Adherence Support Worker_Discussion Paper

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February 2010


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ABOUT THE AUTHOR

Rollo Manning has been in the Northern Territory for the past 14years having moved there from Queanbeyan (NSW) in 1996.

Rollos career has spanned all sectors of the pharmaceutical industry

from the manufacturing sector (10 years with Glaxo Australia); National

administration and lobbying (first National PR Director for Pharmacy

Guild of Australia in Canberra for five years); owned his own retail

pharmacy (Karabar Pharmacy, Queanbeyan for seven years): and

extensive locum jobs over a period of 25 years.

Since moving to Darwin (and a year in retail pharmacy) Rollo took on

the position of Rural Pharmacist at Katherine Hospital supplying the

pharmaceutical needs of the 23 remote Aboriginal community health

centres in the Katherine Region. This he describes as a complete

culture shock due to the absence of pharmaceutical care and theimpression that here was a backwater the world of pharmacy leadership

and organisations had let pass them by. The need for improvement was

urgent and the scope extensive.

It was at this time (1997) that the Commonwealth Government started looking at introducing the Section

100 arrangements for funding the PBS to remote living Aboriginals. Rollo was invited to move to Darwin and

take up the role of Senior Policy Officer (Pharmacy) at Territory Health Services in Head Office.

The experience in seeing how policy was prepared and programs developed, along with representing the NT

on a number of National Committees and Working Parties gave him an insight to the National scene. It was

then he was able to assess the development of measures in relation to Aboriginal health and the role

pharmacists played in the system. The effort was minimal when seen alongside the problems existed.

The opportunity to put theory into practice came along when the Tiwi Health Board (Tiwi Islands)approached Rollo to help them improve the way they were delivering pharmaceutical care to the 2,500

residents of the Tiwi Islands, just 80 Kms off the coast of the mainland. Then followed a two year period of

operating the only pharmacy in Australia not owned by a pharmacist but by an Aboriginal community

controlled health organisation. The success of this operation was beyond dispute but the demise of the Tiwi

Health Board brought about the end of the business. Rollo regrets he has not had to opportunity to do the

same thing at one or more of the larger remote Aboriginals towns across the Top End of the NT.

Unfortunately he says the will to want to move ahead in a self-determining manner is not high on the

priorities of the system when it comes to pharmacy and resolving the enormous issues that confront

Aboriginal people, especially those from remote communities. .

The past seven years has been spent in private consulting with the majority of clients being Aboriginal

health services wanting to improve pharmaceutical care or pharmacy interests wanting to become moreinvolved.

Born in 1938 and into a family with large pharmacy interests Rollo wants to see the introduction of the

Adherence Support Worker as a major contribution to closing the gap and in a way that puts the interests

of the Aboriginal client first.

Equity between remote Aboriginals and the mainstream pharmacy services should be the aim and there is

a lot of ground to be made up. Rollo says.


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DISCUSSION PAPERAdherence Support Workers

An opportunity for the pharmacy profession to make an innovative contribution to theClose the Gapinitiative to reduce the 17 year gap in the life expectancy ofAustralias Aboriginal and Torres Strait Islander people.

An Australian initiative that follows an African example for putting more human resources into the fight against disease

HIV/AIDS in Africa - and chronic diseases in the Australian context among remote living Aboriginal people.

The Northern Territory situation will be used for the context of this discussion.

Contents

Acronyms 3

Executive summary 5

1. Introduction. 7

2.Situation Analysis 8

2.1. Population profile 82.2. Chronic disease profile 92.3. Medication management 102.4. Scope for additional resources 11

3. A new position Adherence Support Worker.. 13

4. Issues to be resolved.. 14

4.1. Scope of activity 144.2. Governance 144.3. Recruitment 154.4. Remuneration 154.5. Job Description 164.6. Training 164.7. Evaluation 18

5. The path ahead. 18

6. Questionnaire to respondents . 19Access through http://www.surveymonkey.com/s/GVVDDY8

7. End Notes. 21


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Acronyms

ABCD Audit and Best Practice for Chronic Disease (Menzies)

ACCHO Aboriginal Community Controlled Health Organisation

AHW Aboriginal Health Worker (Australia)

AIHW Australian Institute of Health and Welfare

ASW Adherence Support Worker (Zambia)

ACW Aboriginal Community Worker (Australia)

AMSANT Aboriginal Medical Services Alliance of the NT

CHAW Community Health Aide Worker (Alaska)

CHAP Community Health Aide Program (Alaska)

CKD Chronic Kidney Disease

COPD Chronic Obstructive Pulmonary Disease

CSHTP Community Services and Health Training Package

DHF NT Department of Health and Families

DoHA CW Department of Health and Ageing

EHSDI Enhanced Health Service Delivery Initiative

ESRF End Stage Renal Disease

FHF Fred Hollows Foundation

FHI Family Health International

HMR Home Medication Review

IHD Ischemic Heart Disease

KAMSC Kimberley Aboriginal Medical Services Council

MJA Medical Journal of Australia

MSHR Menzies School of Health Research

NPS National Prescribing Service

PBS Pharmaceutical Benefits Scheme

QCPP Quality Care Pharmacy Program

RTO Registered Training Organisation

WWHS Wurli Wurlinjang Health Service (Katherine)

ZPCTP Zambia Prevention, Care and Treatment Partnership

DownloadThis paper may be downloaded from http://remoteaboriginals.blogspot.com/

Suggested citationManning R. Discussion Paper - A pharmacy contribution to Closing the Gap-Adherence Support Workers.Pharmacy Guild of Australia Small Projects Completed Reportshttp://www.guild.org.au/rural/content.asp?id=2624

AcknowledgementsSincere thanks are extended to the following for their inspiration and support:

Barbara Pitman, Executive Officer of the Human Services Training Advisory Council of the NT.

