Zeitschriftenartikel zum Thema „Rural health services South Australia Case studies“

The paper outlines the strengths, similarities and differences of metropolitan and rural community health sectors. Case studies are used to look at the history of community health in South Australia, its current status is described and some future directions are proposed. Perspectives are drawn from the authors' collective experiences. Rural and metropolitan community health services in South Australia have developed from different models since they were established in the 1970s. Rural community health services have invariably been established as entities within hospitals and health services, although metropolitan community health services have generally been established as stand alone facilities independent of the acute sector. To illustrate this, two case studies are used to demonstrate the evolution of metropolitan and rural community health services.

Objective: Access to services and workforce shortages are major challenges in rural areas worldwide. In order to improve access to mental health care, it is imperative to understand what services are available, what their capacity is and where existing funds might be spent to increase availability and accessibility. The aim of this study is to investigate mental health service provision in a selection of rural and remote areas across Australia by analysing service availability, placement capacity and diversity. Method: This research studies the health regions of Western New South Wales and Country Western Australia and their nine health areas. Service provision was analysed using the DESDE-LTC system for long-term care service description and classification that allows international comparison. Rates per 100,000 inhabitants were calculated to compare the care availability and placement capacity for children and adolescents, adults and older adults. Results: The lowest diversity was found in northern Western Australia. Overall, Western New South Wales had a higher availability of non-acute outpatient services for adults, but hardly any acute outpatient services. In Country Western Australia, substantially fewer non-acute outpatient services were found, while acute services were much more common. Acute inpatient care services were more common in Western New South Wales, while sub-acute inpatient services and non-acute day care services were only found in Western New South Wales. Conclusion: The number and span of services in the two regions showed discrepancies both within and between regions, raising issues on the equity of access to mental health care in Australia. The standard description of the local pattern of rural mental health care and its comparison across jurisdictions is critical for evidence-informed policy planning and resource allocation.

This paper reports on an assessment of the need for early intervention services for children aged 0-8 years in the Southern Fleurieu sub-region of South Australia and an evaluation of the efficacy of utilising a generic community health service to provide the therapeutic and case management services to appropriately address those needs. Previous studies in regional South Australia estimated the incidence of developmental delay in children to be 5% of the total population aged 0-8 years (Barossa Valley, 1997). This estimate indicated a client group of over 130 in the Southern Fleurieu sub-region. The project team adopted a transdisciplinary model for early identification and intervention, with over half the children on the program aged less than five years, indicating that the program addressed needs of children at an early age. Outcomes have demonstrated the appropriateness of using a transdisciplinary approach in a regional setting and the community health service as the auspice has shown an increase in the capacity for therapists to provide the wide variety of programs that are essential in addressing early childhood delay.

This study explored the perceived healthcare system and process barriers and enablers experienced by GPs and Credentialled Diabetes Educators (CDEs) in Australian primary care, in the delivery of preventative and early intervention foot care to people with diabetes. A qualitative design with inductive analysis approach was utilised and reported according to the Consolidated Criteria for Reporting Qualitative Studies (COREQ). Semi-structured interviews were conducted with two GPs and 14 CDEs from rural, urban and metropolitan areas of Australia. Participants were from New South Wales, South Australia, Victoria, Western Australia, the Northern Territory and Queensland. Barriers to providing foot care constituted five broad themes: (1) lack of access to footcare specialists and services; (2) education and training insufficiencies; (3) human and physical resource limitations related to funding inadequacies; (4) poor care integration such as inadequate communication and feedback across services and disciplines, and ineffectual multidisciplinary care; and (5) deficient footcare processes and guidelines including ambiguous referral pathways. Enablers to foot care were found at opposing ends of the same spectra as the identified barriers or were related to engaging in mentorship programs and utilising standardised assessment tools. This is the first Australian study to obtain information from GPs and CDEs about the perceived barriers and enablers influencing preventative and early intervention diabetes-related foot care. Findings offer an opportunity for the development and translation of effective intervention strategies across health systems, policy, funding, curriculum and clinical practice, in order to improve outcomes for people with diabetes.

This paper outlines a project funded by the World Health Organization (WHO) in the Hills Mallee Southern Region of rural South Australia. The project involves trialling guidelines produced by the WHO to assist regional health services to develop and support partnerships for health development with community groups and organisations. The guidelines suggest the following steps: identifying what Health Development Structures exist in their region by making an inventory of community groups and organisations in their area; analysing them for potential collaboration; and building sustainable alliances for health promotion and joint action on broader health issues. Six hundred community groups and organisations were identified and from the responses an inventory summarising the activities of 228 groups has been prepared. Seventy five percent of these groups and organisations consider that their activities relate to health and 28% have worked with a health service, although few had participated in 'joint projects' with the formal health sector. Detailed case studies were conducted with five groups from which a set of principles for partnership development was established.

Objective The aim of the present study was to examine the relationship between socioeconomic status (SES) and child general practitioner (GP) visits in the first 12 months of life. Methods A longitudinal analysis of 1202 mother and child dyads was conducted as part of the Environments for Healthy Living study from south-east Queensland, Australia, for participants enrolled between 2006 and 2009. Maternally reported survey data (sociodemographic and child health information) were linked with individual Medical Benefits Scheme data from birth to 12 months, identifying GP service use. Results On average, children visited the GP 10.2 times in the first 12 months of life. An inverse relationship was found for SES and child GP visits, with maternal education and child gender the strongest predictors of the total number of GP visits. Almost 70% of participants had all GP consultations bulk billed and only 3.5% paid more than A$100 in total. Conclusions Children from lower SES families may have a greater need for health services due to higher rates of illness and injury. Bulk billing and low-cost access to GP services, regardless of length of consultation, improve equity of access; however, indirect costs may prevent low-income mothers from accessing care for their child when needed. What is known about the topic? The relationship between health and SES, and the influence that health service use can have on this relationship, are well recognised. Previous studies on adult populations in Australia suggest that people of lower SES have more frequent GP consultations due to greater exposure to health risk. However, consultation times are often shorter because short consultations are more likely to be bulk billed, which is resulting in ongoing unmet need. Early childhood visits to the GP can strongly influence long-term health outcomes; however, relatively few studies have examined GP service use among children in Australia. What does this paper add? This paper builds on current knowledge by providing valuable insights into GP service use in the first 12 months of life. It provides evidence to suggest that the relationship between SES and health risk already exists in the first 12 months of life and that bulk billing and low-cost access to GP services improves equity of access. It also highlights the importance of health policy and practice that enables GP service utilisation based on need rather than ability to pay. What are the implications for practitioners? Policies and practice that promote equity of access, such as bulk billing for lower SES families, can assist in improving long-term health outcomes for disadvantaged populations. Greater equity with regard to length of consultation and bulk billing for adults may assist in reducing the disparities in health outcomes between the higher and lower SES populations. Furthermore, indirect costs and the availability of appropriate services for specific groups, such as low income, rural and remote and linguistically and culturally diverse populations, may also be important barriers to access.

Introduction: Many studies have been conducted on how physicians view outreach health services, yet few have explored how rural patients view these services. This study aimed to examine the patient experience and satisfaction with outreach health services in rural NSW, Australia and the factors associated with satisfaction. Methods: A cross-sectional study was conducted among patients who visited outreach health services between December 2020 and February 2021 across rural and remote New South Wales, Australia. Data on patient satisfaction were collected using a validated questionnaire. Both bivariate (chi-squared test) and multivariate analyses (logistic regression) were performed to identify the factors associated with the outcome variable (patient satisfaction). Results: A total of 207 participants were included in the study. The mean age of respondents was 58.6 years, and 50.2% were men. Ninety-three percent of all participants were satisfied with the outreach health services. Respectful behaviours of the outreach healthcare practitioners were significantly associated with the higher patient satisfaction attending outreach clinics. Conclusions: The current study demonstrated a high level of patient satisfaction regarding outreach health services in rural and remote NSW, Australia. Further, our study findings showed the importance of collecting data about patient satisfaction to strengthen outreach service quality.

We aimed to report on variation in levels of uptake of enhanced primary care item numbers between rural and urban Divisions of General Practice between November 1999 and October 2001.Most providers of EPC services and most services (close to 70%)are located in capital cities and other metropolitan centres. The average number of health assessments done per provider was slightly lower (8-14) in remote than urban and rural (20-30) areas. A similar pattern was observed for care plans, but rates of case conferences were similar in rural and urban areas. However, adjusted for population aged 75 years and over, in all jurisdictions except South Australia, between 30% and 144% more health assessments were done per full time equivalent general practitioner (FTE GP) in rural divisions. For rural and urban Divisions of General Practice, there is a wide range in the rate of services provided, between and within Divisions. However, overall, more services are provided per FTE GP in rural Divisions.

Objective: This study examined variables associated with having a once-only contact with the out-patient department of two community mental health services in Italy and Australia. Method: Two 8-year cohorts of patients, who had a new episode of care with out-patient psychiatric departments in South Verona and in Western Australia, were followed-up for 3 months after the first contact, to identify those patients who had no further contact with services. Potential determinants of once-only contact were analysed. Results: Thirty percent of new episodes of care for persons who met the inclusion criteria of the study were once-only contacts with the service in South Verona. In Western Australia, the figure was 24%. Moreover, the proportion of once-only contact patients has increased over time in South Verona whereas, in Western Australia, it has remained stable. In Western Australia, once-only contact patients were younger whereas in South Verona they tended to be older. At both research sites, patients who had a once-only contact were more likely to be male and to have a less severe mental illness. Conclusions: The results of this study suggest that only clinical characteristics were significant determinants of this pattern of contact with services consistently at both sites: the less severe the patient's diagnosis, the more likely the patient is to have a once-only contact. This may well indicate good screening at the initial point of contact by both sets of mental health service providers. Prospective studies are necessary to clarify the problem of ‘onceonly contact’ and to organize a proper psychiatric care.

Objective This paper describes the service distribution and models of rural outreach by specialist doctors living in metropolitan or rural locations. Methods The present study was a national cross-sectional study of 902 specialist doctors providing 1401 rural outreach services in the Medicine in Australia: Balancing Employment and Life study, 2008. Five mutually exclusive models of rural outreach were studied. Results Nearly half of the outreach services (585/1401; 42%) were provided to outer regional or remote locations, most (58%) by metropolitan specialists. The most common model of outreach was drive-in, drive-out (379/902; 42%). In comparison, metropolitan-based specialists were less likely to provide hub-and-spoke models of service (odd ratio (OR) 0.31; 95% confidence interval (CI) 0.21–0.46) and more likely to provide fly-in, fly-out models of service (OR 4.15; 95% CI 2.32–7.42). The distance travelled by metropolitan specialists was not affected by working in the public or private sector. However, rural-based specialists were more likely to provide services to nearby towns if they worked privately. Conclusions Service distribution and models of outreach vary according to where specialists live as well as the practice sector of rural specialists. Multilevel policy and planning is needed to manage the risks and benefits of different service patterns by metropolitan and rural specialists so as to promote integrated and accessible services. What is known about this topic? There are numerous case studies describing outreach by specialist doctors. However, there is no systematic evidence describing the distribution of rural outreach services and models of outreach by specialists living in different locations and the broad-level factors that affect this. What does this paper add? The present study provides the first description of outreach service distribution and models of rural outreach by specialist doctors living in rural versus metropolitan areas. It shows that metropolitan and rural-based specialists have different levels of service reach and provide outreach through different models. Further, the paper highlights that practice sector has no effect on metropolitan specialists, but private rural specialists limit their travel distance. What are the implications for practitioners? The complexity of these patterns highlights the need for multilevel policy and planning approaches to promote integrated and accessible outreach in rural and remote Australia.

Australian-trained doctors are often reluctant to work in rural and remote areas and overseastrained doctors (OTDs) are recruited to practise in many rural Aboriginal medical services. This paper focuses on recent research carried out in Australia to analyse factors affecting OTDs? professional, cultural and social integration and examine their training and support needs. Ten case studies were conducted throughout Australia with OTDs, which also included interviews with spouses/partners, professional colleagues, co-workers, and Aboriginal and Torres Strait Islander community members associated with the health service. Key themes emerging from the data across all informants included the need to better address recruitment, orientation and cross-cultural issues; the importance of effective communication and building community and institutional relationships, both with the local health service and the broader medical establishment.

Promoting men's health in primary care settings such as general practice is now common, but what might primary health care for men's health look like in community health settings? This paper reports on case studies of diverse community-based health and wellbeing services for men in South Australia. The programs selected as case studies include Aboriginal men, gay men and homosexually active men, men from culturally and linguistically diverse backgrounds, older men, middle-aged men, fathers, young men, as well as services that focus on childhood sexual abuse and violence intervention. The case studies share the following main features - they have a social view of health, use a primary health care approach with an emphasis on prevention, address issues of access and equity, use social justice principles, and work across a number of sectors. These features were integrated into a socially just primary health care framework for men's health in community health settings. Socially just primary health care can address health inequities within men's health that are related to, among other things, class, race, ethnicity and sexuality. Socially just primary health care services can work collaboratively with women's health on common concerns such as violence intervention and childhood sexual abuse. Moreover, socially just primary health care services reflect local concerns, where health professionals work with men rather than acting as outside experts.

Background Maternal health services are affected by complex factors from one setting to another. Consequently, health planners should prioritize different interventions and design appropriate programs to enhance maternal health services utilization. Results of prior studies are conflicting. Furthermore, only few studies were done from antenatal to postnatal continuum of care in Ethiopia. Objectives This study aimed to assess prevalence and predictors of skilled maternal health services utilization at Dale-Wonsho health and demographic surveillance site of the Hawassa University, South Ethiopia, in 2019. Methods A community based cross sectional study was conducted from January 1–30; 2019. A total of 682 women who gave birth in the last twelve months were selected by using a two stage sampling technique. Data were collected through face to face interview. Data were entered into Epidata version 3.1. Then, they were exported and analyzed by SPSS version 22. Bi-variable logistic regression analysis was done and variables with p-value less than 0.05 were considered as candidate for multivariable logistic regression analysis. Adjusted Odds Ratios (AOR) with 95% CI were computed, and p-value less than 0.01 was computed to determine the level of significance. Result Prevalence of antenatal care, institutional delivery and postnatal care utilizations were 69.1%, 52.1% and 32.7% respectively. Educated women (AOR = 4.72, 95%CI,2.82,7.9), household training (AOR = 8.52,95%CI = 5.5,13.1), middle wealth quantile(AOR = 0.8,95%CI,0.4–0.7), being richest wealth quantile (AOR = 0.16;95%CI = 0.06,0.41) and pregnancy plan (AOR = 3.65,95%CI,1.67–8.0) were factors positively associated with antenatal care utilization. Husband education (AOR = 4.96,95CI,3.08–8.0), and antenatal care (AOR = 5.9; 95%CI,3.87,9.1) were factors associated with institutional delivery. Maternal education (AOR = 2.5,95CI,1.4–4.4), information about postnatal care service utilization (AOR = 3.6,95CI,2.1,6.2) and women autonomy(AOR = 6.1,95CI,3.8,9.7) were positively associated with postnatal care service. Conclusion Prevalence of antenatal care, institutional delivery and postnatal care services were lower than the targeted plan. Policy makers should focus on capacity building of women both economically and academically. So, women should be more autonomous to utilize health services effectively. Moreover, awareness creation among women should be enhanced about maternal health service.

In 1998 a telemedicine network was established in South Australia and the Northern Territory to deliver educational material to professionals working in child and adolescent mental health in remote areas. The network involved a wide range of health professions, from psychiatrists to psychologists and social workers. The first 12 months of network activity were evaluated by quantitative and qualitative techniques. Four sources of data were used: an activity log, questionnaires, interviews and action research. A total of 36 telemedicine sessions were held, ranging in duration from 45 to 90 min (average 56 min) and involving a total of 45 different professionals, who participated an average of four times each (range 1-15). The most common types of session were case discussions (47%), followed by specialist seminars (36%) and administrative and introductory sessions (17%). The benefits of the network included: networking and peer support; improved efficiency and reduced travel costs; and improved efficiency of health services. The problems included: costs; lack of access to technical support; and the need for staff induction and training.

Objectives: The specific objectives of the study were to (a) identify current best practice in pathology specimen collection and assess the extent to which Australian pathology services currently satisfy best practice standards; and (b) identify training and other strategies that would mitigate any gaps between current and best practice. Methods: A total of 22 case studies were undertaken with pathology collector employers from public, not for profit and private pathology organisations andacross urban and rural locations and eight focus groups with pathology collection services consumers were conducted in December 2012 in four different cities. Results: The preferred minimum qualification of the majority of case study employers for pathology collectors is the nationally recognised Certificate III in Pathology. This qualification maps well to an accepted international best practice guideline for pathology collection competency standards but has some noted deficiencies identified which need to be rectified. These particularly include competencies related to communicating with consumers. The preferred way of training for this qualification is largely through structured and supervised on the job learning experiences supported by theoretical classroom instruction delivered in-house or in off the job settings. The study found a need to ensure a greater proportion of the pathology collection workforce is appropriately qualified. Conclusion: The most effective pathway to best practice pathology collection requires strong policies that define how pathology samples are to be collected, stored and transported and a pathology collection workforce that is competent and presents to consumers with a credible qualification and in a professional manner. Abbreviations: CHF – Consumer Health Forum of Australia; KIMMS – Key Incident Monitoring and Management Systems; NAACLS – National Accrediting Agency for Clinical Laboratory Sciences; NACCHO – National Aboriginal Community Controlled Health Organisation; NPAAC – National Pathology Accreditation Advisory Council; RCPA – Royal College of Pathology Australasia; RTO – Registered Training Organisation.

Computerised information systems for community health services have evolved withadvances in information technology (IT) in Australia and overseas. However, thereis evidence from other sectors for the need to distinguish between an informationsystems (IS) strategy and an IT strategy. This paper uses case studies of computerisedinformation systems developed in New South Wales to identify issues that lead tosuccess and failure. These issues show that many of the shortcomings can beattributed to a poor IS strategy. The paper discusses the shortcomings of an IT-drivenstrategy. It argues that an IS strategy needs to be congruent with the organisationalstrategy for community health and that the system design should satisfy theinformation needs of service personnel if the information is to be used.

