A workforce enhancement model for Australian remote community Primary Health Care services: implementation of a stepped-wedge cluster randomised trial (SW-CRT)

First Nations people in Australia continue to experience a high level of socio-economic disadvantage, driven by the ongoing injustices of colonisation. In remote communities in the Northern Territory (NT) First Nations children experience early onset and persistence of middle ear infections (otitis media), preventable conductive hearing loss and developmental delay, which contribute to a trajectory of further disadvantage, particularly in education and employment. Health services are not resourced to deliver adequate care for these children. This trial of First Nations workforce enhancement is the first to address these issues. This open cohort stepped-wedge cluster randomised trial of on-country training and new job creation was implemented in 2 pilot and 18 randomised remote communities. Governance of all aspects was co-designed, and First Nations led. Qualified trainers delivered three Certificate II units in Aboriginal Primary Health Care (2 weeks), and competency training in ear and hearing health, otoscopy, tympanometry, and hearScreen® (4 weeks). Community residents were eligible for training if they met criteria for NT Government employment. Here we report baseline characteristics and intervention implementation outcomes. On-country training commenced in April 2020 and completed in November 2023. A new job description was approved for Ear Health Facilitators. Two randomised communities declined participation. The COVID-19 pandemic caused direct and long-term disruptions. From 167 expressions of interest, 53 of 89 (60%) enrolled participants completed all training. Lack of services interrupted attendance, whereas Liaison Assistants, meals, and payment were enablers. English language and numeracy were barriers. Trainee self-evaluations showed substantial increases in confidence, knowledge, and skills. Trainers assessed performance against 38 competencies, identifying strengths and areas for training modification. Trainees requested more flexibility and catch-up opportunities, more time for two-way learning, and to practice ear assessments. Thirteen communities employed 15 Ear Health Facilitators. This trial of a remote health workforce enhancement model demonstrated feasibility and preference for on-country work-readiness and technical training with harmonised job creation. This has the potential to improve effectiveness and sustainability of priority health services – in this case, ear and hearing health care. Infrastructure to support development of this workforce was a major barrier. Evaluation of workplace integration, sustainability, and impact on ear and hearing services will be reported separately. This trial was registered on clinicaltrials.gov on 16 April 2019, ID NCT03916029.