Listening first, then leading
The JCU Healthy Ageing Research Team (HART) has been delivering clinical geriatric services and undertaking research with Torres Strait and Northen Peninsula Area (NPA) communities for over 20 years. Led by Professor Edward Strivens, HART’s work is a collaborative method that ensures health interventions are shaped by the communities they serve.
From chronic disease prevention to dementia risk reduction, the team’s projects are grounded in co-design and built on trust, respect, and cultural understanding. This is done by building longstanding respectful relationships and listening to communities to identify what their priorities are. Communities are involved in all steps of the research from design and development through to research translation. Furthermore, much of HART’s success is due to their Torres Strait Islander team members who live and work in the Torres Strait and NPA.
A landmark study conducted by HART found that the prevalence of dementia in the Torres Strait was nearly three times higher than the national average, with earlier onset and high rates of comorbid chronic disease. The study revealed that nearly all participants with cognitive impairment had at least one vascular risk factor, such as hypertension or diabetes — conditions that are preventable and manageable with early intervention.
“These findings highlight the urgent need for culturally appropriate models of care,” says Professor Sarah Russell, lead author of the study. “Healthy lifestyles need to be promoted across the lifespan and services tailored to meet the specific needs of communities.”
Study results were used to set HART's research agenda, and the range of projects completed and underway.
Healthy ageing in the Torres Strait
One of HART’s flagship initiatives is the development of a framework for healthy ageing in the Torres Strait.
Funded by the NHMRC, this five-year project developed a framework to support communities in the Torres Strait and NPA to age well.
“The project commenced by engaging with five communities to set healthy ageing priorities. The team then worked with primary health care centres and community organisations on Continuous Quality Improvement activities to meet these priorities, and improve best practice care for older adults in the region”, says Dr Rachel Quigley, who led this project as part of her PHD.
The resulting framework provides strategies and recommendations to support ageing well at a community level, health service level, and individual level.
Chronic disease prevention
Given the high rates of chronic disease identified in the dementia prevalence study, the team yarned with communities to understand how they envisaged developing the programs to target risk factors for disease.
The Strong Communities, Strong Health project, supported by the Medical Research Future Fund, provided the team with the opportunity to address this.
The project took a strengths-based approach to co-design healthy lifestyle programs, develop and validate diet and physical activity tools designed for the Torres Strait and mapping of community assets to support healthy living.
“We’re not just collecting data, we’re building tools that communities can use,” says Melissa Kilburn, a dietitian on the team completing her PhD on this project. “It’s about creating sustainable change from within.”
Culturally safe mental health screening
Another groundbreaking project focuses on developing social and emotional wellbeing (SEWB) screening tools for use in primary care across the Torres Strait. This initiative, supported by the Ian Potter Foundation, FNQ Hospital Foundation, and Dementia Australia, responds to community feedback that existing tools, based on Western biomedical models, are often inappropriate and ineffective.
Results of yarning with communities found that the word “worry” is the most used term by First Nations peoples in the region to describe low SEWB with reduced community engagement and changes in behaviour, which were key signs of distress.
By developing tools that reflect local language, values, and experiences, HART is helping health workers better identify and support mental health needs in remote communities.
The right tools for the job
The team have also developed cognitive and quality of life screening tools appropriate for the region. “We are working with colleagues nationally to update the only Indigenous cognitive screening tool for dementia, known as the Kimberley Indigenous Cognitive Assessment, to ensure it remains relevant for the region,” says Professor Russell.
The Good Spirit, Good Life tool has also been adapted for the region. The gap for carer support was also addressed in a guide and resource developed in conjunction with carers and service providers in the region.
Reducing dementia risk through health service systems
HART has just completed a 5-year project to promote healthy ageing and reduce dementia risk among Aboriginal and Torres Strait Islander communities.
Funded by the NHMRC Boosting Dementia Research Grant, this initiative combines education, community engagement, and service innovation to address one of the most pressing health challenges facing older Australians. This project has taken a broader focus, working with Indigenous health services across Queensland.
Innovative models of care
With the study on dementia prevalence identifying high rates of mild cognitive impairment in the region, which is a risk factor for dementia, the team are piloting a model of care to address a current gap in service support.
This project is led by Dr Rhiann Sue-See, a geriatrician currently completing her PhD on the project. Working with communities, the team are piloting an eight-week program for community members addressing risk factors such as physical inactivity, poor diet, and social isolation.
All activities are designed to support brain health and wellbeing, delivered in a culturally safe manner by HART's local Torres Strait Islander team members.
A model for the Tropics and beyond
What makes HART’s work unique is its commitment to integrated service delivery. The team includes academics, clinicians, and researchers based in Cairns, and the Torres Strait, all working together to improve health outcomes in the Tropics.
Their model is being recognised nationally as a blueprint for how to do health research ethically, effectively, and equitably. The team are always looking for innovative ways to disseminate research findings such as their recent series of podcasts on dementia risk reduction and healthy ageing narrated by their Torres Strait team members. The series of four podcasts is titled “Let’s Yarn – Ageing Well in the Torres Strait”.
HART’s projects are also contributing to broader policy and practice. Their dementia research is guiding service planning and resource allocation in remote regions.
“Our research priorities are driven by community-identified needs,” says Professor Strivens, the team lead. “That’s how we make sure our work matters.”
“These approaches reflect HART’s commitment to culturally responsive research. By embedding local knowledge and leadership into every stage of the project, the team ensures that health interventions are relevant, respectful, and resilient”.