Terrence Guyula, Senior Male Health Worker, Gapuwiyak, via Nhulunbuy, NT.

Gapuwiyak Men's Clinic - Description and History
Gapuwiyak has a demountable "donga" about 25 metres from the main clinic. It was the vision of Terrence Guyula - Senior Male Health Worker who felt frustrated by numerous current problems in Men's Health and difficulty accessing male patients. It was set up with assistance from Miwatj ongoing costs are mainly covered by Territory Health Services and the Gapuwiyak Community Council. It has a main office and waiting area, a bathroom/toilet and a more private consulting room. The vast majority of men presenting to the Health Service are seen at this clinic although, if it is closed, they can come to the main clinic for things that cannot wait. After opening, the number of adult males attending service increased 600%. These attendance figures have been sustained. We feel this refutes claims that Yolngu men are not interested in their health.

In the early dry season of 1998, Terence, Tim Duggan and the then DM0/now G.P., Stephen Bryce began to plan a major Men's Health Screen. To make the most of the opportunity₁ fairly comprehensive screening was planned. It was decided that each person screened should have random cholesterol and HDL, blood glucose, RPR for syphilis₁ Hepatitis B serology, Urine albumin creatinine ratio, Urine PCR testing for Ghononhoea/ Chlamydia I Trichomonas, HIV test (after watching one of Terence's videos in language to cover informed consent) as well as kill blood count / electrolites / liver function. The screening was extremely well attended and took one week. We received assistance from the Disease Control Unit as well as Miwatj.

The biggest job in any screening programme is processing the results. We have heard stories of some communities chosing not to screen for certain diseases simply because the clinic did not have the resources to educate, medicate and followup the expected newly diagnosed cases. For several weeks following the screening, the DM0 sat in the clinic until 10pm (during his overnight visit) wading through telephone-book-thick wads of pathology results. These results had to be turned into numerous followup lists. At the time, we were so overwhelmed with all the new work we had generated that we did not keep exact figures of numbers of new diagnoses. in hindsight, this would have been very useful.

The most significant finding to us was the number of men with abnormal serum cholesterol. About 30 men had particularly severe cholesterol and required followup in terms of diet/smoking/lifestyle education. They have all been locked into ongoing review and some have gone on to take cholesterol lowering drugs. There were six cases of undiagnosed syphilis and a similar number of gonorrhoea and chlamydia. Three or four new diabetics and around ten men with early kidney disease signified by elevated ACR. Around 30 men were found to have active Hepatitis B infection. Fortunately, none were positive for HIV.

We were quite daunted by all the new lengthy review lists but, as time permitted, started the slow process of working through each man one by one with a full medical review and detailed education about the disease we had turned up. We were assisted greatly in this process by a collection of teaching aids that we had built up. This included an indexed system of teaching cards taken from numerous medical texts and joumals. Included are illustrations of diseased organs, common germs and various other body processes. Many men said that, along with some key language concepts, the illustrations helped them to visualise quite clearly what was going on inside their bodies. Some thanked us for not giving them a story that had been obviously oversimplified (as they had apparently received in the past). They said they were grateful to have final heard the 'Bottom Story'. Other men politely listened us out but seemed a lot more ‘cool' about our message. Fortunately we locked them into a review system and some, at six monthly and twelve monthly review are much more interested in taking concrete action about their respective health / lifestyle issues.

This whole process has had a number of outcomes – most positive, some negative. A lot of previously undiagnosed men are now locked into chronic disease management programmes Due partly to our improved access to the men and our education, compliance levels appear to be quite good. Sources within Territory Health Services tell us that there are some encouraging early trends in terms of reduced chronic disease related admissions -particularly ischaemic heart disease. A number of our "pick ups' were the older more influential members of the community. These men have really come on side in terms of supporting our future planned men's health initiatives and addressing broader related issues like the kinds of food available in Gapuwiyak.

On the negative side, the general workload of the health Service has increased significanfly. Many new patients are now on tong term medication which has increased the pharmacy workload and certainly stretched the pharmacy budget. Also, the patient travel / specialist reviews have increased as more new disease is unearthed. Health services should brace themselves for this increased work if a serious Men's Health programme is kicked off.

Future Plans for Gapuwiyak Men's Health
Terrence Guyula, Tim Duggan and Stephen Bryce have sucessfully applied for two THS Health promotion grants (‘Health Promotion' and ‘Community Nutrition’). when the funds become available, we plan to build on the Community interest that has been generated in firstly cholesterol and heart disease with a broader education programme. The money will be used to acquire further educational materials (Including some teaching models which Yolngu respond very well to) and two way educational sessions are planned through appropriate traditional structures. Early plans are underway for a CD ROM with Yolngu Matha commentary and English text (commercial CD ROMs have proven vary successful out here).

