Integrating health care in Australia: a qualitative evaluation.

BACKGROUND: With aging populations, a growing prevalence of chronic illnesses, higher expectations for quality care and rising costs within limited health budgets, integration of healthcare is seen as a solution to these challenges. Integrated healthcare aims to overcome barriers between primary and secondary care and other disconnected patient services to improve access, continuity and quality of care. Many people in Australia are admitted to hospital for chronic illnesses that could be prevented or managed in the community. Western Sydney has high rates of diabetes, heart and respiratory diseases and the NSW State Ministry of Health has implemented key strategies through the Western Sydney Integrated Care Program (WSICP) to enhance primary care and the outcomes and experiences of patients with these illnesses. METHODS: We aimed to investigate the WSICP's effectiveness through a qualitative evaluation focused on the 10 WSICP strategies using a framework analysis. We administered 125 in-depth interviews in two rounds over 12 months with 83 participants including patients and their carers, care facilitators, hospital specialists and nurses, allied health professionals, general practitioners (GPs) and primary care nurses, and program managers. Most participants (71%) were interviewed twice. We analysed data within a framework describing how strategies were implemented and used, the experiences around these, their perceived value, facilitators and barriers, and participant-identified suggestions for improvement. RESULTS: Care facilitators helped patients access services within the hospital and in primary care and connected general practices with hospital specialists and services. Rapid access and stabilisation clinics with their patient hotlines assisted patients and carers to self-manage chronic illness while connecting GPs to specialists through the GP support-line. Action plans from the hospital informed GPs and their shared care plans which could be accessed by other community health professionals and patients. HealthPathways provided GPs with local, evidence-based guidelines for managing patients. Difficulties persisted in effective widespread access to shared records and electronic communication across sectors. CONCLUSIONS: The combined WSICP strategies improved patient and carer experience of healthcare and capacity of GPs to provide care in the community. Information sharing required longer-term investment and support, though benefits were evident by the end of our research.

Linguistically diverse general practice teaching.

BACKGROUND: Learning about general practice in a context of linguistic diversity is an understudied area. There may be additional learning needs or unrecognised opportunities in this environment. This study explores the experiences of general practitioners (GPs) and medical students on placement where consultations are conducted in a language other than English (LOTE). METHOD: We conducted 19 semi-structured interviews with medical students and GP supervisors who consult in LOTE. We explored experiences of learning, and teaching strategies implemented by GP supervisors. Thematic analysis was undertaken. RESULTS: Participants reported that LOTE consultations provided unique learning opportunities, including use of interpreters and development of cross-cultural communication skills. Facilitators to learning included the GP engaging the student in the consultation by interpreting, and patients being open to student participation. Some students described language as a barrier to learning, where they had difficulty in following the consultation. Time required for interpreting limited interaction and learning in GP consultations. We identified ways to navigate the language barrier; including the GP acting as interpreter, and students learning key phrases in the consultation language to build rapport. DISCUSSION: Learning in the linguistically diverse General Practice environment can be optimised through an active and collaborative approach between the GP, student, and patients. Our findings highlight specific barriers and facilitators to learning. Our participants identified a variety of techniques, including skills in interpreter use and cross-cultural communication skills which can transcend language barriers, to create valuable opportunities for medical students to learn in this setting. Medical students increasingly experience clinical placements in general practices within diverse communities.

"Imagine if I'm not here, what they're going to do?"-Health-care access and culturally and linguistically diverse women in prison.

