Académique Documents
Professionnel Documents
Culture Documents
ES ALLIANC
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AMSANT
Acknowledgements
We wish to acknowledge and thank the following members of the project steering committee
(in alphabetical order):
Professor Robyn McDermott, James Cook University (Chair)
Ms Pat Anderson, Aboriginal Medical Services Alliance of the Northern Territory
Ms Cheryl Belbin, Queensland Health and Ms Julie Watson (proxy second meeting)
Dr Christine Connors, NT Department of Health and Community Services, Darwin
Ms Annie Dullow, Australian Government Department of Health and Ageing
Associate Professor Peter dAbbs, James Cook University
Associate Professor Paul Kelly, Menzies School of Health Research
Professor Kerin ODea, Menzies School of Health Research
Mr PD Ryan, Apunipima Cape York Health Council
Ms Barbara Schmidt, Queensland Health
Associate Professor Paul Scuffham, University of Queensland
Ms Kerrie Simpson, NT Department of Health and Community Services, Alice Springs
Associate Professor Janie Smith, RhED Consulting
Professor Andrew Wilson, University of Queensland.
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Table of contents
Part 1 CURRICULUM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
SECTION 1
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
The problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
The Northern Australian response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
The PHERP curriculum project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
SECTION 2
SECTION 3
SECTION 4
Domain 2
Domain 3
Domain 4
Domain 5
IMPLEMENTATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Prerequisites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Figure 2 Implementation model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Teaching and learning approaches. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Part 2 RESOURCES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
2.1 How to use a population health approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2.2 What are the social determinants of health? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
2.3 What is health promotion?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Figure 3 A framework for health promotion action . . . . . . . . . . . . . . . . . . . . . . . 40
2.4 The chronic care model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Figure 4 The chronic care model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
2.5 Where to find resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Glossary of terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
References
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
1
This document is a package of materials that aims to assist health educators to integrate chronic disease
education into existing and new programs, using a population health approach. It consists of:
background reading about how this chronic disease package came about
a curriculum framework upon which to develop new or adapt existing educational programs in
a population health model
a list of expected core outcomes for all graduate remote and rural primary health care practitioners
working in the prevention, early detection and management of chronic disease
an implementation framework to assist in conducting or managing orientation and professional
development, including accredited programs
some suggested teaching and learning approaches
some tools and resources for educators to use.
Who is it for?
This package is designed for health educators across the disciplines to use in the development and
implementation of their programs. The core expected outcomes, listed in the curriculum section, target all
health practitioners who practise in remote, rural and discrete Indigenous communities across northern
Australia. They include:
Nurses
Aboriginal and Torres Strait Islander health workers
Doctors
Health centre managers and
Allied health professionals audiologists, dietitians, health promotion officers, nutritionists,
occupational therapists, public health professionals, physiotherapists, psychologists, podiatrists,
radiographers, speech pathologists and social workers.
How is it used?
It is intended that this document will be integrated into all aspects of health professional education. This
will enhance what exists and what is being developed, in an effort to bring about positive change in the
prevention, early detection and management of chronic disease. Just like chronic disease itself, which
affects all systems of the body this curriculum should be liberally sprinkled throughout all orientation,
professional development and accredited programs undertaken by remote and rural primary health care
professionals to affect the required change.
Some examples
These are some real examples of how this document is currently being used:
In educating Indigenous health workers the core outcomes have been mapped against the national
competency standards to ensure they are all covered and if not they were added or changed.
In conducting a chronic disease workshop the presentation of the existing workshop has been
turned into a population health model. The content is related to antenatal care, babies, children,
young people and adults across the lifespan. This ensures that the participants examine the issues
using a whole-of-life or population focus, as opposed to looking at diseases and individuals. The
prevention and early detection sessions, which originally occurred three days into the program,
are now covered first.
In orientating all new staff those core prerequisites required by all health professionals
prior to working with chronic disease in remote practice have been identified and included in
their orientation program. Examples include knowing a recall system exists and how to use it,
population health approaches, patterns and prevalence of disease in the communities where
they will work.
See
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How is it assessed?
N/A
Page
Part 1 CURRICULUM
Section 1 Background
The problem
Internationally
Chronic conditions are currently responsible for sixty percent of the global disease burden, which is
expected to rise to eighty percent by the year 2020 (WHO, 2002). This is one of the greatest challenges
facing health care systems throughout the world and it places new long-term health and economic
demands on health care systems as the population ages (WHO, 2002).
Indigenous populations
Chronic conditions are interdependent and intertwined with poverty and are fast being seen as the
diseases of the lower socioeconomic groups (WHO, 2002 p 6). Poverty is also linked with cultural grouping.