Patrick Ball (Professor) Professor of Rural and Remote Pharmacy at the Charles SturtUniversity, Wagga WaggaRob Curry, Program Manager of the Aboriginal Medical Services Alliance of the NT, DarwinTimothy Trudgen of Why Warriors Pty Ltd and the Arnhem Human Enterprise DevelopmentprojectWendy Hoy (Professor) Professor of Medicine and Director of the Centre for Chronic Disease atthe University of Queensland.


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Executive summary

Chronic diseases, only evident in Aboriginal people over the past 30 years, are taking a toll on the lives

of the people and the financial resources of health service deliverers.

Pharmaceutical care can make a contribution to alleviating this menace through the judicious use of

medications. To date, the effort has been minimal from the pharmacy profession. Most of the effort over

the past ten years has focused on supply with little attention given to providing information. Successful

communication is and important issue. Pharmacists must look to innovative methods to close the gap

in information that exists between the Aboriginal sufferer and the health professional prescribing

treatment with Western medicines.

Supply is clearly quite successful but uptake and adherence to prescribed regimen is very low. No

benefit accrues from medication that is not taken.

The introduction of a new role in the Aboriginal remote health workforce is suggested the Adherence

Support Worker as utilized in Africa (Zambia) to assist patients with HIV-AIDS. People who can speak

to the clients in their own language and understanding their culture.

A pilot program in the NT town of Katherine is proposed as a means of testing the concept of Adherence

Support Workers in an Australian remote Aboriginal context.

In mainstream Australia (the dominant culture) billions of dollars are spent annually on both the

treatment cost and an advisory facility through community pharmacies. A pharmacist has to be present

to give advice and counsel on the prescribed medication such as mode of action, need for adherence

and any adverse effects or contraindications. Small labels are also adhered to the packet which gives

reinforcing information. A complete record of the transaction is maintained for future historical

information and monitoring of compliance.

Remote living Aboriginal people obtain their medications from health professionals prescribed by NT law

to supply medication but not possessing the specialized knowledge on pharmacology and

pharmacokinetics which pharmacists possess.

Remote living Aboriginal people do not receive the same service as Non-Indigenous Australians living in

urban areas where a pharmacist is always available to provide advice and counseling when requested.

The amount paid by the PBS for dispensing to Non Indigenous Australians is $6.42 per item while no

such fee is paid to Aboriginal Health Services supplying to remote Aboriginal people.

The cost of the PBS to remote living Aboriginals in the NT is $317 per capita and this compares

favourably with the National figure for non-Indigenous Australians at $288 per capita1.

No data is available on the utilisation of this expenditure and it is in this area that the ASWs can play a

part. The simple supply is not evidence of consumption. It is the responsibility of the funder (the PBS

and taxpayer) to ascertain whether the expenditure is being utilized in a manner for which it is

intended. Such evidence as is available strongly suggests consumption is low.


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A 17 year gap in life expectancy is being quoted as being the gap which has to be closed. In the NT the

gap is wider as indicated when looking at the median age at death2 which shows for males at 43 years

(64 years) and females 53 years (74 years) non-Aboriginal figure shown in brackets.

The burden of disease is such that every avenue of resource needs to be marshaled to help alleviate the

social and economic consequences of chronic diseases.

There are significant social consequences with deaf children unable to benefit from education and young

children losing the guidance of parents who die young.

Pharmacy can make a significant contribution by providing the resources needed to establish the

position of an Adherence Support Worker (ASW) at the community level.

The ASW would become a part of that communitys team in helping to bridge the information gap

between the use of medicines in the management of the disease process as well as other behaviour

modification processes needed for a healthy life free from hospitalisation.

Adherence to prescribed medication should be improved; expenditure on PBS listed medicines may

increase to more comparable levels with mainstream; but in many cases, the medication supplied (and

therefore already paid for) will actually be taken; lifestyles will be enhanced; hospitalisation due to

symptoms of chronic diseases reduced; and, life expectancy improved with a higher age at death.

Pharmacists can make a significant contribution in closing the life expectancy gap and this will happen

so long as they recognize that they are one part of a huge process that includes many other health

professionals working on programs that impinge in some way on the pharmacy discipline.

Statistics that are available from PBS usage data provides a unique opportunity to examine trends in

prescribing for a discreet cohort in the Australian population who have data available unlike any other.

No other population discreet group has such a finite breakdown of medicine usage through the PBS?

This must be used and injected into the analysis of current treatment options when examining the

reasons for health outcomes positive or negative.


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1. IntroductionThe NT Government introduced Strategy 21 in August 1999 which asked all health professionals to focus

their attention on alleviating the five major causes of chronic disease which was costing the NT Government

56% of its total health spending3. These were diabetes, renal disease, chronic obstructive airways disease,

heart disease and problems of the circulatory system. The author, Rollo Manning, who was working in the

Department of Health at the time as the Senior Policy Officer (Pharmacy) was stunned by this revelation.

In 2001 the author left the Department of Health to work for the Tiwi Health Board establishing a new

pharmacy operation for the people of the Tiwi Islands. During this period the realization was made of the

huge burden these chronic diseases had on the human aspects of society. Children were being left without a

parent or carer due to the early age of death; peoples lives were set in turmoil through hospitalization or

the need for constant renal dialysis; and children had to be wormed from three months of age and kept

under close surveillance for infections from the poor environmental health conditions under which they were

living. Many became deaf from ear infections that could have been easily treated and then were unable to

benefit from education and disrupted school for others. It was as if every element of life was against a

healthy life style and the resultant bad health prevented people from receiving a proper education and hold

down a decent job.

It was obvious that more should be done to prevent chronic diseases from getting a hold on the young lives

- but the question was how?.

