SUMMARY

Poor environmental conditions and poor child health in remote Australian Aboriginal communities are a symptom of a disjuncture in the cultures of a disadvantaged (and only relatively recently enfranchised) minority population and a proportionally large, wealthy dominant immigrant population, problematic social policies and the legacy of colonialism. Developing effective health promotion interventions in this environment is a challenge. Taking an ecological approach, the objective of this study was to identify the key social, economic, cultural and environmental factors that contribute to poor hygiene in remote Aboriginal communities, and to determine approaches that will improve hygiene and reduce the burden of infection among children. The methods included a mix of quantitative and qualitative community-based studies and literature reviews. Study findings showed that a combination of crowding, non-functioning health hardware and poor standards of personal and domestic hygiene underlie the high burden of infection experienced by children. Also, models of health promotion drawn from developed and developing countries can be adapted for use in remote Australian Aboriginal community contexts. High levels of disadvantage in relation to social determinants of health underlie the problem of poor environmental conditions and poor child health in remote Australian Aboriginal communities. Measures need to be taken to address the immediate problems that impact on children's health—for example, by ensuring the availability of functional and adequate water and sanitation facilities—but these interventions are unlikely to have a major effect unless the underlying issues are also addressed.

INTRODUCTION

Poor environmental conditions are widely recognized to underlie much of the poor health experienced by the residents of remote Aboriginal communities, especially children. Underlying the problem is a complex interplay between the physical environment, human behaviour and social policy. This article describes a study that examines these issues through the medium of child health. Literature reviews and qualitative and quantitative investigation inform the study. We expect the approach and the findings will have relevance to other remote Australian Aboriginal communities and many other settings around the world.

In Australia, the Indigenous population (Aboriginal and Torres Strait Islander peoples) makes up ∼2.4% of the total population. The Northern Territory (NT) has the largest proportion of its population who are Indigenous (29%, n = 56 900), many of whom live in remote communities ranging in size from a single family group to 2500 people (Australian Bureau of Statistics, 2007). Indigenous Australians are markedly disadvantaged when compared with non-Indigenous Australians on three key indicators: education, employment and income. Even where improvements have been made in these key areas, Indigenous people continue to be worse off than other Australians (Steering Committee for the Review of Government Service Provision, 2008).

Although some remote NT Aboriginal communities were established over 100 years ago, others have only been established in the last 50 years (Downing, 1988). Hence, it is over a relatively short period of time that Aboriginal people living in remote areas of the NT changed from a hunter-gatherer lifestyle to one of permanent settlement (Downing, 1988). In many instances government or mission personnel established contact with Aboriginal people by introducing ‘ration stations’ close to where one small group of hunter-gatherer people lived (Webb, 1970; Downing, 1988). Other groups were then attracted to the area because of the food and goods made freely available. At first, different groups came, stayed for a short time and then left (Webb, 1970; Downing, 1988). As groups became more dependent on handouts they stayed for longer periods of time and authorities then were able to establish permanent settlements (Webb, 1970; Downing, 1988; Djayhgurrnga and Singh, 1989). Aboriginal people soon became institutionalized and families became dependent on ‘handouts’ to meet most of their daily needs (Downing, 1988; Attwood, 2000; Ross, 2000). In 1967, discriminatory clauses concerning Aboriginal people were removed from the Australian Constitution and the federal government assumed responsibility for the affairs of all Australian Indigenous people. Steps to address the extreme disadvantage experienced by Indigenous Australians only commenced after the federal government allocated funding to be specifically used for this purpose (Long, 2000).

Environmental health policies have focused on providing technology and infrastructure such as water and sanitation systems and housing in remote Aboriginal communities. The need for governments to be seen to take action to improve the dire state of Aboriginal housing caused new dwellings to be constructed without considering the suitability of housing design, issues of maintenance and the need for residents to adapt living practices for the new environment (Long, 2000). Few people had insight into the potential problems that might arise (Long, 2000). The level of non-functional health hardware—for example, toilets and taps—in remote Aboriginal communities is high (Bailie and Runcie, 2001; Hoffman and Bailie, 2001) leading to environmental conditions that have a detrimental impact on the health of all householders, especially children (Bailie and Runcie, 2001).