In most first world countries Indigenous people have made significant gains in their health status in the
past twenty years (Ring and Firman, 1998). Indigenous Australians are the striking exception, experiencing
1.5 to 3 times the burden of disease of New Zealand Maoris and Indigenous Canadians, who experienced
a comparable health status some thirty years ago. Compared with those living in poor countries such
as Nigeria, Nepal, Bangladesh and India, life expectancy of Indigenous Australians also falls well behind
(United Nations and AIHW, 2003)
What makes these figures more disturbing is that the burden of disease that Indigenous Australians
suffer is largely preventable, yet chronic disease has reached epidemic proportions in the past decade.
This is particularly true of renal disease, with renal failure doubling every three to four years in some
states (Hoy et al., 1999). The Indigenous Australian diabetes rates are also the highest in the world on
some indicators (AIHW, 2002).
Remote communities
The greatest burden of disease is found in those 1216 discrete remote Indigenous communities which
house some 108 085 people, approximately one quarter of the Australian Indigenous population, of
whom over half live in the Northern Territory (ABS, 2001b, Strong et al., 1998). Queensland has the
second highest population of Indigenous Australians nationally, which includes some 30 000 Torres Strait
Islanders (ABS, 2002f). Torres Strait Islanders also experience comparable levels of preventable chronic
disease to Aborigines, in particular: diabetes which is suffered by 24 percent of those over 15 years,
and more than doubles by the age of 35 years (Edwards and Madden, 2001). Many Indigenous people
have more than one of these preventable diseases and associated co-morbidities such as depression
(Weeramanthri et al., 2003).
The evidence
There is now strong evidence that under-nutrition and poor foetal growth, can predict the development
of hypertension, diabetes, hyperlipidemia, syndrome X and mortality from cardiovascular disease and
chronic lung disease in adulthood (Barker, 1991). This is known as the Barker hypothesis or the early
origins of chronic disease. These are those external factors such as nutrition and smoking, that program
particular body systems during critical periods of growth, such as while in utero and in infancy, with
long term direct consequences for adult chronic disease (Barker, Scrimshaw, cited Weeramanthri et al.,
1999). Links between low birth-weight and the development of renal disease, cardiovascular disease and
diabetes in adulthood have also been found (Barker, 1991, Cass, 2004, Hoy and et al, 1998).
Queensland
In 1999 an inter-sectoral planning meeting was convened to respond to the poor health, education and
economic development of Indigenous people living in the Cape York Peninsula communities. This led to
the development of the Enhanced Model of Primary Health Care (EMPHC) and a framework to describe
the key elements for the model (CHIRRP, 2004a). A key component of the EMPHC is the Chronic Disease
Strategy, which is based on the same three key areas as the Northern Territory (NT) model prevention,
early detection and management using integrated approaches based on available medical evidence.
The diseases targeted are also diabetes, renal disease and chronic airways disease, plus cardiovascular
disease, which includes: hypertension, ischaemic heart disease and rheumatic heart disease; and mental
health and sexually transmitted infections. A unique feature of this process is that it was introduced
as a collaborative practice model of service delivery, and is reportedly very successful in some remote
communities where Indigenous health workers are encouraged, and supported, to take the lead.
Yet what is required is a workforce who can work in the different ways required to prevent, detect and
manage the current epidemic of chronic disease, rather than dealing with the acute results of chronic
illness. As chronic disease often has a gradual onset, with multiple causes, uncertain prognosis, a rare
cure and a lifelong duration, a new way of working is required. Patients and families struggling with
chronic conditions have different needs. They require planned, regular interactions with their caregivers,
with a focus on function and prevention of exacerbations and complications. This includes systematic
assessment, attention to treatment guidelines, and behaviourally sophisticated support for the patients
role as a self-manager, clinically relevant information systems and continuing follow up initiated by
the provider (Wagner, 1998). This means that the training of the workforce needed to be reviewed
and restructured, and the training facilitated using a systematic and population-based approach. As
Weeramanthi et al (2003) advises:
A paradigm shift is needed away from single diseases and towards a comprehensive and
integrated approach.
This workshop proved very successful and follow-up teleconferences with group participants assisted
in evaluating progress. In particular the Indigenous Health Worker representatives have mapped the
curriculum expected outcomes against the National Health Worker Competencies; the Centre for Remote
Health have also mapped them against its multidisciplinary Masters in Remote Health Practice Program
and James Cook University have included elements into their undergraduate nursing program. Work
is being undertaken in both the NT and Qld to improve and adapt their orientation and professional
development programs to include the core expected outcomes of this curriculum. The draft curriculum
was also well circulated to other stakeholders for feedback, which has been included in this final
document.
This project has resulted in:
1 a comprehensive report on the identified training needs
2 a curriculum framework that is comprehensive, practical, integrated, outcomes based, and focused
on those things we can affect using a population health approach
3 a list of core expected outcomes for all remote and rural primary health care professionals who
work in the prevention, early detection and management of chronic disease
4 an implementation model that can be incorporated in all workforce education and training across
the disciplines
5 a web-based annotated bibliography that describes useful educational tools and resources and will
be maintained and updated by the NT Chronic Disease Network as new resources are developed
6 a useful toolbox of resources for educators to reach into for those difficult to educate areas of
population health, the social determinants of health, and health promotion
7 a web-based self-assessment tool for new staff to assess their levels of confidence in the achieving
the core expected outcomes prior to starting in a new position.