Health clinics were over stretched dealing with acute care and the burden of chronic disease was such that

the available resources were being spent on persons who had reached a critical stage of their illness. This

left very little for early detection and management to maintain a healthy life and a normal life expectancy as

was possible in the dominant culture.

Just taking medicines regularly was not sufficient, especially since many that are supplied are not actually

taken and those that are, are not taken as prescribed. The need was established for a mechanism whereby

these problems could be addressed.

This is when the author came across the position ofAdherence Support Worker (ASW) in Africa (Zambia) in

the fight against HIV/AIDS4. The principles involved with that position seem suited to the chronic disease

situation in Australia. The ASW plays a supportive role both to the population and the primary health care

team concentrating on the need for adherence to a wide range of choices to encourage healthy living,

including medication management5.

In Alaska there has been a similar position with the Community Health Aide Workers6. This commenced

some 40 years ago when it was determined that the professionally trained workforce would never be

sufficient to provide front-line care to all the native Indians living across the communities of the vast

continent. Money was made available to recruit and train the CHAWs and this has continued. The success ofthe program is described as having the ability to save millions of dollars in the health budget. Dr Mark

Redding observes that "when the United States begins to focus dollars on achieved outcomes, disparities

will change and potentially billions in unnecessary expenditures can be saved. As soon as the focus centers

on outcomes, Alaska's method of training, employing and supporting individuals directly from the

community will be seen as the key."7 Some elements from the employment and training of CHAWs will be

taken up in the section on training in this paper.

Some in Australia might say that the genesis of the Aboriginal Health Worker (AHW) in the Northern

Territory came from the need for medication adherence by patients being discharged back to remote

communities from the East Arm Leprosarium in Darwin, or following treatment for Tuberculosis. In both

these instances adherence was important to longevity and it was in turn tackled in a special way.


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The thrust of the Adherence Support Worker concept is seen as a special response to a similarly life

threatening situation that exists in this century as those horrific illnesses did 60 years ago. The proposed

role of an ASW in Aboriginal primary health care will be an innovative approach that follows the previous

trends in finding a resolution to the question of adherence. This author worked with the Tiwi Health Board

(2001-2003) and is thus experienced at establishing a pharmacy service in a remote Aboriginal community.

A pharmacy upgrade at Wurli Wurlinjang Health Service (WWHS) in Katherine will provide the infrastructure

within which ASWs can train and work gaining practical experience of working with a Clinical Pharmacist as

well as involvement in the supply chain process. The central aim is to improve Aboriginal health through

the strategies of the Quality Use of Medicine National Strategy and empowering Aboriginal people to

manage their own lifestyle and health.

The ASW concept builds on the need for culturally appropriate communications techniques, described by

Trudgen8 as being essential for successful exchange of knowledge and the development of a shared

understanding of a problem whether that be getting children to school, prisoners avoiding recidivism or

the taking of western medicine.

The target group to become Adherence Support Workers will be either young people who have completed

some schooling and would like to be involved in the improvement of the quality of life for their own people

or older persons with a previous experience in the health sector and keen to get back into work.

The notion of being an Aboriginal Health Worker is attractive but for cultural reasons many do not want to

embark down that path. AHWs are also in high demand from all sectors of the health care industry.

For those that do become AHWs they are a treasured member of staff and pharmacy needs to develop its

own helpers either as Pharmacy Technicians, pharmacy assistants or Adherence Support Workers.

2.Situation Analysis2.1 Population profile

The total population of the Northern Territory is 224,8009. Of this the Aboriginal population is 66,

582 with 53,000 living in remote areas.

The following figures10 are an illustration of how the basic social determinants in health have

impacted on the Aboriginal population and lead to the conclusion that a whole of environment

approach is needed to address these factors.

Important factors include:

54% under 25 years of age

81% living in remote areas with low employment opportunities

59% spoke an Australian Indigenous language at home

37% completed year 8 or below at school

10% completed year 12 at school

44% employed in the labour force

32% of those employed were labourers, 18% community and personal service workers and

11% professionals

35% of those employed worked in public administration and safety,

18% in health care and social assistance and 8% in education and training

The following observation is made in the NT DHF Background Paper: Preventable

Chronic Diseases in Aboriginal Populations (April 2009)11:

The key factors underlying poor health outcomes are poverty, poor education, poor housing,

remoteness and access to services. The health of individuals and populations is influenced and

determined by these factors acting in various combinations. Social determinants help explain and


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predict trends in health, and provide insight as to why some groups have better or worse health

than others. They are the core of disease prevention and health promotion.

Pharmacy and its services is a minor player in the big picture but can nonetheless make a

significant contribution. ASWs will be versed in the social determinants and their importance so

their contribution can be of a holistic nature.

2.2 Chronic disease profile

The most recent data available12 to the Department of Health and Families (DHF) shows a high

prevalence of chronic diseases amongst remote living Aboriginal people with the suggestion that

the situation is actually worse due to under-diagnosis. This showed the following:

A higher prevalence of chronic diseases in women except for ischemic heart disease

Prevalence rates increased progressively with age

Prevalence rates for people 50 years and over were

o Greater than 50% with hypertension and renal disease

o 40% diabetes

o 30% COPD

o 20% IHD

o Of all the people with diabetes 60% are women and 40% are men

Regional variations in prevalence of chronic diseases with Aboriginal people from Central

Australia more likely to have renal disease, diabetes and hypertension and the Top End

more likely to have COPD and ischaemic heart disease

40% of people had at least two conditions before age 50 and 60% after age 50

30% had at least 3 conditions after age 50

More common interactions were between hypertension, diabetes, ischaemic heart disease

and renal disease

Co-morbidities and complications of chronic diseases were common and strongly

associated with increasing age

For many chronic conditions, once the diagnosis is made, outcome depends solely upon the

correct medication being prescribed and taken. There is a need for pharmacy to develop and

articulate its role in the management of patients with chronic disease especially ESRF and

diabetes. The Wurli Wurlinjang Health Service Pharmacy Upgrade Project has the potential to

collaborate with other agencies to develop a more comprehensive picture of the shortfalls in the

present system that needs correcting if we are to move ahead. The ASW will play an important

role in this evolution.

