Emergency examination authorities in Queensland, Australia.

OBJECTIVE: In Queensland, where a person experiences a major disturbance in their mental capacity, and is at risk of serious harm to self and others, an emergency examination authority (EEA) authorises Queensland Police Service (QPS) and Queensland Ambulance Service (QAS) to detain and transport the person to an ED. In the ED, further detention for up to 12 h is authorised to allow the examination to be completed. Little published information describes these critical patient encounters. METHODS: Queensland's Public Health Act (2005), amended in 2017, mandates the use of the approved EEA form. Data were extracted from a convenience sample of 942 EEAs including: (i) patient age, sex, address; (ii) free text descriptions by QPS and QAS officers of the person's behaviour and any serious risk of harm requiring urgent care; (iii) time examination period commenced; and (iv) outcome upon examination. RESULTS: Of 942 EEA forms, 640 (68%) were retrieved at three 'larger central' hospitals and 302 (32%) at two 'smaller regional' hospitals in non-metropolitan Queensland. QPS initiated 342 (36%) and QAS 600 (64%) EEAs for 486 (52%) males, 453 (48%) females and two intersexes (<1%), aged from 9 to 85 years (median 29 years, 17% aged <18 years). EEAs commonly occurred on weekends (32%) and between 2300 and midnight (8%), characterised by 'drug and/or alcohol issues' (53%), 'self-harm' (40%), 'patient aggression' (25%) and multiple prior EEAs (23%). Although information was incomplete, most patients (78%, n = 419/534) required no inpatient admission. CONCLUSIONS: EEAs furnish unique records for evaluating the impacts of Queensland's novel legislative reforms.

Towards best practice during COVID-19: A responsive and relational program with remote schools to enhance the wellbeing of Aboriginal and Torres Strait Islander students.

Purpose: From 2018, the Schools Up North (SUN) programme worked with three remote Australian schools to enhance their capability and resilience to support the wellbeing and mental health of Aboriginal and Torres Strait Islander students and staff. This paper explores the implementation of SUN during the first two years of COVID-19 (2020-2021). Method: Using grounded theory methods, school staff, other service providers and SUN facilitators were interviewed, with transcripts and programme documents coded and interrelationships between codes identified. An implementation model was developed. Results: The SUN approach was place-based, locally informed and relational, fostering school resilience through staff reflection on and response to emerging contextual challenges. Challenges were the: community lockdowns and school closures; (un)availability of other services; community uncertainty and anxiety; school staff capability and wellbeing; and risk of educational slippage. SUN strategies were: enhancing teachers' capabilities and resources, facilitating public health discussions, and advocating at regional level. Outcomes were: enhanced capability of school staff; greater school-community engagement; student belonging and engagement; a voice for advocacy; and continuity of SUN's momentum. Conclusions: The resilience approach (rather than specific strategies) was critical for building schools' capabilities for promoting students and staff wellbeing and provides an exemplar for remote schools globally.

Building patient trust in health systems: A qualitative study of facework in the context of the Aboriginal and Torres Strait Islander Health Worker role in Queensland, Australia.

Healthcare services in Australia are the primary responsibility of state and territory governments, which recruit and deploy health providers in hospital and primary-care services. Among the various health professional roles, that of Aboriginal and Torres Strait Islander Health Worker (A&TSIHW) is one of only two positions that must be occupied by an Aboriginal and/or Torres Strait Islander person, carrying unique responsibility for enacting cultural brokerage and promoting cultural safety at the facility-level. Implicit to these responsibilities is the assumption that A&TSIHW will use cultural capital to build clients' trust in themselves and ultimately the broader health system. Drawing on 82 in-depth interviews including 52 with A&TSIHWs, we applied Kroegar's Facework theory to explore the structures, processes and relationships that contribute to, or inhibit, A&TISHWs' capacity and willingness to build trust (beyond themselves) in government health services in Queensland, Australia. Analysis demonstrates that despite A&TSIHWs viewing and enacting interpersonal trust-building as central to their role, structural features of the health system inhibit the development of service-users' system-level trust. Findings re-establish that health systems are not 'cultureless,' but rather, shaped by a dominant culture that privileges certain actors, types of knowledge, and modes of communication and action, which in turn influence efforts to build trust. The study demonstrates a novel theory-driven approach to exploring the interactions between behavioural and structural factors that influence the production of systems-level trust. In the context of the Queensland public health service findings highlight a disconnect between the expectations of, and support provided to A&TISHWs to engage Aboriginal and Torres Strait Islander service-users.

