Julia Marley

Personal profile

Roles and responsibilities

I am a Principal Research Fellow at RCSWA, based at the Kimberley Aboriginal Medical Services (KAMS) in Broome where I undertake collaborative research into improving Aboriginal health and building research capacity. I lead, coordinate and undertake regional research activity, including preparing and supporting grant and ethics applications, publications and reports; and disseminating results (available from the KAMS research website http://kams.org.au/research/mission-and-aims/). I supervise an Aboriginal Research Officer, Research Fellow and five PhD students.

I have a central role in developing regional research practices that are acceptable to Aboriginal communities and health care services in the Kimberley. In consultation with key Aboriginal people, senior management and researchers at KAMS we have developed a KAMS model of research. By embedding research into existing health services and including Aboriginal people, health service providers, administrators and policy makers as core members of the research team we are better able to determine what information is required to help them improve the PHC services to Aboriginal people, and that the process, interpretation, dissemination and implementation of results are culturally safe. I provided Secretariat services to (2007-2014) and now Chair (from 2015) the Kimberley Aboriginal Health Planning Forum (KAHPF) Research Subcommittee. A significant part of my role on the Subcommittee is to provide advice to researchers and organisations on how health research is to be conducted in the Kimberley.

Working in the Kimberley is very different to that of a “normal” university environment. The usual way of building research capacity is through research projects as part of academic programs at undergraduate, postgraduate and post-doctoral levels. In the remote Kimberley region alternative models need to be explored to develop a sustainable research team, which includes local Aboriginal people. We combine traditional research degree approaches with an “apprenticeship” style program that allows people without the usual academic background to develop skills and follow a range of pathways to reach their capacity. In addition to the researchers I directly supervise I also mentor Aboriginal and non-Indigenous peoples in how to conduct research based on the KAMS model of research.

The research that I have led has had demonstrable outcomes at regional and national levels, including:

The Kimberley Chronic Disease Therapeutic Protocol for the diagnosis of type 2 diabetes was revised in 2015 to use HbA_1c tests instead of glucose tests for screening for diabetes.
Following a review of the KAHPF Research Subcommittee the project submission form and advice to researchers have been revised to hold researchers accountable for the way research is developed, conducted and disseminated.
The Kimberley Chronic Disease Therapeutic Protocol and the national Australian guidelines for the diagnosis of type 2 diabetes were revised in 2007 and 2009, respectively, to include the use of point-of-care glucose testing for diagnosing diabetes as long as it is confirmed by laboratory testing.

Funding overview

During the past 5 years I have been an investigator on projects that have received over five million dollars in funding:

I am one of the lead investigators on the NHMRC ($1,369,612) and WA Department of Health ($250,000) funded project on Improving mental health screening for Aboriginal and Torres Strait Islander pregnant women and mothers of young children (KMMS project).
I am the lead investigator on the RCSWA, Val Lishman Foundation and Diabetes Australia funded project that is Developing algorithms to improve predicting the development of and screening for gestational diabetes mellitus in rural communities (ORCHID Study).
I am one of the four co-ordinating Chief Investigators on the recently funded NHMRC grant ($1,969,771) improving primary care for Aboriginal mothers and babies in the Kimberley region of Western Australia: a population and region based cluster randomised trial driven by local health service providers (Nini Helthiwan Study).
I am an Associate Investigator and member of the Governance Committee of the NHMRC funded ($2,494,998) Centre of research excellence in improving health services for Aboriginal and Torres Strait Islander children (CRE ISAC).
I led the recently completed NMHRC funded ($778,514) randomised controlled trial of an intensive smoking cessation intervention in Kimberley Aboriginal primary healthcare settings (The BOABS Study). This study demonstrated that culturally appropriate, multi-dimensional Indigenous smoking cessation programs can be successfully implemented in remote primary health care and intensive one-on-one interventions with substantial involvement from Aboriginal and Torres Strait Islander peoples appear to improve sustained smoking cessation in Indigenous Australians in this setting.

Previous positions

Senior Research Fellow (2009-2016). The Rural Clinical School of Western Australia, The University of Western Australia. Boome

Research Fellow (2006-2009). The Rural Clinical School of Western Australia, The University of Western Australia. Broome

Research Fellow (2001-2005). Renal and Autoimmunity Group, Centre for Inflammation Research. University of Edinburgh, Edinburgh UK.

Research Fellow (2000-2001). Lymphocyte Signalling and Development. Babraham Institute, Cambridge UK.