Young children living in remote Aboriginal communities experience a high burden of common childhood infections—including ear, respiratory, skin and diarrhoeal disease—and high levels of underweight (14.5%), stunting (11.3%) and wasting (9.0%) (Li et al., 2007). A complex suite of factors, which include poor nutrition, acute and chronic infections and parasitic diseases, combine to inhibit the healthy growth of Aboriginal children in the NT (Brewster, 2003; Li et al., 2007). This impacts on their growth, and on children's wellbeing, cognitive development and educational outcomes. It leads to a greater likelihood of developing chronic disease in adulthood and to social disadvantage throughout life (Collins, 1995; Graham and Power, 2004; Kuh et al., 2004).

Efforts to improve Aboriginal children's health have focused to date largely on using vaccines and improved medical management to treat or eradicate diseases (Listorti and Doumani, 2002; McDonald et al., 2008). Past health promotion initiatives that aimed to reduce the prevalence of common childhood infectious diseases tended to focus on preventing the transmission of specific infections (Wong et al., 2001; Ewald et al., 2003). The impact of poor personal, domestic and community hygiene on children's health and the need for more general health-promoting approaches have largely been ignored (Commonwealth Department of Health and Aged Care, 1999; Listorti and Doumani, 2002). This has meant slow progress in improving Aboriginal child health in remote communities. There has been little or no research into the problem of hygiene as it relates to environmental living conditions that lead to poor health outcomes in remote Australian Aboriginal communities. This study aimed to identify the key social, economic, cultural and environmental factors that contribute to poor hygiene in one remote Aboriginal community so as to identify approaches that will reduce the burden of infection among children.

This study received ethics approval from the NT Department of Health and Community Services and Menzies School of Health Research's Human Research Ethics Committee. Support for the study was obtained initially from key community members and service providers in the community. Later the community's local governing agency, made up of senior members of the community and traditional landowners, gave their written approval. All persons who participated in the study gave written consent.

METHODS

Setting

Located in central Arnhem Land in the NT, the study community was identified as a suitable site for this research because its location, climate, population size and health profile are typical of many remote Indigenous communities in northern Australia. Furthermore, the author had already established trusting relationships with a number of community members, members of the local governing agency, the coordinator and staff of the women's resource centre and health centre staff. The author's experience of previously living and working in the community greatly assisted in developing the approaches taken and the methodology for the study's fieldwork components.

The community evolved from a base used by a group of non-Indigenous buffalo hunters in the late nineteenth century; from 1925 to the mid 1970s it was a mission station; it became self-governing in the 1970s. From less than 20 people in 1925, the population is now estimated to be between 854 (Australian Bureau of Statistics, 2002) and 1100 persons (Territory Housing, 2000). In 2001, 37.5% of the community's total Indigenous population were aged <15 years, and 49% of these children were <4 years old (Australian Bureau of Statistics, 2002).

Worldwide, despite different experiences of colonialism, Indigenous people have experienced some common impacts, manifestations of which include: alcohol and substance abuse; high levels of violence within families and among community members; and economic deprivation (Libesman, 2004). In the study community, these impacts have led to high levels of community, household and individual dysfunction. High rates of diabetes, renal disease and respiratory disease are present in the community; children's health is poor (d'Espaignet et al., 1998; Li et al., 2007).

The services available in the study community are similar to those available in most remote Australian Indigenous communities of similar population size. They include a store, health centre, police station, primary school, art centre, garage, social club, bank and social welfare and post office agencies. At the time of the study, the local governing agency, through grant-in-aid funding, provided additional community services—for example, some aged care and a women's resource centre. The local governing agency administered: the community housing program's construction, and repairs and maintenance; and environmental health programs, including garbage collection and disposal, animal control and the maintenance of public places. Essential services available to the community included electricity (the community had its own generator), piped bore water, sewerage treatment (pond) system, airstrip and telephone communications.