Rhetoric, Reality and Racism: The Governance of Aboriginal and Torres Strait Islander Health Workers in a State Government Health Service in Australia.

BACKGROUND: In northern Australia, Aboriginal and Torres Strait Islander Health Workers (A&TSIHWs) are unique members of nominally integrated teams of primary care professionals. Spurred by research documenting ongoing structural violence experienced by Indigenous health providers and more recent challenges to recruitment and retention of A&TSIHWs, this study aimed to explore whether the governance of the A&TSIHW role supports full and meaningful participation. METHODS: The qualitative study was co-designed by a team of Aboriginal, Torres Strait Islander and non-Indigenous collaborators. Data collection comprised document review and interviews with A&TSIHWs (n=51), clinicians (n=19) community members (n=8) and administrators (n=5) in a north Queensland health district. We analysed governance at multiple levels (regulatory, organisational, and socio-cultural) and used critical race theory to deepen exploration of the role of race and racism in shaping it. RESULTS: Governance of the A&TSIHW role occurs within a health system where racism is built into, and amplified by, formal and informal rules at all levels. Racially discriminatory structures such as the previous but long-standing relegation of A&TSIHW into the same career stream as cleaners were mirrored in discriminatory rules and managerial practices such as an absence of career-specific corporate support and limited opportunities to participate in, or represent to, key leadership groups. These interacted with and helped perpetuate workplace norms permissive of disrespect and abuse by non-Indigenous professionals. Ongoing resistance to the structural violence required of, and demonstrated by A&TSIHWs speaks to the gap between rhetoric and reality of governance for A&TSIHWs. CONCLUSION: Strengthening governance to support A&TSIHWs requires critical attention be given to the role of race and racism in regulatory structures, organisational practice, and inter-professional relationships. Addressing all domains will be essential to achieve systemic change that recognises, supports and embeds the unique knowledge, skills and functions of the A&TSIHW role.

Recent amendments to Queensland legislation make mental health presentations to hospital emergency departments more difficult to scrutinise.

The Queensland Police Service (QPS) and Queensland Ambulance Service may detain and transport persons experiencing major disturbances in their mental capacity to an ED for urgent care. Queensland's new mental health legislation (March 2017) makes this legal intervention difficult to scrutinise. For a large non-metropolitan region, QPS records for emergency examination orders (EEOs) and emergency examination authorities (EEAs) were compared with annual reports of Queensland's Director of Mental Health and Chief Psychiatrist. From 2009-2010 to March 2017, QPS-registered EEOs totalled 12 903 while annual reports attributed 9441 to QPS (27% fewer). From March 2017 to 2019-2020, QPS-registered EEAs totalled 6887. Annual reports declared 1803 EEAs in total for this period, without distinguishing those registered by QPS from the Queensland Ambulance Service. Past year proportions of EEOs, however, indicate perhaps ~1100 originated with QPS (84% fewer). Information crucial for considered emergency mental healthcare responses for thousands of people is no longer readily available.

Unique knowledge, unique skills, unique role: Aboriginal and Torres Strait Islander Health Workers in Queensland, Australia.