The pharmacy will be able to carry out the following activity:

identify patients at risk

communicate with patients on a range of factors that impact on chronic disease with the

assistance of the community leaders.

improve the understanding that people have of the risks associated with lifestyle choices

that could impact on their disease state

enhance the degree to which people will adhere to the recommendations given to them by

health care advisors

research factors which will lead to the need for targeted strategies to improve

understandings

Each of the above will be possible through the ASWs.


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2.3 Medication management

Evidence in the published literature indicates support for the management of medication in

controlling the symptoms of chronic diseases and prolonging a healthy life free from

hospitalisation, early renal dialysis or death.

The work of Professor Wendy Hoy13 with renal disease on the Tiwi Islands indicates support for

attention to drug adherence. The report states:

In the treatment cohort, average blood pressure fell dramatically with treatment14, and urine

ACR, previously deteriorating, stabilised. Average serum creatinine level rose over the first

2 years, and then fell to below baseline values.

At an average of 3.4 years after enrolment, all-cause natural deaths in participants with overt

albuminuria had fallen by 50%, and deaths from renal causes had fallen by 57%, when compared

with historical controls matched for baseline disease severity. Whole-of-community trends in

terminal events supported these estimates. Savings in dialysis avoided were estimated at

$3.4 million, representing $12 879 per treated person over that period.

A recent publication in the MJA15 showed a high incidence of hospitalisation through chronic

diseases caused by under utilization of treatment options. The paper said:

Our study of avoidable hospitalisation rates confirms that Aboriginal Australians in the NT

experience significantly higher levels of avoidable hospitalisations than non-Aboriginal people.

Moreover, the gap between avoidable hospitalisation rates in Aboriginal and non-Aboriginal people

widened during the study period, particularly for those aged 2544 and 45 years and over. The

related finding that much of the increase in avoidable hospitalisation rates in the Aboriginal

population is attributable to chronic diseases emphasises the potential for appropriately targeted

primary care interventions to reduce morbidity in this population.

It stated that avoidable hospitalisations were the result ofchronic conditions, which comprise

chronic disease complications that can be managed in primary care by effective drug therapy,

patient education and lifestyle modification; they include diabetes complications, chronic

obstructive pulmonary disease (COPD) and hypertension;

Article I. The Final Report of the Audit and Best Practice in Chronic Disease (ABCD)16 noted as

one of its key lessons:

There were significant system barriers to following up abnormal clinical findings and medication

intensification, which limited translation of favourable levels of service delivery into improved

patient outcomes.

It further, in discussing the outcome of the process, that improvements in diabetes care

appeared to be limited by inadequate attention to abnormal clinical findings and medication

adjustment.

The report concluded If future diabetes quality improvement interventions are expected to

improve patient outcomes, medication adjustment measurements should be routinely included in

the spectrum of quality of care measures, and barriers to making medical regimen changes in

healthcare systems need to be identified and addressed.

A report from the AIHW in May 200917 on the subject of chronic kidney disease said:

Taking medications is an important component of managing and treating all stages of CKD.

Medications are used to slow the progression of disease, treat underlying causes and contributing

factors (such as diabetes, high blood pressure, cardiovascular diseases and cholesterol), treat

complications of disease, and replace lost kidney function.


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Dr Fred McConnel, a 40 year plus practitioner in Aboriginal health summed up the situation well by

saying18:

Indigenous Australian health care has been particularly beset with treatment failure as a result of

poor compliance. McConnel suggests that compliance per se is not the problem but rather the

extent to which it is apparent is a measure of dissonance between the belief systems. This gap

between the culture of Western medicine and Indigenous culture should not be narrowed by the

extinction of Indigenous belief, but by the development of a shared knowledge which includes

Indigenous health beliefs and practices.

It is hoped that the Adherence Support Worker, coming from the local community and speaking

the language of the people, will be able to help bridge this gap from the standpoint of the existing

knowledge (world view) of the patient. The ASW will be asked to try and build on that knowledge

an understanding of western medicines and their place in managing the chronic diseases that were

not around at the time of colonisation, or indeed until some 30-40 years ago. The 1970s was

when lifestyle changed so dramatically with the government decision of self-determination and the

added bonus of sit down money through unemployment welfare benefits giving access to a

world of pleasures not previously available and boosted by the purchase of colour television19.

This clear challenge to the pharmacy profession must be addressed and ASWs are seen by this

writer as a clear solution at the grassroots level.

2.4 Scope for additional resources

There is little doubt that the information gap between the client and the clinician needs bridging in

the area of remote Aboriginal health practice.

In mainstream Australia this is achieved through a well organized and trained set of positions led

by the pharmacist in charge of each of the 5,000 community pharmacies strategically placed

throughout the Nation in every town, suburb or regional shopping centres. The pharmacist is

available to provide advice and counsel to all clients who obtain a Pharmaceutical Benefit

medicine on the prescription of a doctor. This effort is augmented through the trained pharmacy

technicians or shop assistants, who will have been trained in a manner set down in the Quality

Care Pharmacy Program (QCPP)20.

A range of incentive payments21 are available to the Community Pharmacy to encourage them to

access and make available a range of services to assist the client base.

For the Aboriginal Health Service no such assistance is provided. The Community Pharmacy

receives from the PBS $6.42 to dispense a benefit. The AHS has to perform the same function

with stock made available through the PBS using the Section 100 supply arrangement but

receives no payment to cover the costs.