This paper describes the rationale and process for developing a set of Aboriginal patient journey mapping tools with Aboriginal patients, health professionals, support workers, educators and researchers in the Managing Two Worlds Together project between 2008 and 2015. Aboriginal patients and their families from rural and remote areas, and healthcare providers in urban, rural and remote settings, shared their perceptions of the barriers and enablers to quality care in interviews and focus groups, and individual patient journey case studies were documented. Data were thematically analysed. In the absence of suitable existing tools, a new analytical framework and mapping approach was developed. The utility of the tools in other settings was then tested with health professionals, and the tools were further modified for use in quality improvement in health and education settings in South Australia and the Northern Territory. A central set of patient journey mapping tools with flexible adaptations, a workbook, and five sets of case studies describing how staff adapted and used the tools at different sites are available for wider use.

IntroductionOver 310 000 women gave birth in Australia in 2016, with approximately 80 000 births in the state of Victoria. While most of these births occur in metropolitan Melbourne and other large regional centres, a significant proportion of Victorian women birth in local rural health services. The Victorian state government recently mandated the provision of a maternal and neonatal emergency training programme, called Maternal and Newborn Emergencies (MANE), to rural and regional maternity service providers across the state. MANE aims to educate maternity and newborn care clinicians about recognising and responding to clinical deterioration in an effort to improve clinical outcomes. This paper describes the protocol for an evaluation of the MANE programme.Methods and analysisThis study will evaluate the effectiveness of MANE in relation to: clinician confidence, skills and knowledge; changes in teamwork and collaboration; and consumer experience and satisfaction, and will explore and describe any governance changes within the organisations after MANE implementation. The Kirkpatrick Evaluation Model will provide a framework for the evaluation. The participants of MANE, 27 rural and regional Victorian health services ranging in size from approximately 20 to 1000 births per year, will be invited to participate. Baseline data will be collected from maternity service staff and consumers at each health service before MANE delivery, and at four time-points post-MANE delivery. There will be four components to data collection: a survey of maternity services staff; follow-up interviews with Maternity Managers at health services 4 months after MANE delivery; consumer feedback from all health services collected through the Victorian Healthcare Experience Survey; case studies with five regional or rural health service providers.Ethics and disseminationThis evaluation has been approved by the La Trobe University Science, Health and Engineering College Human Ethics Sub-Committee. Findings will be presented to project stakeholders in a deidentified report, and disseminated through peer-reviewed publications and conference presentations.

A survey of the contracting out of hospital ancillary services within health districts in the National Health Service, in England and Wales over the period 1985 to 1991, reveals a number of patterns including a north–south divide and a rural–urban split. However, apparently similar districts reveal widely differing experiences of contracting out. Detailed case studies of contracting out in two such districts are used to demonstrate the value of a contextually sensitive approach in understanding this diversity of outcomes. Within each district there is a complex evolution of policy involving interactions between numerous actors and their distinctive local contexts that serve to form differing organisational cultures.

Definitions of clinical governance are varied and there is no one agreed model. This paper explored the perspectives of rural and remote primary healthcare services, located in North Queensland, Australia, on the meaning and goals of clinical governance. The study followed an embedded multiple case study design with semi-structured interviews, document analysis and non-participant observation. Participants included clinicians, non-clinical support staff, managers and executives. Similarities and differences in the understanding of clinical governance between health centre and committee case studies were evident. Almost one-third of participants were unfamiliar with the term or were unsure of its meaning; alongside limited documentation of a definition. Although most cases linked the concept of clinical governance to key terms, many lacked a comprehensive understanding. Similarities between cases included viewing clinical governance as a management and administrative function. Differences included committee members’ alignment of clinical governance with corporate governance and frontline staff associating clinical governance with staff safety. Document analysis offered further insight into these perspectives. Clinical governance is well-documented as an expected organisational requirement, including in rural and remote areas where geographic, workforce and demographic factors pose additional challenges to quality and safety. However, in reality, it is not clearly, similarly or comprehensively understood by all participants.

South Western Sydney (SWS) is one of the fastest growing regions in the state of New South Wales (Australia). Much of the population live in local government areas (LGAs) with levels of disadvantage higher than the state average, with a predominance of non-communicable and chronic diseases that are typically associated with age-related and behavioural factors. This necessitates the management of social determinants of health through the integrated provision of primary and social care. The SWS Local Health District and Primary Health Network is exploring the potential of community health alliances (CHAs) as an innovative approach to support the provision of integrated health services. CHAs are a population health approach for addressing health challenges faced by people who share a common area of residence, sociocultural characteristic or health need, and are characterised by a shared mission, shared resource needs and acquiring/developing necessary organisational knowledge and skills. We explore how CHAs operate as social enterprises that utilise digital health and citizen engagement to deliver integrated people-centred health services (IPCHS) by conducting two case studies of CHAs operating in SWS: in Wollondilly and Fairfield LGAs. Using this approach, we aim to unpack the conceptual convergence that enables social enterprises to utilise digital health interventions and citizen engagement strategies to co-produce IPCHS with a view to developing theory and a framework for engaging digital citizens in integrated primary health care via social enterprise.

Background HIV clinical service planning requires accurate estimates of the number of people living with HIV (PLHIV) and the capacity of existing clinical services, each by geographical location. The aim of this study was to quantify current HIV clinical service capacity in Australia. Methods: This study was a retrospective analysis of records of HIV clinical service capacity in Australia. Participants were general practitioners who completed an annual survey in 2007–2009. Information on the number of hospital departments, sexual health services, antiretroviral-prescribing general practitioners (ARV-GPs) and shared-care services providing expertise in HIV management from 2007 to 2010 were also available. Results: From 2007 to 2009, the proportion of ARV-GP survey respondents treating 2–9 patients with HIV per week increased from 36.5% to 49.1%, with a corresponding decrease in the average proportion who saw less than one patient with HIV per week. The estimated number of PLHIV has increased by 12.5% in metropolitan areas, and 16.5% in rural and remote areas over the period 2007–2010; however, the total number of services with at least one HIV ARV-GP has decreased over the same period. Conclusions: Current methods to estimate clinical service capacity reveal decreasing supply in the workforce in Australia despite increasing numbers of PLHIV. Further training of HIV clinicians and their placement in regions of greatest supply–demand deficits are required. Further studies are required to precisely quantify and locate the capacity of the HIV clinical workforce with expertise in HIV case-management to enable efficient service planning.

Access to water, sanitation, and hygiene (WASH)—including drainage-services—is essential for public health and socio-economic development, but access remains inadequate and inequitable in low- to middle-income countries such as South Africa. In South Africa, rural areas and small towns generally depend on a limited and climate-sensitive economic base (e.g., farming), and they have a limited capacity and are located in areas where transport challenges can increase WASH access risks. Climate change shifts hydrological cycles, which can worsen WASH access and increase susceptibility to the interlinked impacts of droughts and flooding in already vulnerable regions. We adopted a transdisciplinary approach to explore the needs, barriers, and vulnerabilities with respect to WASH in rural areas and small towns in South Africa—using two case studies to explore climate risk and vulnerability assessment (CRVA) in one rural village in the northern Limpopo province and a small town in the Western Cape province. This holistic approach considered natural (environment and climate) and socio-economic (economic, social, governance, and political) factors and how they interplay in hampering access to WASH. Extreme weather events characterized by frequent and intense droughts or floods aggravate surface and groundwater availability and damage water infrastructure while threatening agriculture-dependent livelihoods. The lack of reliable transport infrastructure increases risks posed by flooding as roads to vital supplies are prone to damage. High inequality linked to rising unemployment and the Apartheid legacy of a segregated service delivery system result in inequitable access to WASH services. The intertwined ways in which natural elements and historical, social, economic, governance, and policy aspects are changing in South Africa increase WASH vulnerability in rural areas and small towns.

This issue of the journal commences with an editorial that provides some discussion about the current approaches to Covid and the tensions that exists in that context..... Editorial SettingsCovid-19: A strife of interests for us all and what problem are we attempting to solve? Research Articles Gender Equity in Australian Health Leadership Research Articles Assessing Quality of Healthcare Delivery When Making Choices: National Survey on Health Consumers’ Decision Making Practices Research Articles The Case for a Reciprocal Health Care Agreement between Australia and South Korea Commentary COVID-19 and Working Within Health Care Systems: the future is flexible Review Articles Review of Public Private Partnership in the Health Care in Hong Kong Viewpoint Article Hong Kong’s Growing Need for Palliative Care Services and the Role of the Nursing Profession Commentary Vietnam’s Healthcare System Decentralization: how well does it respond to global health crises such as covid-19 pandemic? Research Articles Publicly Financed Health Insurance Schemes and Horizontal Inequity in Inpatient Service Use in India Research Articles Distress and Quality of Life among Type II Diabetic Patients: Role of physical activity Viewpoint Article Achievements and Challenges of Iran Health System after Islamic Revolution: Structural reforms at the second step Research Articles Strategic Analysis of Community Participation in Primary Health Care in Iran and Presentation of Promotion Strategies Using Internal and External Environment Assessment Techniques Research Articles Utilization of Healthcare Services & Healthcare Expenditure Patterns in the Rural Households of Nepal

The purpose of this study was to trial the suitability of an oral health promotion toolkit in a chair-side setting to determine: an individual’s knowledge; understanding of oral and general health behaviour and evaluate the commitment of dental practitioners to undertake an assessment of the individual’s attitude and aptitude to undertake a home care preventive plan. All participants were 18 years and over and came from low socio-economic backgrounds in rural New South Wales, Australia. The study evaluated 59 case studies regarding their knowledge of oral and general health. The study included an oral health profiling questionnaire, based on validated oral health promotion outcome measures, a full course of dental care provided by a private dental practitioner or a dental student. Out of the 59 participants, 47% of participants cleaned their teeth twice per day, 69% used fluoride toothpaste and 47% applied the toothpaste over all the bristles. The questionnaire, based on Watt et al. (2004) verified oral health prevention outcome measures was a sound approach to determine an individual’s knowledge, understanding of oral and general health behaviour. However, dental practitioners’ commitment to assessing the individual was low.

Abstract The reform of water pricing practices and tariff mechanisms plays an important role in improving water supply services. However, setting tariff policies is a process that is rife with controversy. The current urban development rhythm and consequent challenges, in several developing cities, requires an urgent review and the establishment of an increasingly more ‘integrated’ management system with a suitable water tariff policy to promote water security. Many lessons can be learned from the successes and failures of water pricing policies in other countries and world regions, taking into account the context, status and development of the water supply sector. In this paper, several case studies are assessed throughout different countries or regions (South Africa, Vietnam, Malaysia, Singapore, Australia, and Europe) to provide key information able to support successful policy ‘transfer routes’. Based on those lessons, key policy recommendations are summarized to pave the way towards water security, particularly in rapidly growing urban centres that suffer already from water stress.

AimsThis research sought (a) to investigate the similarities and differences in how pharmaceutical services are provided by community pharmacies (CPs) and dispensing doctor practices (DPs) and (b) to identify the issues relevant to determining the quality of pharmaceutical services in these settings.BackgroundUK pharmaceutical services, including dispensing prescriptions and public health advice, can be provided from both (CP) and, in rural areas, (DP). While there is much similarity between CPs and DPs in the types of services provided, there is also the potential for variation in service quality across settings.MethodsA postal questionnaire of DPs and CPs in South West England was conducted to provide a descriptive overview of pharmaceutical services across the settings. A subsection of questionnaire respondent sites were selected to take part in case studies, which involved documentary analyses, observation and staff interviews.FindingsSurvey response was 39% for CPs (52/134) and 48% (31/64) for DPs. There were three CP and four DP case study sites, with 17 staff interviews. More pharmacies than practices were open at the weekend and they had more staff trained above NVQ level 2. Both doctors and pharmacists saw themselves as medicines experts, as being accessible and having good relationships with patients. Workplace practices and organisational ethos varied both within and across settings, with good practice observed in both. Overall, CPs and DPs have much in common. Workplace culture and an evidence-based approach to checking prescriptions and error reporting need to be considered in future assessments of service quality.

BackgroundThe notion of a community hospital in England is evolving from the traditional model of a local hospital staffed by general practitioners and nurses and serving mainly rural populations. Along with the diversification of models, there is a renewed policy interest in community hospitals and their potential to deliver integrated care. However, there is a need to better understand the role of different models of community hospitals within the wider health economy and an opportunity to learn from experiences of other countries to inform this potential.ObjectivesThis study sought to (1) define the nature and scope of service provision models that fit under the umbrella term ‘community hospital’ in the UK and other high-income countries, (2) analyse evidence of their effectiveness and efficiency, (3) explore the wider role and impact of community engagement in community hospitals, (4) understand how models in other countries operate and asses their role within the wider health-care system, and (5) identify the potential for community hospitals to perform an integrative role in the delivery of health and social care.MethodsA multimethod study including a scoping review of community hospital models, a linked systematic review of their effectiveness and efficiency, an analysis of experiences in Australia, Finland, Italy, Norway and Scotland, and case studies of four community hospitals in Finland, Italy and Scotland.ResultsThe evidence reviews found that community hospitals provide a diverse range of services, spanning primary, secondary and long-term care in geographical and health system contexts. They can offer an effective and efficient alternative to acute hospitals. Patient experience was frequently reported to be better at community hospitals, and the cost-effectiveness of some models was found to be similar to that of general hospitals, although evidence was limited. Evidence from other countries showed that community hospitals provide a wide spectrum of health services that lie on a continuum between serving a ‘geographic purpose’ and having a specific population focus, mainly older people. Structures continue to evolve as countries embark on major reforms to integrate health and social care. Case studies highlighted that it is important to consider local and national contexts when looking at how to transfer models across settings, how to overcome barriers to integration beyond location and how the community should be best represented.LimitationsThe use of a restricted definition may have excluded some relevant community hospital models, and the small number of countries and case studies included for comparison may limit the transferability of findings for England. Although this research provides detailed insights into community hospitals in five countries, it was not in its scope to include the perspective of patients in any depth.ConclusionsAt a time when emphasis is being placed on integrated and community-based care, community hospitals have the potential to assume a more strategic role in health-care delivery locally, providing care closer to people’s homes. There is a need for more research into the effectiveness and cost-effectiveness of community hospitals, the role of the community and optimal staff profile(s).FundingThe National Institute for Health Research Health Services and Delivery Research programme.

IntroductionThere are few robust and directly comparable studies of the epidemiology of psychotic disorders in the Global South. INTREPID II is designed to investigate variations in untreated psychotic disorders in the Global South in (1) incidence and presentation (2) 2-year course and outcome, (3) help-seeking and impact, and (4) physical health.MethodsINTREPID II is a programme of research incorporating incidence, case–control and cohort studies of psychoses in contiguous urban and rural areas in India, Nigeria and Trinidad. In each country, the target samples are 240 untreated cases with a psychotic disorder, 240 age-matched, sex-matched and neighbourhood-matched controls, and 240 relatives or caregivers. Participants will be followed, in the first instance, for 2 years. In each setting, we have developed and are employing comprehensive case-finding methods to ensure cohorts are representative of the target populations. Using methods developed during pilot work, extensive data are being collected at baseline and 2-year follow-up across several domains: clinical, social, help-seeking and impact, and biological.Ethics and disseminationInformed consent is sought, and participants are free to withdraw from the study at any time. Participants are referred to mental health services if not already in contact with these and emergency treatment arranged where necessary. All data collected are confidential, except when a participant presents a serious risk to either themselves or others. This programme has been approved by ethical review boards at all participating centres. Findings will be disseminated through international conferences, publications in international journals, and through local events for key stakeholders.

Background: Studies on the experiences of consumers with Motor Neurone Disease Associations at end of life and bereavement are lacking, and their role and capability within the broader sectors of health and disability are unknown. Objectives: To ascertain the experiences and views of bereaved motor neurone disease caregivers with Motor Neurone Disease Associations about service gaps and needed improvements before and during bereavement and to propose a model of care that fits with consumer preferences and where Motor Neurone Disease Associations are effective enablers of care. Methods: A national bereavement survey was facilitated in 2019 by all Motor Neurone Disease Associations in Australia. A total of 363 respondents completed the section on support provided by Motor Neurone Disease Associations. A mixed-method design was used. Results: Respondents were generally positive about support received before bereavement (73-76%), except for emotional support (55%). Positive experiences related to the following: information, equipment advice/provision, advocacy/linking to services, showing empathy/understanding, personal contact and peer social support. Negative experiences included lack of continuity in case management and contact, perceived lack of competence or training, lack of emotional support and a lack of access to motor neurone disease services in rural areas. Suggested improvements were as follows: more contact and compassion at end of life and postdeath; better preparation for end of life; option of discussing euthanasia; providing referrals and links for counseling; access to caregiver support groups and peer interaction; provision of a genuine continuum of care rather than postdeath abandonment; guidance regarding postdeath practicalities; and more access to bereavement support in rural areas. Conclusion: This study provides consumer perspectives on driving new or improved initiatives by Motor Neurone Disease Associations and the need for a national standardised approach to training and service delivery, based on research evidence. A public health approach to motor neurone disease end-of-life care, of international applicability, is proposed to address the needs and preferences of motor neurone disease consumers, while supporting the capability of Motor Neurone Disease Associations within a multidisciplinary workforce to deliver that care.