When used as intended, these processes and documents will assist in providing more relevant orientation
programs to prepare novices and experienced staff to use population health and systems based
approaches to primary health care, and increase the capacity of staff to work in the prevention, early
detection and management of chronic disease. This process has also assisted health educators across
northern Australia to work together across the border, to discuss the issues, and find positive solutions
to common problems.
Introduction
During the consultation phase of this project one interviewee described the challenges of working in
remote practice as:
Its like dropping a person into a war zone with their paints and easel and saying paint (31).
This alerts us to the daily challenges educators face in the orientation, preparation and continuing
education of remote health professionals to ensure that what they teach applies to the realities that
health professionals face in their daily work.
There are some unique features of remote health practice that need to be considered in the preparation
of the workforce for these challenging roles.
Remote health practice:
is strongly multidisciplinary in nature; with a large number of sole practitioners in any given
discipline
includes an extended clinical role
involves providing health services to a small, highly mobile and dispersed population with poorer
health status
is distinctly cross-cultural
often takes place in extreme climatic conditions with problematic transport
can be geographically, professionally and socially isolating
often has limited political clout and limited opportunity for change
often has a high turnover of health professionals, which can result in poor continuity of programs
(CRANA, Humphreys, Wakerman and Lenthall, cited: Smith, 2004a).
These factors were taken into consideration in developing the following curriculum framework.
10
CURRICULUM MODEL
POPULATION HEALTH BASED
Focuses on the health of the whole population across the lifespan: pregnant women,
the foetus, babies, young children, young people, adults men, women and older people.
Workforce
needs
Focus on areas of
workforce need and
identified skills gaps:
PREVENTION
Planning, education,
health promotion
EARLY DETECTION
Brief interventions,
systematic approach,
protocols
Management
Self management.
Impact upon
THE SOCIAL DETERMINANTS
OF HEALTH:
employment: income and social
status, food supply, housing,
education, social support,
environmental issues, alcohol
and drugs, lifestyle: exercise.
MANAGEMENT OF
CHRONIC DISEASE:
diabetes, cardiovascular
disease, renal disease, sexually
transmitted infections, chronic
obstructive pulmonary disease,
mental health.
Domains of
Remote Practice
POPULATION HEALTH
and the context of
remote practice
COMMUNICATION
and cultural skills
SYSTEMS and
organisational approaches
PROFESSIONAL, legal
and ethical role
CLINICAL SKILLS in
remote primary health
care practice.
11
Underlying principles
The curriculum is based on the following principles:
Principle 1
Population health focused all educational initiatives need to have a population health
focus, i.e. how the issues affect specific population groups pregnant women and
the foetus, babies, school children, young people, adults, older people and gender
specific issues.
Principle 2
Identifies core skills it provides a list of core expected knowledge, skills and attitudes
expected of all remote and rural health professionals.
Principle 3
Needs based designed to focus on identified areas of need and skills gaps. These included:
using a population health approach, the social determinants of health, prevention, early
detection, community development and health promotion.
Principle 4
Remote Indigenous focused the curriculum materials are remote Indigenous focused, as
that is where the greatest burden of disease is suffered. The materials can be easily adapted
for other settings as required.
Principle 5
Applies to practice all educational materials developed, adapted and implemented will
demonstrate how they apply to remote primary health care practice. Therefore particular
educational strategies have been listed in Section 4.
Principle 6
12
Principle 7
Principle 8
Evaluation all materials developed will have a monitoring and evaluation strategy
attached to ensure the philosophy and intent is maintained and sustainable in the long
term. Critical will be the orientation of educational staff to the underpinning philosophy
and their commitment to maintain it.
Assumptions
This curriculum and implementation model includes the following assumptions.
a Prerequisites:
Cross-cultural awareness That all remote health practitioners have undertaken a cross-cultural
awareness program as a minimum prerequisite.
Other professional skills That all remote health practitioners have undertaken, at graduate
or postgraduate levels, those other important educational activities required to work in
remote Indigenous communities; for example: self-care, advanced clinical skills; knowledge
of Indigenous health status.
b Role of Industry partners and the tertiary educational sector:
That employers of the remote health workforce and educational providers will see it as their
responsibility to ensure this curriculum framework is integrated into workforce education
and training, through the use of policy and strong leadership, as described in Section 4
Implementation.
That North Queensland considers adopting a similar model to the Pathways Program found
throughout the Northern Territory from 2005, in the recruitment and orientation of their staff.