Design

This study's design is based on social ecological theory as it applies to research concerning hygiene improvement. Stokols (Stokols, 1992) describes social ecological theory as a set of theoretical principles for understanding the interrelations among diverse personal and environmental factors in human health and illness. Study methods included a mix of narrative and systematic literature reviews, and quantitative and qualitative community-based studies. An extended report of the study including full details of the design, methods and data analysis is available (McDonald, 2007).

Literature reviews

The literature reviews explored the significant social, cultural, economic and environmental factors that shape the lifestyles of people in remote Aboriginal communities, and aimed to provide an overview of past hygiene improvement approaches used with little success. The literature reviews were used to identify the: The findings of the literature reviews informed community-based qualitative research activities.

  • size and significance of childhood infections in remote Aboriginal communities

  • most appropriate and effective health promotion models, approaches and methods to address problems of poor hygiene, including how hygiene promotion models used in developing countries might inform the development of local programs

  • hygiene interventions for which there is sound epidemiological evidence of effect.

Community-based studies

Research in the study community aimed to: gain a better understanding of the extent to which the risk factors of poor housing, crowding and a low standard of hygiene existed in houses where children under 7 years lived; and describe community members’ knowledge about the transmission mechanisms of common childhood infections, and their attitudes towards hygiene behaviours needed to reduce the transmission of these infections.

The researchers conducted on behalf of the community a housing survey which was part of an existing Indigenous Housing Association of the NT (IHANT) program. This was to identify, as a basis for developing more effective hygiene improvement measures: levels of housing functionality, the likely reasons for non-functional infrastructure, and to what extent environmental contamination was present in and around houses.

Focus groups, case studies and interviews were used to: gain an understanding of what motivates and supports current hygiene-related child care practices; and identify opportunities to improve hygiene. The focus groups used the ‘three-pile sorting cards’ participatory research methodology (Srinivasan, 1993), whereby participants discuss and sort cards depicting local scenes as ‘good’, ‘not good’ or ‘unsure’. Case studies used the positive deviant approach (Berggren and Wray, 2002). In-depth interviews were conducted with key informants (Figure 1).

Fig. 1:

Hygiene behaviours and community members’ knowledge, attitudes and practices: methods and process.

Fig. 1:

Hygiene behaviours and community members’ knowledge, attitudes and practices: methods and process.

FINDINGS

Significant background factors

It is generally agreed that Aboriginal Australians living in remote communities experience extreme disadvantage (Steering Committee for the Review of Government Service Provision, 2008). The level of this disadvantage causes some NT Aboriginal writers to describe a cycle of ‘grief, anger and despair’ that leads to substance abuse, violence, suicide, poor nutrition and child neglect in many remote communities (AMSANT, 2001). Hunter (Hunter, 1995) observed that Indigenous Australians are more likely to encounter multiple risk factors with access to fewer sources of resilience. Many Aboriginal people who live in remote communities are disempowered to the extent that they accept their predicament. High levels of individual, family and community dysfunction impede outside efforts to mobilize communities. The legacy of past government policies has led Aboriginal people to distrust outsiders and be suspicious of new government policies and programs (Scougall, 2006; Baum, 2007).

Past hygiene improvement approaches

The overview of past approaches used to improve hygiene in remote Aboriginal communities was mostly drawn from historical records and unpublished reports, an indication of the low priority accorded this issue previously. Governments appear not to have recognized the impact of establishing permanent settlements and the role of related social influences on individual and group health and hygiene behaviour. In some cases the approaches used led to resistance in adopting health-promoting behaviours (Tatz, 1974; Brady, 1991). There was, and is still, no central plan or coordination of activities to promote hygiene in remote communities. Programmes based on single interventions continue to be funded, for example—one-off educational workshops and awareness-raising campaigns. Providing health and hygiene education to primary caregivers on a one-to-one basis or in small group sessions continues to be the main method for promoting child health.