Background Weaknesses in the provision of mental health crisis support are evident and improvements that include voluntary sector provision are promoted. There is a lack of evidence regarding the contribution of the voluntary sector and how this might be used to the best effect in mental health crisis care. Aim To investigate the contribution of voluntary sector organisations to mental health crisis care in England. Design Multimethod sequential design with a comparative case study. Setting England, with four case studies in North England, East England, the Midlands and London. Method The method included a scoping literature review, a national survey of 1612 voluntary sector organisations, interviews with 27 national stakeholders and detailed mapping of the voluntary sector organisation provision in two regions (the north and south of England) to develop a taxonomy of voluntary sector organisations and to select four case studies. The case studies examined voluntary sector organisation crisis care provision as a system through interviews with local stakeholders (n = 73), eight focus groups with service users and carers and, at an individual level, narrative interviews with service users (n = 47) and carers (n = 12) to understand their crisis experience and service journey. There was extensive patient and public involvement in the study, including service users as co-researchers, to ensure validity. This affected the conduct of the study and the interpretation of the findings. The quality and the impact of the involvement was evaluated and commended. Main findings A mental health crisis is considered a biographical disruption. Voluntary sector organisations can make an important contribution, characterised by a socially oriented and relational approach. Five types of relevant voluntary sector organisations were identified: (1) crisis-specific, (2) general mental health, (3) population-focused, (4) life-event-focused and (5) general social and community voluntary sector organisations. These voluntary sector organisations provide a range of support and have specific expertise. The availability and access to voluntary sector organisations varies and inequalities were evident for rural communities; black, Asian and minority ethnic communities; people who use substances; and people who identified as having a personality disorder. There was little evidence of well-developed crisis systems, with an underdeveloped approach to prevention and a lack of ongoing support. Limitations The survey response was low, reflecting the nature of voluntary sector organisations and demands on their time. This was a descriptive study, so evaluating outcomes from voluntary sector organisation support was beyond the scope of the study. Conclusions The current policy discourse frames a mental health crisis as an urgent event. Viewing a mental health crisis as a biographical disruption would better enable a wide range of contributory factors to be considered and addressed. Voluntary sector organisations have a distinctive and important role to play. The breadth of this contribution needs to be acknowledged and its role as an accessible alternative to inpatient provision prioritised. Future work A whole-system approach to mental health crisis provision is needed. The NHS, local authorities and the voluntary sector should establish how to effectively collaborate to meet the local population’s needs and to ensure the sustainability of the voluntary sector. Service users and carers from all communities need to be central to this. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 29. See the NIHR Journals Library website for further project information.

Objective The primary objective of this study was to evaluate the effect of an online education program used to implement the Australian (New South Wales) whiplash guidelines with general practitioners (GP). The secondary aim was to identify factors associated with learning. Methods An online educational and evaluation activity was developed to reflect the key messages for GP from the Australian whiplash guidelines. The educational activity was hosted on the Royal Australian College of General Practitioners’ website (www.gplearning.com.au) for a period of 3 years. Participants were recruited through advertisement and media releases. Participants completed a baseline evaluation of their knowledge, participated in the interactive educational activity and completed a post-knowledge questionnaire. The primary outcome was change in professional knowledge, predictors of learning were computed using linear regression. Results Two hundred and fifteen GP participated. Knowledge significantly improved between baseline and post-knowledge questionnaire scores (P < 0.00001). A total of 57.2% of participants improved their knowledge by more than 20%, indicating a large effect. Low baseline knowledge predicted learning, accounting for 71% of the variance. Conclusions Online education of GP significantly improved their knowledge in relation to guidelines for whiplash. Those with low baseline knowledge improved their knowledge the most, suggesting that implementation strategies should be targeted at this group. What is known about the topic? Clinical guidelines are usually developed to improve knowledge and ultimately change clinical practice to reflect best practice management of that condition. However, developing and publishing guidelines alone rarely changes knowledge or clinical practice. With GP, effective implementation strategies to improve knowledge have included face to face education such as interactive educational meetings and educational outreach. However, these strategies are expensive and time consuming. Whiplash is a significant health problem in Australia, and although GP are commonly consulted for this condition, an individual GP may only see one whiplash case per year, meaning that face to face implementation strategies may not be pragmatic for this condition. What does this paper add? This paper shows that online education was effective in improving GP knowledge of clinical guidelines for whiplash. The effect was as large as the reported effects for face to face education in other studies. Importantly this paper shows that the less GP knew about whiplash, the more they learnt, indicating that the strategy was effective for those who most required the education. Finally, the online strategy reached GP in rural and remote places in Australia. This paper therefore shows that online education can be an effective method to improve GP knowledge about managing whiplash. It is hoped that it may provide the impetus to use this strategy for implementing clinical guidelines for other conditions. What are the implications for practitioners? Practitioners can be confident that using an online educational program will improve their knowledge of managing conditions they previously knew little about. It is hoped that this will translate into a change in clinical practice. For example, GP using this strategy improved knowledge in knowing when to X-ray, when to refer and what interventions to provide for people with whiplash. For any health practitioners managing whiplash access to this information is still available using the New South Wales Motor Accident Authority website (www.maa.nsw.gov.au)

Australia has seen an unprecedented proliferation in large scale water recycling schemes since the late 1990s. This has been driven by a recent decade of drought, policies to encourage water efficiency in new homes and buildings in urban areas, and to reduce pressure on rain-fed water supplies by replacement with alternate water sources in rural areas. Underpinning these drivers are principles of economic and environmental sustainability and protection of public health. National guidelines for recycling of treated sewage, released in 2006, replaced an approach using prescriptive end point water quality targets, with a 12-step risk-based framework for the planning and operation of Australian water recycling schemes. Essential to this risk-based approach is an understanding of the sewage treatment system and assessing the risks in the catchment, the treatment process, distribution system and end use environment. Inherent also in this process is the identification of critical control points with tangible operational targets for pre-empting, preventing and correcting off-spec conditions before they derail a scheme. Validation of systems through microbial log reduction targets for indicator viruses, bacteria, protozoa and helminths, differentiated according to end use and expected exposures, may be obtained through treatment, site controls or a combination of both. Drawing on case studies from the Australian states of New South Wales (NSW) and Queensland (Qld), this paper gives insight to preventative risk management of water recycling schemes with typical risk profiles. Some advantages and disadvantages of the guideline approach are considered. The information paints a picture of the industry's risk management obligations in the planning phase and may be of use to practitioners in other regions where planning for safe and sustainable water recycling is developing.

Climate change induced sea-level rise (SLR) is on its increase globally. Regionally the lowlands of China, Vietnam, Bangladesh, and islands of the Malaysian, Indonesian and Philippine archipelagos are among the world’s most threatened regions. Sea-level rise has major impacts on the ecosystems and society. It threatens coastal populations, economic activities, and fragile ecosystems as mangroves, coastal salt-marches and wetlands. This paper provides a summary of the current state of knowledge of sea level-rise and its effects on both human and natural ecosystems. The focus is on coastal urban areas and low lying deltas in South-East Asia and Vietnam, as one of the most threatened areas in the world. About 3 mm per year reflects the growing consensus on the average SLR worldwide. The trend speeds up during recent decades. The figures are subject to local, temporal and methodological variation. In Vietnam the average values of 3.3 mm per year during the 1993-2014 period are above the worldwide average. Although a basic conceptual understanding exists that the increasing global frequency of the strongest tropical cyclones is related with the increasing temperature and SLR, this relationship is insufficiently understood. Moreover the precise, complex environmental, economic, social, and health impacts are currently unclear. SLR, storms and changing precipitation patterns increase flood risks, in particular in urban areas. Part of the current scientific debate is on how urban agglomeration can be made more resilient to flood risks. Where originally mainly technical interventions dominated this discussion, it becomes increasingly clear that proactive special planning, flood defense, flood risk mitigation, flood preparation, and flood recovery are important, but costly instruments. 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It was the Canadian philosopher Marshall McLuhan who first introduced the term ‘global village’ into the lexicon, almost fifty years ago. He was referring to the phenomenon of global interconnectedness of which we are all too aware today. At that time, we were witnessing the world just opening up. In 1946, British Airways had commenced a twice weekly service from London to New York. The flight involved one or two touch downs en-route and took a scheduled 19 hours and 45 minutes. By the time McLuhan had published his book “Understanding media; the extensions of man”, there were regular services by jet around the globe. London to Sydney was travelled in just under 35 hours. Moving forward to a time immediately pre-covid, there were over 30 non-stop flights a day in each direction between London and New York. The travel time from London to Sydney had been cut by a third, to slightly under 22 hours, with just one touchdown en-route. The world has well and truly ‘opened up’. No place is unreachable by regular services. But that is just one part of the picture. In 1962, the very first live television pictures were transmitted across the Atlantic, via satellite. It was a time when sports’ fans would tune in besides a crackling radio set to hear commentary of their favourite game relayed from the other side of the world. Today of course, not only can we watch a live telecast of the Olympic Games in the comfort of our own homes wherever the games are being held, but we can pick up a telephone and talk face to face with friends and relatives in real time, wherever they may be in the world. To today’s generation – generation Z – this does not seem in the least bit remarkable. Indeed, they have been nicknamed ‘the connected generation’ precisely because such a degree of human interconnectedness no longer seems worth commenting on. The media technology and the transport advances that underpin this level of connectedness, have become taken for granted assumptions to them. This is why the global events of 2020 and the associated public health related reactions, have proved to be so remarkable to them. It is mass travel and the closeness and variety of human contact in day-to-day interactions, that have provided the breeding ground for the pandemic. Consequently, moving around and sharing close proximity with many strangers, have been the activities that have had to be curbed, as the initial primary means to manage the spread of the virus. This has caused hardship to many, either through the loss of a job and the associated income or, the lengthy enforced separation from family and friends – for the many who find themselves living and working far removed from their original home. McLuhan’s powerful metaphor was ahead of its time. His thoughts were centred around media and electronic communications well prior to the notion of a ‘physical’ pandemic, which today has provided an equally potent image of how all of our fortunes have become intertwined, no matter where we sit in the world. Yet it is this event which seems paradoxically to have for the first time forced us to consider more closely the path of progress pursued over the last half century. It is as if we are experiencing for the first time the unleashing of powerful and competing forces, which are both centripetal and centrifugal. On the one hand we are in a world where we have a World Health Organisation. This is a body which has acted as a global force, first declaring the pandemic and subsequently acting in response to it as a part of its brief for international public health. It has brought the world’s scientists and global health professionals together to accelerate the research and development process and develop new norms and standards to contain the spread of the coronavirus pandemic and help care for those affected. At the same time, we have been witnessing nations retreating from each other and closing their borders in order to restrict the interaction of their citizens with those from other nations around the world. We have perceived that danger and risk are increased by international travel and human to human interaction. As a result, increasingly communication has been carried out from the safety and comfort of one’s own home, with electronic media taking the place of personal interaction in the real world. The change to the media dominated world, foreseen by McLuhan a half century ago, has been hastened and consolidated by the threats posed by Covid 19. Real time interactions can be conducted more safely and more economically by means of the global reach of the internet and the ever-enhanced technologies that are being offered to facilitate that. Yet at a geopolitical level prior to Covid 19, the processes of globalism and nationalism were already being recognised as competing forces. In many countries, tensions have emerged between those who are benefitting from the opportunities presented by the development of free trade between countries and those who are invested in more traditional ventures, set in their own nations and communities. The emerging beneficiaries have become characterised as the global elites. Their demographic profile is one associated with youth, education and progressive social ideas. However, they are counter-balanced by those who, rather than opportunities, have experienced threats from the disruptions and turbulence around them. Among the ideas challenged, have been the expected certainties of employment, social values and the security with which many grew up. Industries which have been the lifeblood of their communities are facing extinction and even the security of housing and a roof over the heads of self and family may be under threat. In such circumstances, some people may see waves of new immigrants, technology, and changing social values as being tides which need to be turned back. Their profile is characterised by a demographic less equipped to face such changes - the more mature, less well educated and less mobile. Yet this tension appears to be creating something more than just the latest version of the generational divide. The recent clashes between Republicans and Democrats in the US have provided a very potent example of these societal stresses. The US has itself exported some of these arenas of conflict to the rest of the world. Black lives Matter and #Me too, are social movements with their foundation in the US which have found their way far beyond the immediate contexts which gave them birth. In the different national settings where these various tensions have emerged, they have been characterised through labels such as left and right, progressive and traditional, the ‘haves’ versus the ‘have nots’ etc. Yet common to all of this growing competitiveness between ideologies and values is a common thread. The common thread lies in the notion of competition itself. It finds itself expressed most potently in the spread and adoption of ideas based on what has been termed the neoliberal values of the free market. These values have become ingrained in the language and concepts we employ every day. Thus, everything has a price and ultimately the price can be represented by a dollar value. We see this process of commodification around us on a daily basis. Sports studies’ scholars have long drawn attention to its continuing growth in the world of sport, especially in situations when it overwhelms the human characteristics of the athletes who are at the very heart of sport. When the dollar value of the athlete and their performance becomes more important than the individual and the game, then we find ourselves at the heart of some of the core problems reported today. It is at the point where sport changes from an experience, where the athletes develop themselves and become more complete persons experiencing positive and enriching interactions with fellow athletes, to an environment where young athletes experience stress and mental and physical ill health as result of their experiences. Those who are supremely talented (and lucky?) are rewarded with fabulous riches. Others can find themselves cast out on the scrap heap as a result of an unfair selection process or just the misfortune of injury. Sport as always, has proved to be a mirror of life in reflecting this process in the world at large, highlighting the heights that can be climbed by the fortunate as well as the depths that can be plumbed by the ill-fated. Advocates of the free-market approach will point to the opportunities it can offer. Figures can show that in a period of capitalist organised economies, there has been an unprecedented reduction in the amount of poverty in the world. Despite rapid growth in populations, there has been some extraordinary progress in lifting people out of extreme poverty. Between 1990 and 2010, the numbers in poverty fell by half as a share of the total population in developing countries, from 43% to 21%—a reduction of almost 1 billion people (The Economist Leader, June 1st, 2013). Nonetheless the critics of capitalism will continue to point to an increasing gap between the haves and don’t haves and specifically a decline in the ‘middle classes’, which have for so long provided the backbone of stable democratic societies. This delicate balance between retreating into our own boundaries as a means to manage the pandemic and resuming open borders to prevent economic damage to those whose businesses and employment depend upon the continuing movement of people and goods, is one which is being agonised over at this time in liberal democratic societies around the world. The experience of the pandemic has varied between countries, not solely because of the strategies adopted by politicians, but also because of the current health systems and varying social and economic conditions of life in different parts of the world. For many of us, the crises and social disturbances noted above have been played out on our television screens and websites. Increasingly it seems that we have been consuming our life experiences in a world dominated by our screens and sheltered from the real messiness of life. Meanwhile, in those countries with a choice, the debate has been between public health concerns and economic health concerns. Some have argued that the two are not totally independent of each other, while others have argued that the extent to which they are seen as interrelated lies in the extent to which life’s values have themselves become commodified. Others have pointed to the mental health problems experienced by people of all ages as a result of being confined for long periods of time within limited spaces and experiencing few chances to meet with others outside their immediate household. Still others have experienced different conditions – such as the chance to work from home in a comfortable environment and be freed from the drudgery of commuting in crowded traffic or public transport. So, at a national/communal level as well as at an individual level, this international crisis has exposed people to different decisions. It has offered, for many, a chance to recalibrate their lives. Those who have the resources, are leaving the confines of the big capital cities and seeking a healthier and less turbulent existence in quieter urban centres. For those of us in what can be loosely termed ‘an information industry’, today’s work practices are already an age away from what they were in pre-pandemic times. Yet again, a clear split is evident. The notion of ‘essential industries’ has been reclassified. The delivery of goods, the facilitation of necessary purchase such as food; these and other tasks have acquired a new significance which has enhanced the value of those who deliver these services. However, for those whose tasks can be handled via the internet or offloaded to other anonymous beings a readjustment of a different kind is occurring. So to the future - for those who have suffered ill-health and lost loved ones, the pandemic only reinforces the human priority. Health and well-being trumps economic health and wealth where choices can be made. The closeness of human contact has been reinforced by the tales of families who have been deprived of the touch of their loved ones, many of whom still don’t know when that opportunity will be offered again. When writing our editorial, a year ago, I little expected to be still pursuing a Covid related theme today. Yet where once we were expecting to look back on this time as a minor hiccough, with normal service being resumed sometime last year, it has not turned out to be that way. Rather, it seems that we have been offered a major reset opportunity in the way in which we continue to progress our future as humans. The question is, will we be bold enough to see the opportunity and embrace a healthier more equitable more locally responsible lifestyle or, will we revert to a style of ‘progress’ where powerful countries, organisations and individuals continue to amass increased amounts of wealth and influence and become increasingly less responsive to the needs of individuals in the throng below. Of course, any retreat from globalisation as it has evolved to date, will involve disruption of a different kind, which will inevitably lead to pain for some. It seems inevitable that any change and consequent progress is going to involve winners and losers. Already airline companies and the travel industry are putting pressure on governments to “get back to normal” i.e. where things were previously. Yet, in the shadow of widespread support for climate activism and the extinction rebellion movement, reports have emerged that since the lockdowns air pollution has dropped dramatically around the world – a finding that clearly offers benefits to all our population. In a similar vein the impossibility of overseas air travel in Australia has resulted in a major increase in local tourism, where more inhabitants are discovering the pleasures of their own nation. The transfer of their tourist and holiday dollars from overseas to local tourist providers has produced at one level a traditional zero-sum outcome, but it has also been accompanied by a growing appreciation of local citizens for the wonders of their own land and understanding of the lives of their fellow citizens as well as massive savings in foregone air travel. Continuing to define life in terms of competition for limited resources will inevitably result in an ever-continuing run of zero-sum games. Looking beyond the prism of competition and personal reward has the potential to add to what Michael Sandel (2020) has termed ‘the common good’. Does the possibility of a reset, offer the opportunity to recalibrate our views of effort and reward to go beyond a dollar value and include this important dimension? How has sport been experiencing the pandemic and are there chances for a reset here? An opinion piece from Peter Horton in this edition, has highlighted the growing disconnect of professional sport at the highest level from the communities that gave them birth. Is this just another example of the outcome of unrestrained commodification? Professional sport has suffered in the pandemic with the cancelling of fixtures and the enforced absence of crowds. Yet it has shown remarkable resilience. Sport science staff may have been reduced alongside all the auxiliary workers who go to make up the total support staff on match days and other times. Crowds have been absent, but the game has gone on. Players have still been able to play and receive the support they have become used to from trainers, physiotherapists and analysts, although for the moment there may be fewer of them. Fans have had to rely on electronic media to watch their favourites in action– but perhaps that has just encouraged the continuing spread of support now possible through technology which is no longer dependent on personal attendance through the turnstile. Perhaps for those committed to the watching of live sport in the outdoors, this might offer a chance for more attention to be paid to sport at local and community levels. Might the local villagers be encouraged to interrelate with their hometown heroes, rather than the million-dollar entertainers brought in from afar by the big city clubs? To return to the village analogy and the tensions between global and local, could it be that the social structure of the village has become maladapted to the reality of globalisation? If we wish to retain the traditional values of village life, is returning to our village a necessary strategy? If, however we see that today the benefits and advantages lie in functioning as one single global community, then perhaps we need to do some serious thinking as to how that community can function more effectively for all of its members and not just its ‘elites’. As indicated earlier, sport has always been a reflection of our society. Whichever way our communities decide to progress, sport will have a place at their heart and sport scholars will have a place in critically reflecting the nature of the society we are building. It is on such a note that I am pleased to introduce the content of volume 43:1 to you. We start with a reminder from Hoyoon Jung of the importance of considering the richness provided by a deep analysis of context, when attempting to evaluate and compare outcomes for similar events. He examines the concept of nation building through sport, an outcome that has been frequently attributed to the conduct of successful events. In particular, he examines this outcome in the context of the experiences of South Africa and Brazil as hosts of world sporting events. The mega sporting event that both shared was the FIFA world cup, in 2010 and 2014 respectively. Additional information could be gained by looking backwards to the 1995 Rugby World Cup in the case of South Africa and forward to the 2016 Olympics with regard to Brazil. Differentiating the settings in terms of timing as well as in the makeup of the respective local cultures, has led Jung to conclude that a successful outcome for nation building proved possible in the case of South Africa. However, different settings, both economically and socially, made it impossible for Brazil to replicate the South African experience. From a globally oriented perspective to a more local one, our second paper by Rafal Gotowski and Marta Anna Zurawak examines the growth and development, with regard to both participation and performance, of a more localised activity in Poland - the Nordic walking marathon. Their analysis showed that this is a locally relevant activity that is meeting the health-related exercise needs of an increasing number of people in the middle and later years, including women. It is proving particularly beneficial as an activity due to its ability to offer a high level of intensity while reducing the impact - particularly on the knees. The article by Petr Vlček, Richard Bailey, Jana Vašíčková XXABSTRACT Claude Scheuer is also concerned with health promoting physical activity. Their focus however is on how the necessary habit of regular and relevant physical activity is currently being introduced to the younger generation in European schools through the various physical education curricula. They conclude that physical education lessons, as they are currently being conducted, are not providing the needed 50% minimum threshold of moderate to vigorous physical activity. They go further, to suggest that in reality, depending on the physical education curriculum to provide the necessary quantum of activity within the child’s week, is going to be a flawed vision, given the instructional and other objectives they are also expected to achieve. They suggest implementing instead an ‘Active Schools’ concept, where the PE lessons are augmented by other school-based contexts within a whole school programme of health enhancing physical activity for children. Finally, we step back to the global and international context and the current Pandemic. Eric Burhaein, Nevzt Demirci, Carla Cristina Vieira Lourenco, Zsolt Nemeth and Diajeng Tyas Pinru Phytanza have collaborated as a concerned group of physical educators to provide an important international position statement which addresses the role which structured and systematic physical activity should assume in the current crisis. This edition then concludes with two brief contributions. The first is an opinion piece by Peter Horton which provides a professional and scholarly reaction to the recent attempt by a group of European football club owners to challenge the global football community and establish a self-governing and exclusive European Super League. It is an event that has created great alarm and consternation in the world of football. Horton reflects the outrage expressed by that community and concludes: While recognising the benefits accruing from well managed professionalism, the essential conflict between the values of sport and the values of market capitalism will continue to simmer below the surface wherever sport is commodified rather than practised for more ‘intrinsic’ reasons. We conclude however on a more celebratory note. We are pleased to acknowledge the recognition achieved by one of the members of our International Review Board. The career and achievements of Professor John Wang – a local ‘scholar’- have been recognised in his being appointed as the foundation E.W. Barker Professor in Physical Education and Sport at the Nanyang Technological University. This is a well-deserved honour and one that reflects the growing stature of the Singapore Physical Education and Sports Science community within the world of International Sport Studies. John Saunders Brisbane, June 2021