BACKGROUND: Women in prison have complex medical needs and poorer health status than the general population. Culturally and linguistically diverse (CALD) women in prison, particularly those with limited English proficiency (LEP), have distinct needs and risk additional isolation, discrimination and marginalization when they are in prison. OBJECTIVE: We sought to examine how cultural and linguistic diversity, particularly LEP, affects the health-care experiences of women in prison. DESIGN, SETTING AND PARTICIPANTS: We conducted focus groups and semi-structured qualitative interviews with CALD women and frontline nursing staff in the three female Correctional Centres in New South Wales, Australia. RESULTS: Participants comprised 30 women in prison and nine nurses. Both women and staff reported communication difficulties as a significant and additional barrier to accessing and receiving health care. For some women with LEP, barriers to care were perceived as discrimination. Fellow prisoners were often utilized as support persons and informal interpreters ("peer interpreters") in place of formally trained interpreters. While peer interpreters were perceived as useful, potential challenges to their use were vulnerability to coercion, loss of confidentiality, untrained health advice and errors of interpretation. CONCLUSION: The persistent use of peer interpreters in prison is complicated by the lack of clearly defined roles, which can include informal peer support roles and lay health advice. These are highly complex roles for which they are unlikely to be adequately trained or supported, despite perceived benefits to their use. Improved understanding and facilitation of health-related communication could enhance equity of access for CALD women in prison.

Developing cultural competence in general practitioners: an integrative review of the literature.

BACKGROUND: Cultural competence is a broad concept with multiple theoretical underpinnings and conflicting opinions on how it should be materialized. While it is recognized that cultural competence should be an integral part of General Practice, literature in the context of General Practice is limited. The aim of this article is to provide a comprehensive summary of the current literature with respect to the following: the elements of cultural competency that need to be fostered and developed in GPs and GP registrars; how is cultural competence being developed in General Practice currently; and who facilitates the development of cultural competence in General Practice. METHODS: We conducted an integrative review comprising a systematic literature search followed by a synthesis of the results using a narrative synthesis technique. RESULTS: Fifty articles were included in the final analysis. Cultural competence was conceptualized as requiring elements of knowledge, awareness/attitudes and skills/behaviours by most articles. The ways in which elements of cultural competence were developed in General Practice appeared to be highly varied and rigorous evaluation was generally lacking, particularly with respect to improvement in patient outcomes. Formal cultural competence training in General Practice appeared to be underdeveloped despite GP registrars generally desiring more training. The development of most aspects of cultural competence relied on informal learning and in-practice exposure but this required proper guidance and facilitation by supervisors and educators. Levels of critical and cultural self-reflection amongst General Practitioners and GP registrars varied and were potentially underdeveloped. Most standalone training workshops were led by trained medical educators however the value of cultural mentors was recognised by patients, educators and GP registrars across many studies. CONCLUSIONS: Cultural competency development of GP registrars should receive more focus, particularly training in non-conscious bias, anti-racism training and critical self-reflectiveness. There is a need for further exploration of how cultural competence training is delivered within the GP training model, including clarifying the supervisor's role. It is hoped this discussion will inform future research and training practices in order to achieve quality and respectful care to patients across cultures, and to remove health inequities that exist between cultural groups.

Cross-cultural training of general practitioner registrars: how does it happen?

An equitable multicultural society requires general practitioners (GPs) to be proficient in providing health care to patients from diverse backgrounds. GPs are required to have a certain attitudes, knowledge and skills known as cultural competence. Given its importance to registrar training, the aim of this study was to explore ways in which GP registrars are currently developing cultural competence. This study employed a survey design for GP registrars in Western Sydney. Training approaches to cultural competence that are relevant to the Australian General Practice setting include exposure to diversity, attitudes, knowledge and skills development. The 43 GP registrar respondents in Western Sydney are exposed to a culturally diverse patient load during training. Registrars report a variety of teachings related to cross-cultural training, but there is little consistency, with the most common approach entailing listening to patients' personal stories. Exposure to cultural diversity appears to be an important way in which cultural competency is developed. However, guidance and facilitation of skills development throughout this exposure is required and currently may occur opportunistically rather than consistently.

Strategies to promote practice nurse capacity to deliver evidence-based care: An example from sexual healthcare.