Childhood infections

The level and significance of the burden of infection experienced by children living in remote Aboriginal communities was high. According to routinely collected growth data, ∼30% of the children under 5 years in the community were categorized as failing to thrive, that is, their growth rates were <−2SD Weight for Age (World Health Organization, 1979). Reliable community level morbidity data were not available, but NT Indigenous infant mortality and hospitalization rates indicated the extent of the problem: NT Aboriginal infants aged between 4 weeks and 1 year were seven times more likely to be admitted to hospital than non-Aboriginal children of the same age. The majority of these admissions were for respiratory, infectious and parasitic diseases (69%); the average number of conditions associated with each episode of hospitalization was 2.7 (d'Espaignet et al., 1998). Chronic suppurative otitis media was very common in remote NT communities (Coates et al., 2002) and bronchiectasis was not uncommon (Coates et al., 2002). Scabies and group A streptococcal pyoderma was endemic in many communities (Carapetis and Currie, 1998; Wong et al., 2001). Subsequently, the prevalence of post-streptococcal glomerulonephritis was high (White et al., 2001) and led to children's continuing high rates of rheumatic fever and rheumatic heart disease (Borghi et al., 2002; Currie, 2002). In some communities, children still experienced high rates of trachoma (Taylor, 2001).

Health promotion models

The comprehensive review of health promotion models, frameworks and theories found two models suitable for use in the context of remote Aboriginal communities. The PRECEDE/PROCEED model (Green and Kreuter, 1999) is based on clearly articulated and tested theories. The Hygiene Improvement Framework (HIF) (Bateman and McGahey, 2004) addresses the necessary technical components. Both models support the use of a comprehensive ecological approach that enables the multiple factors which underlie a problem to be addressed strategically. Both were developed to apply at multiple levels and involve intersectoral activity.

The PRECEDE/PROCEED model is particularly suitable to use in remote communities because the necessary planning processes are more likely to prevent unintended consequences occurring as a result of an intervention. This model also provides for reciprocal determinism theory—that is, it acknowledges that the environment influences and sets limits on behaviours, so that behaviour can be modified by changing environmental variables (Green and Kreuter, 1999).

The HIF was developed by the United States Agency for International Development's Environmental Health Project as an integrated approach to prevent diarrhoeal disease in developing countries (Bateman and McGahey, 2004). This framework has three core components: access to hardware, hygiene promotion and the promotion of enabling environments.

Integrating the two models takes account of the technical, planning and process factors necessary to address the problem of poor hygiene in remote Aboriginal communities effectively (Figure 2).

Fig. 2:

PRECEDE/PROCEED model and HIF: integrated model. Adapted from [(Green and Kreuter, 1999), p. 50], and [(Bateman and McGahey, 2004), p. 10].

Fig. 2:

PRECEDE/PROCEED model and HIF: integrated model. Adapted from [(Green and Kreuter, 1999), p. 50], and [(Bateman and McGahey, 2004), p. 10].

Hygiene interventions

The systematic review of the epidemiological literature on hygiene interventions showed that the quality of the reported evidence was generally poor. Only one study provided sound epidemiological evidence of effect to support the outcome; there is clear and strong evidence that education and hand washing with soap prevent diarrhoeal disease among children (Luby et al., 2004).

This intervention should be included in all hygiene improvement programmes. The need for hand washing with soap is arguably of greater importance in remote Aboriginal communities, where high rates of disease among children reflect high levels of environmental contamination with infective material. Hand washing with soap has benefits beyond prevention of diarrhoeal disease. Luby et al. (Luby et al., 2005) showed that their intervention of hygiene education, hand washing with soap and encouraging frequent bathing resulted in a 34% lower incidence of impetigo (95% CI 0.48, 0.84), and a 50% lower incidence of pneumonia (95% CI 0.35, 0.66) among children aged <5 years compared with the control group. In the context of remote Aboriginal communities, however, ready access to soap, a sufficient quantity of water and functional health hardware cannot be taken for granted.