Education in Oceania continues to reflect the embedded implicit and explicit colonial practices and processes from the past. This paper conceptualises a cultural approach to education and leadership appropriate and relevant to the Republic of the Marshall Islands. As elementary school leaders, we highlight Kanne Lobal, a traditional Marshallese navigation practice based on indigenous language, values and practices. We conceptualise and develop Kanne Lobal in this paper as a framework for understanding the usefulness of our indigenous knowledge in leadership and educational practices within formal education. Through bwebwenato, a method of talk story, our key learnings and reflexivities were captured. We argue that realising the value of Marshallese indigenous knowledge and practices for school leaders requires purposeful training of the ways in which our knowledge can be made useful in our professional educational responsibilities. Drawing from our Marshallese knowledge is an intentional effort to inspire, empower and express what education and leadership partnership means for Marshallese people, as articulated by Marshallese themselves. Introduction As noted in the call for papers within the Waikato Journal of Education (WJE) for this special issue, bodies of knowledge and histories in Oceania have long sustained generations across geographic boundaries to ensure cultural survival. For Marshallese people, we cannot really know ourselves “until we know how we came to be where we are today” (Walsh, Heine, Bigler & Stege, 2012). Jitdam Kapeel is a popular Marshallese concept and ideal associated with inquiring into relationships within the family and community. In a similar way, the practice of relating is about connecting the present and future to the past. Education and leadership partnerships are linked and we look back to the past, our history, to make sense and feel inspired to transform practices that will benefit our people. In this paper and in light of our next generation, we reconnect with our navigation stories to inspire and empower education and leadership. Kanne lobal is part of our navigation stories, a conceptual framework centred on cultural practices, values, and concepts that embrace collective partnerships. Our link to this talanoa vā with others in the special issue is to attempt to make sense of connections given the global COVID-19 context by providing a Marshallese approach to address the physical and relational “distance” between education and leadership partnerships in Oceania. Like the majority of developing small island nations in Oceania, the Republic of the Marshall Islands (RMI) has had its share of educational challenges through colonial legacies of the past which continues to drive education systems in the region (Heine, 2002). The historical administration and education in the RMI is one of colonisation. Successive administrations by the Spanish, German, Japanese, and now the US, has resulted in education and learning that privileges western knowledge and forms of learning. This paper foregrounds understandings of education and learning as told by the voices of elementary school leaders from the RMI. The move to re-think education and leadership from Marshallese perspectives is an act of shifting the focus of bwebwenato or conversations that centres on Marshallese language and worldviews. The concept of jelalokjen was conceptualised as traditional education framed mainly within the community context. In the past, jelalokjen was practiced and transmitted to the younger generation for cultural continuity. During the arrival of colonial administrations into the RMI, jelalokjen was likened to the western notions of education and schooling (Kupferman, 2004). Today, the primary function of jelalokjen, as traditional and formal education, it is for “survival in a hostile [and challenging] environment” (Kupferman, 2004, p. 43). Because western approaches to learning in the RMI have not always resulted in positive outcomes for those engaged within the education system, as school leaders who value our cultural knowledge and practices, and aspire to maintain our language with the next generation, we turn to Kanne Lobal, a practice embedded in our navigation stories, collective aspirations, and leadership. The significance in the development of Kanne Lobal, as an appropriate framework for education and leadership, resulted in us coming together and working together. Not only were we able to share our leadership concerns, however, the engagement strengthened our connections with each other as school leaders, our communities, and the Public Schooling System (PSS). Prior to that, many of us were in competition for resources. Educational Leadership: IQBE and GCSL Leadership is a valued practice in the RMI. Before the IQBE programme started in 2018, the majority of the school leaders on the main island of Majuro had not engaged in collaborative partnerships with each other before. Our main educational purpose was to achieve accreditation from the Western Association of Schools and Colleges (WASC), an accreditation commission for schools in the United States. The WASC accreditation dictated our work and relationships and many school leaders on Majuro felt the pressure of competition against each other. We, the authors in this paper, share our collective bwebwenato, highlighting our school leadership experiences and how we gained strength from our own ancestral knowledge to empower “us”, to collaborate with each other, our teachers, communities, as well as with PSS; a collaborative partnership we had not realised in the past. The paucity of literature that captures Kajin Majol (Marshallese language) and education in general in the RMI is what we intend to fill by sharing our reflections and experiences. To move our educational practices forward we highlight Kanne Lobal, a cultural approach that focuses on our strengths, collective social responsibilities and wellbeing. For a long time, there was no formal training in place for elementary school leaders. School principals and vice principals were appointed primarily on their academic merit through having an undergraduate qualification. As part of the first cohort of fifteen school leaders, we engaged in the professional training programme, the Graduate Certificate in School Leadership (GCSL), refitted to our context after its initial development in the Solomon Islands. GCSL was coordinated by the Institute of Education (IOE) at the University of the South Pacific (USP). GCSL was seen as a relevant and appropriate training programme for school leaders in the RMI as part of an Asia Development Bank (ADB) funded programme which aimed at “Improving Quality Basic Education” (IQBE) in parts of the northern Pacific. GCSL was managed on Majuro, RMI’s main island, by the director at the time Dr Irene Taafaki, coordinator Yolanda McKay, and administrators at the University of the South Pacific’s (USP) RMI campus. Through the provision of GCSL, as school leaders we were encouraged to re-think and draw-from our own cultural repository and connect to our ancestral knowledge that have always provided strength for us. This kind of thinking and practice was encouraged by our educational leaders (Heine, 2002). We argue that a culturally-affirming and culturally-contextual framework that reflects the lived experiences of Marshallese people is much needed and enables the disruption of inherent colonial processes left behind by Western and Eastern administrations which have influenced our education system in the RMI (Heine, 2002). Kanne Lobal, an approach utilising a traditional navigation has warranted its need to provide solutions for today’s educational challenges for us in the RMI. Education in the Pacific Education in the Pacific cannot be understood without contextualising it in its history and culture. It is the same for us in the RMI (Heine, 2002; Walsh et al., 2012). The RMI is located in the Pacific Ocean and is part of Micronesia. It was named after a British captain, John Marshall in the 1700s. The atolls in the RMI were explored by the Spanish in the 16th century. Germany unsuccessfully attempted to colonize the islands in 1885. Japan took control in 1914, but after several battles during World War II, the US seized the RMI from them. In 1947, the United Nations made the island group, along with the Mariana and Caroline archipelagos, a U.S. trust territory (Walsh et al, 2012). Education in the RMI reflects the colonial administrations of Germany, Japan, and now the US. Before the turn of the century, formal education in the Pacific reflected western values, practices, and standards. Prior to that, education was informal and not binded to formal learning institutions (Thaman, 1997) and oral traditions was used as the medium for transmitting learning about customs and practices living with parents, grandparents, great grandparents. As alluded to by Jiba B. Kabua (2004), any “discussion about education is necessarily a discussion of culture, and any policy on education is also a policy of culture” (p. 181). It is impossible to promote one without the other, and it is not logical to understand one without the other. Re-thinking how education should look like, the pedagogical strategies that are relevant in our classrooms, the ways to engage with our parents and communities - such re-thinking sits within our cultural approaches and frameworks. Our collective attempts to provide a cultural framework that is relevant and appropriate for education in our context, sits within the political endeavour to decolonize. This means that what we are providing will not only be useful, but it can be used as a tool to question and identify whether things in place restrict and prevent our culture or whether they promote and foreground cultural ideas and concepts, a significant discussion of culture linked to education (Kabua, 2004). Donor funded development aid programmes were provided to support the challenges within education systems. Concerned with the persistent low educational outcomes of Pacific students, despite the prevalence of aid programmes in the region, in 2000 Pacific educators and leaders with support from New Zealand Aid (NZ Aid) decided to intervene (Heine, 2002; Taufe’ulungaki, 2014). In April 2001, a group of Pacific educators and leaders across the region were invited to a colloquium funded by the New Zealand Overseas Development Agency held in Suva Fiji at the University of the South Pacific. The main purpose of the colloquium was to enable “Pacific educators to re-think the values, assumptions and beliefs underlying [formal] schooling in Oceania” (Benson, 2002). Leadership, in general, is a valued practice in the RMI (Heine, 2002). Despite education leadership being identified as a significant factor in school improvement (Sanga & Chu, 2009), the limited formal training opportunities of school principals in the region was a persistent concern. As part of an Asia Development Bank (ADB) funded project, the Improve Quality Basic Education (IQBE) intervention was developed and implemented in the RMI in 2017. Mentoring is a process associated with the continuity and sustainability of leadership knowledge and practices (Sanga & Chu, 2009). It is a key aspect of building capacity and capabilities within human resources in education (ibid). Indigenous knowledges and education research According to Hilda Heine, the relationship between education and leadership is about understanding Marshallese history and culture (cited in Walsh et al., 2012). It is about sharing indigenous knowledge and histories that “details for future generations a story of survival and resilience and the pride we possess as a people” (Heine, cited in Walsh et al., 2012, p. v). This paper is fuelled by postcolonial aspirations yet is grounded in Pacific indigenous research. This means that our intentions are driven by postcolonial pursuits and discourses linked to challenging the colonial systems and schooling in the Pacific region that privileges western knowledge and learning and marginalises the education practices and processes of local people (Thiong’o, 1986). A point of difference and orientation from postcolonialism is a desire to foreground indigenous Pacific language, specifically Majin Majol, through Marshallese concepts. Our collective bwebwenato and conversation honours and values kautiej (respect), jouj eo mour eo (reciprocity), and jouj (kindness) (Taafaki & Fowler, 2019). Pacific leaders developed the Rethinking Pacific Education Initiative for and by Pacific People (RPEIPP) in 2002 to take control of the ways in which education research was conducted by donor funded organisations (Taufe’ulungaki, 2014). Our former president, Dr Hilda Heine was part of the group of leaders who sought to counter the ways in which our educational and leadership stories were controlled and told by non-Marshallese (Heine, 2002). As a former minister of education in the RMI, Hilda Heine continues to inspire and encourage the next generation of educators, school leaders, and researchers to re-think and de-construct the way learning and education is conceptualised for Marshallese people. The conceptualisation of Kanne Lobal acknowledges its origin, grounded in Marshallese navigation knowledge and practice. Our decision to unpack and deconstruct Kanne Lobal within the context of formal education and leadership responds to the need to not only draw from indigenous Marshallese ideas and practice but to consider that the next generation will continue to be educated using western processes and initiatives particularly from the US where we get a lot of our funding from. According to indigenous researchers Dawn Bessarab and Bridget Ng’andu (2010), doing research that considers “culturally appropriate processes to engage with indigenous groups and individuals is particularly pertinent in today’s research environment” (p. 37). Pacific indigenous educators and researchers have turned to their own ancestral knowledge and practices for inspiration and empowerment. Within western research contexts, the often stringent ideals and processes are not always encouraging of indigenous methods and practices. However, many were able to ground and articulate their use of indigenous methods as being relevant and appropriate to capturing the realities of their communities (Nabobo-Baba, 2008; Sualii-Sauni & Fulu-Aiolupotea, 2014; Thaman, 1997). At the same time, utilising Pacific indigenous methods and approaches enabled research engagement with their communities that honoured and respected them and their communities. For example, Tongan, Samoan, and Fijian researchers used the talanoa method as a way to capture the stories, lived realities, and worldviews of their communities within education in the diaspora (Fa’avae, Jones, & Manu’atu, 2016; Nabobo-Baba, 2008; Sualii-Sauni & Aiolupotea, 2014; Vaioleti, 2005). Tok stori was used by Solomon Islander educators and school leaders to highlight the unique circles of conversational practice and storytelling that leads to more positive engagement with their community members, capturing rich and meaningful narratives as a result (Sanga & Houma, 2004). The Indigenous Aborigine in Australia utilise yarning as a “relaxed discussion through which both the researcher and participant journey together visiting places and topics of interest relevant” (Bessarab & Ng’andu, 2010, p. 38). Despite the diverse forms of discussions and storytelling by indigenous peoples, of significance are the cultural protocols, ethics, and language for conducting and guiding the engagement (Bessarab & Ng’andu, 2010; Nabobo-Baba, 2008; Sualii-Sauni & Aiolupotea, 2014). Through the ethics, values, protocols, and language, these are what makes indigenous methods or frameworks unique compared to western methods like in-depth interviews or semi-structured interviews. This is why it is important for us as Marshallese educators to frame, ground, and articulate how our own methods and frameworks of learning could be realised in western education (Heine, 2002; Jetnil-Kijiner, 2014). In this paper, we utilise bwebwenato as an appropriate method linked to “talk story”, capturing our collective stories and experiences during GCSL and how we sought to build partnerships and collaboration with each other, our communities, and the PSS. Bwebwenato and drawing from Kajin Majel Legends and stories that reflect Marshallese society and its cultural values have survived through our oral traditions. The practice of weaving also holds knowledge about our “valuable and earliest sources of knowledge” (Taafaki & Fowler, 2019, p. 2). The skilful navigation of Marshallese wayfarers on the walap (large canoes) in the ocean is testament of their leadership and the value they place on ensuring the survival and continuity of Marshallese people (Taafaki & Fowler, 2019; Walsh et al., 2012). During her graduate study in 2014, Kathy Jetnil-Kijiner conceptualised bwebwenato as being the most “well-known form of Marshallese orality” (p. 38). The Marshallese-English dictionary defined bwebwenato as talk, conversation, story, history, article, episode, lore, myth, or tale (cited in Jetnil Kijiner, 2014). Three years later in 2017, bwebwenato was utilised in a doctoral project by Natalie Nimmer as a research method to gather “talk stories” about the experiences of 10 Marshallese experts in knowledge and skills ranging from sewing to linguistics, canoe-making and business. Our collective bwebwenato in this paper centres on Marshallese ideas and language. The philosophy of Marshallese knowledge is rooted in our “Kajin Majel”, or Marshallese language and is shared and transmitted through our oral traditions. For instance, through our historical stories and myths. Marshallese philosophy, that is, the knowledge systems inherent in our beliefs, values, customs, and practices are shared. They are inherently relational, meaning that knowledge systems and philosophies within our world are connected, in mind, body, and spirit (Jetnil-Kijiner, 2014; Nimmer, 2017). Although some Marshallese believe that our knowledge is disappearing as more and more elders pass away, it is therefore important work together, and learn from each other about the knowledges shared not only by the living but through their lamentations and stories of those who are no longer with us (Jetnil-Kijiner, 2014). As a Marshallese practice, weaving has been passed-down from generation to generation. Although the art of weaving is no longer as common as it used to be, the artefacts such as the “jaki-ed” (clothing mats) continue to embody significant Marshallese values and traditions. For our weavers, the jouj (check spelling) is the centre of the mat and it is where the weaving starts. When the jouj is correct and weaved well, the remainder and every other part of the mat will be right. The jouj is symbolic of the “heart” and if the heart is prepared well, trained well, then life or all other parts of the body will be well (Taafaki & Fowler, 2019). In that light, we have applied the same to this paper. Conceptualising and drawing from cultural practices that are close and dear to our hearts embodies a significant ontological attempt to prioritize our own knowledge and language, a sense of endearment to who we are and what we believe education to be like for us and the next generation. The application of the phrase “Majolizing '' was used by the Ministry of Education when Hilda Heine was minister, to weave cultural ideas and language into the way that teachers understand the curriculum, develop lesson plans and execute them in the classroom. Despite this, there were still concerns with the embedded colonized practices where teachers defaulted to eurocentric methods of doing things, like the strategies provided in the textbooks given to us. In some ways, our education was slow to adjust to the “Majolizing '' intention by our former minister. In this paper, we provide Kanne Lobal as a way to contribute to the “Majolizing intention” and perhaps speed up yet still be collectively responsible to all involved in education. Kajin Wa and Kanne Lobal “Wa” is the Marshallese concept for canoe. Kajin wa, as in canoe language, has a lot of symbolic meaning linked to deeply-held Marshallese values and practices. The canoe was the foundational practice that supported the livelihood of harsh atoll island living which reflects the Marshallese social world. The experts of Kajin wa often refer to “wa” as being the vessel of life, a means and source of sustaining life (Kelen, 2009, cited in Miller, 2010). “Jouj” means kindness and is the lower part of the main hull of the canoe. It is often referred to by some canoe builders in the RMI as the heart of the canoe and is linked to love. The jouj is one of the first parts of the canoe that is built and is “used to do all other measurements, and then the rest of the canoe is built on top of it” (Miller, 2010, p. 67). The significance of the jouj is that when the canoe is in the water, the jouj is the part of the hull that is underwater and ensures that all the cargo and passengers are safe. For Marshallese, jouj or kindness is what living is about and is associated with selflessly carrying the responsibility of keeping the family and community safe. The parts of the canoe reflect Marshallese culture, legend, family, lineage, and kinship. They embody social responsibilities that guide, direct, and sustain Marshallese families’ wellbeing, from atoll to atoll. For example, the rojak (boom), rojak maan (upper boom), rojak kōrā (lower boom), and they support the edges of the ujelā/ujele (sail) (see figure 1). The literal meaning of rojak maan is male boom and rojak kōrā means female boom which together strengthens the sail and ensures the canoe propels forward in a strong yet safe way. Figuratively, the rojak maan and rojak kōrā symbolise the mother and father relationship which when strong, through the jouj (kindness and love), it can strengthen families and sustain them into the future. Figure 1. Parts of the canoe Source: https://www.canoesmarshallislands.com/2014/09/names-of-canoe-parts/ From a socio-cultural, communal, and leadership view, the canoe (wa) provides understanding of the relationships required to inspire and sustain Marshallese peoples’ education and learning. We draw from Kajin wa because they provide cultural ideas and practices that enable understanding of education and leadership necessary for sustaining Marshallese people and realities in Oceania. When building a canoe, the women are tasked with the weaving of the ujelā/ujele (sail) and to ensure that it is strong enough to withstand long journeys and the fierce winds and waters of the ocean. The Kanne Lobal relates to the front part of the ujelā/ujele (sail) where the rojak maan and rojak kōrā meet and connect (see the red lines in figure 1). Kanne Lobal is linked to the strategic use of the ujelā/ujele by navigators, when there is no wind north wind to propel them forward, to find ways to capture the winds so that their journey can continue. As a proverbial saying, Kanne Lobal is used to ignite thinking and inspire and transform practice particularly when the journey is rough and tough. In this paper we draw from Kanne Lobal to ignite, inspire, and transform our educational and leadership practices, a move to explore what has always been meaningful to Marshallese people when we are faced with challenges. The Kanne Lobal utilises our language, and cultural practices and values by sourcing from the concepts of jouj (kindness, love), kautiej (respect), and jouj eo mour eo (reciprocity). A key Marshallese proverb, “Enra bwe jen lale rara”, is the cultural practice where families enact compassion through the sharing of food in all occurrences. The term “enra” is a small basket weaved from the coconut leaves, and often used by Marshallese as a plate to share and distribute food amongst each other. Bwe-jen-lale-rara is about noticing and providing for the needs of others, and “enra” the basket will help support and provide for all that are in need. “Enra-bwe-jen-lale-rara” is symbolic of cultural exchange and reciprocity and the cultural values associated with building and maintaining relationships, and constantly honouring each other. As a Marshallese practice, in this article we share our understanding and knowledge about the challenges as well as possible solutions for education concerns in our nation. In addition, we highlight another proverb, “wa kuk wa jimor”, which relates to having one canoe, and despite its capacity to feed and provide for the individual, but within the canoe all people can benefit from what it can provide. In the same way, we provide in this paper a cultural framework that will enable all educators to benefit from. It is a framework that is far-reaching and relevant to the lived realities of Marshallese people today. Kumit relates to people united to build strength, all co-operating and working together, living in peace, harmony, and good health. Kanne Lobal: conceptual framework for education and leadership An education framework is a conceptual structure that can be used to capture ideas and thinking related to aspects of learning. Kanne Lobal is conceptualised and framed in this paper as an educational framework. Kanne Lobal highlights the significance of education as a collective partnership whereby leadership is an important aspect. Kanne Lobal draws-from indigenous Marshallese concepts like kautiej (respect), jouj eo mour eo (reciprocity), and jouj (kindness, heart). The role of a leader, including an education leader, is to prioritise collective learning and partnerships that benefits Marshallese people and the continuity and survival of the next generation (Heine, 2002; Thaman, 1995). As described by Ejnar Aerōk, an expert canoe builder in the RMI, he stated: “jerbal ippān doon bwe en maron maan wa e” (cited in Miller, 2010, p. 69). His description emphasises the significance of partnerships and working together when navigating and journeying together in order to move the canoe forward. The kubaak, the outrigger of the wa (canoe) is about “partnerships”. For us as elementary school leaders on Majuro, kubaak encourages us to value collaborative partnerships with each other as well as our communities, PSS, and other stakeholders. Partnerships is an important part of the Kanne Lobal education and leadership framework. It requires ongoing bwebwenato – the inspiring as well as confronting and challenging conversations that should be mediated and negotiated if we and our education stakeholders are to journey together to ensure that the educational services we provide benefits our next generation of young people in the RMI. Navigating ahead the partnerships, mediation, and negotiation are the core values of jouj (kindness, love), kautiej (respect), and jouj eo mour eo (reciprocity). As an organic conceptual framework grounded in indigenous values, inspired through our lived experiences, Kanne Lobal provides ideas and concepts for re-thinking education and leadership practices that are conducive to learning and teaching in the schooling context in the RMI. By no means does it provide the solution to the education ills in our nation. However, we argue that Kanne Lobal is a more relevant approach which is much needed for the negatively stigmatised system as a consequence of the various colonial administrations that have and continue to shape and reframe our ideas about what education should be like for us in the RMI. Moreover, Kannel Lobal is our attempt to decolonize the framing of education and leadership, moving our bwebwenato to re-framing conversations of teaching and learning so that our cultural knowledge and values are foregrounded, appreciated, and realised within our education system. Bwebwenato: sharing our stories In this section, we use bwebwenato as a method of gathering and capturing our stories as data. Below we capture our stories and ongoing conversations about the richness in Marshallese cultural knowledge in the outer islands and on Majuro and the potentialities in Kanne Lobal. Danny Jim When I was in third grade (9-10 years of age), during my grandfather’s speech in Arno, an atoll near Majuro, during a time when a wa (canoe) was being blessed and ready to put the canoe into the ocean. My grandfather told me the canoe was a blessing for the family. “Without a canoe, a family cannot provide for them”, he said. The canoe allows for travelling between places to gather food and other sources to provide for the family. My grandfather’s stories about people’s roles within the canoe reminded me that everyone within the family has a responsibility to each other. Our women, mothers and daughters too have a significant responsibility in the journey, in fact, they hold us, care for us, and given strength to their husbands, brothers, and sons. The wise man or elder sits in the middle of the canoe, directing the young man who help to steer. The young man, he does all the work, directed by the older man. They take advice and seek the wisdom of the elder. In front of the canoe, a young boy is placed there and because of his strong and youthful vision, he is able to help the elder as well as the young man on the canoe. The story can be linked to the roles that school leaders, teachers, and students have in schooling. Without each person knowing intricately their role and responsibility, the sight and vision ahead for the collective aspirations of the school and the community is difficult to comprehend. For me, the canoe is symbolic of our educational journey within our education system. As the school leader, a central, trusted, and respected figure in the school, they provide support for teachers who are at the helm, pedagogically striving to provide for their students. For without strong direction from the school leaders and teachers at the helm, the students, like the young boy, cannot foresee their futures, or envisage how education can benefit them. This is why Kanne Lobal is a significant framework for us in the Marshall Islands because within the practice we are able to take heed and empower each other so that all benefit from the process. Kanne Lobal is linked to our culture, an essential part of who we are. We must rely on our own local approaches, rather than relying on others that are not relevant to what we know and how we live in today’s society. One of the things I can tell is that in Majuro, compared to the outer islands, it’s different. In the outer islands, parents bring children together and tell them legends and stories. The elders tell them about the legends and stories – the bwebwenato. Children from outer islands know a lot more about Marshallese legends compared to children from the Majuro atoll. They usually stay close to their parents, observe how to prepare food and all types of Marshallese skills. Loretta Joseph Case There is little Western influence in the outer islands. They grow up learning their own culture with their parents, not having tv. They are closely knit, making their own food, learning to weave. They use fire for cooking food. They are more connected because there are few of them, doing their own culture. For example, if they’re building a house, the ladies will come together and make food to take to the males that are building the house, encouraging them to keep on working - “jemjem maal” (sharpening tools i.e. axe, like encouraging workers to empower them). It’s when they bring food and entertainment. Rubon Rubon Togetherness, work together, sharing of food, these are important practices as a school leader. Jemjem maal – the whole village works together, men working and the women encourage them with food and entertainment. All the young children are involved in all of the cultural practices, cultural transmission is consistently part of their everyday life. These are stronger in the outer islands. Kanne Lobal has the potential to provide solutions using our own knowledge and practices. Connie Joel When new teachers become a teacher, they learn more about their culture in teaching. Teaching raises the question, who are we? A popular saying amongst our people, “Aelon kein ad ej aelon in manit”, means that “Our islands are cultural islands”. Therefore, when we are teaching, and managing the school, we must do this culturally. When we live and breathe, we must do this culturally. There is more socialising with family and extended family. Respect the elderly. When they’re doing things the ladies all get together, in groups and do it. Cut the breadfruit, and preserve the breadfruit and pandanus. They come together and do it. Same as fishing, building houses, building canoes. They use and speak the language often spoken by the older people. There are words that people in the outer islands use and understand language regularly applied by the elderly. Respect elderly and leaders more i.e., chiefs (iroj), commoners (alap), and the workers on the land (ri-jerbal) (social layer under the commoners). All the kids, they gather with their families, and go and visit the chiefs and alap, and take gifts from their land, first produce/food from the plantation (eojōk). Tommy Almet The people are more connected to the culture in the outer islands because they help one another. They don’t have to always buy things by themselves, everyone contributes to the occasion. For instance, for birthdays, boys go fishing, others contribute and all share with everyone. Kanne Lobal is a practice that can bring people together – leaders, teachers, stakeholders. We want our colleagues to keep strong and work together to fix problems like students and teachers’ absenteeism which is a big problem for us in schools. Demetria Malachi The culture in the outer islands are more accessible and exposed to children. In Majuro, there is a mixedness of cultures and knowledges, influenced by Western thinking and practices. Kanne Lobal is an idea that can enhance quality educational purposes for the RMI. We, the school leaders who did GCSL, we want to merge and use this idea because it will help benefit students’ learning and teachers’ teaching. Kanne Lobal will help students to learn and teachers to teach though traditional skills and knowledge. We want to revitalize our ways of life through teaching because it is slowly fading away. Also, we want to have our own Marshallese learning process because it is in our own language making it easier to use and understand. Essentially, we want to proudly use our own ways of teaching from our ancestors showing the appreciation and blessings given to us. Way Forward To think of ways forward is about reflecting on the past and current learnings. Instead of a traditional discussion within a research publication, we have opted to continue our bwebwenato by sharing what we have learnt through the Graduate Certificate in School Leadership (GCSL) programme. Our bwebwenato does not end in this article and this opportunity to collaborate and partner together in this piece of writing has been a meaningful experience to conceptualise and unpack the Kanne Lobal framework. Our collaborative bwebwenato has enabled us to dig deep into our own wise knowledges for guidance through mediating and negotiating the challenges in education and leadership (Sanga & Houma, 2004). For example, bwe-jen-lale-rara reminds us to inquire, pay attention, and focus on supporting the needs of others. Through enra-bwe-jen-lale-rara, it reminds us to value cultural exchange and reciprocity which will strengthen the development and maintaining of relationships based on ways we continue to honour each other (Nimmer, 2017). We not only continue to support each other, but also help mentor the next generation of school leaders within our education system (Heine, 2002). Education and leadership are all about collaborative partnerships (Sanga & Chu, 2009; Thaman, 1997). Developing partnerships through the GCSL was useful learning for us. It encouraged us to work together, share knowledge, respect each other, and be kind. The values of jouj (kindness, love), kautiej (respect), and jouj eo mour eo (reciprocity) are meaningful in being and becoming and educational leader in the RMI (Jetnil-Kijiner, 2014; Miller, 2010; Nimmer, 2017). These values are meaningful for us practice particularly given the drive by PSS for schools to become accredited. The workshops and meetings delivered during the GCSL in the RMI from 2018 to 2019 about Kanne Lobal has given us strength to share our stories and experiences from the meeting with the stakeholders. But before we met with the stakeholders, we were encouraged to share and speak in our language within our courses: EDP05 (Professional Development and Learning), EDP06 (School Leadership), EDP07 (School Management), EDP08 (Teaching and Learning), and EDP09 (Community Partnerships). In groups, we shared our presentations with our peers, the 15 school leaders in the GCSL programme. We also invited USP RMI staff. They liked the way we presented Kannel Lobal. They provided us with feedback, for example: how the use of the sail on the canoe, the parts and their functions can be conceptualised in education and how they are related to the way that we teach our own young people. Engaging stakeholders in the conceptualisation and design stages of Kanne Lobal strengthened our understanding of leadership and collaborative partnerships. Based on various meetings with the RMI Pacific Resources for Education and Learning (PREL) team, PSS general assembly, teachers from the outer islands, and the PSS executive committee, we were able to share and receive feedback on the Kanne Lobal framework. The coordinators of the PREL programme in the RMI were excited by the possibilities around using Kanne Lobal, as a way to teach culture in an inspirational way to Marshallese students. Our Marshallese knowledge, particularly through the proverbial meaning of Kanne Lobal provided so much inspiration and insight for the groups during the presentation which gave us hope and confidence to develop the framework. Kanne Lobal is an organic and indigenous approach, grounded in Marshallese ways of doing things (Heine, 2002; Taafaki & Fowler, 2019). Given the persistent presence of colonial processes within the education system and the constant reference to practices and initiatives from the US, Kanne Lobal for us provides a refreshing yet fulfilling experience and makes us feel warm inside because it is something that belongs to all Marshallese people. Conclusion Marshallese indigenous knowledge and practices provide meaningful educational and leadership understanding and learnings. They ignite, inspire, and transform thinking and practice. The Kanne Lobal conceptual framework emphasises key concepts and values necessary for collaborative partnerships within education and leadership practices in the RMI. The bwebwenato or talk stories have been insightful and have highlighted the strengths and benefits that our Marshallese ideas and practices possess when looking for appropriate and relevant ways to understand education and leadership. Acknowledgements We want to acknowledge our GCSL cohort of school leaders who have supported us in the development of Kanne Lobal as a conceptual framework. A huge kommol tata to our friends: Joana, Rosana, Loretta, Jellan, Alvin, Ellice, Rolando, Stephen, and Alan. References Benson, C. (2002). Preface. In F. Pene, A. M. Taufe’ulungaki, & C. Benson (Eds.), Tree of Opportunity: re-thinking Pacific Education (p. iv). Suva, Fiji: University of the South Pacific, Institute of Education. Bessarab, D., Ng’andu, B. (2010). Yarning about yarning as a legitimate method in indigenous research. International Journal of Critical Indigenous Studies, 3(1), 37-50. Fa’avae, D., Jones, A., & Manu’atu, L. (2016). Talanoa’i ‘a e talanoa - talking about talanoa: Some dilemmas of a novice researcher. AlterNative: An Indigenous Journal of Indigenous Peoples,12(2),138-150. Heine, H. C. (2002). A Marshall Islands perspective. In F. Pene, A. M. Taufe’ulungaki, & C. Benson (Eds.), Tree of Opportunity: re-thinking Pacific Education (pp. 84 – 90). Suva, Fiji: University of the South Pacific, Institute of Education. Infoplease Staff (2017, February 28). Marshall Islands, retrieved from https://www.infoplease.com/world/countries/marshall-islands Jetnil-Kijiner, K. (2014). Iep Jaltok: A history of Marshallese literature. (Unpublished masters’ thesis). Honolulu, HW: University of Hawaii. Kabua, J. B. (2004). We are the land, the land is us: The moral responsibility of our education and sustainability. In A.L. Loeak, V.C. Kiluwe and L. Crowl (Eds.), Life in the Republic of the Marshall Islands, pp. 180 – 191. Suva, Fiji: University of the South Pacific. Kupferman, D. (2004). Jelalokjen in flux: Pitfalls and prospects of contextualising teacher training programmes in the Marshall Islands. Directions: Journal of Educational Studies, 26(1), 42 – 54. http://directions.usp.ac.fj/collect/direct/index/assoc/D1175062.dir/doc.pdf Miller, R. L. (2010). Wa kuk wa jimor: Outrigger canoes, social change, and modern life in the Marshall Islands (Unpublished masters’ thesis). Honolulu, HW: University of Hawaii. Nabobo-Baba, U. (2008). Decolonising framings in Pacific research: Indigenous Fijian vanua research framework as an organic response. AlterNative: An Indigenous Journal of Indigenous Peoples, 4(2), 141-154. Nimmer, N. E. (2017). Documenting a Marshallese indigenous learning framework (Unpublished doctoral thesis). Honolulu, HW: University of Hawaii. Sanga, K., & Houma, S. (2004). Solomon Islands principalship: Roles perceived, performed, preferred, and expected. Directions: Journal of Educational Studies, 26(1), 55-69. Sanga, K., & Chu, C. (2009). Introduction. In K. Sanga & C. Chu (Eds.), Living and Leaving a Legacy of Hope: Stories by New Generation Pacific Leaders (pp. 10-12). NZ: He Parekereke & Victoria University of Wellington. Suaalii-Sauni, T., & Fulu-Aiolupotea, S. M. (2014). Decolonising Pacific research, building Pacific research communities, and developing Pacific research tools: The case of the talanoa and the faafaletui in Samoa. Asia Pacific Viewpoint, 55(3), 331-344. Taafaki, I., & Fowler, M. K. (2019). Clothing mats of the Marshall Islands: The history, the culture, and the weavers. US: Kindle Direct. Taufe’ulungaki, A. M. (2014). Look back to look forward: A reflective Pacific journey. In M. ‘Otunuku, U. Nabobo-Baba, S. Johansson Fua (Eds.), Of Waves, Winds, and Wonderful Things: A Decade of Rethinking Pacific Education (pp. 1-15). Fiji: USP Press. Thaman, K. H. (1995). Concepts of learning, knowledge and wisdom in Tonga, and their relevance to modern education. Prospects, 25(4), 723-733. Thaman, K. H. (1997). Reclaiming a place: Towards a Pacific concept of education for cultural development. The Journal of the Polynesian Society, 106(2), 119-130. Thiong’o, N. W. (1986). Decolonising the mind: The politics of language in African literature. Kenya: East African Educational Publishers. Vaioleti, T. (2006). Talanoa research methodology: A developing position on Pacific research. Waikato Journal of Education, 12, 21-34. Walsh, J. M., Heine, H. C., Bigler, C. M., & Stege, M. (2012). Etto nan raan kein: A Marshall Islands history (First Edition). China: Bess Press.