This will assist in an effort to curb the high levels of staff turnover and increase the capacity
of the entire workforce in dealing with chronic disease.
c Cultural respect:
That the local traditional values and beliefs of remote Indigenous people will be acknowledged,
respected and incorporated into the program outcomes and implementation processes, lead by
Indigenous people. This will assist in ensuring culturally safe practice within an empowered, respectful,
multidisciplinary team.
13
These expected core outcomes were developed by examining curriculum, professional standards
and the stated learning objectives, and/or core competencies, listed under the disciplines of:
Medicine General practice (RACGP Training Program, 1999), rural and remote medicine
(ACRRM, 2002), the pilot remote vocational training stream (ACRRM and RACGP Training
Program, 2000); CDAMS Indigenous Health Curriculum Framework (CDAMS, 2004)
Nursing Nursing competencies (ANC, 2000), remote area nurse competencies (CRANA and
CRAMS, 2001); Orientation manual for the remote area nurse (Veiwasenavanua et al., 2003)
Indigenous health worker Population health competencies (CSHTA Ltd, 2004); National
Strategic Framework (Standing Committee on Aboriginal and Torres Strait Islander Health,
2002)
Public Health Public health competencies (Human Capital Alliance, 2004)
Allied health Continuing education needs of allied health professionals in Central Australia
(Glynn, 2003)
Plus the following documents:
NT Preventable Chronic Disease Strategy (Weeramanthri et al., 2003)
Nth Zone, Chronic Disease Strategy, Primary health care centre implementation manual;
Standard treatment manual (CHIRRP, 2004a, 2004b)
CA remote PHC atlas (Central Aust Dept Health and Community Services, 2003)
Flinders University Guide to learning Graduate studies in remote health practice
- remote nursing practice, and remote medical practice (Centre for Remote Health, 2004)
Menzies School of Health Research Guide to learning Graduate Diploma and Master
of Public Health (Menzies School of Health Research, 2004)
CARPA standard treatment manual 4th edition; and reference manual (CARPA, 2003, 2004)
PHERP project results from the consultation process and educators workshop
(Smith, 2004).
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15
Social determinants:
Make the links between social factors and their affect on the health outcomes in that community:
poverty, nutrition, education and employment opportunities, social support, transport, control
over ones life, self management
Barker hypothesis and health outcomes in adulthood
spiritual and cultural backgrounds
family relationships and support in relation to a chronic condition.
Community health action:
Facilitate community health action through community directed initiatives:
Participate in community based prevention and education strategies.
Share health information in ways that are understood by the community.
Inspire and maintain community interest in health issues through activities, such as: getting health
on the agenda at community council meetings.
Act as an advocate as requested, to encourage good health decision making and improve health
outcomes.
Advocate for good educational opportunities for children and women.
16
Self management:
Develop long term professional relationships that help chronically ill patients to take responsibility
for their own health:
Jointly negotiate an effective, realistic management plan that determines who else needs to be
involved carers / family members.
Agree on respective responsibilities and limits.
Appreciate the multiple issues experienced by the individual and their family and offer
realistic support.
Build the patients confidence in managing their own condition.
Find common ground with patients about their problems and expectations.
Positively reinforce any achievements, no matter how small (no growling).
Respond sensitively to fluctuations in the physical and mental state of chronically ill patients and
their circumstances family, cultural.
Clarify informed consent.
Cultural skills and respect:
Elicit the patients health concerns in a culturally appropriate way that considers: their emotional
state, state of health, social disadvantage, traditional health beliefs and cultural background:
Be respectful of other cultures stand back, listen, summarise the problems, and place them in the
cultural context in which the patient lives.
Respectfully seek appropriate cultural advice and traditional healing advice as required.
Teamwork:
Interact respectfully within the cross-cultural multidisciplinary team:
Participate, contribute and value contributions from all team members.
Maintain professional boundaries in all client interactions.
Encourage community representatives with particular interest in an issue to contribute to
the team.
Brief interventions:
Discuss the principles and value of brief interventions, and promote small achievable changes:
Perform brief interventions as per the protocols re: smoking, passive smoking, nutrition, physical
activity and alcohol intake as a routine part of the consultation and screening process.
Health promotion / education:
Use opportunities for health promotion and education that are relevant to, and owned by,
the community:
Communicate meaningful health information to community groups that acknowledges expressed
needs and facilitates and supports community driven initiatives.
Engage the community in identifying issues and planning action.
Advocate for the employment of local people within the system.
Engage the client group in a way that is appropriate to them.
Consider the health of the community in all interactions.
Participate in health education programs school, workplace, store, canteen.
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18
Prevention
Pregnant women:
Establish structured time to provide education to school groups about conception, pregnancy and
the underlying determining factors that affect adult health outcomes.
Identify, record and monitor/follow up antenatal patients regularly.
Provide nutritional advice to pregnant women.
Advise women re: smoking, alcohol intake, and exercise during pregnancy.
Use brief interventions re smoking and alcohol cessation.