PURPOSE: Evidence-based practice is pivotal to effective patient care. However, its translation into practice remains limited. Given the central role of primary care in many healthcare systems, it is important to identify strategies that bolster clinician-capacity to promote evidence-based care. The purpose of this paper is to identify strategies to increase Practice Nurse capacity to promote evidence-based sexual healthcare within general practice. DESIGN/METHODOLOGY/APPROACH: A survey of 217 Practice Nurses in an Australian state and ten respondent-interviews regarding two resources to promote evidence-based sexual healthcare - namely, a clinical aide and online training. FINDINGS: The perceived impact of both resources was determined by views on relevance and design - particularly for the clinical aide. Resource-use was influenced by role and responsibilities within the workplace, accessibility, and support from patients and colleagues. RESEARCH LIMITATIONS/IMPLICATIONS: This is the first Australian study to reveal strategies to promote evidence-based sexual healthcare among Practice Nurses. The findings provide a platform for future research on knowledge translation processes, particularly among clinicians who might be disengaged from sexual healthcare. PRACTICAL IMPLICATIONS: Given the benefits of evidence-based practices, it is important that managers recognize their role, and the role of their services, in promoting these. Without explicit support for evidence-based care and recognition of the Practice Nurse role in such care, knowledge translation is likely to be limited. ORIGINALITY/VALUE: Knowledge translation among Practice Nurses can be facilitated by: resources-deemed informative, relevant, and user-friendly, as well as support from patients, colleagues, and their workplace.

Cultural competency training of GP Registrars-exploring the views of GP Supervisors.

INTRODUCTION: An equitable multicultural society requires General Practitioners (GPs) to be proficient in providing health care to patients from diverse backgrounds. This requires a certain set of attitudes, knowledge and skills known as cultural competence. While training in cultural competence is an important part of the Australian GP Registrar training curriculum, it is unclear who provides this training apart from in Aboriginal and Torres Strait Islander training posts. The majority of Australian GP Registrar training takes place in a workplace setting facilitated by the GP Supervisor. In view of the central role of GP Supervisors, their views on culturally competent practice, and their role in its development in Registrars, are important to ascertain. METHODS: We conducted 14 semi-structured interviews with GP Supervisors. These were audiotaped, transcribed verbatim and thematically analyzed using an iterative approach. RESULTS: The Supervisors interviewed frequently viewed cultural competence as adequately covered by using patient-centered approaches. The Supervisor role in promoting cultural competence of Registrars was affirmed, though training was noted to occur opportunistically and focused largely on patient-centered care rather than health disparities. CONCLUSION: Formal training for both Registrars and Supervisors may be beneficial not only to develop a deeper understanding of cultural competence and its relevance to practice but also to promote more consistency in training from Supervisors in the area, particularly with respect to self-reflection, non-conscious bias and utilizing appropriate cultural knowledge without stereotyping and assumption-making.

The role of primary health care services to better meet the needs of Aboriginal Australians transitioning from prison to the community.

BACKGROUND: Aboriginal Australians are more likely than other Australians to cycle in and out of prison on remand or by serving multiple short sentences-a form of serial incarceration and institutionalisation. This cycle contributes to the over-representation of Aboriginal Australians in prison and higher rates of recidivism. Our research examined how primary health care can better meet the health care and social support needs of Aboriginal Australians transitioning from prison to the community. METHODS: Purposive sampling was used to identify 30 interviewees. Twelve interviews were with Aboriginal people who had been in prison; ten were with family members and eight with community service providers who worked with former inmates. Thematic analysis was conducted on the interviewees' description of their experience of services provided to prisoners both during incarceration and on transition to the community. RESULTS: Interviewees believed that effective access to primary health care on release and during transition was positively influenced by providing appropriate healthcare to inmates in custody and by properly planning for their release. Further, interviewees felt that poor communication between health care providers in custody and in the community prior to an inmate's release, contributed to a lack of comprehensive management of chronic conditions. System level barriers to timely communication between in-custody and community providers included inmates being placed on remand which contributed to uncertainty regarding release dates and therefore difficulties planning for release, cycling in and out of prison on short sentences and being released to freedom without access to support services. CONCLUSIONS: For Aboriginal former inmates and family members, release from prison was a period of significant emotional stress and commonly involved managing complex needs. To support their transition into the community, Aboriginal former inmates would benefit from immediate access to culturally- responsive community -primary health care services. At present, however, pre-release planning is not always available, especially for Aboriginal inmates who are more likely to be on remand or in custody for less than six months.