Abstract Background The sustainability of Australian rural maternity services is under threat due to current workforce shortages. In July 2019, a new midwifery caseload model of care was implemented in rural South Australia to provide midwifery continuity of care and promote a sustainable workforce in the area. The model is unique as it brings together five birthing sites connecting midwives, doctors, nurses and community teams. A critical precursor to successful implementation requires those working in the model be ready to adopt to the change. We surveyed clinicians at the five sites transitioning to the new model of care in order to assess their organizational readiness to implement change. Methods A descriptive study assessing readiness for change was measured using the Organizational Readiness for Implementing Change scale (ORIC). The 12 item Likert scale measures a participant’s commitment to change and change efficacy. All clinicians working within the model of care (midwives, nurses and doctors) were invited to complete an e-survey. Results Overall, 55% (56/102) of clinicians participating in the model responded. The mean ORIC score was 41.5 (range 12–60) suggesting collectively, midwives, nurses and doctors began the new model of care with a sense of readiness for change. Participants were most likely to agree on the change efficacy statements, “People who work here feel confident that the organization can get people invested in implementing this change and the change commitment statements “People who work here are determined to implement this change”, “People who work here want to implement this change”, and “People who work here are committed to implementing this change. Conclusion Results of the ORIC survey indicate that clinicians transitioning to the new model of care were willing to embrace change and commit to the new model. The process of organizational change in health care settings is challenging and a continuous process. If readiness for change is high, organizational members invest more in the change effort and exhibit greater persistence to overcome barriers and setbacks. This is the first reported use of the instrument amongst midwives and nurses in Australia and should be considered for use in other national and international clinical implementation studies.