Monitor maternal weight during pregnancy.
Consider water supply, cost of food, socioeconomic status of the mother and negotiate
a successful plan.
Describe the early indicators of pregnancy related problems (gestational diabetes, pre-eclampsia,
intrauterine growth retardation) and intervene and refer as required.
Support women in improving their environmental factors prior to delivery.
Babies and children:
Describe normal childhood development.
Identify abnormal indicators early.
Describe the factors that impact upon early childhood development.
Discuss the links between the determinants of health and chronic disease (Barker hypothesis,
social determinants of health).
Provide nutritional advice relevant to the childs age, food supply, family income and
social situation.
Monitor the haemoglobin level of children to assess and implement a management plan
for anaemia using dietary approach as indicated.
Initiate brief intervention whenever appropriate.
Participate in basic childhood immunisation programs.
Provide preventative health advice and intervene in those conditions that effect the normal
childhood development and education otitis media, urinary tract infections and upper respiratory
tract infections.
Promote well being though education of the mother/ family/ carer to nutritional information
the childs growth story.
Identify and follow up children at risk.
Maintain child health records.
Refer and follow up appropriately.
Early detection
Screening:
Use screening procedures and investigations appropriately to identify asymptomatic individuals with
risk factors and/or chronic conditions:
Describe the role of screening and the importance of follow up.
Competently perform, record and interpret results of growth assessment programs, school screening
and adult health checks.
Implement and monitor structured community screening programs.
19
Be aware of the local issues that might impact upon the decision to treat a patient locally or
refer on.
Advocate for the remote community in acquiring resources to enable comprehensive chronic
disease care.
Legislation:
Have an understanding of the legislation governing their profession regarding notification of disease,
birth, death, autopsy and consent.
Teamwork:
Work respectfully in a cross-cultural team:
Understand and respect the different priorities, cultural considerations and family commitments
of Indigenous team members.
Discuss the role of the Indigenous health worker, health centre manager and other team
members.
Discuss, and work within, the different scope of practice of the remote health workforce, utilising
available resources appropriately.
Self-care:
Discuss their own strengths, values, and vulnerabilities in maintaining a personal and professional
balance when working in isolation:
Identify the boundary issues relevant to working as a remote practitioner caring for friends,
relatives, colleagues, and patients with long term conditions.
Debrief as required.
Discuss self-care issues when working in a remote cross-cultural environment.
Identify personal support mechanisms such as mentors, regular time out.
Note: There are numerous clinical skills in the care of pregnant women that are not included in this
section, such as taking a foetal heart rate, as it was felt that these were skills that should only be
used by a midwife or doctor. They were therefore not seen as core skills for all health practitioners. It
should however be noted that these are vitally important and should be included in programs for those
practitioners.
22
General equipment
Blood pressure
Centrifuge
Capillary haemoglobin
Dressings - basic
Electrocardiograph
Eye chart
Glucometer
Haemocue machine
Height
Length (infants)
Waist circumference
Monofiliment
Weight
Opthalmoscope
Oxygen saturation
Otoscope
Oxygen therapy
Peak flow
Phlebotomy / venepuncture
Pulse oximeter
Pulse rate
Slit lamp
Respiration rate
Sphygmomanometer
Temperature
Spirometer
Urinalysis
Stadiometer
Tape measures
Vaccinations - standard
Thermometer
Visual acuity.
Venepuncture equipment
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Section 4 Implementation
Prerequisites
For the successful integration of the expected core outcomes of this curriculum into all workforce
education and training, the following structures need to be in place:
Policy
Industry, employers and educational providers need to have written policy with input from the community
and clinicians regarding:
Orientation programs
A structured orientation program is a prerequisite for any practitioner working in remote, rural
and Indigenous communities. The Pathways Program from Central Australia offers a good model
to follow or adapt.
The program should include the content that has been identified by the educational provider.
For example content such as: using a population health based systems approach; the social factors
that determine health; the health status of the Indigenous population and the core clinical skills.
Professional development and accredited programs
All existing and new professional development and accredited programs integrate the relevant
expected core outcomes of the curriculum into their programs.
25
Figure 2 (below) describes the implementation cycle. It starts with policy, which is developed in
consultation with the community based on needs, and the various roles of the stakeholders involved.
This will ensure integration of the curriculum into all workforce training, which will improve workforce
capacity and health outcomes.
Figure 2 Implementation Model
IMPLEMENTATION MODEL
Feedback from
all stakeholders
Improved
population health
outcomes
Apply to
practice
THE COMMUNITY
Define needs based on health outcomes and
contribute to policy.
INDUSTRY/EMPLOYERS
Directors show commitment, leadership,
ensure financial support and policy is in
place.
Managers implement policy, advocate, plan,
support and resource the educators and PHC
workforce
Educators undertake training. Adapt
existing/develop new programs using a
population health model, use listed resources
PHC workforce undertake training, adopt
population focus and systematic approach to
prevention, early detection and management
of chronic disease in the community
Increase
workforce capacity.