Investigating general practitioner engagement with pharmacists in Home Medicines Review.

The Home Medicines Review (HMR) involves a home visit from an accredited HMR pharmacist to review a patient's medicines, and a report to the patient's general practitioner (GP) with recommendations for improving medicine management. Notwithstanding evidence supporting the benefits of medicines review, broad uptake by GPs in Australia remains low. We developed the 10-item Home Medicines Review Inventory (HMRI) to assess GP attitudes and behaviours regarding the HMR and modelled factors associated with the frequency of GP engagement with HMRs. Four items assessing frequency of behaviours and six items assessing attitudes related to HMR were answered by 180 GPs in a national GP survey. The HMRI's psychometric properties were examined with exploratory factor analysis (EFA), Rasch analysis, and correlations with related instruments. Structural equation modelling was used to evaluate factors associated with HMR-related behaviours. EFA and Rasch analysis generally supported the current format of the instrument. Attitudes to HMR, gender, previous positive experiences with pharmacists, a system for working together, and participation in joint education activities predicted frequency of HMR-related behaviours. Although GPs' attitudes to HMR were generally positive, HMR-related behaviours tended to occur with low frequency. This instrument may be used to investigate why HMR uptake has thus far been low and also help identify opportunities for building interprofessional communication and trust between GPs and pharmacists.

Development and validation of a measure and a model of general practitioner attitudes toward collaboration with pharmacists.

BACKGROUND: Collaboration between general practitioners (GPs) and community pharmacists has been shown to be effective in improving patient outcomes. However, little is known about GP attitudes toward collaborating with their pharmacist counterparts and variables that influence this interprofessional collaboration. OBJECTIVES: To develop and validate, in the context of primary care in Australia 1) an instrument to measure GP attitudes toward collaborating with pharmacists and 2) a model that illustrates how GP attitudes (and other variables) influence GP-pharmacist collaborative behavior. METHODS: The "Attitudes Toward Collaboration Instrument for GPs" (ATCI-GP) was developed to measure GP attitudes toward GP-pharmacist collaboration based on existing literature and qualitative interviews with GPs and community pharmacists. The ATCI-GP and a previously validated behavioral measure "Frequency of Interprofessional Collaboration Instrument for GPs" (FICI-GP) were included in a survey and administered to a sample of 1145 GPs in 12 divisions of general practice across Australia. Principal component analysis (PCA) was used to assess the structure of the ATCI-GP. Structural equation modeling was used to determine how attitudes (measured by the ATCI-GP) and other variables, influence collaborative behavior (measured by the FICI-GP). RESULTS: Three hundred and seventy-six surveys were completed and returned for a response rate of 33%. PCA of the ATCI-GP suggested a two factor ("interactional and practitioner determinants" and "role for pharmacist in medication management") solution accounting for 66.2% of the variance. The model for GP-pharmacist collaboration demonstrated adequate fit (χ(2)/df = 2.27, CFI = .99, RMSEA = .060, 90% CI [.052-.069]). Factors found to predict collaboration included: 1) Interactional and practitioner determinants 2) environmental determinants and 3) GP perception of the pharmacists' role in medication management. CONCLUSIONS: The study provides evidence for the validity of the ATCI-GP for measuring GP-pharmacist collaboration from the GPs perspective and supports a model for collaboration in which collaborative behavior is influenced by a number of variables.

Community pharmacist attitudes towards collaboration with general practitioners: development and validation of a measure and a model.