Abstract Background Despite having a high healthcare need, persons with complex conditions are less likely to receive comprehensive care. Individuals with SCI experience difficulties accessing services 2-4 times more than the general population. There is little agreement concerning the factors that influence these access restrictions. Few studies focus on health system impact on characteristics on access. Objective To outline barriers and facilitators to service access among persons with SCI across 22 countries in terms of health system characteristics Methods InSCI(2017): 1st community survey on experience of persons with SCI, 12591 participants, 22 countries (Australia, Brazil, China, France, Germany, Greece, Indonesia, Italy, Japan, Lithuania, Malaysia, Morocco, the Netherlands, Norway, Poland, Romania, South Africa, South Korea, Spain, Switzerland, Thailand, USA). Data analysis 1. Hierarchical cluster analysis based on Gower distance (to group systems by access restrictions: Acceptability, Approachability, Availability, Affordability, Appropriateness). 2. Generalized linear mixed-effects decision tree (to explore the association of system characteristics and access, including WHO and OECD system indicators (e.g. UHC index, expenditure, human resources). Missing values were imputed with missforest. Results 12% of persons with SCI reported having an access restriction, most of them (7%) with Availability. By country, the highest unmet needs were reported in Poland (25%), Germany, Lithuania, and Romania (13). 1. Cluster analysis: 7 health systems clusters (groups) were identified. 2. By June 2022, we will have the results of the second analysis: the association of system characteristics with access and how it is modified by socio-demographic and medical factors. Expected conclusions The study identifies factors a country could modify in order to improve access and strengthen the system for persons with SCI/disability, that might be relevant to general population as well. Key messages • Persons with SCI often experience similar access restrictions across countries, incl. those with high-performing health systems. System strengthening in this area is further required in all countries. • Health systems are fragmented, e.g. healthcare quality and access inside a country differs by region, urban/rural setting etc., hence, the systems are challenging to classify.

Abstract Background Capitation models of care in dentistry started around 1973 with varying degrees of success in meeting the needs of the individuals and expectations of the participating private practitioners. These studies mostly identified that capitation payments resulted in under treatment whilst fee-for-service models often led to over treatment. The objective of this study was to develop a new way of doing business using an outsourcing capitation model of care to meet population health needs and activity-based funding requirements of rural Local Health Districts with a local university dental school. This payment model is an alternate referral pathway for public oral health practitioners from the existing New South Wales Oral Health Fee-for-Service Scheme that focuses on urgent treatment to one that offers an all-inclusive preventive approach that concentrates on sustaining good long-term oral health for the individual. Method The reflective study analysed various adult age cohorts (18–24, 25–34, 35–44, 45–54, 55–64, 65–74 and 75 + years) based on 950 participants randomly selected from the Greater Southern adult public dental waiting lists. The study’s capitation formula was derived from NSW government adult treatment items (n = 447,625). Dental care was provided through the local university’s dental clinics utilising only dental students under clinical supervision. All data were sourced from NSW Oral Health Data Warehouse during 1 January 2012–30 June 2018 and analysed by using SAS 9.3 and Version 13 Microsoft Excel. Results There were 10,305 dental care items and 1129 capitation courses of care totalling A$599,026. This resulted in an average of 11 dental care items being provided to each participant. The capitation payment formula utilising the most provided dental care items of 100 individual patients proved to be economical and preventive focused. Conclusion The systematic reflection showed that this unique methodology in developing an adult capitation payment formula associated to diagnostic pathways that resulted in: (i) more efficient usage of government expenditure on public dental services, (ii) provision of person-centred courses of dental care, and (iii) utilisation of university dental education programs to best practice treatment and holistic care.

“Human beings are not born once and for all on the day their mothers give birth to them [...] life obliges them over and over again to give birth to themselves.” (Garcia Marquez 165) Introduction The refugee experience is, at heart, one of rebirth. Just as becoming a new, distinctive being—biological birth—necessarily involves the physical separation of mother and infant, so becoming a refugee entails separation from a "mother country." This mother country may or may not be a recognised nation state; the point is that the refugee transitions from physical connectedness to separation, from insider to outsider, from endemic to alien. Like babies, refugees may have little control over the timing and conditions of their expulsion. Successful resettlement requires not one rebirth but multiple rebirths—resettlement is a lifelong process (Layton)—which in turn require hope, imagination, and energy. In rebirthing themselves over and over again, people who have fled or been forced from their homelands become both mother and child. They do not go through this rebirthing alone. A range of agencies and individuals may be there to assist, including immigration officials, settlement services, schools and teachers, employment agencies and employers, English as a Second Language (ESL) resources and instructors, health-care providers, counsellors, diasporic networks, neighbours, church groups, and other community organisations. The nature, intensity, and duration of these “midwives’” interventions—and when they occur and in what combinations—vary hugely from place to place and from person to person, but there is clear evidence that post-migration experiences have a significant impact on settlement outcomes (Fozdar and Hartley). This paper draws on qualitative research I did in 2012 in a regional town in New South Wales to illuminate some of the ways in which settlement aides ease, or impede, refugees’ rebirth as fully recognised and participating Australians. I begin by considering what it means to be resilient before tracing some of the dimensions of the resettlement process. In doing so, I draw on data from interviews and focus groups with former refugees, service providers, and other residents of the town I shall call Easthaven. First, though, a word about Easthaven. As is the case in many rural and regional parts of Australia, Easthaven’s population is strongly dominated by Anglo Celtic and Saxon ancestries: 2011 Census data show that more than 80 per cent of residents were born in Australia (compared with a national figure of 69.8 per cent) and about 90 per cent speak only English at home (76.8 per cent). Almost twice as many people identify as Aboriginal or Torres Strait Islander as the national figure of 2.5 per cent (Australian Bureau of Statistics). For several years Easthaven has been an official “Refugee Welcome Zone”, welcoming hundreds of refugees from diverse countries in Africa and the Middle East as well as from Myanmar. This reflects the Department of Immigration and Citizenship’s drive to settle a fifth of Australia’s 13,750 humanitarian entrants a year directly in regional areas. In Easthaven’s schools—which is where I focused my research—almost all of the ESL students are from refugee backgrounds. Defining Resilience Much of the research on human resilience is grounded in psychology, with a capacity to “bounce back” from adverse experiences cited in many definitions of resilience (e.g. American Psychological Association). Bouncing back implies a relatively quick process, and a return to a state or form similar to that which existed before the encounter with adversity. Yet resilience often requires sustained effort and significant changes in identity. As Jerome Rugaruza, a former UNHCR refugee, says of his journey from the Democratic Republic of Congo to Australia: All the steps begin in the burning village: you run with nothing to eat, no clothes. You just go. Then you get to the refugee camp […] You have a little bread and you thank god you are safe. Then after a few years in the camp, you think about a future for your children. You arrive in Australia and then you learn a new language, you learn to drive. There are so many steps and not everyone can do it. (Milsom) Not everyone can do it, but a large majority do. Research by Graeme Hugo, for example, shows that although humanitarian settlers in Australia face substantial barriers to employment and initially have much higher unemployment rates than other immigrants, for most nationality groups this difference has disappeared by the second generation: “This is consistent with the sacrifice (or investment) of the first generation and the efforts extended to attain higher levels of education and English proficiency, thereby reducing the barriers over time.” (Hugo 35). Ingrid Poulson writes that “resilience is not just about bouncing. Bouncing […] is only a reaction. Resilience is about rising—you rise above it, you rise to the occasion, you rise to the challenge. Rising is an active choice” (47; my emphasis) I see resilience as involving mental and physical grit, coupled with creativity, aspiration and, crucially, agency. Dimensions of Resettlement To return to the story of 41-year-old Jerome Rugaruza, as related in a recent newspaper article: He [Mr Rugaruza] describes the experience of being a newly arrived refugee as being like that of a newborn baby. “You need special care; you have to learn to speak [English], eat the different food, create relationships, connections”. (Milsom) This is a key dimension of resettlement: the adult becomes like an infant again, shifting from someone who knows how things work and how to get by to someone who is likely to be, for a while, dependent on others for even the most basic things—communication, food, shelter, clothing, and social contact. The “special care” that most refugee arrivals need initially (and sometimes for a long time) often results in their being seen as deficient—in knowledge, skills, dispositions, and capacities as well as material goods (Keddie; Uptin, Wright and Harwood). As Fozdar and Hartley note: “The tendency to use a deficit model in refugee resettlement devalues people and reinforces the view of the mainstream population that refugees are a liability” (27). Yet unlike newborns, humanitarian settlers come to their new countries with rich social networks and extensive histories of experience and learning—resources that are in fact vital to their rebirth. Sisay (all names are pseudonyms), a year 11 student of Ethiopian heritage who was born in Kenya, told me with feeling: I had a life back in Africa [her emphasis]. It was good. Well, I would go back there if there’s no problems, which—is a fact. And I came here for a better life—yeah, I have a better life, there’s good health care, free school, and good environment and all that. But what’s that without friends? A fellow student, Celine, who came to Australia five years ago from Burundi via Uganda, told me in a focus group: Some teachers are really good but I think some other teachers could be a little bit more encouraging and understanding of what we’ve gone through, because [they] just look at you like “You’re year 11 now, you should know this” […] It’s really discouraging when [the teachers say] in front of the class, “Oh, you shouldn’t do this subject because you haven’t done this this this this” […] It’s like they’re on purpose to tell you “you don’t have what it takes; just give up and do something else.” As Uptin, Wright and Harwood note, “schools not only have the power to position who is included in schooling (in culture and pedagogy) but also have the power to determine whether there is room and appreciation for diversity” (126). Both Sisay and Celine were disheartened by the fact they felt some of their teachers, and many of their peers, had little interest in or understanding of their lives before they came to Australia. The teachers’ low expectations of refugee-background students (Keddie, Uptin, Wright and Harwood) contrasted with the students’ and their families’ high expectations of themselves (Brown, Miller and Mitchell; Harris and Marlowe). When I asked Sisay about her post-school ambitions, she said: “I have a good idea of my future […] write a documentary. And I’m working on it.” Celine’s response was: “I know I’m gonna do medicine, be a doctor.” A third girl, Lily, who came to Australia from Myanmar three years ago, told me she wanted to be an accountant and had studied accounting at the local TAFE last year. Joseph, a father of three who resettled from South Sudan seven years ago, stressed how important getting a job was to successful settlement: [But] you have to get a certificate first to get a job. Even the job of cleaning—when I came here I was told that somebody has to go to have training in cleaning, to use the different chemicals to clean the ground and all that. But that is just sweeping and cleaning with water—you don’t need the [higher-level] skills. Simple jobs like this, we are not able to get them. In regional Australia, employment opportunities tend to be limited (Fozdar and Hartley); the unemployment rate in Easthaven is twice the national average. Opportunities to study are also more limited than in urban centres, and would-be students are not always eligible for financial assistance to gain or upgrade qualifications. Even when people do have appropriate qualifications, work experience, and language proficiency, the colour of their skin may still mean they miss out on a job. Tilbury and Colic-Peisker have documented the various ways in which employers deflect responsibility for racial discrimination, including the “common” strategy (658) of arguing that while the employer or organisation is not prejudiced, they have to discriminate because of their clients’ needs or expectations. I heard this strategy deployed in an interview with a local businesswoman, Catriona: We were advertising for a new technician. And one of the African refugees came to us and he’d had a lot of IT experience. And this is awful, but we felt we couldn't give him the job, because we send our technicians into people's houses, and we knew that if a black African guy rocked up at someone’s house to try and fix their computer, they would not always be welcomed in all—look, it would not be something that [Easthaven] was ready for yet. Colic-Peisker and Tilbury (Refugees and Employment) note that while Australia has strict anti-discrimination legislation, this legislation may be of little use to the people who, because of the way they look and sound (skin colour, dress, accent), are most likely to face prejudice and discrimination. The researchers found that perceived discrimination in the labour market affected humanitarian settlers’ sense of satisfaction with their new lives far more than, for example, racist remarks, which were generally shrugged off; the students I interviewed spoke of racism as “expected,” but “quite rare.” Most of the people Colic-Peisker and Tilbury surveyed reported finding Australians “friendly and accepting” (33). Even if there is no active discrimination on the basis of skin colour in employment, education, or housing, or overt racism in social situations, visible difference can still affect a person’s sense of belonging, as Joseph recounts: I think of myself as Australian, but my colour doesn’t [laughs] […] Unfortunately many, many Australians are expecting that Australia is a country of Europeans … There is no need for somebody to ask “Where do you come from?” and “Do you find Australia here safe?” and “Do you enjoy it?” Those kind of questions doesn’t encourage that we are together. This highlights another dimension of resettlement: the journey from feeling “at home” to feeling “foreign” to, eventually, feeling at home again in the host country (Colic-Peisker and Tilbury, Refugees and Employment). In the case of visibly different settlers, however, this last stage may never be completed. Whether the questions asked of Joseph are well intentioned or not, their effect may be the same: they position him as a “forever foreigner” (Park). A further dimension of resettlement—one already touched on—is the degree to which humanitarian settlers actively manage their “rebirth,” and are allowed and encouraged to do so. A key factor will be their mastery of English, and Easthaven’s ESL teachers are thus pivotal in the resettlement process. There is little doubt that many of these teachers have gone to great lengths to help this cohort of students, not only in terms of language acquisition but also social inclusion. However, in some cases what is initially supportive can, with time, begin to undermine refugees’ maturity into independent citizens. Sharon, an ESL teacher at one of the schools, told me how she and her colleagues would give their refugee-background students lifts to social events: But then maybe three years down the track they have a car and their dad can drive, but they still won’t take them […] We arrive to pick them up and they’re not ready, or there’s five fantastic cars in the driveway, and you pick up the student and they say “My dad’s car’s much bigger and better than yours” [laughs]. So there’s an expectation that we’ll do stuff for them, but we’ve created that [my emphasis]. Other support services may have more complex interests in keeping refugee settlers dependent. The more clients an agency has, the more services it provides, and the longer clients stay on its books, the more lucrative the contract for the agency. Thus financial and employment imperatives promote competition rather than collaboration between service providers (Fozdar and Hartley; Sidhu and Taylor) and may encourage assumptions about what sorts of services different individuals and groups want and need. Colic-Peisker and Tilbury (“‘Active’ and ‘Passive’ Resettlement”) have developed a typology of resettlement styles—“achievers,” “consumers,” “endurers,” and “victims”—but stress that a person’s style, while influenced by personality and pre-migration factors, is also shaped by the institutions and individuals they come into contact with: “The structure of settlement and welfare services may produce a victim mentality, leaving members of refugee communities inert and unable to see themselves as agents of change” (76). The prevailing narrative of “the traumatised refugee” is a key aspect of this dynamic (Colic-Peisker and Tilbury, “‘Active’ and ‘Passive’ Resettlement”; Fozdar and Hartley; Keddie). Service providers may make assumptions about what humanitarian settlers have gone through before arriving in Australia, how they have been affected by their experiences, and what must be done to “fix” them. Norah, a long-time caseworker, told me: I think you get some [providers] who go, “How could you have gone through something like that and not suffered? There must be—you must have to talk about this stuff” […] Where some [refugees] just come with the [attitude] “We’re all born into a situation; that was my situation, but I’m here now and now my focus is this.” She cited failure to consider cultural sensitivities around mental illness and to recognise that stress and anxiety during early resettlement are normal (Tilbury) as other problems in the sector: [Newly arrived refugees] go through the “happy to be here” [phase] and now “hang on, I’ve thumped to the bottom and I’m missing my own foods and smells and cultures and experiences”. I think sometimes we’re just too quick to try and slot people into a box. One factor that appears to be vital in fostering and sustaining resilience is social connection. Norah said her clients were “very good on the mobile phone” and had links “everywhere,” including to family and friends in their countries of birth, transition countries, and other parts of Australia. A 2011 report for DIAC, Settlement Outcomes of New Arrivals, found that humanitarian entrants to Australia were significantly more likely to be members of cultural and/or religious groups than other categories of immigrants (Australian Survey Research). I found many examples of efforts to build both bonding and bridging capital (Putnam) in Easthaven, and I offer two examples below. Several people told me about a dinner-dance that had been held a few weeks before one of my visits. The event was organised by an African women’s group, which had been formed—with funding assistance—several years before. The dinner-dance was advertised in the local newspaper and attracted strong interest from a broad cross-section of Easthaveners. To Debbie, a counsellor, the response signified a “real turnaround” in community relations and was a big boon to the women’s sense of belonging. Erica, a teacher, told me about a cultural exchange day she had organised between her bush school—where almost all of the children are Anglo Australian—and ESL students from one of the town schools: At the start of the day, my kids were looking at [the refugee-background students] and they were scared, they were saying to me, "I feel scared." And we shoved them all into this tiny little room […] and they had no choice but to sit practically on top of each other. And by the end of the day, they were hugging each other and braiding their hair and jumping and playing together. Like Uptin, Wright and Harwood, I found that the refugee-background students placed great importance on the social aspects of school. Sisay, the girl I introduced earlier in this paper, said: “It’s just all about friendship and someone to be there for you […] We try to be friends with them [the non-refugee students] sometimes but sometimes it just seems they don’t want it.” Conclusion A 2012 report on refugee settlement services in NSW concludes that the state “is not meeting its responsibility to humanitarian entrants as well as it could” (Audit Office of New South Wales 2); moreover, humanitarian settlers in NSW are doing less well on indicators such as housing and health than humanitarian settlers in other states (3). Evaluating the effectiveness of formal refugee-centred programs was not part of my research and is beyond the scope of this paper. Rather, I have sought to reveal some of the ways in which the attitudes, assumptions, and everyday practices of service providers and members of the broader community impact on refugees' settlement experience. What I heard repeatedly in the interviews I conducted was that it was emotional and practical support (Matthews; Tilbury), and being asked as well as told (about their hopes, needs, desires), that helped Easthaven’s refugee settlers bear themselves into fulfilling new lives. References Audit Office of New South Wales. Settling Humanitarian Entrants in New South Wales—Executive Summary. May 2012. 15 Aug. 2013 ‹http://www.audit.nsw.gov.au/ArticleDocuments/245/02_Humanitarian_Entrants_2012_Executive_Summary.pdf.aspx?Embed=Y>. Australian Bureau of Statistics. 2011 Census QuickStats. Mar. 2013. 11 Aug. 2013 ‹http://www.censusdata.abs.gov.au/census_services/getproduct/census/2011/quickstat/0>. Australian Survey Research. Settlement Outcomes of New Arrivals—Report of Findings. Apr. 2011. 15 Aug. 2013 ‹http://www.immi.gov.au/media/publications/research/_pdf/settlement-outcomes-new-arrivals.pdf>. Brown, Jill, Jenny Miller, and Jane Mitchell. “Interrupted Schooling and the Acquisition of Literacy: Experiences of Sudanese Refugees in Victorian Secondary Schools.” Australian Journal of Language and Literacy 29.2 (2006): 150-62. Colic-Peisker, Val, and Farida Tilbury. “‘Active’ and ‘Passive’ Resettlement: The Influence of Supporting Services and Refugees’ Own Resources on Resettlement Style.” International Migration 41.5 (2004): 61-91. ———. Refugees and Employment: The Effect of Visible Difference on Discrimination—Final Report. Perth: Centre for Social and Community Research, Murdoch University, 2007. Fozdar, Farida, and Lisa Hartley. “Refugee Resettlement in Australia: What We Know and Need To Know.” Refugee Survey Quarterly 4 Jun. 2013. 12 Aug. 2013 ‹http://rsq.oxfordjournals.org/search?fulltext=fozdar&submit=yes&x=0&y=0>. Garcia Marquez, Gabriel. Love in the Time of Cholera. London: Penguin Books, 1989. Harris, Vandra, and Jay Marlowe. “Hard Yards and High Hopes: The Educational Challenges of African Refugee University Students in Australia.” International Journal of Teaching and Learning in Higher Education 23.2 (2011): 186-96. Hugo, Graeme. A Significant Contribution: The Economic, Social and Civic Contributions of First and Second Generation Humanitarian Entrants—Summary of Findings. Canberra: Department of Immigration and Citizenship, 2011. Keddie, Amanda. “Pursuing Justice for Refugee Students: Addressing Issues of Cultural (Mis)recognition.” International Journal of Inclusive Education 16.12 (2012): 1295-1310. Layton, Robyn. "Building Capacity to Ensure the Inclusion of Vulnerable Groups." Creating Our Future conference, Adelaide, 28 Jul. 2012. Milsom, Rosemarie. “From Hard Luck Life to the Lucky Country.” Sydney Morning Herald 20 Jun. 2013. 12 Aug. 2013 ‹http://www.smh.com.au/national/from-hard-luck-life-to-the-lucky-country-20130619-2oixl.html>. Park, Gilbert C. “’Are We Real Americans?’: Cultural Production of Forever Foreigners at a Diversity Event.” Education and Urban Society 43.4 (2011): 451-67. Poulson, Ingrid. Rise. Sydney: Pan Macmillan Australia, 2008. Putnam, Robert D. Bowling Alone: The Collapse and Revival of American Community. New York: Simon & Schuster, 2000. Sidhu, Ravinder K., and Sandra Taylor. “The Trials and Tribulations of Partnerships in Refugee Settlement Services in Australia.” Journal of Education Policy 24.6 (2009): 655-72. Tilbury, Farida. “‘I Feel I Am a Bird without Wings’: Discourses of Sadness and Loss among East Africans in Western Australia.” Identities: Global Studies in Culture and Power 14.4 (2007): 433-58. ———, and Val Colic-Peisker. “Deflecting Responsibility in Employer Talk about Race Discrimination.” Discourse & Society 17.5 (2006): 651-76. Uptin, Jonnell, Jan Wright, and Valerie Harwood. “It Felt Like I Was a Black Dot on White Paper: Examining Young Former Refugees’ Experience of Entering Australian High Schools.” The Australian Educational Researcher 40.1 (2013): 125-37.