Although the size of the effects was small and the quality of the studies generally poor, there was some evidence of the effects on reducing rates of diarrhoeal disease among children of: hygiene education and other hygiene behaviour change interventions—for example, washing dishes immediately after meals (Pinfold and Horan, 1996), using potties (Huttly et al., 1998), and the provision of water supply, sanitation and hygiene education (Stanton et al., 1987). Studies of face washing and hygiene education (West et al., 1995), and insecticide spraying to control flies to reduce rates of trachoma (Emerson et al., 1999) failed largely to provide any evidence of effect. This is likely to be due to factors such as the endemic nature of trachoma and its transmission occurring through multiple routes (McDonald et al., 2008).

The many interrelated factors that underlie poor living conditions and poor hygiene, both of which lead to poor health outcomes in remote communities, make it unlikely that a single intervention will be sufficient to reduce the rate of infections experienced by children. Therefore, it might be appropriate to pursue interventions that have limited evidence of effect but recognized as helping reduce the risk of disease, for example—face washing to reduce transmission of trachoma (Emerson et al., 2000). Hygiene interventions may fail to show an impact on rates of infection for a number of reasons (McDonald et al., 2008).

Housing and environmental contamination

Children under 7 years lived in 47 of the 86 houses surveyed in the study community. In 41 one of the 47 houses (89.3%), one or more items needed major or urgent repair or an essential item was missing. Household items considered necessary to easily carry out six key healthy living practices—wash people, wash clothes, functioning toilet, remove waste water, remove waste rubbish and prepare and store food (Pholeros et al., 1993)—were checked; in total, 231 needed repair or were missing.

Officers who completed the survey identified the primary reasons for items having major problems and/or needing urgent repairs as: normal wear and tear (27.3%, n = 38), provision of inappropriate technology (23%, n = 32) and general damage (considered to be caused by residents trying to do repairs themselves; 13.7%, n = 19). They gave several reasons to explain these findings. Firstly, they considered that, at the time of the survey, the community did not have the resources available to undertake timely repair and maintenance of essential items. Many households had stopped reporting their repair needs because the waiting time was so long or they believed action would not be taken. Many householders readily accepted dysfunctional infrastructure items—for example, leaking taps or sinks slow to empty—until the problem became more serious. Some householders appeared not to recognize that items of infrastructure need ongoing maintenance to stay in good order, but others failed to recognize and report problems early (when minor repairs would suffice).

The majority of the surveyed houses were three-bedroom houses (n = 38). The average number of persons living in the three-bedroom houses was nine (4.8 adults and 4.2 children <16 years); the minimum was three (2 adults and 1 child <16 years); the maximum was 15 (7 adults and 8 children <16 years). On the basis of the housing occupancy standard of a maximum of two persons for each available bedroom (Australian Bureau of Statistics, 2000), a significant level of crowding was present in many of the houses where children under 7 years lived; however, no statistically significant association was found between the level of crowding and the number of items that were missing or needed repairs. The assessment for environmental contamination showed that in 19 (42.2%) of all houses where children under 7 years lived, faeces or other decaying matter was observed in the immediate living environment (Table 1). In five (11%) of the houses, contaminated matter was observed on surfaces both inside and outside the house.

Table 1:

Observed household contamination in one Aboriginal community: IHANT survey, May 2002

Environmental health indicatora Houses
 
No.b 
Kitchen bench tops showed obvious signs of contaminated surfaces 13 28.8 
Faeces or other decaying matter observed on surfaces inside the house (not kitchen bench tops) 20.0 
Faeces or other decaying matter observed on sealed surrounds of the house 17.8 
Any contaminated surfaces observed inside or on sealed surrounds of the house 19 42.2 
Environmental health indicatora Houses
 
No.b 
Kitchen bench tops showed obvious signs of contaminated surfaces 13 28.8 
Faeces or other decaying matter observed on surfaces inside the house (not kitchen bench tops) 20.0 
Faeces or other decaying matter observed on sealed surrounds of the house 17.8 
Any contaminated surfaces observed inside or on sealed surrounds of the house 19 42.2 

aContaminants observed inside or on the sealed surrounds of houses where children <7 years lived (n = 45).

bData missing for two houses.

Community knowledge, attitudes and practices

The level of knowledge displayed by community members about the transmission mechanisms of common childhood infections was, at face value, reasonable. Overall, however, most participants did not have a good understanding about hygiene; frequently during discussions, participants contradicted themselves or used factual information out of context.