BACKGROUND: Community Pharmacists and General Practitioners (GPs) are increasingly being encouraged to adopt more collaborative approaches to health care delivery as collaboration in primary care has been shown to be effective in improving patient outcomes. However, little is known about pharmacist attitudes towards collaborating with their GP counterparts and variables that influence this interprofessional collaboration. This study aims to develop and validate 1) an instrument to measure pharmacist attitudes towards collaboration with GPs and 2) a model that illustrates how pharmacist attitudes (and other variables) influence collaborative behaviour with GPs. METHODS: A questionnaire containing the newly developed "Attitudes Towards Collaboration Instrument for Pharmacists" (ATCI-P) and a previously validated behavioural measure "Frequency of Interprofessional Collaboration Instrument for Pharmacists" (FICI-P) was administered to a sample of 1215 Australian pharmacists. The ATCI-P was developed based on existing literature and qualitative interviews with GPs and community pharmacists. Principal Component Analysis was used to assess the structure of the ATCI-P and the Cronbach's alpha coefficient was used to assess the internal consistency of the instrument. Structural equation modelling was used to determine how pharmacist attitudes (as measured by the ATCI-P) and other variables, influence collaborative behaviour (as measured by the FICI-P). RESULTS: Four hundred and ninety-two surveys were completed and returned for a response rate of 40%. Principal Component Analysis revealed the ATCI-P consisted of two factors: 'interactional determinants' and 'practitioner determinants', both with good internal consistency (Cronbach's alpha = .90 and .93 respectively). The model demonstrated adequate fit (χ2/df = 1.89, CFI = .955, RMSEA = .062, 90% CI [.049-.074]) and illustrated that 'interactional determinants' was the strongest predictor of collaboration and was in turn influenced by 'practitioner determinants'. The extent of the pharmacist's contact with physicians during their pre-registration training was also found to be a significant predictor of collaboration (B = .23, SE = .43, p <.001). CONCLUSIONS: The results of the study provide evidence for the validity of the ATCI-P in measuring pharmacist attitudes towards collaboration with GPs and support a model of collaboration, from the pharmacist's perspective, in which collaborative behaviour is influenced directly by 'interactional' and 'environmental determinants', and indirectly by 'practitioner determinants'.

Development and validation of the GP frequency of interprofessional collaboration instrument (FICI-GP) in primary care.

Existing validated measures of pharmacist-physician collaboration focus on measuring attitudes toward collaboration and do not measure frequency of interactions that comprise actual collaborative behavior. Therefore, the aim of this study was to develop and validate an instrument to measure the frequency of collaboration between general practitioners (GPs) and pharmacists from the GP's perspective. An 11-item Frequency of Interprofessional Collaboration Instrument for GPs (FICI-GP) was developed and administered to 1118 GPs in eight divisions of general practice in New South Wales, Australia. Two hundred and fifty-eight (23%) GP surveys were completed and returned. Principal component analysis suggested removal of one item for a final one-factor solution. The refined 10-item FICI-GP had a Cronbach's alpha of 0.87. After collapsing the original five-point response scale to a three-point response scale, the refined FICI-GP demonstrated fit to the Rasch model. Criterion validity of the FICI-GP was supported by the correlation of FICI-GP scores with scores on a previously validated physician-pharmacist collaboration instrument as well as by predicted differences in FICI-GP scores between subgroups of respondents stratified on age, co-location with pharmacists and interactions during residency. The refined 10-item FICI-GP was shown to have good internal consistency, criterion validity and fit to the Rasch model.

Development and initial validation of the Pharmacist Frequency of Interprofessional Collaboration Instrument (FICI-P) in primary care.