Aboriginal and Torres Strait Islander Health Workers (A&TSIHWs) are a professional cadre of Australian health workers typically located in primary care clinics. The role is one of only two that is 'identified'- that is, it must be occupied by an Aboriginal and/or Torres Strait Islander person - and holds specific responsibilities in relation to advocating for facility-level cultural safety. However, lack of understanding of the distinctive skills, scope and value associated with the A&TSIHW role remains pervasive in the broader health workforce. Positioned to represent the perspective of those working as A&TSIHWs, and drawing on 83 in-depth interviews with A&TSIHWs and others, this qualitative study reports on the core functions and distinctive orientation of the role, and seeks to articulate its distinctive value in the modern Queensland health service. Findings highlight the multifaceted (generalist) nature of the A&TSIHW role, which comprises three core functions: health promotion, clinical service and cultural brokerage. Underpinning these cross-cutting functions, is the role's unique orientation, defined by client-centredness and realised through Indigenous strengths based ways of knowing, being and doing. The findings highlight how the A&TSIHW role is one of the only mechanisms through which Aboriginal and Torres Strait Islander knowledge can be brought to bear on context-specific adaptations to routine health service practices; and through which the impacts of lack of cultural or self-awareness among some non-Indigenous health professionals can be mitigated. The complexity of such work in a government health system where a dominant biomedical culture defines what is valued and therefore resourced, is under-recognised and undervalued and contributes to pressures and stress that are potentially threatening the role's long-term viability.

Health professionals' perception of the New Zealand National Child Protection Alert System: An online survey.

AIM: To describe the multi-disciplinary child protection teams which administer the National Child Protection Alert System in District Health Boards in New Zealand and the understanding and perceptions of that system held by team members. METHODS: This is a mixed-method observational study. In December 2016 and January 2017, all child protection alert system multi-disciplinary team members were invited to participate in an online survey. Quantitative data were expressed with simple descriptive statistics. Qualitative findings were analysed using thematic analysis. RESULTS: Ninety-one (56.9%) of 160 team members nationwide completed the survey. All 20 District Health Boards and multiple disciplines were represented. Most respondents agreed that they received good information to make decisions (74/90, 82.2%), that it was usually easy to reach consensus (82/91, 90.1%), that the system helped to keep children safe (72/91, 79.1%) and that it did not stigmatise families (49/91, 53.9%). Qualitative analysis identified considerable variation in understanding of the system and a need for more training to support more consistent implementation of the system. CONCLUSIONS: Overall, health professionals responsible for the child protection alert system regard it positively but express a need for more training for team members and front-line staff to maximise the system's potential and minimise any risk of stigmatisation.

"Need Everyone Helping to Keep Off Because Everyone Helping to Keep On" - Reducing Harms from Cannabis use in Remote Indigenous Australian Communities Involves More Than Just Users.

BACKGROUND: Heavy cannabis use in remote Indigenous Australian communities potentially contributes to existing health disparities. Community members' perceptions of cannabis harms will support harm-minimization in these settings. OBJECTIVE: To describe perceived cannabis harms reported by a cohort of Indigenous Australians living in small, isolated communities as an indication of their existing resources for change. METHOD: Inductive thematic analysis of 407 semi-structured interviews with participants in a cohort study in three remote communities in Cape York in far north Queensland (Australia) revealed major areas of concern about cannabis. Three attitudinal categories were defined according to reported cannabis impacts and urgency for change: 1- "LOW CONCERN" said cannabis was a low priority community issue; 2- "SOME CONCERN" tolerated cannabis use but identified personal or community-level concerns; and 3- "HIGH CONCERN" expressed strong aversion to cannabis and identified serious personal or community-level harms. The characteristics and the patterns of concerns were summarized across the groups. RESULTS: "Category 1- LOW CONCERN" (n = 107), mostly current users, emphasized personal "financial impacts" and "stress." "Category 2 - SOME CONCERN" (n = 141) perceived community level impacts warranting systematic action, particularly on "employment"; and "Category 3 - HIGH CONCERN" (n = 159), most of the never users, emphasized concerns for families and youth. Irrespective of use history, the cohort reported financial and abstinence-related stress, overlapping alcohol issues and generally endorsed alleviating impacts on children and youth. CONCLUSION: Nearly ubiquitous experience with cannabis harms and impacts in this cohort suggests resources for harm reduction including family and cultural obligation, stress relief, financial management, and engagement are available across all community members, not just users.