This confusion was apparent in the focus groups that used the three-pile sorting cards. It applied to scenarios generally considered ‘good’ or ‘not good’, and rated similarly so by participants. When participants identified both ‘good’ and ‘not good’ behaviours they associated with these scenarios, they preferred to say they were ‘unsure’ of their response rather than state that a highly valued behaviour was ‘not good’. For example, the depiction of a mother sleeping with her children (Figure 3) was generally regarded very positively. Participants stated, ‘She's looking after her children. She doesn't drink or anything’, ‘The mother loves the kids, she's looking after her children’ and ‘The mother is telling kids good stories … looking after those kids’; however, two groups recognized that it was not good for a child with scabies to be sleeping with other children.

Fig. 3:

Mother sleeping with her children: three-pile sorting card image.

Fig. 3:

Mother sleeping with her children: three-pile sorting card image.

Focus group participants exhibited a tolerant attitude towards children defecating in the open, as well as towards children depicted with discharging sores and ear and nasal discharge. Findings about the levels of knowledge and attitudes towards specific hygiene behaviours, and the role these behaviours play in reducing the transmission of infection include:

  • the positive effects of regular bathing with soap to prevent skin infections were not well recognized in the study community

  • participants did not recognize the health risks associated with the faeces of infants and young children

  • all participants were unaware of the concept of toilet training children from a young age

  • the role of flies and dogs in transmitting infections appeared to be exaggerated

  • some participants were familiar with the concept of germs and the role they play in causing disease

  • the concept of infections being transferred by coughing appeared to be understood, but the concept of children's nasal discharge being infectious did not appear to be recognized

  • there appeared to be a high level of tolerance towards seeing children with nasal discharge

  • spitting was well tolerated on condition that it was where others were not going to walk or well away from where a group was sitting.

DISCUSSION

Complex interrelated factors, both historical and contemporary, are responsible for the poor living conditions and continued high rates of common childhood infections in remote Aboriginal communities. High levels of disadvantage in relation to social determinants of health underlie many of these factors. Difficult issues to be resolved include the unintended consequences of past government policies. The complexity of the problem requires a strategic approach that addresses the underlying issues. Achieving such a strategic intersectoral approach is a challenge given the current ‘silo’ approach to government program development and delivery.

An ecologically based assessment can provide the foundation for developing culturally grounded prevention interventions for Indigenous contexts (Okamoto et al., 2006). The integrated PRECEDE/PROCEED model and HIF described in this article offers a suitable mechanism to undertake ecologically based assessments in remote Aboriginal communities and to plan, implement and evaluate comprehensive health promotion programmes aimed at reducing the rate of infections among children in these communities.

Evidence-based interventions are necessary (Couzos and Murray, 2003) but the success of any intervention is dependent on: (i) the physical and social environment being enabling; (ii) community members having the necessary skills and knowledge; and (iii) the intervention and the approach used being well received by community members. Involving community members in designing and delivering interventions is the only means of ensuring programs are culturally appropriate and acceptable (Coombs, 1978; Coombs et al., 1983).

In this article, we identified that hand washing with soap is the single intervention most likely to reduce the rate of infection among children. However, the potential success of the intervention is based on meeting the three aforementioned prerequisites. Furthermore, consistent with the principles of the Ottawa Charter for Health Promotion (World Health Organization, 1986) and good primary health care practice, all health-promoting activities among disadvantaged groups need to include strategies to empower individuals and groups.

The implications for future hygiene promotion are extensive. They include recognition of cultural beliefs and practices, and the need for multifaceted approaches that build community capacity. Programme development approaches that demonstrate sensitivity, and engage all members of a community, will work best (Table 2); as will health promotion practice that operates across sectors to focus on practical strategies that raise awareness and achieve behaviour change in communities (Table 3).