Better systems
Leadership,
commitment
and policy
development
Support
and Policy
Implementation
Adapt
curriculum
Orientation programs
Professional development
Accredited programs
26
boomerang) is circulated clockwise and held by the person whose turn it is to speak. This is their
opportunity to express their views. The rules are:
what is said in this circle is confidential
this is a safe environment
no-one can speak unless it is their turn
you may choose not to speak when your turn comes around
you must be honest and respect the views of others.
Audiovisual
Use of films and video to stimulate discussion.
Case studies
Use real cases from the practitioners own experience to explain concepts, and the experience of
the group to find solutions.
Distance learning
Using accredited education modules with feedback
Videos, CDROMS, PowerPoint presentations with voiceovers
Link up with existing disciplinary activities and university accredited programs.
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Part 2 RESOURCES
Introduction
The consultative process revealed that there were certain areas that educators and the primary
health care workforce find more challenging. Therefore, this section provides core educational
support information in those identified areas.
It includes:
2.1 How to use a population health approach
2.2 What are the social determinants of health? And what does this mean for rural and remote
Indigenous Australians?
2.3 What is health promotion? And how do I apply it to my practice?
and two tools:
2.4 The chronic care model by Wagner et al.
2.5 Where to find useful resources how to access the annotated bibliography and selfassessment tool.
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30
Issue
Individual/clinical
perspective
Population health
perspective
Domestic violence
Tuberculosis
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Issue
Educating from an
individual/clinical
perspective
Educating from a
population health
approach
Childhood
malnutrition
Diabetes
It is important to remember that small changes in the health of the general population are
likely to have a greater impact on the health of the population, than changes in the health
status of high risk or sick individuals (Rose cited: Baum 2004).
32
Gender
Being male or female determines our predisposition towards certain diseases, our longevity and our
relative power in society through our roles, attitudes, behaviours and values that are determined by
society (Health Canada, 2002). Attitudes to health also differ between the sexes. For example: men are
more likely to increase their physical activity as an important healthy behaviour to lose weight, whereas
women tend to focus more on social, environmental and dietary changes (AIHW, 2002a). These gender
factors contribute towards determining our health status.
Culture
Cultures are made and change by humans. Therefore a persons culture contributes towards their
knowledge, attitudes and belief systems, which influence their health behaviours and their health status.
Culture also contributes towards marginalisation of some groups, stigmatisation and devaluation of
their language. These can be exacerbated by lack of access to culturally appropriate health care services
(Health Canada, 2002). This is one reason why Indigenous groups worldwide prefer community-controlled
health services; Indigenous people manage them.
Genetic makeup
The basic biology of the human body and our own genetic makeup predispose us to particular diseases or
health problems, such as diabetes or haemophilia. Some diseases, like muscular dystrophy, result entirely
from a persons genetic makeup (AIHW, 2002a).
Social determinants
The social determinants of health make up those social factors that can also affect our health, like our
income, diet, level of education, environment and level of social support; and whether we choose to
smoke, have ten children or work in stressful conditions (WHO, 1998). Each of these factors is important
in its own right. At the same time, they are also interrelated.
33
For example: if a mother is a smoker, evidence suggests that she is more likely to come from a lower
socioeconomic group, that she probably has a lower level of education, and is more likely to have a child
with a low birth weight that may lead to health problems during childhood and adulthood. Research
shows a strong relationship between the income level of the mother and the babys birth weight, and the
mothers level of coping skills and her sense of control over her own life circumstances (Labonte, 1998).
Adding these factors to her genetic makeup, culture, level of education and environmental conditions will
determine the future health status of the child. We also know that every additional year of education for
the mother improves her health literacy and results in better health status for her child (Health Canada,
2002, McMurray, 2003). Therefore: educate a woman educate a nation (Health Canada 2002).
Social determinant
of health
2 Stress
Social and psychological circumstances can cause long-term stress.
Continuing anxiety, insecurity, low
self-esteem, social isolation and lack
of control over work and home life
have a powerful effect on health
(WHO, 1998). The biological stress
response can cause depression,
susceptibility to infection, diabetes,
high blood pressure and the risk of
heart attack or stroke (WHO, 1998).
34
Social determinant
of health
4 Education
Education is directly related to
employment and income, which in
turn affects housing, nutrition and
health. It provides people with skills
to access health information; it also
assists with problem solving and
helps give them a sense of control
over their life circumstances (Health
Canada 2002).
6 Social support
Support from families, friends and
communities helps people solve
problems, deal with adversity and
maintain a sense of mastery and
control over their life circumstances
(Health Canada 2002). Mutual trust
and respect in the community protect
people and their health (WHO, 1998).