The AHS is behind from the start in being able to provide a service anywhere as comprehensive

for the Aboriginal client compared with the mainstream population.. To expect any assistance in

bridging the information gap from the Community Pharmacy is expecting too much when there is

no money available to pay for anything. From the above it is obvious that equity is needed for

Aboriginal clients of health services supplied through the Section 100 arrangements. This will only

happen when more resources are made available both in money to support the pharmacy

service and positions for pharmacists are created to be involved in the training and evaluation of

medication adherence.


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This paper is proposing a Trial to be conducted in conjunction with the upgrade of the pharmacy

service at a large Aboriginal community controlled health service where the position of ASW will

be piloted to gauge the effect and usefulness of the position.

There are some 50 pharmacists working in and around Aboriginal health across Australia in a

differing array of roles and from different governance structures. These include:

a. State/Territory employed pharmacists with a responsibility towards improving quality care,

systems or training.

b. Community (retail) Pharmacists that supply s100 PBS to AHSs.

c. Independent consulting pharmacists accredited to undertake Home Medication Reviews

(HMR) and contracted to retail pharmacies.

d. Health Services who have employed their own pharmacists

e. Academic Pharmacists attached to a rural health division of a university

The National Prescribing Service initiated a program for outreach pharmacists working in the

remote Aboriginal health setting and has introduced a learning program to meet their needs. The

majority of these pharmacists are likely to vist a community maybe once in six months so the

opportunity to develop a meaningful rapport with the clinic staff and trust with the people is

virtually nil. The fly in fly out visitors are frowned on by community members but in the case of

pharmacy it is a case of anything is better than nothing. Most communities and their health

services would not have seen a pharmacist before let alone know what they do.

There are only six pharmacists working full time with Aboriginal Community Controlled Health

Organisation and then not at any one community for any length of time. In the NT there are some

six communities with a population of over 1,500 which could sustain a pharmacy on site.

It is only when there are pharmacists located at these large communities that an impact will be

made on QUM. Until then it is unlikely there will be Aboriginal people putting up their hand to be a

pharmacy technician and the ASW may well be an attractive path for a community worker.

In the meantime the NPS program will provide some guidance to those pharmacists with a little

time to spend in any one community which is hoped by this writer to lead to many more

pharmacists able to spend all their time in the larger communities.

The market place is desperately in need of additional resources although many are completely

unaware of what a pharmacist can do.


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3 A new position Adherence Support WorkerThis paper proposes that a Trial be implemented, centered on the town of Katherine in the NT.

Central to the Trial will be the current pharmacy upgrade program being implemented by the Wurli

Wurlinjang Health Service (WWHS) which incorporates the utilisation of local Aboriginal people as

pharmacy assistants, pharmacy technicians and Adherence Support Workers.

In order to capitalize on the establishment of infrastructure to support the ASWs a further four positions

will be offered to the nearby Aboriginal remote communities to the east of Katherine with their health

services owned and administered by the Sunrise Health Service.

Due to the Trial nature of the operation a partnership is being sought from the Fred Hollows

Foundation which collaborates with Sunrise in a number of allied health undertakings testing new

approaches. This then takes the burden of organizational requirements away from the Sunrise

management and places new and emerging services in the communities.

The approach to the FHF will be to invite two communities from the Katherine East region to show

interest in having two ASWs each to participate in the Trial that will be testing the concepts outlined in

this paper.

The following is the proposal currently before WWHS and the FHF which if accepted will see one male

and one female ASW located in Katherine and at the two interested communities.

f. Commitment through the WWHS and FHF/Sunrise interest will be confirmed to host the

ASW positions to test the concept and refine the definition and mode of operation of the

workers

g. Governance the Trial will be over sighted through a Steering Committee comprising

representatives from the following key stakeholders:

i. Wurli Wurlinjang Health Service

ii. Sunrise Health Service

iii. Fred Hollows Foundation

iv. Centre for Remote Health (Katherine) evaluation

v. NT Department of Health and Families

A Project Manager will provide the secretariat to the Steering Committee and over sight the

entire project.

h. Recruitment this will be done by each host organisation following the criteria established

by this Discussion Paper with an evaluation refining the process after six months of

operation in the field.

i. Training the recommendations in this paper will be followed using, in the first instance,

the materials from Zambia and identifying elements of accredited courses with the CSHTP.

The Trial will be a crucial part of establishing a best fit training arrangement. The training

will be conducted out of the Training Centre at WWHS with resources and lecturers obtained

from funding established for the Trial.

j. Evaluation the Centre for Remote Health in Katherine has been invited to evaluate the

Wurli Pharmacy Upgrade Project and this will be extended to the ASW Trial.

k. Budget a budget for the Trial is being prepared and will be finalised when the detail is

confirmed with the key stakeholders who will be represented on the Steering Committee.

The budget will cover wages, training, recruitment costs, per diem expenses while

undertaking training, evaluation, project management and administration costs incurred by

WWHS and FHF.

The contribution an ASW can make to medication management for community members will be put to

the test. Along with this will go the feasibility, practicality and degree of integration able to be achieved

as part of the total health and social development aspects of community life.


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4 Issues to be resolved4.1 Scope of activity

The experience from programs overseas has influenced the proposal to scope the activity of an

ASW in the Australian context. This has been added to by observing the present move towards

Community Support Workers in Aboriginal health across a number of clinical areas. Examples of

this already in place are in the following categories:

Ear

Eye

Mental Health

Alcohol and Other Drugs

Nutrition

Reproductive health

Skin

Talks were held in the course of the research with the hosts of the Ear (DHF) and Skin (MSHR) to

ascertain the philosophy behind the appointments, their success and factors important to that

success. A similarity existed in each category where information, education and culturally

appropriate approaches were needed to get the messages across to clients in the specific subject

areas.