Current projects

ORCHID Study: Predicting gestational diabetes mellitus in rural communities

Developing algorithms to improve predicting the development of and screening for GDM in rural communities

Gestational diabetes mellitus (GDM) is impaired glucose tolerance first detected in pregnancy. GDM is associated with a range of adverse neonatal and maternal outcomes. GDM is the commonest maternal antenatal abnormality in Australia. Screening is conducted in order to detect women at risk of disease, facilitating earlier management and treatment. Currently available evidence indicates that treatment of GDM with dietary modifications, glucose monitoring, and metformin and insulin (if needed) can significantly reduce the risk for adverse birth outcomes.

Current screening recommendations are for all pregnant women who are not known to have diabetes or GDM to have an oral glucose tolerance test (OGTT) at 24-28 weeks gestation. Women need to be fasted for this test and blood samples are taken immediately prior to consumption of a 75g glucose drink, and 1 and 2 hours later. Many women decline screening.

Alternative methods for diagnosing GDM or alternative methods for screening that lead to a reduction in the number of OGTTs required need to be found if we are to improve screening rates. We want to see if levels of glycation products such as HbA1c at first and third trimester antenatal visit predict the risk of developing GDM later in pregnancy or can be used instead of OGTT where an OGTT is difficult to achieve or refused by the patient.

The aims of this project are:

To determine at baseline the number of 24-28 week OGTTs completed on at least 100 antenatal patients in each study region expected to have had an OGTT.
To determine the relationship between first trimester antenatal information, including glycation products such as HbA1c, blood sugar levels, family history, obesity, maternal age, ethnic background, and 24-28 week glycation products, with 24-28 week OGTT.
To determine the proportion of women enrolled in the study requiring an OGTT who complete the OGTT at 24-28 weeks gestation.
To increase research interest and capacity among health service and RCSWA staff and students, and to build skills in rural and remote health service research.

To ensure that the project findings are generalisable to the broader regional, remote primary health care environment, it will be carried out in a range of health care services across Western Australia: Kimberley, Southwest, Greater South, Midwest and Goldfields.

This project is a collaboration between The Rural Clinical School of WA, KAMS, WA Country Health Services – Kimberley, Harry Perkins Institute and is funded in part through an RCSWA Multi-site Project Grant, Lishman Health Foundation grant and Diabetes Australia grant.

Progress to date: We are in the final stages of data analysis.

Prevention of type 2 diabetes amongst young Aboriginal people in Derby, Western Australia

Type 2 diabetes (T2DM) is a largely preventable disease that involves a significant burden on individuals and communities. Aboriginal and Torres Strait Islander people have higher rates of T2DM than other Australians in all age groups, with larger differences in younger age groups – a time when the onset of diabetes is associated with earlier progression to serious health complications.

The primary prevention of T2DM though lifestyle modification, for people who may have pre-diabetes and for communities in general, is considered to be a beneficial approach. In this project, under the guidance of Derby Aboriginal Health Service (DAHS), young people in Derby will be actively involved in developing and implementing an intervention to support lifestyle changes with a view to preventing T2DM. The overall aim of this PhD project is to contribute to the prevention of type 2 diabetes amongst young people in Derby through supporting healthy lifestyle changes.

The specific aims of this PhD project are to:

Describe the pattern of glycated haemoglobin (HbA1c) levels in young Aboriginal people in Derby (15-39 years of age, with a major focus on 15-25 years of age), and identify the factors associated with individuals having improved glycaemic control over time.
Identify lifestyle interventions that are acceptable to young people in Derby and are considered to be of most potential benefit for them.
Trial a pilot community-driven lifestyle intervention with Derby Aboriginal Health Service (DAHS) and assess acceptability and the short-term outcomes of this intervention.

Progress to date: We are in the final stages of data analysis.

Qualitative and quantitative effects of exenatide use in Kimberley Aboriginal patients with type 2 diabetes

There are many Aboriginal patients in the Kimberley with type 2 diabetes, and the care of these patients poses significant challenges throughout the Kimberley. The mainstay of treatment until recently was lifestyle advice, oral tablets and insulin. In 2015 a new injectable medication, exenatide, was added as a therapeutic option. It works via a different mechanism to insulin and is often used in combination with oral tablets. Previous studies have shown benefits in reducing blood sugar levels, assisting in weight loss, and being well tolerated. The injection is usually given twice a day, but is now also available in a weekly dose.