35
Social determinant
of health
7 Addiction
Alcohol dependence, illicit drug
use and cigarette smoking are all
closely associated with markers of
social and economic disadvantage
and worsening inequalities in health
(WHO, 1998).
10 Lifestyle choices
Our lifestyle choices can prevent
disease, help us cope with challenges,
solve problems and make choices that
enhance health and develop selfreliance (Health Canada, 2002).
36
Conclusion
Research tells us that to be poor means to be unhealthy (Health Canada, 2002, WHO, 1998). Poverty is
linked with all aspects of peoples lives. It is linked with our ability to access a good education, which
affects our ability to find a good job, which affects our type of housing and the food we can put on the
table for our children. It is a vicious cycle that places us in a certain social class that in turn can continue
the cycle of poverty. Research also tells us that living in rural and remote Australia means that we will
probably be poorer, and certainly less healthy; especially if we are also Indigenous.
The way we define health differs between different groups and different cultures. Rural people view
their health as the absence of disease and their ability to be productive, which is evidenced in their
behaviours. They present later for treatment and consequently have poorer health outcomes than cityliving Australians, as they see health services as curative services. Indigenous Australians also view their
health differently from other Australians. They see health holistically as including the social, emotional,
spiritual and cultural well-being of the whole community and place heavy emphasis on the land,
dignity and community self-esteem (NAHS Evaluation Committee, 1994). Nevertheless, they also come
off second best when we compare their health status with all the social determinants of health. These
factors all increase with geographical remoteness.
Disturbingly, government-funded health services use international definitions of health, not the
definitions used by rural and Indigenous peoples. These conflicting factors contribute significantly to
the way in which health services are provided to rural, remote and Indigenous communities as they work
from different foundations and value systems. Hence many health promotion initiatives are not taken
up, or are rejected by rural and Indigenous people and the cycle of ill health continues.
We know that more doctors, nurses and hospitals do not make better health; they only provide health
services and infrastructure, which contribute only 10 per cent towards health outcomes (McMurray,
1999). Nonetheless, rural health dollars are largely spent on providing workforce incentives and running
innovative programs for health professionals rather than on those factors that make for better health,
such as access to education, nutritious food, adequate income, control over ones life, clean water
and suitable housing. Additionally, the key factors that make for better health are funded from other
government departments housing, education and employment outside the health department. A lack
of coordination exists between the Commonwealth, state and regional health departments. Therefore the
difficulties inherent in attempting to impact upon these other departments compound the problem.
37
Written by Jenni Judd, Senior Health Promotion and Policy Officer, Preventable Chronic Disease Program,
NT Dept of Health and Community Services, Darwin; and adapted by Janie Smith.
Health promotion is the process of enabling people to increase control over and to improve their health
(WHO 1984 cited: Catford, 2004). It is where individuals are viewed as health creators, rather than health
consumers, knowing that the people themselves win health (Keleher and Murphy, 2004).
Many health professionals see health promotion as only using pamphlets and posters to provide health
information to patients. While these tools have their use, health promotion is far broader.
Table 4 Examples of health promotion in action and what the remote health professional can do.
Problem
Lack of physical
activity
Advocate for:
Shaded walkways to encourage people to walk
Swimming pool installation to encourage physical activity, social
interaction, improved self-esteem and prevention of otitis media and skin
infections
Community daily walking drop-offs groups
Obesity
Spread of disease
Diabetes
Smoking
39
Upstream
Disease
prevention
Communication
strategies
Health,
education &
empowerment
Community
& health
development
Infrastructure &
systems change
Primary
Health
information
Knowledge
Engagement
Policy
Secondary
Behaviour change
campaigns
Understanding
Community
action
Legislation
Skill development
Advocacy
Organisational
change
Tertiary
Primary care
approaches
Lifestyle/behaviourist
approaches
Sociological
approaches
Source: Murphy, B. and Keleher, H. 2003
40
Most health professionals may find that their work falls into the downstream primary care approaches.
The usefulness of this model is that it allows people to reflect on their current practice and to try to utilise
methods that fall across the downstream, midstream and upstream interventions. The important thing to
remember is that infrastructure and systems change can be made at the local level, and this will assist
in improving health outcomes for all. Examples of this might include: having specific men and womens
areas in the clinic, or better access for young people. It is also important to recognise that integrated
multi-level strategies and interventions require health and other sectors to work in partnership with the
community to enhancing health.
Good references for this information are found in:
Australias Rural and Remote Health: A social justice perspective, Smith J, Tertiary Press, 2004,
Melbourne. In Chapter 8: Remote Indigenous health, the Stella and Rob live in Nabvana story,
introduces the social determinants of health as a good case study for orientation and workforce
development.
Brief Interventions for Hazardous and Harmful Drinking a manual for use in primary health care,
Babor TF and Higgins-Biddle JC, 2001, Dept of Mental Health and Substance Dependence, WHO,
Geneva. Download from: www.who.int/substance_abuse/publications/alcohol/en/
Community Health and Wellness: A sociological approach, McMurray A, 2nd Ed, 2003 Mosby,
Marrickville NSW.
