% v. 36%, P = 0.011), but there was no change at the hospital (0.02% v. 0.02%). Staff feedback suggested measures to improve screening: simple guidelines, targeted screening, patient and staff education, point-of-care HbA1c tests and a whole-of-clinic approach to implementation. Implementing a screening algorithm for young-onset diabetes in Aboriginal Australians is challenging, but practical measures can be taken to improve screening.
Andreana Manifold, David Atkinson, Julia V. Marley, Lydia Scott, Gavin Cleland, Paula Edgill and Sally Singleton. Complex diabetes screening guidelines for high-risk adolescent Aboriginal Australians: a barrier to implementation in primary health care. Aust J Prim Health 2019; 25:501-508. https://doi.org/10.1071/PY19030
KIDDY Screening #1 – plain language report for community (181 KB)
KIDDY Screening #1 – plain language report for staff (241 KB)
- Dr Sally Singleton
- Dr Emma Griffiths, KAMS and RCSWA
- Dr Gavin Cleland, WACHS-Kimberley
- Dr Lydia Scott, WACHS-Kimberley
- Dr Andreana Manifold, RCSWA
- Assoc Professor Julia Marley, KAMS and RCSWA
- Prof David Atkinson, RCSWA
End-Stage Kidney Disease (ESKD) rates are much higher for Aboriginal and Torres Strait Islander people, particularly those living in remote areas. Despite this, they are much less likely to receive a transplant. Concerns about this inequity have recently sparked national inquiries and the formation of the National Kidney Transplantation Taskforce (NIKTT), to which Kimberley Renal Services (KRS) provides representation.
Assessment of transplant suitability requires a review with each patient for medical, surgical and social risk factors, however no templates are available to support this process. Elsewhere a formalised process has been found to increase transplant waitlisting, but this was in a metropolitan renal unit with low numbers of Aboriginal and Torres Strait Islander patients. We would like to employ a CQI approach to develop a process for transplant suitability assessment, which will increase access to transplant waitlisting for our patients and contribute to the improvement of access to renal transplantation for Aboriginal and Torres Strait Islander Australians.
This project will have three phases:
- Develop a template and process to improve the transparency and efficiency of transplant suitability assessment. To do this we will consult with specialists in the field of nephrology and transplantation, and Aboriginal Health Workers and Care Coordinators working with Kimberley Renal Services.
- Incorporate this process into the patient’s usual schedule of care with the visiting RPH nephrologist. Each patient will be able to ask where he or she is in the assessment process and we will seek informed consent to include his or her details in the evaluation phase.
- Evaluate the process and make recommendations for future implementation. This will include numbers of patients assessed and waitlisted at the start and end of the CQI activity period and barriers and enablers to implementation. For patients who have consented to include their data, we will also summarise individual barriers and enablers to transplant waitlisting and patient feedback.
- Emma Griffiths
- James Stacey
- Assoc Prof Julia Marley
- Prof David Atkinson
- Johan Rosman
Social & Emotional Wellbeing
Improving mental health screening for Aboriginal and Torres Strait Islander pregnant women and mothers of young children
This study aims to improve screening for, and contribute to addressing, mental health issues during pregnancy and the first 12 months after the birth of the baby.
The locally developed, culturally appropriate and user friendly Kimberley Mum’s Mood Scale (KMMS) was validated against clinical assessment in a sample of 91 Kimberley Aboriginal women. Kimberley regional guidelines now recommend using the KMMS to screen for anxiety and depression during the perinatal period for Aboriginal women. The next step for Kimberley health services are to increase and improve KMMS screening in pregnancy and postnatally and address identified mental health issues. Project staff will work closely with Kimberley services to find out:
- How the KMMS can best be implemented into routine practice in each service
- If, during routine use:
- The KMMS cut point of moderate still detects everyone with GP assessed clinically moderate or high severity depression and anxiety, and:
- That the management plans developed during the KMMS for those at lower risk are appropriate.
In order to meaningfully assess the above and to test for applicability in other remote regions to inform recommendations for wider use, it is important to re-evaluate the KMMS in a larger population during real world implementation. In partnership with health services and Aboriginal communities in northern Western Australia (WA) and Far North Queensland (FNQ), this study aims to:
- adapt the Kimberley Mum’s Mood Scale (KMMS) and develop locally appropriate versions for participating partners as required;
- evaluate the real-world performance of KMMS in the Kimberley and other remote regions in northern Australia; and
- evaluate the process of implementation.
Progress so far:
A protocol paper for the study has been developed in conjunction with partner health services and the investigators of the study.