Aims

The overall aim of the project is to contribute to improving the management of type 2 diabetes in Kimberley Aboriginal patients. The specific aims are to:

To evaluate the acceptability of exenatide among Kimberley Aboriginal patients with type 2 diabetes.
To describe the efficacy of exenatide among the study population to improve glycaemic control and other components of the metabolic syndrome.
To use this project and the findings to build capacity amongst the local Aboriginal community regarding diabetes management and skills for future research.
To provide feedback to local clinicians regarding the use of exenatide in local Aboriginal communities.

Progress to date: We are in the final stages of data analysis.

Kimberley Investigation and Description of type 2 Diabetes of Young-onset (KIDDY)

Young-onset diabetes refers to type 2 diabetes mellitus (T2DM) that is first diagnosed at a young age (less than 25 years old). The number of people being diagnosed with young onset diabetes is increasing around Australia, particularly in Aboriginal or Torres Strait Islander youth. This is concerning because young-onset diabetes has been shown to be a more aggressive version of diabetes than the later-onset type, and is associated with earlier progression to complications. These complications can include damage to the eyes (retinopathy), kidneys (nephropathy), nerves (neuropathy) and the heart and brain (cardiovascular disease). Importantly, there are things that can be done, which can prevent or slow down the onset of these complications.

We are concerned at some of the preventable early complications that we are seeing in young people with diabetes in the Region. We would like to be able to work out the best way to support young people with young-onset diabetes across the Kimberley.

What will this evaluation project involve?:

Describing the current situation of young-onset diabetes in the Kimberley
Identifying best practice screening guidelines for young-onset diabetes in our region

Progress to date: We are in the final stages of data analysis for piloting the new protocol.

Improving mental health screening for Aboriginal and Torres Strait Islander pregnant women and mothers of young children

This study aims to improve screening for, and contribute to addressing, mental health issues during pregnancy and the first 12 months after the birth of the baby.

The locally developed, culturally appropriate and user friendly Kimberley Mum’s Mood Scale (KMMS) was validated against clinical assessment in a sample of 91 Kimberley Aboriginal women. Kimberley regional guidelines now recommend using the KMMS to screen for anxiety and depression during the perinatal period for Aboriginal women. The next step for Kimberley health services are to increase and improve KMMS screening in pregnancy and postnatally and address identified mental health issues. Project staff will work closely with Kimberley services to find out:

How the KMMS can best be implemented into routine practice in each service
If, during routine use:
- The KMMS cut point of moderate still detects everyone with GP assessed clinically moderate or high severity depression and anxiety, and:
- That the management plans developed during the KMMS for those at lower risk are appropriate.

In order to meaningfully assess the above and to test for applicability in other remote regions to inform recommendations for wider use, it is important to re-evaluate the KMMS in a larger population during real world implementation. In partnership with health services and Aboriginal communities in northern Western Australia (WA) and Far North Queensland (FNQ), this study aims to:

adapt the Kimberley Mum’s Mood Scale (KMMS) and develop locally appropriate versions for participating partners as required;
evaluate the real-world performance of KMMS in the Kimberley and other remote regions in northern Australia; and
evaluate the process of implementation.

Progress to date:

The NINI HELTHIWAN project: Improving Primary Care for Aboriginal mothers and babies in the Kimberley region of Western Australia

Providing quality health care for pregnant women and young children in remote areas is both vitally important and challenging. We are conducting three inter-related research projects that will contribute to the development of a regional enhanced model of primary health care for Aboriginal pregnant women and mothers of young children.

Nini regional midwife coordinators are helping to improve the support of primary care providers who are caring for Aboriginal mothers through a peer led process [telephone assistance, email, clinic visits]. Nini Helthiwan is using a randomised stepped wedge cluster design to provide this extra support by:

Improving guidelines and training tools for regional priorities:
- Maternal nutrition, and substance abuse [alcohol and cigarette smoking]
- Social and emotional wellbeing [Kimberley Mum’s Mood Scale (KMMS)]
- Treatment and follow up practices for maternal and infant anaemia [iron infusion policy]
- Early infant care practices [breastfeeding, bonding, attachment]
Assistance with problem solving and follow up [referrals, care-co-ordination, discharge planning]
Assistance with implementing regional guidelines:
- Screening for perinatal anxiety and depression [Implementing the KMMS Study]
- Screening for gestational diabetes [ORCHID Study]
On the job education and training, including assistance with use of electronic primary care systems.

To see if improvements in health care leads to improved health outcomes Nini regional child health workers (located in West and East Kimberley), are assessing neurodevelopment and anaemia levels in Kimberley Aboriginal babies and anaemia levels in their mothers when the baby is 6-10 months old.

Progress to date: We are analysing data from the study.