Objective: To determine how innovation occurs and identify the factors that support innovation in a rural hospital in New South Wales, Australia. Design: Situated within a larger case study, this research collected qualitative data using semi-structured interviews. Setting: Inner regional hospital, located in a city, providing a broad range of acute and primary health services to a rural community. Participants: Hospital executives, department managers, consultant and staff specialist surgeons, physicians, nursing, nursing managers and allied health staff were recruited after a phone, personal or email approach. Main Outcome measure: Qualitative interviews (n=25) conducted in a rural hospital. Results: Fourteen innovations were identified. Factors supporting innovation were when individuals who were valued by team members had the ability to make within team innovations with ease; clinicians with ideas for improvement led innovation; external agencies- the Clinical Excellence Commission and the Agency for Clinical Innovation provided expertise, ideas, and motivation for innovation. Limiting factors included time for innovation, creative thinking, planning, and implementation. Funding, the bureaucracy and multiple points of consultation to make changes were also identified. Conclusions: Innovation occurred despite the absence of factors theory suggests are required. In rural settings, there are limited staff and resources leading to scarcity with no additional capacity in the system and innovation is a necessity. Further innovation could be unleashed if small amounts of resourcing and time were provided to staff with innovative ideas to improve services, change processes or introduce new ways of working.

Background: There are many factors that influence access to public health services, such as the context people live in, the existing health services, and personal, cultural and community factors. People with disabilities (activity limitations), through their experience of health services, may offer a particular understanding of the performance of the health services, thus exposing health system limitations more clearly than perhaps any other health service user.Aim: This article explores how activity limitations interact with factors related to context, systems, community and personal factors in accessing public health care services in South Africa.Setting: We present four case studies of people with disabilities from four low-resource diverse contexts in South Africa (rural, semi-rural, farming community and peri-urban) to highlight challenges of access to health services experienced by people with activity limitations in a variety of contexts.Methods: One case study of a person with disabilities was chosen from each study setting to build evidence using an intensive qualitative case study methodology to elucidate individual and household experiences of challenges experienced by people with activity limitations when attempting to access public health services. In-depth interviews were used to collect data, using an interview guide. The analysis was conducted in the form of a thematic analysis using the interview topics as a starting point.Results: First, these four case studies demonstrate that equitable access to health services for people with activity limitations is influenced by a complex interplay of a variety of factors for a single individual in a particular context. Secondly, that while problems with access to public health services are experienced by everyone, people with activity limitations are affected in particular ways making them particularly vulnerable in using public health services.Conclusion: The revitalisation of primary health care and the introduction of national health insurance by the Health Department of South Africa open a window of opportunity for policy makers and policy implementers to revisit and address the areas of access to public health services for people with activity limitations.

AbstractBackgroundThe shortage of healthcare professionals (HCP) negatively affects health services in rural areas in many parts of the world, as is the case in South Africa. Innovative programs designed to improve the recruitment strategies for health system in a rural area are essential. They need support with a scholarship and mentorship programme for young people from rural areas to study for health science degrees, with the aim that they would take up a post at the hospital in their community, once qualified.This paper reports the perceptions and experiences of the students and graduates sponsored by the foundation, and those of managers from the facilities where the students were ultimately placed, in order to gauge whether such a programme can make a sustainable contribution to address the shortage of health personnel in rural areas and to what extent this is happening.MethodsThe authors used qualitative methods, combining semi-structured in-depth interviews and focus groups and the data were analyzed thematically.ResultsThe results provide information on students interviewed who appreciated the financial and socio-emotional support that they received. On the other hand, graduates value the availability of jobs in their home community on completion of their studies. The managers reported the success of the programme in increasing the number of healthcare personnel at the hospitals, and the increased range of available medical services. Since the graduates are familiar with the language and culture of their patients the managers considered that they are better able to assist them.ConclusionsThe system was well thought-out and achieved its goal of improving health services in an underdeveloped rural area of South Africa. More could be achieved if other government services in the area were simultaneously improved and if the system were replicated elsewhere. The students and graduates from rural areas are involved on sustaining health services in rural areas while rural managers support the programme and make suggestions for improvement and to promote the program in other regions.

AbstractDrought is a global threat to public health. Increasingly, the impact of drought on mental health and wellbeing is being recognised. This paper investigates the relationship between drought and wellbeing to determine which drought indices most effectively capture wellbeing outcomes. A thorough understanding of the relationship between drought and wellbeing must consider the: (i) three aspects of drought (duration, frequency and magnitude); (ii) different types of drought (e.g. meteorological, agricultural, etc.); and (iii) the individual context of specific locations, communities and sectors. For this reason, we used a variety of drought types, drought indices, and time windows to identify the thresholds for wet and dry epochs that enhance and suppress impacts to wellbeing. Four postcodes in New South Wales (NSW), Australia are used as case studies in the analysis to highlight the spatial variability in the relationship between drought and wellbeing. The results demonstrate that the relationship between drought indices and wellbeing outcomes differs temporally, spatially and according to drought type. This paper objectively tests the relationship between commonly used drought indices and wellbeing outcomes to establish if current methods of quantifying drought effectively capture wellbeing outcomes. For funding, community programs and interventions to result in successful adaptation, it is essential to critically choose which drought index, time window and wellbeing outcome to use in empirical studies. The uncertainties associated with these relationships must be accounted for and it must also be realized that results will differ based on these decisions.

ObjectiveTo describe how the Better Evidence Better Outcomes Linked Data (BEBOLD) platform has been used to partner with government agencies to generate evidence to support service reform that contributes to improving outcomes for children and families in contact with the child protection system. ApproachData was drawn from the BEBOLD platform, a whole-of-population linked de-identified administrative data platform for all children in South Australia born from 1991-2016 (n~500,000), as well as their parents. Data linked included birth registrations, perinatal statistics, child protection services, family health services, education, youth justice, housing and homelessness, emergency department presentations and hospitalisation, as well as adult drug and alcohol services. ResultsWe present case studies illustrating how the BEBOLD platform has been used to 1) investigate the descriptive epidemiology of child protection contact patterns with a focus on priority populations (e.g. young parents); 2) describe service interactions of child protection populations in a way that highlights prevention potential (e.g. the overlap between public housing and child protection); and 3) identify policy defined target populations to inform contracting of support services (e.g. estimate counterfactual reunification rates for a defined population to inform development of a Social Impact Bond). ConclusionUsing linked data to take an intelligent system view of potential priority populations can inform policy and service delivery in a resource restricted setting. Descriptive epidemiology of child protection contact patterns, population sizes, transitions, and characteristics can aid services to explore elements of service or system design including eligibility criteria.