BACKGROUND: Existing validated measures of pharmacist-physician collaboration focus on measuring attitudes toward collaboration and do not measure frequency of collaborative interactions. OBJECTIVE: To develop and validate an instrument to measure the frequency of collaboration between pharmacists and general practitioners (GPs) from the pharmacist's perspective. METHODS: An 11-item Pharmacist Frequency of Interprofessional Collaboration Instrument (FICI-P) was developed and administered to 586 pharmacists in 8 divisions of general practice in New South Wales, Australia. The initial items were informed by a review of the literature in addition to interviews of pharmacists and GPs. Items were subjected to principal component and Rasch analyses to determine each item's and the overall measure's psychometric properties and for any needed refinements. RESULTS: Two hundred and twenty four (38%) of pharmacist surveys were completed and returned. Principal component analysis suggested removal of 1 item for a final 1-factor solution. The refined 10-item FICI-P demonstrated internal consistency reliability at Cronbach's alpha=0.90. After collapsing the original 5-point response scale to a 4-point response scale, the refined FICI-P demonstrated fit to the Rasch model. Criterion validity of the FICI-P was supported by the correlation of FICI-P scores with scores on a previously validated Physician-Pharmacist Collaboration Instrument. Validity was also supported by predicted differences in FICI-P scores between subgroups of respondents stratified on age, colocation with GPs, and interactions during the intern-training period. CONCLUSION: The refined 10-item FICI-P was shown to have good internal consistency, criterion validity, and fit to the Rasch model. The creation of such a tool may allow for the measure of impact in the evaluation of interventions designed to improve interprofessional collaboration between GPs and pharmacists.

Facilitating uptake of Aboriginal Adult Health Checks through community engagement and health promotion.

BACKGROUND: Adult Health Checks (AHCs) for Aboriginal and Torres Strait Islander people (MBS Item 710) promote comprehensive physical and psychosocial health assessments. Despite the poor uptake of health assessments in Aboriginal and Torres Strait Islander people, a small number of successful implementation initiatives have been reported. In order to ensure uptake of these screening initiatives, there remains a need to demonstrate the feasibility of models of implementing AHCs. AIMS: The aim of this paper is to address the process issues and overarching outcomes of a two-day targeted screening and assessment programme to increase the uptake of AHCs at an Aboriginal Community Controlled Medical Service. METHOD: Clients of an urban Aboriginal Medical Service (AMS) were invited to undertake an AHC during a two-day screening initiative. On-site general practitioners (GPs), nurses, and Aboriginal Health Workers (AHWs) worked within a team to facilitate screenings at an AMS. Barriers and facilitators to the initiative and strategies for quality improvement were discussed by the team. A review of medical notes was undertaken six months following the screening days to document uptake of recommendations. RESULTS: Forty clients undertook AHCs as part of the initiative. In total, 113 diagnostic tests, interventions, specialist referrals and medication initiatives had been enacted within the following six months as a result of screening day visits. Benefits to individual clients, the community, the AMS and staff were identified. CONCLUSIONS: The screening day demonstrated feasibility and acceptability of this approach and provides support for its implementation in other health facilities. Importantly, this service was provided in a culturally sensitive framework and within an interdisciplinary teamwork model. This targeted approach increased uptake of assessment items and provided opportunities for health advice and risk factor modification.

Improving medication uptake in aboriginal and Torres Strait islander peoples.

BACKGROUND: Poor medication adherence is associated with adverse health outcomes. Improving access and adherence to pharmacological therapy is important in achieving optimal health outcomes for Indigenous populations. In spite of the impressive evidence base for cardiovascular pharmacotherapy, strategies for promoting adherence and evidence based practice are less well refined and the challenges for Indigenous populations are more pronounced. AIM: To identify factors impacting on medication adherence in Aboriginal Australians and identify solutions to improve the quality use of medicines. METHOD: The World Health Organization adherence model was used to classify barriers to adherence. Key elements of this model are (1) health care team/health system; (2) socio-economic factors; (3) therapy; (4) patient; and (5) condition related. RESULTS: Entrenched socio-economic differentials aggravate challenges to medication adherence amongst Aboriginal Australians. Initiatives to promote the quality use of medicines, such as the Quality Use of Medicines Maximised for Aboriginal and Torres Strait Islander People (QUMAX) Program, are important strategies to promote adherence. CONCLUSIONS: Medication adherence is a complex issue and addressing modifiable factors is imperative to improve health outcomes. Subsidised access to medications whether living in urban, regional, rural or remote areas is an important strategy in Closing the Gap.