The ASW will essentially be an addition to the overall closing the gap effort and will need to be

aware of the efforts of others so as not to cause any demarcation disputes. While everyone

needs to have a general knowledge of the entire picture across the social determinants and

accuses of chronic diseases a specialized knowledge of medicines and their mode of action and

likely effects and side effects is the raison detre for the position. This sets the ASW apart from

the above list while at the same time wanting to work in collaboration with the above.

The trail in Katherine will determine how feasible this ideal is.

4.2 Governance

The host organisation to employ an ASW could be any of the following:a.Community controlled health service

b. Government owned and operated health service

c.Non Government sector organisation e.g. Red Cross, Fred Hollows, Somerville

d. Community organisation e.g. resource centre, family centre

The community should decide that an ASW would be useful to it and then it is matter of where

they would want to see the position hosted. During the course of the research the writer found

that there was a Womens Resource Centre that was keen to host a position; a community

Womens Centre; a government owned health service and also a Shire Council.

This paper suggests that there be no firm statement on where the position should be hosted and

it be left to the community to decide where it sees the best effect being gained. Once the role is

established and efficiency ensured it is hoped that promotion of the role could cross all sectorswith an interest in closing the gap.

The Alaskan Community Health Aide Worker Program was reviewed in 200422 when it was seen

that issues relating to governance were important issues in ensuring job retention. The Oral

History Project was undertaken to explore the early days of the CHAP program. The structure of

the interviews23 was to elicit information on the following topics:

job recruitment and training,

communication issues with doctors and patients,

changes in health care delivery,

mixing of western and traditional medicine,

level of involvement from doctors,


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how providers' health care practices were influenced by the community health aide

program,

stories of success, failure, satisfaction and frustration with the program,

impact of new technology on the delivery of medical care, and

influences the job and the program had on personal lives and careers.

The outcome of the interviews showed that the major issues confronting CHAWs related to

governance24. These were:

Organizational factors salary, educational opportunities, retirement benefits, opportunities for

promotion, respect from others in the tribal health organisation, supervisory style and support.

Job content work duties, work autonomy, utilization of abilities, volume of patients relative to

staffing, amount of on call required.

Work environment working relationships with supervising doctors, relationships and support

from other co-workers and support from the community and village council.

Personal factors child care responsibilities, elder care responsibilities family support and

ability to participate in

It can be learnt from this that the whole of person needs have to be addressed. In the remote

Aboriginal context this presents challenges because of the low level of social capital in

communities and the urgent need to address leadership issues. The ASWs will need support from

a number of different parties including family, clan group, health service, local shire

representatives and co-workers. These will be issues that need to be addressed by the Steering

Committee in the beginning of the Katherine Trial.

4.3 RecruitmentThe recruitment of the ASWs will be a matter best dealt with by the body chosen to host the

workers. The Steering Committee will be able to guide this process and suggest a best approach

to the host organisation.

In the case of Wurli Wurlinjang this will be handled through the HR Department.

A strategy for finding the remaining positions for the Trial will be discussed at the first meeting of

the Steering Committee.

The proposal in this Paper is that either young people looking for a career opportunity or older

people wanting to return to the health workforce be targeted as prospective ASWs.

4.4 RemunerationThe best guide to a suitable remuneration structure is obtained from the NT DHF Community

Workers. This is described in the Fact Sheet for Aboriginal Community Workers25.

The suggestion is that the salary scale be linked to the NT Commission of Public Employment

Salary Scales. The ACW will be working to the rate applicable to an Administrative Officer Class 2,

3 or 4 depending on level of responsibility.

The ASWs could be linked in a similar way however it will depend on the host organisation and

whether they are seen as health workers or administrative assistants.

This will be another matter for the Trial Steering Committee.


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4.5 Job DescriptionWhile it is not the intention of this Paper to put matters off to the Trial Steering Committee, it is

believed that a Job Description should emerge in a final form from the evaluation of the Trial.

The basic elements of a Job Description, that will be built on are suggested as being:

Primary Objective to assist people in communities to understand the central role that

medicines play in alleviating the symptoms of chronic diseases that will help them to lead a

socially fulfilling life, free from hospitalisation and expecting a longer life expectancy.

Key Responsibilities

1. To plan and work on interventions that will enable individuals and families to be engaged indiscussions on health status, social determinants and the role of medicines in chronic disease

management..

2. To obtain as much information as possible on the degree of compliance they are following andthe outcome of medicine taking.

3. To provide information to individuals and families that will help them to understand theimportance of taking medicines seriously.

4. To interact and liaise in a positive manner with other people working in the health careenvironment in the community.

5. To feed back to the Pharmacy Program the data able to have been gained to assist inevaluating the usefulness of the program to health outcomes.

6. To make suggestion on how the role can be best implemented with the least amount ofintrusion on the individuals and families but in the best way of achieving a longer life for all

involved.

Selection criteria

1. Being a member of the community with good bilingual abilities to communicate across both

cultures.

2. Ability to understand the sensitivities of working in the community and a good knowledge of

the clan (tribal) structures.

3. Good English literacy and numeracy, comprehension and analytical ability.

4. Preparedness and willingness to learn in a new subject area pharmaceutical care.

5. Able to work in a collaborative with all sectors of the health care and community service

industry.

6. Being creative in ability to find new ways of doing things and communicating with people on a

subject they may have little prior knowledge.

7. A strong desire to improve themselves and have the opportunity to be involved in something

that will lead to a rewarding and happy future.

4.6 TrainingA project in itself exists to model the training program for ASWs. Given funding support this could

become a relevant component to workforce development and training programs being developed

in other innovative areas as demonstrated through the EHSDI program.