Cannabis Use Among Remote Indigenous Australians: Opportunities to Support Change Identified in Two Waves of Sampling.

Background: Cannabis harms among Indigenous populations in Australia, New Zealand, Canada and the United States may be magnified by poorer health and heavy use. However, little direct evidence is available to evaluate cannabis' impacts. In communities in remote northern Queensland (Australia) where cannabis has become endemic, opportunities to support change were investigated. Methods: Opportunistically recruited participants (aged 15-49 years) discussed their cannabis use history in interviews in two waves of population sampling in Cape York (Queensland). Wave 1 included 429 people (235 males and 194 females); and wave 2 included 402 people (228 males and 174 females). Current users (used cannabis during the year before interview) described frequency of use, amount consumed, expenditure and dependence symptoms. Other substance use was recorded for 402 people at wave 2. Results: Wave 1: 69% reported lifetime use and 44% current use. Males (55%) were more likely than females (30%) to be current users (P < 0.001). Most (96%) current users described at least weekly use; nearly half (48%) were "heavy" users (≥6 cones/session at least once/week) and 77% met cannabis dependence criteria. Three communities spent up to $AUD14,200/week on cannabis, around $AUD2.0 million/year, or around 9% of community people's total income on cannabis. The majority (79%) of current users wanted to quit or reduce their cannabis use. Wave 2: no difference was observed in the proportion of lifetime (69%, |z| = 0.04, P = 0.968) or current cannabis users (39%, |z| = 1.39, P = 0.164); nor current use among males (71%, |z| = 0.91, P = 0.363) or females (62%, |z| = 0.36, P = 0.719). However, a significant reduction in current users by 15% (|z| = 2.36, P = 0.018) was observed in one community. Of 105 wave 1 current users re-assessed in 2, 29 (27%) had ceased use. These participants reported cost and family commitments as reasons to change and that social support and employment enabled abstinence. Current and lifetime cannabis use were closely associated with all other substance use, particularly tobacco and alcohol (both P > 0.001). Conclusions: High rates of heavy cannabis use in remote Australian Indigenous communities warrant action. Successful cessation among some individuals suggests that significant opportunities are available to support change even where cannabis use may be endemic.

Substance misuse intervention research in remote Indigenous Australian communities since the NHMRC 'Roadmap'.

OBJECTIVE: Describe program theories of substance misuse interventions with Aboriginal and Torres Strait Islander (Indigenous) Australians funded by the National Health and Medical Research Council (NHMRC) since the 'Roadmap' for Indigenous health. METHODS: Projects funded 2003-2013 were categorised by intervention strategies. Realist concepts informed the program theory: intended resources and responses; influence of context on outcomes; explicit and implicit program assumptions. RESULTS: Seven interventions were included. Three randomised controlled trials targeted tobacco using psychosocial interventions in primary health centres using the program theory: "Local Indigenous health workers extend and sustain the effects of conventional clinical brief intervention by engendering social and cultural resources". Four pragmatic trials of multiple-component, community-based interventions using controlled, semi-controlled or before-and-after designs used the program theory: "Discrete intervention components targeting locally defined substance misuse issues will activate latent capacities to create an environment that favours cessation." Publications did not report clear effect, implementation fidelity or explicit mechanisms affecting participant thinking. CONCLUSIONS: Rigorous intervention designs built on 'Roadmap' principles neither reduced substance use in the populations studied nor identified transferable mechanisms for behaviour change. Implications for public health: Substance misuse impacts among Indigenous Australians remain severe. Theoretical mechanisms of behaviour change may improve intervention design.