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This program recognises and implements prevention changes that aim to reduce the level and impact of preventable chronic health conditions and promote better health for Aboriginal and Torres Strait Islander people and communities living in the Illawarra and Shoalhaven areas.

The Aunty Jean's Good Health Team started as an idea for a program with a real difference in health for Aboriginal and Torres Strait Islander people. The program has been built around the community's capacity to work together to achieve better health outcomes, with Elders leading the way.

The aim of the Aunty Jean's Good Health programs are targeted at Aboriginal and Torres Strait Islander people with, or at risk of, chronic illness. Aboriginal and Torres Strait Islander people with chronic illness are often socially isolated and don't seek help. The objective of Aunty Jean's programs is to create a supportive environment, for participants to learn, be active and become confident in self-management of their condition/s.

The aim of the Aunty Jean's Aboriginal Chronic Care Programs are to work within a target community group of Aboriginal and Torres Strait Islander people in the Illawarra and Shoalhaven who are at risk of chronic disease. The aim is to improve the physical wellbeing for these Aboriginal and Torres Strait Islander communities, via group exercise support, health education and screening.

A vascular health approach that includes diabetes, heart disease, stroke, hypertension and kidney disease has been adopted because of the shared risk conditions and common approaches needed to prevent and manage these conditions in Aboriginal and Torres Strait Islander communities.

Objectives to the program were to deliver a flexible, approach to chronic care program delivery for people at risk or suffering from chronic diseases.  With a focus on changes to lifestyle choices to improve their quality of life by:

• facilitate the implementation of the components of the NSW Aboriginal Health Strategic Plan (which relate to chronic disease).
• improving standards of clinical care for Aboriginal and Torres Strait Islander people with or at risk of vascular disease ensuring a more consistent approach, support for chronic disease self-management and reduction in hospitalisation for preventable complications.
• playing a key role in facilitating the development of appropriate Chronic Care Program initiatives in relation to vascular disease in Aboriginal and Torres Strait Islander people.
• providing input into implementation of related strategies of the Aboriginal Health Strategic Plan that are pertinent to the delivery of a continuum of prevention and care for Aboriginal and Torres Strait Islander people in relation to chronic disease.
• facilitating and supporting the implementation of local initiatives aiming to improve the provision of prevention and care programs to the Aboriginal and Torres Strait Islander community.
• facilitating a more coordinated approach to Aboriginal health by directly linking with other related Aboriginal health strategies.

To determine the needs of a program aimed at Aboriginal people at risk of chronic disease.

• Increased awareness of services and resources available to the community.
• Increased awareness of chronic health issues affecting these communities.
• Attendance at exercise program.
• Participation in screening.
• Participating in nutrition education.
• Participate in individual tailored daily home program.
• Participants to fill in required information into dairy.

The program identified, out of the10 participants who initially commenced, when the program started in 2002, and the current participants, have identified improvements in:

1. Loss of weight
2. Reduced hospital admissions
3. Social lifestyle improvements (addresses social isolation)
4. Prevention from surgery
5. BSL lowered on those who identified at risk of diabetes and those who are a diabetic
6. Increased knowledge of lifestyle diseases and preventative measures
7. Increase in physical activities
8. Participants claim a reduction of depression
9. Ability to set health management goals with educators

A screening health check that includes, heart disease, stroke, hypertension and kidney disease has been adopted because of the shared risk conditions and common approaches needed to prevent and manage these conditions in Aboriginal communities.

The program commenced in May 2004 and the community members' results showed a high statistical improvement to their health status, which reduces the risk of chronic lifestyle diseases such as diabetes, heart disease, high blood pressure and obesity. The program has also been adopted by the Shoalhaven area, which has been has been operational since May 2004, and will be celebrating it's fifth birthday in May 2009.

The Shoalhaven group has had over ninety people attend the program, with a core group of people being up to 25 attending per week. This core group are not necessarily the same people every week as the program is designed in such a way that people attend the program when they need to, the program runs from mid February to mid December every year.

All participants attending also showed a marked improvement to their health status.

The Aunty Jeans program, adopted the Mini Olympics which started in 2005, a friendly competition between Nowra and Wollongong programs with about 30 participants attending. This has now grown and since 2007 other area health services are coming along with Aboriginal elders. Areas include Nambucca Heads, Eden (about 60 participants) and in 2008 Albury, Eden, Bega and La Perouse competed for the medals as well as Nowra and Wollongong with about 80 people competing. Competition is strong.