The most direct and relevant material available for the training of ASW is in the learning programs

developed by FHI/ZPCTP26 in Africa and available to the Australian project with permission from

the owners of the material.

This Paper suggests that for the conduct of a pilot program in the Katherine (NT) setting the

materials already in place (ex Zambia) be used to initiate action that would then be evaluated for

usefulness as the pilot progresses. These manuals and support materials are available on the

Internet.


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UNESCO Open Training Platform at

http://opentraining.unesco-ci.org/cgi-

bin/page.cgi?g=Categories%2FCommunity_development%2FSocial_work%2Findex.html;d=1

The general principles involved in the work of an ASW will be the same whilst the technical

material relating to the disease states need modification. This would allow the role to follow the

African model with the subject in the chronic disease context in Australia replacing the HIV/AIDS

material from Zambia.

The Facilitators Guide provides good resource material and includes a CD with PowerPoint

presentation that can be modified to the Australian remote Aboriginal setting. This can be viewed

at:

http://www.fhi.org/NR/rdonlyres/ez7jwe4qdytdhkweuuwiueiepgdwwsu4cgwy6zob3qesx4btbexzm

uk5la5u5vrfxya6pzbi2jzdvp/ASWFacilitatorsGuideHVenhv.pdf

The basic subjects to background the role of an ASW are covered as being:

Values and Beliefs

Communication Skills

Developing Good Relationships

Adherence

Health Facility Roles and Responsibilities

Community Roles and Responsibilities

Ethics and Professional Behavior

Problem-Solving

Data Collection and Monitoring

Consideration needs to be given to the incorporation of the ASW training into the Community

Service and Health Training Package. This however can be examined once it is established that

the role, through the pilot, has a sustainable future in the health workforce. The intent to use the

Zambian materials is to assist in developing a finished role when it will be possible to move on to

a more exact and appropriate training program.

In this context the following can be used as a starting point.

Community Services and Health Training Industry Council

The Health Training Package (HLT 07) contains the pharmacy support program through the

following accredited courses:

HLT31407 Certificate III in Hospital/Health Services Pharmacy Support

HLT40507 Certificate IV in Hospital/Health Services Pharmacy Support

The content of these can be viewed through the PDF of HLT07 Health Training Package accessed

at https://www.cshisc.com.au/docs/HLT07-QualificationsFramework-Vol%202.pdf

This program focuses on the supply and management side of pharmacy services and is thus not

considered applicable to the ASW role which is a community support role rather than a in-service

technician function.

The Community Services Training Package (CHC08) contains the program being followed by

the NT Government Department of Health and Families (DHF) for its Aboriginal Community

Workers being funded under the EHSDI program. Some elements of this program could be

utilised. The added advantage of this course is that it is being delivered by Charles Darwin

University as Certificate III (CHC30802) and IV (CHC 040902) in Community Services Work at

http://eagle.cdu.edu.au/ntu/apps/coursere.nsf/vwwCourse3prVET/B455AF640A434C5E6925753D

002272E1?OpenDocument

The publication of the Hesperian Foundation publication Where there is no Doctor27 will also be

reviewed for useful segments.


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Additional material available for both the HLT07 and CHC 08 could be useful in broadening the

scope of knowledge for the ASW and allow them to appreciate the roles of fellow Community

Support Workers. Examples if this are:

Mental Health Training for Workers in Aboriginal and/or Torres Strait Islander

Communities Resource Kit (CD)

Communication and Promotion of Skills Sets in Training Packages

Chronic Disease Self Management Resource Kit

Renal Care Skill Set Identification & Development Project (HLT07)

While the pre-requisites for the above subjects are beyond the scope of the ASW the resources

developed could be useful in the context of communications and knowledge to be passed to the

ASW.

Kimberley Aboriginal Medical Services Council Medication Assistant Training

KAMSC Centre for Aboriginal Primary Health Care Training, Education & Research (CAPTER) began

delivering a pilot Medication Assistant training course in July 2008. The content of this course

contains elements that could be useful for the ASW Training. In particular, the subjects discussing

the use of medication in a number of chronic disease states will be assessed if they become

available for general distribution.

This Paper suggests the Zambian material, appropriately modified, be used in the first instance

followed by an evaluation of the role leading to a more targeted training program that could meet

the requirements of Health Service Assistants in the CSHTP of the National Skills Advisory Council.

Comments on this approach will be welcomed.

4.7 EvaluationThe Steering Committee will guide the Evaluation process and an approach will be made to the

Centre for Remote Health in Katherine (evaluators of the main pharmacy upgrade program) to

see if the ASW Trial could be built into the program as a whole. An amount of money will need to

be set aside to cover evaluation cost.

Key Performance Indicators will be determined as well as a current assessment of the clients

understanding of the role of medicines in chronic disease management. It will then be possible to

measure change as time goes on.

The detail of the evaluation will be developed with the evaluator, the Steering Committee and the

Principal Pharmacist appointed to the WWHS Upgrade project.

5 The path aheadThe writer hopes that this Discussion Paper will allow those interested in the subject of pharmacy

involvement in Aboriginal health to view the subject with a renewed enthusiasm. There is a need to

look at this project as one having all the elements needed to enable an intrusion into the subject in a

manner that will attack the problems from the grass roots level. At the same time it will take

advantage of current thinking towards community control, chronic disease management and

workforce development.

Pharmacy as a profession has been left behind and a number of other allied health professionals have

to take a role in medication management which under normal circumstances would have been

handled by pharmacists, or at least directed by them.

Endorsement of the plan outlined in this document will enable the Trial to proceed and given the

institutional support needed funding will enable a practical example of action much needed in the

approach to policy and program development in many areas of Aboriginal disadvantage.This plan gives the pharmacy profession a real opportunity to assist in Closing the Gap.