We would also like focus further on STO screening and management. With the quieter dry season now upon us, it is probably time for another Community screen. It will be interesting to see if last year's screen has had any effect on this year's disease incidence.

A modest but full colour newspaper is soon to be released - edited by Terence Guyula. This will be funded by Rotary Club and produced locally on a colour bubble-jet printer. The newly acquired clinic computers and digital camera will greatly assist this process. We plan to use the paper to promote and recognise positive health issues and traditional practices in Gapuwiyak The first edition will have input about cooking fish the traditional way, Strong Woman Strong Babies input as well as outstation and traditional art content. It has been rewarding to finally have the technology to realise a longterm dream of Terrence and Stephen.

Ongoing Problems for the Gapuwiyak Men's Health Programme

At times, Terence feels somewhat isolated in the clinic - particularly when he has a difficult clinical problem and all the other staff are too busy to help or offer advice. This problem had been partially buffered by the fact that Terrence is quite senior and experienced. However, if other programmes are started with fairly junior or inexperienced Health Workers, there is the potential for real problems. We have heard stories of Health Workers being unable to get advice on a particular patient and then being blamed for a bad outcome.

The Men's Clinic must be adequately supplied with equipment and stores. It has been unfortunate that the Male Health Worker has had to scrounge around the community for office furniture such as desks and chairs. Equipment that’s essential to any clinic (e.g. oxygen supplies, resuscitation equipment etc.) should be supplied from the outset so equipment is not being constantly borrowed.

It constantly wastes Terrence's time having to walk backwards and forwards with client histories. We need to continue to work through issues of positioning and access of Men's medical records.

We would like to see a more formalised continuing education process put in place for the Male Health Workers. This should not only include clinical training but also the development of managerial and health promotion skills. There are many areas of training that local Health Staff simply do not have time to do themselves, Finding the right balance between workshops away from Gapuwiyak and on-site, hands on training can be a challenge. We have made Health Workers an integral part of the functioning of this clinic. When they are off at workshops, the effectiveness of the clinic grinds down considerably. This needs to be balanced against the need for sufficient ongoing education and training. We would argue that the right balance is not always reached and both the service providers and educators should continue to talk to each other and work on this one,

A male RN3a, Ross Jackson was recruited to assist with Men's Health. Unfortunately, through the very busy wet season when the clinic fills up with sick infants and staff are often off on fatigue breaks, he has found it very difficult to get away (sick infants of course have to take priority) and help Terence. Lack of clerical support has compounded the issue as the RN3b has to spend long hours in the office, putting an increased load on Ross in terms of covering the main clinic. Both Terrence and Ross have been disappointed that things could not have worked out better. The G.P. attempts to come over whenever requested by phone, but in the midst of a busy clinic or on Outstation visit days this may not be possible. Phone advice can usually be provided.

The lack of a clinic courier is another problem. When a patient is due to be picked .up for a non-urgent review (e.g. diabetic). Terrence needs to close the clinic and go pick up the patient himself. This wastes considerable time particularly when someone with health skills has to do work that could be done by someone else. We continue to look for someone through the CDEP programme but have yet to find someone appropriate who will stay in the job long term. Fortunately our current student Health Worker has taken on some of that load.

Terence has expressed that he would like to be doing more Community based education and more chronic disease work. The Men's clinic is frequently very busy which ties him up with acute medical problems and prevents him from getting to the broader preventive issues. At times this had become a major frustration although we are looking into asking Miwatj to send relief / support staff to free Terrence up for special programmes and projects.

Important Principles in any Arnhem Land Men's Health Programme

1. A seperate Men¹s Health space with a separate waiting area and toilet.
We consider this a core and non-negotiable principle. The exact nature of this space will vary. Perhaps a part of an existing clinic; perhaps a donger like at Gapuwiyak; perhaps a caravan. In terms of the Preventable Chronic Diseases Strategy, if the above principle is not addressed then half of the target adult population (ie men) will be extremely difficult to access. Senior Territory Health Services staff have been very interested and sympathetic when these issues are brought up. However have explained that funding to put Men's clinics in every community does not exist at present. Perhaps cooperative efforts between organisations like Miwatj (which currently has a strong Men's Health focus) and Territory Health Services will come up with workable solutions.

2. A competent and well -supported Male Health Worker
There are potentially excellent Male Health Workers in every community. Unfortunately, the current system often prevents these men from becoming competent and functional. Those who have worked in this district for some time will have seen several Male Health Workers or Health Worker students throw in the towel. Part of this problem would be having to work in a female dominated clinic which men rarely attend. We have heard stories where male health workers spend most of the day filing and sweeping the floor. In this situation he learns little and becomes quickly demoralised. Often closely connected with this is the lack of a men's health space.