Our paper ‘Risk and Resilience’ analysed 91 KMMS assessments from the validation study to identify different risk and protective factors associated with perinatal depression and anxiety. Almost all of the women had protective factors and that contributed to them not experiencing anxiety or depression despite many women experiencing significant risk factors. The most prominent protective factor was positive relationships with family members. This study highlights the importance of health professional exploring a woman’s whole context; that is, the way she experiences stress and risk and how her protective factors support her. This will help the woman and her health professional best understand and support her mental health and wellbeing. Assessing Aboriginal women’s perinatal mental health by only looking at risk is not enough.
Our paper ‘Having a quiet word’, reflects on the yarning-based consultation process we undertook with Aboriginal women in the Pilbara region of Western Australia to explore the acceptability of the KMMS as a feature of their perinatal health care. Fifteen women aged 18-42 were interviewed for the study. The group consisted of pregnant women (n = 4), women who had a child under the age of three (n = 6), and women who were both pregnant and had a child under the age of three (n = 5). Participants valued the KMMS for its narrative-based approach to screening that explored the individual’s risk and protective factors. While support for the KMMS was apparent, particular qualities of the administering health care professional were viewed as critical to the tool being well received and culturally safe. Building on these findings, we will work with our partner health services in the Pilbara to validate the KMMS with Pilbara Aboriginal women.
Our paper ‘Why validation is not enough’ looks at what happens after a new screening tool (the KMMS) has been validated. It explores the views of health care professionals and intended end users (in this case Aboriginal women who held administrative, professional or executive roles) to explore the trajectory for clinical implementation and use. This paper highlights some of the complexities involved in implementing a culturally secure perinatal mental health screening tool. Time constraints and a perception that the KMMS is only appropriate for women with literacy issues were identified by health professionals as significant barriers to KMMS uptake. In contrast the Aboriginal women interviewed considered the KMMS to be important for literate Aboriginal women and placed high value on having the time and space to ‘yarn’ with health professionals about issues that are important to them. Aboriginal women identified the KMMS as holistic, which aligned with their views and expectations of culturally safe care. The KMMS (along with the Here and Now assessment) are the only two Aboriginal specific mental health tools that inductively and iteratively build risk profiles that are focused on a patient’s strengths and resiliency, not just deficits.
Throughout the study we identified a range of practical improvements that would assist with the KMMS implementation including: a KMMS graphic make over, a rewrite of the user manual and training program, and improvements relating to the KMMS on electronic medical record systems.
Emma Carlin, Sarah J. Blondell, Yvonne Cadet-James, Sandra Campbell, Melissa Williams, Catherine Engelke, Des Taverner, Rhonda Marriott, Karen Edmonds, David Atkinson and Julia V. Marley. Study protocol: Improving mental health screening for Aboriginal and Torres Strait Islander pregnant women and mothers of young children. BMC Public Health 2019; 9: 1521. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-7845-3
Emma Carlin, David Atkinson and Julia V Marley. ‘Having a Quiet Word’: Yarning with Aboriginal Women in the Pilbara Region of Western Australia about Mental Health and Mental Health Screening during the Perinatal Period. Int. J. Environ. Res. Public Health 2019, 16: 4253. Available from: https://doi.org/10.3390/ijerph16214253
Emma Carlin, Erica Spry, David Atkinson, Julia V Marley. Why validation is not enough: setting the scene for the implementation of the Kimberley Mum’s Mood Scale. PloS ONE 2020;15(6):e0234346. Available from: https://journals.plos.org/plosone/article/authors?id=10.1371/journal.pone.0234346
Emma Carlin, Kimberley H. Seear, Katherine Ferrari, Erica Spry, David Atkinson, Julia V. Marley. Risk and resilience: a mixed methods investigation of Aboriginal Australian women’s perinatal mental health screening assessments. Social Psychiatry Psychiatric Epidemiology (2020). https://doi.org/10.1007/s00127-020-01986-7.
