Current Research Projects
Below are links to the information pages on the current KAMS and Kimberley RCSWA research projects. For further information please contact:
Associate Professor Julia Marley
08 9194 3200 or Julia.Marley@rcswa.edu.au
Developing algorithms to improve predicting the development of and screening for GDM 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:
We looked at the antenatal records of 551 pregnant women 16 years and older without pre-existing diabetes delivered in 2013. This was from across WA including many sites from the southern regions, the Goldfields and the northern Kimberley region. We also looked at the results for Aboriginal women and non-Aboriginal women:
- We found that only half the women were getting the OGTT done. It is meant to be all of them. Some women had different types of blood glucose testing done.
- Aboriginal women were less likely to have the OGTT done but more likely to have other blood glucose tests done.
- One fifth of rural WA women had no blood glucose testing done.
During the study we identified problems with the collection tubes used to measure blood glucose. Glycolysis is the process cells use to convert glucose into energy. Glycolysis continues in blood samples long after collection. Fluoride-oxalate (FLOX) is added to blood collection tubes to stop glycolysis. However, FLOX is slow to work, taking four hours to stabilise glucose completely. The OGTT diagnostic criteria that we use is based on the large international Hyperglycaemia and Adverse Pregnancy Outcome (HAPO) study. This study used a very strict protocol for OGTT collection: blood was collected into FLOX tubes, and samples were immediately placed on ice and processed within one hour of test completion (FLOXICE). Ice helped slow down the cells to stop them using glucose. This is not practical in most clinical settings and is not done in WA. FC Mix tubes are used internationally because they stop glycolysis straight away and therefore keep blood glucose results accurate over time, even at room-temperature.
We estimate 62% of ORCHID women with GDM were misclassified as normal due to glycolysis (GDM incidence, FLOXRT 10.8% v FLOXICE 28.5%).
Glucose in FC Mix tubes remained stable for 24-hours. FC Mix tubes gave slightly higher results compared to FLOXICE (fasting glucose: +0.20 mmol/L). We estimate GDM incidence in ORCHID would be 45% using FC Mix tubes. As such, use of these tubes in the clinic may require revision of GDM diagnostic thresholds. The biggest impact of addressing this issue will be felt on the women diagnosed on fasting blood glucose. Most will be managed with diet, exercise and timed delivery at the end of pregnancy. A smaller number will require greater clinical input, insulin or other hypoglycaemic medication and more specialised intervention. Overall the major impact of using the best possible processes is likely to be the need for more comprehensive education programs about sugar control for all pregnant women, as greater numbers will be picked up in the lower risk end of the GDM spectrum.
We are using new collection tubes (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. We will also compare the glucose 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.
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.
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)
- 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
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
Over the past 20 years an epidemic of end-stage kidney disease (ESKD) has occurred among Aboriginal and Torres Strait Islander people in remote areas of Australia. The Kimberley Satellite Dialysis Centre (KSDC) was established in October 2002 in recognition of the growing need for dialysis in the Kimberley and after requests from patients to be able to dialyse in the region. Prior to this patients requiring haemodialysis either relocated to Perth for treatment or stayed at home to die.
Most reports on kidney disease in the Australian Aboriginal and Torres Strait Islander population in scientific journals describe the progression of kidney disease and treatment options prior to dialysis. There are very few published reports on health outcomes, including survival times for Aboriginal and Torres Strait Islander patients on dialysis.
The aims of this study are:
- To determine the future need for dialysis in the Kimberley
- To undertake a clinical audit of the implementation of best-practice guidelines for Kimberley clients with proteinuria and chronic kidney disease
- To determine the outcomes of haemodialysis and peritoneal patients in the Kimberley
- Assoc Prof Julia Marley
- Prof David Atkinson
Progression of chronic kidney disease to end stage: A retrospective cohort study from the Kimberley region
Chronic kidney disease (CKD) is a significant health problem within Australia; accounting for almost $900 million in health care expenditure in 2004-05. Rates of detected CKD in the Kimberley region continue to increase.
Within Australia, rural and remote Aboriginal and Torres Strait Islander people are some of the most significantly affected by CKD. This is reflected by higher incidence rates of CKD within this population, particularly end-stage kidney disease (ESKD) where renal replacement therapy (RRT) is required to sustain life.
Certain risk factors have been well established to contribute to the development, and worsening of pre-existing CKD. These include diabetes, cardiovascular disease and smoking. A growing body of evidence is also supporting a link between acute kidney injury and the progression of exiting CKD. The relative contribution of acute and chronic stressors to the progression of CKD in the Aboriginal population has not been previously documented. This study will aim to address this gap.
The aims of this study are:
- To identify the number of episodes of acute kidney injury in a cohort of patients with CKD
- To describe the cause and severity of these acute kidney injury episodes
- To compare the progression of chronic kidney disease towards ESKD between people with CKD with and without a history of acute kidney injury, whilst identifying and controlling for chronic disease indicators that are known to increase the risk of progression to ESKD
- To document service indicators (care provided by the Kimberley Renal Services and visiting nephrology services) and the impact on risk of progression to ESKD.
- Dr Emma Griffiths
- Joseph Mohan
- Marcin Skladaniec
- Prof David Atkinson
- Assoc Prof Julia Marley
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 ‘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
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)
- 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
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.
- 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
- 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