Also, it is worth noting that doctors and nurses who work in remote communities (like East Arnhem) would ensure that they had several years of supervised experience before becoming a ‘practitioner’ in a remote clinic. In the same way, after graduating from a one year course at Batchelor College, a male health worker would not be capable of running a Men's Health Clinic without close supervision. We are concerned at stories of Health Workers who have been given too much responsibility too quickly and been set up to fail. (At the same time it is also wrong to withhold responsibility from Health Workers when they are ready for it)

We would argue that a newly qualified Health Worker needs a minimum of four hours per day of supervision / mentoring (ideally full time). There must also be help readily available if a difficult problem is encountered. This 'apprenticeship' style of learning is more consistent with traditional Aboriginal methods of teaching than the ‘classroom’ approach. For Female Health Workers, this mentoring usually happens automatically as they work alongside nursing staff or DMOs. One is more likely to be left on one's own in a separate Men's Clinic.

Who the mentor is would probably vary as per size and character of the community. It could be a Senior Male Health Worker or a male registered nurse. Alternatively a male G.P. with an interest in Men's issues may be appropriate. Long term staff are infinitely more effective in this role for a multitude of reasons. Because of cross-cultural issues, it takes six to twelve months for a good working relationship to develop between staff (there needs to be learning on both sides). High staff turnover in a community will regularly sabotage this process. Large amounts of clerical work and in some places, pressures to pursue Medicare vouchers will both potentially distract staff from the mentoring process. Hopefully the mentor can strike the right balance between close supervision and ‘sitting on their hands’ to allow a Health Worker to reach maximum potential.

3. The Clinic / Health Centre must have the resources to absorb the extra work the Men's Clinic generates
If a Men's Clinic gets up and running, one can expect more pathology, more filing, more patient travel. more referrals, longer follow-up and review lists; a larger pharmacy and a more pressured pharmacy budget. Hopefully, after hours call outs, overtime and medical evacuations will reduce but one should expect some lag time before significant benefits are seen. Large communities with infrequent DM0 visits or ones with a long line of short-term DMOs will have marked difficulties coping with all the newly diagnosed chronic disease that a Men's screen could produce. Ensuring regular and quality specialist visits can help to buffer these problems and cut down on patient travel.

We have heard of clinics going considerably over budget as a result of aggressive chronic disease screening. Perhaps this can be discussed ahead of time.

4. Good quality education must be available for the men on various issues as they arise
This can be very time consuming but is essential to any long-term positive outcomes being sustained. Good education is an essential factor in patients complying with their treatments. We have invested a lot in terms of acquiring good educational resources and refining our educational approaches. There appears to be encouraging early signs that this is paying off.

5. A compromise - the "Men's Health Week"
To be realistic, many communities will have to wait several years before they have an actual Men's clinic. Issues revolve around lack of resources, lack of suitable staff and some times resistance from certain sectors or the community (although in our experience support for the idea of a men's clinic is generally very strong). A compromise would be the ‘Men's Health Week’ where existing male clinic staff, usually boosted by extra staff from say Miwatj or the Disease Control Unit set up in a tent or and appropriate Council building away from the main clinic. During the week, screening is done and usually some form of health education.

These weeks are generally well attended and successful, however the actual screening process is only a small proportion of the total work involved. The main work (depending on how comprehensive the screening) lies in sorting through all the results, generating review lists and then going and managing all the positive findings. Health services should bear this in mind in the planning stages. We have heard stories of ‘successful’ screening programmes which generate huge amounts of data that no one ever has time to look at.

The intermittent programmes (while certainly very worthwhile) fail to address the followings: The lack of a permanent Men's space where ongoing follow-up and management of positive findings can take place (many of these consultations require urine specimens). Intermittent Men's weeks cannot provide the long-term support and education of chronic disease and cannot provide ongoing STD contact tracing and follow-up

Conclusion

Gapuwiyak's Men's clinic now provides a space where Men can come, without embarrassment, for acute medical problems and STD management. As a result of screening, it has taken on a lot of chronic disease management and now looks after all the dosette boxes, depot medications and home visits for the men of the Community. There has also developed a strong educational focus and our Health Worker reports a much higher level of job satisfaction then before the clinic was open. We feel the success of the clinic lies in a competent Male Health Worker showing some initiative and vision and then being taken seriously and supported by those around him. It is probably time that many Arnhem Land Communities look seriously at getting underway or boosting their Men's Health Programmes. Every Community needs to find its own solution, one that it can own and develop. We hope that our ideas, stories and recommendations have been of use to those headed down that path.

Terrance Guyula, Senior Male Health Worker

Stephen Bryce, Gapuwiyak Community Doctor

Ross Jackson, Registered Nurse 3A

Tim Duggan, Miwatj Health Educator

21/6/99