Expanding roles of Aboriginal health workers in the primary care setting: seeking recognition.

The work of Aboriginal health workers (AHWs) in the primary care setting is discussed, emphasising that partnership with non-Indigenous health providers such as nurses and general practitioners brings complementary skills together to improve the health care available to Aboriginal clients, and to decrease the cultural and communication barriers to delivering such health care. The diverse skills and responsibilities of AHWs, which include clinical, health promotion, education and leadership roles, are illustrated. The current focus on increasing AHW educational opportunities, and the need to recognise AHWs as core health professionals and equal members of the health care team is presented. The increasing recognition of the role of AHWs in providing cultural mentorship for non-Indigenous colleagues is discussed.

Too many of us have gone early - priorities in heart health education for Aboriginal people.

Aboriginal people have a higher burden of cardiovascular risk factors and heart disease and poorer outcomes after heart attacks when compared with other Australians. Indigenous status is also a risk factor for delayed response to heart attack symptoms. A community DVD about preventing and managing heart disease was made at the Aboriginal Medical Service Western Sydney in 2005. The aim of this article is to reflect on the process of making the DVD as a community driven health promotion activity and to explore questions raised and insights gained about heart health education for Aboriginal people in the context of the existing literature. The importance of education about heart attack symptom recognition and prompt hospital presentation, as well as risk factor management, by general practitioners and other health practitioners working with Aboriginal people, is highlighted.

A partnership model in the development and implementation of a collaborative, cardiovascular education program for Aboriginal Health Workers.

A partnership model was established among key education providers, policy makers, non-government organisations, the local area health service and Aboriginal community controlled organisations aimed at increasing collaboration, skill development, cultural competence and increasing access to mentorship and expertise for Aboriginal Health Workers (AHWs). A group of 21 AHWs, within two cohorts, undertook the program between October 2005 and June 2006. A mixed-method evaluation using quantitative and qualitative data collection methods was undertaken prospectively. Knowledge and confidence scores significantly increased for all participants over the course duration. Student evaluation demonstrated a desire for group-based activities and the high value placed on clinical visits. Feedback on both outcome and process measures will inform course delivery and design.

Expanding roles of Aboriginal health workers in the primary care setting: seeking recognition.

The work of Aboriginal health workers (AHWs) in the primary care setting is discussed, emphasising that partnership with non-Indigenous health providers such as nurses and general practitioners brings complementary skills together to improve the health care available to Aboriginal clients, and to decrease the cultural and communication barriers to delivering such health care. The diverse skills and responsibilities of AHWs, which include clinical, health promotion, education and leadership roles, are illustrated. The current focus on increasing AHW educational opportunities, and the need to recognise AHWs as core health professionals and equal members of the health care team is presented. The increasing recognition of the role of AHWs in providing cultural mentorship for non-Indigenous colleagues is discussed.

Stressful life events, resources, and access: key considerations in quitting smoking at an Aboriginal Medical Service.

OBJECTIVE: Aboriginal and Torres Strait Islander people experience adverse health outcomes and have high rates of smoking and related illnesses. This brief report describes stress as a barrier to quitting smoking derived from reflections within an Aboriginal Medical Service and makes recommendations for intervention development. METHODS: A high-intensity smoking cessation program was conducted within a suburban Aboriginal Medical Service in Western Sydney, Australia, over a 10-month period. The intervention included weekly cessation counselling sessions and dispensation of free nicotine replacement therapy (NRT). RESULTS: During the observation period, 32 clients made quit attempts. To date, three clients (9%) have quit smoking. Chronic and intercurrent life stressors were noted to be the main barriers to smoking cessation described by participants. CONCLUSIONS: Achieving smoking cessation among Indigenous people is made significantly more complex because of multiple life stressors experienced. IMPLICATIONS: Future interventions targeting Indigenous Australians should take greater account of stressful life events and their impact on quitting smoking.