This article makes a case for the everyday while on tour and argues that the ability to continue with everyday routines and social relationships, while at the same time moving through and staying in liminal or atypical zones of tourist locales, is a key part of some kinds of tourist experience. Based on ethnographic field research with grey nomads (retirees who take extended tours of Australia in caravans and motorhomes) everyday life while on tour is examined, specifically the overlap and intersection between the out-of-the-ordinary “tourist zone” and the ordinariness of the “everyday zone.” The “everyday zone” and “tourist zone” can be readily differentiated by their obvious geospatial boundaries (being at home or being away on holiday). More specifically, the “everyday zone” refers to the routines of quotidian life, or the mundane practices which make up our daily, at-home lives. These practices are closely connected with the domestic realm and include consumption practices (clothing, cooking, mass media) and everyday social interactions. The “tourist zone” is similarly concerned with consumption. In this zone, however, tourists are seen to consume places; the culture, landscape, and peoples of exotic or out-of-the-ordinary tourist locales. Needless to say this consumption of place also includes the consumption of services and objects available in the tourist destinations (Urry, “The Consuming of Place” 220). The notion of tourists being away from home has often been contrasted with constructions of home—with the dull routines of everyday life—by social scientists and tourist marketers alike in an effort to illuminate the difference between being “away” and being at “home.” Scott McCabe and Elizabeth Stokoe suggest that peoples’ notion of “home” takes into account the meaning of being away (602). That is to say that when people are away from home, as tourists for example, they often compare and contrast this with the fundamental aspects of living at home. Others, however, argue that with the widespread use of mobile communication technologies, the distinction between the notion of being at “home” and being “away” becomes less clear (White and White 91). In this sense, the notion of home or the everyday is viewed with an eye towards social relationships, rather than any specific geographical location (Jamal and Hill 77–107; Massey 59–69; Urry, “The Tourist Gaze” 2–14; White and White 88–104). It can be argued, therefore, that tourism entails a fusion of the routines and relationships associated with the everyday, as well as the liminal or atypical world of difference. This article is based on semi-structured interviews with 40 grey nomads, as well as four months of ethnographic fieldwork carried out in rural and remote Australia—in Western Australia, the Northern Territory, and South Australia. Grey nomads have been part of Australian senior culture for at least four decades. They are a relatively heterogeneous group of tourists encompassing a range of socio-economic backgrounds, preferred activities, health status, and favoured destinations (Davies et al. 40–1; Economic Development Committee 4; Holloway 117–47), as well age cohorts—including the frugal generation (1910–1932), the silent generation (1931–1946), and the baby boomer generation (1946–65). Grey nomads usually tour as spousal couples (Tourism Research Australia 26; Onyx and Leonard 387). Some of these couples live solely on government pensions while others are obviously well-resourced—touring in luxury motorhomes costing well over half a million dollars. Some prefer to bush camp in national parks and other isolated locations, and some choose to stay long term in caravan parks socialising with other grey nomads and the local community. All grey nomads, nonetheless, maintain a particularly close link with the everyday while touring. Mobile communication technologies anchor grey nomads (and other tourists) to the everyday—allowing for ready contact with existing family and friends while on tour. Grey nomads’ mobile dwellings, their caravans and motorhomes, integrate familiar domestic spaces with a touring life. The interior and exterior spaces of these mobile dwellings allow for easy enactment of everyday, domestic routines and the privatised world of adult spousal relationships. This peripatetic form of dwelling, where the dwelling itself accommodates both travel and an everyday domestic life further blurs the distinctions between the “everyday zone” and the “tourist zone”. In this sense grey nomads carry out a lifestyle that is both anchored and mobile; anchored in the everyday domestic life while at the same time being nomadic or geographically unstable. This blurring of the boundaries between the “everyday zone” and “tourist zone” is attractive to senior tourists, offering them a relatively safe and comfortable incursion into tourist locales, where established routines and patterns of everyday life can be maintained. Other homes-away-from-homes such as serviced apartments, holiday homes and house swaps also offer greater connection to the everyday, but are geographically anchored to specific tourism spaces. The caravan or motorhome allows this at-home connection for the peripatetic tourist offsets the relative rigours of outback touring in remote and rural Australia. Everyday Social Relationships in the “Tourist Zone” When tourists go away from home, they are usually thought of as being away from both place (home) and relationships (family and friends). Nowadays, however, being away from home does not necessarily mean being away from family and friends. This is because the ease and speed of today’s telecommunication technologies allows for instantaneous contact with family and friends back home—or the virtual co-presence of family and friends while being away on tour. In the past, those friends and relations who were geographically isolated from each other still enjoyed social contact via letters and telegrams. Such contacts, however, occurred less frequently and message delivery took time. Long distance telephone calls were also costly and therefore used sparingly. These days, telecommunication technologies such as mobile phones and the Internet, as well as the lower cost of landline phone calls, mean that everyday social contact does not need to be put on hold. Keeping in contact is now a comparatively fast, inexpensive, and effortless activity and socialising with distant friends and relatives is now a routine activity (Larsen 24). All grey nomads travel with a mobile phone device, either a digital mobile, Next G or satellite phone (Obst, Brayley and King 8). These phones are used to routinely keep in contact with family and friends, bringing with them everyday familial relationships while on tour. “We ring the girls. We’ve got two daughters. We ring them once a week, although if something happens Debbie [daughter] will ring us” (Teresa). Grey nomads also take advantage of special deals or free minutes when they scheduled weekly calls to family or friends. “I mainly [use] mobile, then I ring, because I’ve got that hour, free hour” (Helen). E-mail is also a favoured way of keeping in contact with family and friends for some grey nomads. This is because the asynchronicity of e-mail interaction is very convenient as they can choose the times when they pick up and send messages. “Oh, thank goodness for the e-mail” (Pat). Maintaining social contact with family and friends at a distance is not necessarily as straightforward as when grey nomads and other tourists are at home. According to discussants in this study and the Regional Telecommunications Independent Review Committee, mobile phone coverage within Australia is still rather patchy when outside major metropolitan areas. Consequently, the everyday task of kin keeping via the phone can be somewhat intermittent, especially for those grey nomads who spend a great deal of time outside major towns in rural and remote Australia. “You can never get much [reception] but [...] they can just ring the mobile and just leave a message and we will get that message [later]” (Rena). Similarly, using the Internet to e-mail family and friends and catch up with online banking can only be carried out when passing through larger towns. “I do it [using the Internet] like every major town we went through. I’d stop and do a set of e-mails and I used to do my banking” (Maureen). The intermittent phone coverage in remote and rural Australia was not always viewed as an inconvenience by discussants in this study. This is because continuing engagement with family and friends while on tour may leave little respite from the ongoing obligations or any difficulties associated with family and friends back home, and encroach on the leisure and relaxation associated with grey nomad touring. “I don’t want the phone to ring […] That’s one thing I can do without, the phone ringing, especially at 4:00 in the morning” (Rena). In this way, too much co-presence, in the form of mobile phone calls from family and friends, can be just as much a nuisance when away from home as when at home—and impinge on the feeling of “being away from it all.” Naomi White and Peter White also suggest that “being simultaneously home and away is not always experienced in a positive light” (98) and at times, continued contact (via the phone) with friends and family while touring is not satisfying or enjoyable because these calls reiterate the “dynamics evident in those that are [usually] geographically proximate” (100). Thus, while mobile communication technologies are convenient tools for grey nomads and other tourists which blur the boundaries between the “everyday zone” and “tourist zones” in useful and pleasurable ways, their overuse may also encroach on tourists’ away time, thus interfering with their sense of solitude and quiescence when touring in remote or rural Australia. The “Everyday Zone” of the Caravan or Motorhome Being a tourist involves “everyday practices, ordinary places and significant others, such as family members and friends, but co-residing and at-a-distance” (Larsen 26). While tourism involves some sense of liminality, in reality, it is interspersed with the actuality of the everyday routines and sociabilities enacted while touring. Tim Edensor notes that; Rather than transcending the mundane, most forms of tourism are fashioned by culturally coded escape attempts. Moreover, although suffused with notions of escape from normativity, tourists carry quotidian habits and responses with them: they are part of the baggage. (61) Grey nomads go further than this by bringing on tour with them a domestic space in which everyday routines and sociabilities are sustained. Travelling in this manner “makes possible, and probably encourages, greater continuity with everyday routine than many other kinds of holiday making” (Southerton et al. 6). To be able to sleep in your own bed with your own pillow and linen, or perhaps travel with your dogs, makes caravanning and motorhoming an attractive touring option for many people. Thus, the use of caravans or motorhomes when travelling brings with it a great deal of mobile domesticity while on tour. The caravan or motorhome is furnished with most of the essentially-domestic objects and technologies to enable grey nomads to sleep, eat, relax, and be entertained in a manner similar to that which they enjoy in the family home, albeit within smaller dimensions. Lorna: We have shower, toilet. We had microwave, stereo. We have air conditioning and heating.Eric: Yeah, reverse cycle air conditioning.Lorna: Reverse cycle. What else do we have?Eric: Hot water service. Gas or 240 volt. 12 volt converter in that, which is real good, it runs your lights, runs everything like that. You just hook it into the main power and it converts it to 12 volt. Roll out awning plus the full annex.Lorna: Full annex. What else do we have? There’s a good size stove in it. The size of caravans and motorhomes means that many domestic tasks often take less time or are simplified. Cleaning the van takes a lot less time and cooking often becomes simplified, due to lack of bench and storage space. Women in particular like this aspect of grey nomad travel. “It is great. Absolutely. You don’t have toilets to clean, you don’t have bathrooms to clean. Cooking your meals are easier because everything is all […] Yeah. It’s more casual” (Sonya). This touring lifestyle also introduces new domestic routines, such as emptying chemical toilets, filling water tanks, towing and parking the van and refilling gas tanks, for example. Nonetheless grey nomads, spend significantly less time on these domestic tasks when they are touring. In this sense, the caravan or motorhome brings with it the comforts and familiarity of home, while at the same time minimising the routine chores involved in domestic life. With the core accoutrements of everyday life available, everyday activities such as doing the dishes, watching television, preparing and eating a meal—as well as individual hobbies and pastimes—weave themselves into a daily life that is simultaneously home and away. This daily life, at home in the caravan or motorhome, brings with it possibilities of a domestic routinised lifestyle—one that provides welcome comfort and familiarity when travelling and a retreat from the demands of sightseeing. On the farm I used to make jam and cakes, so I do it again [in the caravan]. I make jam, I made marmalade a couple of weeks ago. We’d often stay home [in the caravan], I’d just clean or do a bit of painting. (Jenny) Touring in a caravan or motorhome allows for some sense of predictability: that you own and control the private spaces of your own mobile dwelling, and can readily carry out everyday domestic routines and sociabilities. “We go for a long walk. We come back and we see friends and we stop and have a coffee with them, and then you come home in the caravan at 2.30 and you can still have lunch” (Yvonne). Touring in a caravan or motorhome also frees grey nomads from dependence on prearranged tourist experiences such as organised tours or hotel meal times where much of the tourist experience can be regimented. We always went in hotels and you always had to dress up, and you had to eat before a certain time, and you had your breakfast before a certain time. And after 2.30 you can’t have lunch anymore and sometimes we have lunch at 2 o’clock. I like the caravan park [better]. (Donald) Despite the caravan or motorhome having close links with everyday life and the domestic realm, its ready mobility offers a greater sense of autonomy while touring: that you are unfettered, not bound to any specific place or timetable, and can move on at whim. Grey nomads often cross paths with other tourists dependent on guided bus tours. “They go in [to Kakadu] on a bus trip. All they do is go in on the main road, they’re in there for the day and there’re back. That’s absolutely ridiculous” (Vance). This autonomy, or freedom to structure their own tourist experiences, allows grey nomads the opportunity to travel at a leisurely pace. Even those grey nomads who travel to the same northern destination every year take their time and enjoy other tourist locations along the way. We take our time. This time, last time, we did three weeks before we got in [to] Broome. We spent a lot [of time] in Karratha but also in Geraldton. And when we came back, in Kalbarri, [we had] a week in Kalbarri. But it’s nice going up, you know. You go all through the coast, along the coast. (John) Caravan or motorhome use, therefore, provides for a routinised everyday life while at the same time allowing a level of autonomy not evident in other forms of tourism—which rely more heavily on pre-booking accommodation and transport options. These contradictory aspects of grey nomad travel, an everyday life of living in a caravan or motorhome coupled with freedom to move on in an independent manner, melds the “everyday zone” and the “tourist zone” in a manner appealing to many grey nomads. Conclusion Theories of tourism tend to pay little attention to the aspects of tourism that involve recurrent activities and an ongoing connectedness with everyday life. Tourism is often defined: by contrasting it to home geographies and everydayness: tourism is what they are not. [...] The main focus in such research is on the extraordinary, on places elsewhere. Tourism is an escape from home, a quest for more desirable and fulfilling places. (Larsen 21) Nonetheless, tourism involves everyday routines, everyday spaces and an everyday social life. Grey nomads find that mobile phones and the Internet make possible the virtual co-presence of family and friends allowing everyday relationships to continue while touring. Nonetheless, the pleasure of ongoing contact with distant family and friends while touring may at times encroach on the quietude or solitude grey nomads experienced when touring remote and rural Australia. In addition to this, grey nomads’ caravans and motorhomes are equipped with the many comforts and domestic technologies of home, making for the continuance of everyday domiciliary life while on tour, further obfuscating the boundaries between the “tourist zone” and the “everyday zone.” In this sense grey nomads lead a lifestyle that is both anchored and mobile. This anchoring involves dwelling in everyday spaces, carrying out everyday domestic and social routines, as well as maintaining contact with friends and family via mobile communication technologies. This anchoring allows for some sense of predictability: that you own and control the private spaces of your own mobile dwelling, and can readily carry out everyday domestic routines and sociabilities. Conversely, the ready mobility of the caravan or motorhome offers a sense of autonomy: that you are unfettered, not bound to any specific place and can move on at whim. This peripatetic form of dwelling, where the dwelling itself is the catalyst for both travel and an everyday domestic life, is an under researched area. Mobile dwellings such as caravans, motorhomes, and yachts, constitute dwellings that are anchored in the everyday yet unfixed to any one locale. References Davies, Amanda, Matthew Tonts, and Julie Cammell. Coastal Camping in the Rangelands: Emerging Opportunities for Natural Resource Management. Perth: Rangelands WA, 2009. 24 Sep. 2011 ‹http://www.rangelandswa.com.au/pages/178/publications›. Economic Development Committee. Inquiry into Developing Queensland’s Rural and Regional Communities through Grey Nomad Tourism. Brisbane: Queensland Parliament, 2011. 23 Sep. 2011 ‹http://www.parliament.qld.gov.au/Documents/TableOffice/TabledPapers/2011/5311T3954.pdf›. Edensor, Tim. “Performing Tourism, Staging Tourism: (Re)Producing Tourist Space and Practice.” Tourist Studies 1 (2001): 59–81. Holloway, Donell. Grey Nomads: Retirement, Leisure and Travel in the Australian Context. PhD diss. Edith Cowan University: Perth, 2010. Jamal, Tanzin, and Steve Hill. “The Home and the World: (Post) Touristic Spaces of (in) Authenticity.” The Tourist as a Metaphor of The Social World. Ed. Graham Dann. Wallingford: CAB International, 2002. 77–107. Larsen, Jonas. “De-Exoticizing Tourist Travel: Everyday Life and Sociality on the Move.” Leisure Studies 27 (2008): 21–34. Massey, Doreen. “Power-Geometry and a Progressive Sense of Place.” Mapping the Futures: Local Cultures, Global Change. Eds. Jon Bird et al. London: Routeledge, 1993. 59–69. McCabe, Scott, and Elizabeth Stokoe. “Place and Identity in Tourists’ Accounts.” Annals of Tourism Research 31 (2004): 601–22. Obst, Patricia L., Nadine Brayley, and Mark J. King. “Grey Nomads: Road Safety Impacts and Risk Management.” 2008 Australasian Road Safety Research, Policing and Education Conference. Adelaide: Engineers Australia, 2008. Onyx, Jenny, and Rosemary Leonard. “The Grey Nomad Phenomenon: Changing the Script of Aging.” The International Journal of Aging and Human Development 64 (2007): 381–98. Regional Telecommunications Independent Review Committee. Regional Telecommunications Review Report: Framework for the Future. Canberra: RTIRC, 2008. Southerton, Dale, Elizabeth Shove, Alan Warde, and Rosemary Dean. “Home from Home? A Research Note on Recreational Caravanning.” Department of Sociology, Lancaster University. 1998. 10 Jan. 2009 ‹http://www.lancs.ac.uk/fass/sociology/papers/southerton-et-al-home-from-home.pdf›. Tourism Research Australia. Understanding the Caravan industry in WA: Grey Nomads—Fast Facts. Perth, Australia: Tourism WA (n.d.). Urry, John. “The Consuming of Place.” Discourse, Communication, and Tourism. Eds. Adam Jaworski and Annette Pritchard. Clevedon: Channel View Publications, 2005. 19–27. ———. The Tourist Gaze. London: Sage, 2002. 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Background: The philosophy of primary healthcare forms the basis of South Africa’s health policy and provides guidance for healthcare service delivery in South Africa. Healthcare service provision in South Africa has shown improvement in the past five years. However, it is uncertain as to whether the changes have reached rural areas and if primary healthcare is implemented successfully in these areas.Objectives: The aim of this article is to explore the extent to which the principles of primary healthcare are implemented in a remote, rural setting in South Africa.Method: A descriptive, qualitative design was implemented. Data were collected through interviews and case studies with 36 purposively-sampled participants, then analysed through Interpretative Phenomenological Analysis.Results: Findings indicated challenges with regard to client-centred care, provision of health promotion and rehabilitation, the way care was organised, the role of the doctor, healthworker attitudes, referral services and the management of complex conditions.Conclusion: The principles of primary healthcare were not implemented successfully. The community was not involved in healthcare management, nor were users involved in their personal health management. The initiation of a community-health forum is recommended. Service providers, users and the community should identify and address the determinants of ill health in the community. Other recommendations include the training of service managers in the logistical management of ensuring a constant supply of drugs, using a Kombi-type vehicle to provide user transport for routine visits to secondary- and tertiary healthcareservices and increasing the doctors’ hours.

Abstract Background COVID-19 has a direct impact on the employment of older people. This adds to the challenge of ageism. The World Health Organization has started a worldwide campaign to combat ageism and has called for more research and evidence-based strategies that have the potential to be scaled up. This study specifically aims to identify solutions to combat the adverse effects of COVID-19 on the global ageing workforce. Methods We present 15 case studies from different countries and report on what those countries are doing or not doing to address the impact of COVID-19 on ageing workers. Results We provide examples of how COVID-19 influences older people’s ability to work and stay healthy, and offer case studies of what governments, organizations or individuals can do to help ensure older people can obtain, maintain and, potentially, expand their current work. Case studies come from Australia, Austria, Canada, China, Germany, Israel, Japan, Nigeria, Romania, Singapore, Sweden, South Korea, Thailand, United Kingdom (UK), and the United States (US). Across the countries, the impact of COVID-19 on older workers is shown as widening inequalities. A particular challenge has arisen because of a large proportion of older people, often with limited education and working in the informal sector within rural areas, e.g. in Nigeria, Thailand and China. Remedies to the particular disadvantage experienced by older workers in the context of COVID are presented. These range from funding support to encouraging business continuity, innovative product and service developments, community action, new business models and localized, national and international actions. The case studies can be seen as frequently fitting within strategies that have been proven to work in reducing ageism within the workplace. They include policy and laws that have increased benefits to workers during lockdowns (most countries); educational activities such as coaching seniorpreneurship (e,g, Australia); intergenerational contact interventions such as younger Thai people who moved back to rural areas and sharing their digital knowledge with older people and where older people reciprocate by teaching the younger people farming knowledge. Conclusion Global sharing of this knowledge among international, national and local governments and organizations, businesses, policy makers and health and human resources experts will further understanding of the issues that are faced by older workers. This will facilitate the replication or scalability of solutions as called for in the WHO call to combat ageism in 2021. We suggest that policy makers, business owners, researchers and international organisations build on the case studies by investing in evidence-based strategies to create inclusive workplaces. Such action will thus help to challenge ageism, reduce inequity, improve business continuity and add to the quality of life of older workers.