Table 2:

Program development: key findings and implications

Program approaches
 
Finding Elements for future hygiene promotion 
Social, economic, cultural and infrastructure factors contribute to the problem of unhealthy living conditions and poor hygiene in remote Indigenous communities A multifaceted or ecological program approach is required to address the multiple causes of the problem; suggest incorporating constructs of the PRECEDE/PROCEED model and the HIF 
Little capacity at organizational, household or individual levels in remote Indigenous communities to address the problems The model and approach taken needs to incorporate capacity building at the organizational and individual levels 
Multifaceted approaches required to reach all community members to accommodate traditional child-rearing practices such as shared mothering Programs need to reach and engage all members of the community, not just the primary carers of children; a ‘whole of community approach’ is most appropriate 
Some community members have found solutions to important hygiene challenges Use and build on solutions that are already present in a community to increase the chances of feasibility, acceptability and appropriateness of interventions 
Most young children do not receive personal or domestic hygiene education at home Greater emphasis needs to be placed on teaching good hygiene to children at school and preschool in a way that they can easily apply in their homes 
Cultural beliefs and practices need to be acknowledged and respected; although some practices increase the risk of infection they provide other social and emotional benefits to children Interventions should be designed and implemented using community-based participatory research methods to ensure cultural and social appropriateness 
Hygiene and environmental health are sensitive topics; Indigenous Australians living in remote communities are aware of how they might be perceived by non-Indigenous Australians Community members should not be made to feel ‘shamed’; the child welfare sector suggests using minimal intrusion approaches to overcome any residual anger and hostility caused by past government policies (Litwin, 1997
Program approaches
 
Finding Elements for future hygiene promotion 
Social, economic, cultural and infrastructure factors contribute to the problem of unhealthy living conditions and poor hygiene in remote Indigenous communities A multifaceted or ecological program approach is required to address the multiple causes of the problem; suggest incorporating constructs of the PRECEDE/PROCEED model and the HIF 
Little capacity at organizational, household or individual levels in remote Indigenous communities to address the problems The model and approach taken needs to incorporate capacity building at the organizational and individual levels 
Multifaceted approaches required to reach all community members to accommodate traditional child-rearing practices such as shared mothering Programs need to reach and engage all members of the community, not just the primary carers of children; a ‘whole of community approach’ is most appropriate 
Some community members have found solutions to important hygiene challenges Use and build on solutions that are already present in a community to increase the chances of feasibility, acceptability and appropriateness of interventions 
Most young children do not receive personal or domestic hygiene education at home Greater emphasis needs to be placed on teaching good hygiene to children at school and preschool in a way that they can easily apply in their homes 
Cultural beliefs and practices need to be acknowledged and respected; although some practices increase the risk of infection they provide other social and emotional benefits to children Interventions should be designed and implemented using community-based participatory research methods to ensure cultural and social appropriateness 
Hygiene and environmental health are sensitive topics; Indigenous Australians living in remote communities are aware of how they might be perceived by non-Indigenous Australians Community members should not be made to feel ‘shamed’; the child welfare sector suggests using minimal intrusion approaches to overcome any residual anger and hostility caused by past government policies (Litwin, 1997
Table 3:

Health promotion practice: key findings and implications

Finding Key elements for future hygiene promotion 
Interventions and implementation strategies
 
Study participants did not understand clearly infection transmission mechanisms of common childhood infections Interventions need to promote an awareness of the transmission mechanisms and likely immediate and long-term consequences of infections for the health of children 
Size of the problem indicates single interventions are unlikely to make a health impact—for example, promoting only handwashing when there are high levels of environmental contamination Multifaceted interventions are required, for example: intersectoral planning and service delivery; community health hardware maintenance programs; environmental health, domestic and personal hygiene behaviour change and educational programmes 
Care needs to be taken proposed interventions do not introduce additional social or health risks An example is promoting the use of potties when it is likely that faeces still might not be disposed of correctly or the potties not cleaned appropriately 
Opportunity to build on positive attitudes held by community members Communication strategies to promote hygiene can facilitate behaviour change by using images that are positively valued by community members—for example, a family sitting together and eating 
Education content 
High tolerance of young children defecating in the open poses an ongoing health risk to all children Acceptable and feasible methods need to be identified to counter the negative effects of this practice (or change the behaviour); achieve this by using participatory methods to develop interventions 
Low level of awareness exists around the risks posed by common childhood infections and the potentially infectious nature of discharge and exudates due to respiratory and skin infections Health education and hygiene promotion programs should aim to raise the level of awareness around the potentially infectious nature of faeces and most body fluids 
Low level of compliance among community members to performing the most basic of hygiene behaviours—for example, handwashing after changing infants’ nappies and contact with young children's faeces The content of hygiene education programs need to focus initially on the performance of basic hygiene behaviours at the appropriate times: didactic teaching methods should be avoided; use of ‘scare’ strategies is not likely to be effective; providing positive images, the use of role models and social marketing strategies are likely to be most successful 
Finding Key elements for future hygiene promotion 
Interventions and implementation strategies
 