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6. Questionnaire to respondents

A survey of opinions on the content of this Discussion Paper has been prepared andcan be accessed through the following weblink:

http://www.surveymonkey.com/s/GVVDDY8

Please access and fill out the survey. Your assistance in gathering information to

support a funding application will be greatly appreciated.

Send all comments, suggestions, criticisms or support to the author at the

following address:Rollo Manning

PO Box 98 Parap NT 0804

Email: [email protected]

Telephone: 08 8942 2101 or 0411 049 872


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7. Endnotes:

1 Australian Institute of Health and Welfare 2009. Expenditure on health for Aboriginal and Torres StraitIslander people 200607. Health and welfare expenditure series no. 39. Cat. No. HWE 48. Canberra: AIHW.

2 AIHW Aboriginal and Torres Strait Islander health performance framework 2008 report

3 Hon Stephen Dunham. Ministerial Statement. Preventable Chronic Diseases Strategy. Eighth AssemblyFirst Session 10/08/1999 Parliamentary Record No:18

4 Torpey KE, Kabaso ME, Mutale LN, Kamanga MK, Mwango AJ, et al. (2008) Adherence Support Workers: AWay to Address Human Resource Constraints in Antiretroviral Treatment Programs in the Public HealthSetting in Zambia. PLoS ONE 3(5): e2204. doi:10.1371/journal.pone.0002204

5 Mary B Morris, Bushimbwa Tambatamba Chapula, Benjamin H Chi, Albert Mwango, Harmony F Chi, JoyceMwanza, Handson Manda, Carolyn Bolton, Debra S Pankratz, Jeffrey SA Stringer and Stewart E Reid. BMCHealth Services Research 2009, 9:5 Use of task-shifting to rapidly scale-up HIV treatment services:experiences from Lusaka, Zambia

6 Nice P, Johnson W. The Alaskan Health Aide Program a tradition of helping ourselves. Self published by PNice 1998

7 Barbara Morgan. Aides work to help Native Alaskans have better health care: Alaska's Community HealthAide Program is a model for other states. Alaska Business Monthly. March 2003.

8 Trudgen R. Why warriors lie down and die. Darwin, NT: Aboriginal Resource and Development Services,2000.

9 ABS. Quarter ending June 2009.

10 Australian Bureau of Statistics 4713.7.55.001 - Population Characteristics, Aboriginal and TorresStrait Islander Australians, Northern Territory, 2006.

11 NT DHF Background Paper: Preventable Chronic Diseases in Aboriginal Populations (April 2009)

12 Zhao Y, Connors C, Wright J, Guthridge S, Bailie R. 2008. Estimating chronic disease prevalenceamong the remote Aboriginal population of the Northern Territory using multiple data sources. ANZJPH2008; 32 (4): 307-13.

13 Clinical outcomes associated with changes in a chronic disease treatment program in an AustralianAboriginal community. Wendy E Hoy, Srinivas N Kondalsamy-Chennakesavan and Jennifer L Nicol. MJA2005; 183 (6): 305-309

14 Coversyl (Perindopril Servier) daily morning dose

15 Avoidable hospitalisation in Aboriginal and non-Aboriginal people in the Northern Territory. Shu Q Li,Natalie J Gray, Steve L Guthridge and Sabine L M Pircher. MJA 2009; 190 (10): 532-536

16 Bailie, RS, Si D, Dowden M, Lonergan K, (2007)Audit and Best Practice for Chronic Disease ProjectFinal Report, Menzies School of Health Research

17 Australian Institute of Health and Welfare 2009. An overview of chronic kidney disease in Australia, 2009.Cat. no. PHE 111. Canberra: AIHW.

18 McConnel F. Compliance, culture and the health of Indigenous people. Rural and Remote Health (online)2003. Accessed through http://www.rrh.org.au/articles/subviewnew.asp?ArticleID=190 January 12th 2010.


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19 Manning R. When bad health is normalwhat is good health? How marketing through TV ads hasinfluenced the health of remote living Aboriginal people. Presentation to NT Chronic Disease NetworkConference. Darwin. September 2006http://www.rollomanning.com/site/pdf/aboriginal/ManningGood_Health.pdf

20 Training and QCPP. Accessed through http://www.guild.org.au/training/content.asp?id=96712th January 2010.

21 Pharmacy Guild of Australia website. Accessed throughhttp://www.guild.org.au/mmr/content.asp?ID=408 12th January 2010.

22 The Alaska Community Health Aide Program: An integrative Literature Review and Visions for FutureResearch. Accessed through http://nursing.uaa.alaska.edu/acrh/projects/report_chap-lit.pdf. 10th January2010

23 University of Alaska Fairbanks, Alaska and Polar Regions Collection. Elmer E. Rasmuson Library. OralHistory Program. Community Health Aides Program Project Jukebox, Accessed through

http://jukebox.uaf.edu/CHA/htm/background.htm 10th January 2010.

24 Factors influencing Retention and Attrition of Alaska Community Health Aides/Practitioners: AQualitative Study. Accessed through http://nursing.uaa.alaska.edu/acrh/projects/report_chap-retention.pdf 10th January 2010

25 NT DHF Career Fact sheets. Aboriginal Community Worker Accessed throughhttp://www.health.nt.gov.au/library/scripts/objectifyMedia.aspx?file=pdf/9/57.pdf&siteID=1&str_title=Aboriginal%20Community%20Worker%20Career%20Factsheet.pdf. Accessed 10th January2010.

26 Accessed through http://www.fhi.org/en/HIVAIDS/pub/res_ASW_CD.htm 10th January 2010

27 Where There Is No Doctor A village health care handbookby David Werner with CarolThuman and Jane Maxwell. Tenth revised printing: May 2009. Hesperian Foundation.

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