Hands on Health Promotion, (Eds) Moodie R, Hulme A, 2004, IR Communications Melbourne.
Understanding Health - A determinants approach, edited by Keleher and Murphy, 2004, Oxford
University Press, South Melbourne.
World Health Organisations website: www.who.int
41
The following chronic care model, found in: Wagner, E 1998, Chronic disease management: What will it
take to improve care for chronic illness. Effective Clinical Practice. 1998;1:2-4, has been adapted for use
in this document with permission from the American College of Physicians.
Background
Chronic conditions are a fact of life for many Australians who have their daily activities limited in some
way because of their condition, and many are unable to live independently. As a result, many managed
care and integrated delivery systems have taken a great interest in correcting the many deficiencies in
the current management of diseases such as diabetes, heart disease, depression, asthma and others, most
of which are based on the acute care paradigm. Those deficiencies include:
rushed practitioners not following established practice guidelines
lack of care coordination
lack of active follow-up to ensure the best outcomes
patients inadequately trained to manage their illnesses.
Overcoming these deficiencies will require nothing less than a transformation of health care, from a
system that is essentially reactive responding mainly when a person is sick to one that is proactive
and focused on keeping a person as healthy as possible (Wagner, 1998).
Evidence has emerged that those who redesign their care to use a comprehensive and systematic
approach, expressly designed to help patients manage chronic disease, will do much better than those
who continue to work from the acute paradigm (Wagner, 1998).
42
1 Community
2 Health System
3 SelfManagement
Support
Informed,
Activated
Patient
Delivery
System
Design
Productive
Interactions
Decision
Support
6 Clinical
Information
Systems
Prepared,
Proactive
Practice Team
The Chronic Care Model identifies the essential elements of a health care system that encourage high
quality chronic disease care. These elements include:
Reorientation of the health service to create a culture, organisation and mechanisms that promote
safe, high quality organised and planned care with strong leadership and support from management
Evidence based practice rely on a high grade evidence base and protocols to improve daily practice
and outcomes
Patient centred support build around meeting the patients needs for confidence and skills in self
management of their condition though education
Clinical information systems organise patient and population data to facilitate efficient and
effective care and teamwork
The community mobilise community resources to meet the needs of patients partnerships, policies
and programs, plus cultural sensitivity and awareness (Wagner, 2004).
This model aims to result in informed activated self-managing patients and prepared, proactive teams
of health professionals.
For further detailed information about the Chronic Care Model please refer to:
www.improvingchroniccare.org/change/index.html
43
An annotated bibliography of useful chronic disease educational resources and a selfassessment tool have been developed and can be found on the following website:
www.nt.gov.au/health/healthdev/health_promotion/publications/resource_database.shtml
44
Glossary of terms
Acute care model A model of medical practice designed for acute care. Its features emphasise triage,
patient flow, short appointments, diagnosis and treatment of symptoms, reliance on laboratory tests and
prescriptions, didactic patient education and patient initiated follow-up (Wagner, 1998).
Acute conditions Those medical conditions with an acute onset, accurate prognosis, short-term
treatment and where a cure is likely.
Advocacy A process which openly aims to change laws, regulations, policy and organisational practices
that impact upon the ability of the individual and communities to make healthy choices (Keleher and
Murphy, 2004).
Barker hypothesis The early origins of chronic disease. The environmental factors that program
particular body systems during critical periods of growth in utero and infancy with long term direct
consequences for adult chronic disease (Barker, Scrimshaw, cited: Weeramanthri et al., 2003)
Brief interventions Seizing opportunities as part of each consultation to advise about health promotion,
in particular smoking, nutrition, alcohol intake and physical activity.
Burden of disease The physical, emotional, social and economic impact that disease, injury or disability
places on the individual, the community and the nation.
Chronic conditions Those long term medical conditions that have a gradual onset, multiple causes,
uncertain prognosis, with usually a lifelong duration and an unlikely cure: diabetes, renal disease,
cardiovascular disease, chronic obstructive pulmonary disease.
Chronic care model A model of practice designed for chronic care. It includes planned systematic
assessment, a focus on function and the prevention of exacerbations, attention to treatment guidelines,
support for the patients role as a self-manager, clinically relevant information systems and continuing
follow up initiated by the provider (Wagner, 1998).
Community development Working with people and communities as they define their own goals,
mobilise resources and develop action plans for addressing problems they collectively have identified
(Wass, 2002).
Curriculum framework The overall structure of the whole curriculum.
Curriculum model The design and interlinking parts of the curriculum.
Domains of remote practice The integrated organising structure of what is to be achieved in the
curriculum, ie. the critical knowledge, skills and attitudes.
Downstream approach Dealing with the individual who is sick or injured on a one to one basis.
45
46
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