The "Aunty Jean's Good Health Team" has been adapted in the Greater Southern Area Health Service with about another 6-7 towns starting up their own programs using SESIAHS framework and resources adapted to meet the needs of their communities, Albury, Eden, Bega, Batemans Bay, Tumut and Narrandera.

The Aunty Jeans program participants successfully developed a community chronic care DVD resource, funded by the IMB society. The DVD was successfully launched on the 30th September 2008. The Shoalhaven program is now undergoing accreditation. The Wollongong Program will follow on later as an accredited program. Once accreditation has taken place Aunty Jean's can then be distributed across the state, as a successful health program to engage Aboriginal and Torres Strait Islander communities at risk of chronic lifestyle diseases.

Screening health checks include heart disease, stroke, diabetes, hypertension and kidney disease, because of the shared risk conditions and common approaches needed to prevent and manage these conditions in Aboriginal and Torres Strait Islander communities. One Clinical Nurse Consultant and One Clinical Nurse Specialist provide screening and monitoring, along with Cardiac Rehab workers to oversee individual clients at the Shoalhaven program, including follow up and referral.

The Shoalhaven program works in partnership with the Nowra Division of General Practice that provides the services of a dietician. The dietician attends to individual client care needs as well as delivers group education at the program. The Illawarra area is also in the process of developing the same partnership with the Wollongong Division of General Practice.  Both the Illawarra and Shoalhaven Aunty Jean's programs include a series of warm ups (gentle stretching exercise) followed by an exercise circuit as well as education sessions on Good Nutrition, that incorporate sessions on preparing easy nutritious meals.

To run a weekly chronic care program to the local Aboriginal community in the Nowra and Dapto area, was achieved by

• Monthly team meetings with major stakeholders
• Working in partnership with the university of Wollongong, Heart Foundation
• Community consultation days
• Planned a comprehensive weekly chronic care program 
• Planned transport, venue, catering, physiologist, nurses and equipment
• Evaluation processes

The Aunty Jean's Good Health Team, previously known as, Illawarra Aboriginal Vascular Health Program (IAVHP) worked with program participants in Berkeley and Shoalhaven, the University of Wollongong (UoW) Faculty of Health & Behavioural Sciences and Audiovisual Production and Services Unit, to make a DVD which tells the personal stories of people who have benefited from the Aunty Jean's Program.

The DVD has been made for Elders and other participants of the Aunty Jean's Programs, to share their stories with family and community, to encourage improved health behaviours and participation in the program. It will also be used for other Aboriginal Health Workers and service providers wishing to commence a program in their community. The funding for the DVD project was obtained by the University of Wollongong from the IMB Community Foundation.

• The Aunty Jean's Good Health Team started as an idea for a program with a difference. The program has been built around the community's capacity to work together to achieve better health outcomes, with Elders leading the way.
• The Aunty Jean's Good Health Team targets Aboriginal and Torres Strait Islander people with, or at risk of, chronic illness. Aboriginal and Torres Strait Islander people with chronic illness are often socially isolated and don't seek help. The program has created a supportive environment, for participants to learn, be active and become confident in self-management of their condition/s.
• The Aunty Jean's Good Health Program has become a firmly established Chronic Care Program, now running for five years, and has been adapted in the Illawarra and Shoalhaven communities.

• All new participants entering the program can be captured in the rehabilitation data as per the SAP KPI (a) and will significantly increase the numbers into a rehabilitation program together with the recruitment strategy of new participants.
  (a) 60% of Aboriginal people with a chronic disease participating in and completing Rehabilitation, Com Packs and CAPAC programs.
• The NSW Department of Health's Chronic Care for Aboriginal People team met with SESIAHS Aboriginal Chronic Care staff to outline necessary steps required to modify the Aunty Jean’s program for Accreditation (within the Walgan Tilly framework) as a Rehabilitation Program and will be launched in July.
• An Action Plan has been developed to ensure the required changes to the program are in place by June 2009. Due to the short timeframe it may be necessary to release identified stakeholders to assist with the strategies outlined in the project plan.

Aboriginal Vascular Health Worker, South Eastern Sydney Illawarra Area Health Service
Phone: 02 4422 8111