Protocol Study Paper – peer reviewed publication (613 KB)
‘Having a quiet word’ – peer reviewed publication (290 KB)
‘Having a quiet word’ – plain language report for community (129 KB)
‘Having a quiet word’ – plain language report for staff (130 KB)
‘Why validation is not enough’ – peer reviewed publication (635 MB)
‘Why validation is not enough’ – plain language report for community (110 KB)
‘Why validation is not enough’ – plain language report for staff (109 KB)
‘Risk and Resilience’ – peer reviewed publication (487 KB)
‘Risk and Resilience’ – plain language report for community (130 KB)
‘Risk and Resilience’ – plain language report for staff (106 KB)
- Emma Carlin, Research Fellow, RCSWA
- Katherine Ferrari, KMMS Project Officer, KAMS
- Diana Jans, KMMS Research Project Officer, Apunipima Cape York Health Council, Cairns
- Professor David Atkinson, RCSWA
- A/Professor Julia Marley, RCSWA
- A/Professor Mark Wenitong, Apunipima Cape York Health Council, Cairns
- Professor Karen Edmond, Unicef and University of Western Australia
- Dr Ernest Hunter, James Cook University, Cairns
- Dr Catherine Engelke, Rural Clinical School of WA, WA Country Health Service – Kimberley, Kununurra
- Professor Rhonda Marriott, Murdoch University, WA Department of Health, Perth
- Dr Sandra Campbell, James Cook University, Cairns
- Dr Stephanie Trust, Kununurra Medical, Kununurra
- A/Professor Murray Chapman, Abbotsford Psychiatry, Perth
- Ms Janet de San Miguel, KAMS, Broome
- Dr Emma Griffiths, KAMS and RCSWA, Broome
- A/Professor Rubin, Apunipima Cape York Health Council, Cairns
- Dr Karla Canuto, Apunipima Cape York Health Council, Cairns
- Ms Melissa Williams, WA Country Health Service – Kimberley, Broome
- Dr David Cutts, WA Country Health Service – Pilbara
- Dr Sarah McEwan, WA Country Health Service – Pilbara
- Dr Kylee Cox, WA Country Health Service – Central Office, Perth
- Donna Stephen, KAMS
- Jayne Kotz, Murdoch University, Perth
- Dr Sharon Evans, RCSWA, Perth
Bringing Cultural ways and healing into mental health and wellbeing systems to better serve the needs of Aboriginal and Torres Strait Islander people and communities. UWA in partnership with KAMS are working towards empowering access and outcomes for Kimberley Aboriginal people by developing, implementing and evaluating a new or improved model of SEWB & MH care for the ACCHS. More detail can be found at: https://timhwb.org.au/.
Project Staff: Zaccariah Cox, Aboriginal Wellbeing Research Officer; Emma Carlin, Senior Research Officer
Changing mental health services to improve the mental health of Aboriginal young people living in WA. The team from Curtin, Elder’s & Young people from Broome in partnership with KAMS are working with Headspace Broome to co-design improved ways of operating to encourage access and better outcomes for Aboriginal young people.
Project Staff: Zaccariah Cox, Aboriginal Wellbeing Research Officer; Emma Carlin, Senior Research Officer
Improving Health Services
Accessing health care at a remote Western Australian Aboriginal Community Controlled Health Service: Pilot Study
Derby Aboriginal Health Service (DAHS) is an Aboriginal Community Controlled Health Service (ACCHS) in the Kimberley region of Western Australia. The emphasis of the service is on Aboriginal health, preventive health, remote health, primary care and chronic disease management. The service has a Chief Executive Officer and is run by a board of local Aboriginal people. The buildings and infrastructure of the service have been designed to be appealing and accessible to Aboriginal people. DAHS should be the most accessible form of health care available for Aboriginal people in Derby and surrounding communities. In practice, however, DAHS finds it difficult to initiate and maintain relationship with many people. Anecdotally the group which is most difficult to access is the 16-25 year old age group. DAHS would like to know why this is so.
- To document the utilisation of health care services at a remote Western Australian Community Controlled Health Service by 16-25 year olds.
- To identify the barriers and enablers of access for 16-25 year olds.
Findings so far:
- 26 young Aboriginal people were interviewed.
- Participants appreciated interacting with Aboriginal staff, local staff, and longer term DAHS staff. This improved communication and interpersonal interactions, which were reported to be of prime importance for young Aboriginal people accessing health services.
- Maintaining confidentiality, minimising shame, and gender matching with health staff were also key issues for young people. Seeking health care was often based on acute need rather than proactive or preventive care; however, participants recognised that providing health education and health promotion should be a priority for the service.
- Improving youth engagement seems to be central to increasing acceptability and, hence, use. This requires that staff able to engage with young people are recruited, trained, and retained. More immediately, a range of simpler changes to service provision focus and environment for young people could potentially make important differences.
Warwick S, Atkinson D, Kitaura T, LeLievre M, Marley JV. Young Aboriginal People’s Perspective on Access to Health Care in Remote Australia: Hearing Their Voices. Prog Community Health Partnersh 2019; 13:171-181.
- Dr Susannah Warwick, RCSWA Derby
- A/Professor Julia Marley, RCSWA
- Tracey Kitaura, DAHS
- Matthew LeLievre, DAHS
- Professor David Atkinson, RCSWA
The NINI HELTHIWAN project: Improving Primary Care for Aboriginal mothers and babies in the Kimberley region of Western Australia
Providing quality health care for pregnant women and young children in remote areas is both vitally important and challenging. We are conducting three inter-related research projects that will contribute to the development of a regional enhanced model of primary health care for Aboriginal pregnant women and mothers of young children.