Study participants did not understand clearly infection transmission mechanisms of common childhood infections Interventions need to promote an awareness of the transmission mechanisms and likely immediate and long-term consequences of infections for the health of children 
Size of the problem indicates single interventions are unlikely to make a health impact—for example, promoting only handwashing when there are high levels of environmental contamination Multifaceted interventions are required, for example: intersectoral planning and service delivery; community health hardware maintenance programs; environmental health, domestic and personal hygiene behaviour change and educational programmes 
Care needs to be taken proposed interventions do not introduce additional social or health risks An example is promoting the use of potties when it is likely that faeces still might not be disposed of correctly or the potties not cleaned appropriately 
Opportunity to build on positive attitudes held by community members Communication strategies to promote hygiene can facilitate behaviour change by using images that are positively valued by community members—for example, a family sitting together and eating 
Education content 
High tolerance of young children defecating in the open poses an ongoing health risk to all children Acceptable and feasible methods need to be identified to counter the negative effects of this practice (or change the behaviour); achieve this by using participatory methods to develop interventions 
Low level of awareness exists around the risks posed by common childhood infections and the potentially infectious nature of discharge and exudates due to respiratory and skin infections Health education and hygiene promotion programs should aim to raise the level of awareness around the potentially infectious nature of faeces and most body fluids 
Low level of compliance among community members to performing the most basic of hygiene behaviours—for example, handwashing after changing infants’ nappies and contact with young children's faeces The content of hygiene education programs need to focus initially on the performance of basic hygiene behaviours at the appropriate times: didactic teaching methods should be avoided; use of ‘scare’ strategies is not likely to be effective; providing positive images, the use of role models and social marketing strategies are likely to be most successful 

An important limitation of the study's findings is that the fieldwork was conducted in only one remote community. Nevertheless, the study findings are generally consistent with other Australian and international research (Webb, 1970; Francis et al., 1971; Hamilton, 1981; Fewtrell and Colford, 2004). Time and resources did not allow this research to address the important contribution that poor nutrition makes to the poor health of children living in these communities. Significant gains in Aboriginal child health are unlikely to be achieved until both issues—hygiene and nutrition—are addressed effectively.

The findings of the study were disseminated to community members and more widely by means of a policy briefing paper and information sheets for community-based health workers. There was general consensus among community members and those working in Aboriginal health in the Top End that this study's findings reflect the reality of the problem and needs on the ground.

The challenge of using an ecological approach to achieve a sustained impact on hygiene and health in remote communities lies in gaining the ongoing commitment of government. This commitment is essential to allow sufficient time and resources for community development approaches and effective intersectoral action, both of which are central to gaining the trust of community leaders so as to develop hygiene programmes with their input and cooperation. It is crucial that programmes do not engage in victim-blaming or denigrating Aboriginal culture, however unwittingly. Instead the focus should be to raise self-esteem, and empower individuals and communities through increasing knowledge and practical action to improve child health.

FUNDING

E.M. was supported by a National Health and Medical Research Council (NHMRC) PhD—Primary Health Care and Cooperative Research Centre for Aboriginal Health Scholarships to do this study.

ACKNOWLEDGEMENTS

This research was completed with the assistance and goodwill of community members and administrators, government field staff, senior policy-makers and managers from various government departments.

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