Nini regional midwife coordinators are helping to improve the support of primary care providers who are caring for Aboriginal mothers through a peer led process [telephone assistance, email, clinic visits]. Nini Helthiwan is using a randomised stepped wedge cluster design to provide this extra support by:
- Improving guidelines and training tools for regional priorities:
- Maternal nutrition, and substance abuse [alcohol and cigarette smoking]
- Social and emotional wellbeing [Kimberley Mum’s Mood Scale (KMMS)]
- Treatment and follow up practices for maternal and infant anaemia [iron infusion policy]
- Early infant care practices [breastfeeding, bonding, attachment]
- Assistance with problem solving and follow up [referrals, care-co-ordination, discharge planning]
- Assistance with implementing regional guidelines:
- Screening for perinatal anxiety and depression [Implementing the KMMS Study]
- Screening for gestational diabetes [ORCHID Study]
- On the job education and training, including assistance with use of electronic primary care systems.
To see if improvements in health care leads to improved health outcomes Nini regional child health workers (located in West and East Kimberley), are assessing neurodevelopment and anaemia levels in Kimberley Aboriginal babies and anaemia levels in their mothers when the baby is 6-10 months old.
Progress so far:
Australian pregnancy care guidelines note the importance of culturally safe care, but this is not always assured for Aboriginal women. Studies exploring Aboriginal women’s antenatal care experiences in various locations have identified local strengths and priority areas. Throughout the Kimberley, 124 Aboriginal women who had accessed antenatal care in 2015–2018 provided qualitative data during the Nini health assessment or standalone interview with an Aboriginal researcher. Most women expressed that overall they had a positive antenatal care experience. Key themes were:
- importance of positive relationships with antenatal care providers,
- the valuable role of family support during the antenatal period,
- challenges travelling for care and limitations of the Patient Assisted Travel Scheme, communication of pregnancy related information, and the provision of services including high staff turnover.
- Almost all antenatal care providers described were non-Aboriginal. A few women spoke about involvement of Aboriginal Health Workers in their antenatal care, including recommending expansion of these roles.
The experiences shared by these Kimberley women add to evidence from other parts of Australia, showing a need to improve culturally safe antenatal care for all Aboriginal women. This includes having more local Aboriginal antenatal care providers. There also needs to be more support for the large number of women and their families who need to travel for care.
Our paper ‘When I Got the News’ explored the experiences of Kimberley Aboriginal men during ANC, including their perceptions of being an expecting father, their social and emotional wellbeing, and their experience with health providers. The 10 Aboriginal men shared that fatherhood starts when their partner becomes pregnant and that their sense of responsibility increased as they sought to help their partner emotionally, practically and financially. The men talked about modifying their own behaviours in preparation for fatherhood, through a reduction in alcohol and less socialising. Several men self-reflected on their own absent fathers in their childhood and shared that this inspired them to be a more involved present father in their children’s lives. Aboriginal men support having a healthy pregnancy and being part of their partner’s pregnancy is important to them. The men talked about the importance for health services to include Aboriginal fathers, the need for programs and resources that will help Aboriginal men with knowledge and tools to better understand and support their partners to have a safe and healthy pregnancy.
Kimberley H. Seear, Erica P. Spry, Emma Carlin, David N. Atkinson, Julia V. Marley. Aboriginal women’s experiences of strengths and challenges of antenatal care in the Kimberley: A qualitative study. Women and Birth. 2021; http://dx.doi.org/10.1016/j.wombi.2020.12.009
Emma Carlin, Zaccariah Cox, Erica Spry, Conor Monahan, Julia V. Marley, David Atkinson. “When I got the news”: Aboriginal fathers in the Kimberley region yarning about their experience of the antenatal period. Health promotion journal of Australia. 2020: https://doi.org/10.1002/hpja.375
‘Nini Women’s: antenatal care experiences’ – plain language report (168 KB)
‘When I Got the News’ – peer reviewed publication (375 KB)
‘When I Got the News’ – plain language report for community (132 KB)
‘When I Got the News’ – plain language report for staff (132 KB)
- Professor David Atkinson, RCSWA
- A/Professor Julia Marley, RCSWA
- Dr Stephanie Trust, Kununurra Medical
- Dr Catherine Engelke, RCSWA
- Kristy Newett, WACHS-Kimberley
- Pat McCready, KAMS
- Jo Forbes, KAMS
- Emma Griffiths, RCSWA
- Zaccariah Cox, KAMS
- Erica Spry, RCSWA
- Emma Carlin, RCSWA
- Cath Josif, RCSWA
- Melissa Williams, WACHS-Kimberley
- Janet de San Miguel, KAMS
- Dr Stephanie Sherrard, PMH
- Prof Karen Edmond, UWA
- Natalie Strobel, UWA
- Rhonda Marriott, Murdoch Uni