Health Promotion International, Vol. 25 No. 1
doi:10.1093/heapro/daq004
# The Author (2010). Published by Oxford University Press. All rights reserved.
For Permissions, please email: [email protected]
An ecological approach to health promotion in remote
Australian Aboriginal communities
ELIZABETH MCDONALD1*, ROSS BAILIE1, JOCELYN GRACE2
and DAVID BREWSTER3
1
Menzies School of Health Research, Institute of Advanced Studies, Charles Darwin University, Darwin,
NT, Australia, 2National Drug Research Institute, Curtin University of Technology, Perth, WA, Australia
and 3School of Medicine, James Cook University, Cairns, QLD, Australia
*Corresponding author. E-mail: [email protected]
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 communitybased 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.
Key words: Indigenous Australian; child health; ecological approach; hygiene
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 ¼ 56 900), many of whom live in
42
An ecological approach to health promotion
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,
43
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
44
E. McDonald et al.
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 selfgoverning 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:
An ecological approach to health promotion
(i) size and significance of childhood infections in remote Aboriginal communities
(ii) 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
(iii) hygiene interventions for which there is
sound epidemiological evidence of effect.
The findings of the literature reviews
informed community-based qualitative research
activities.
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
45
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).
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).
Fig. 1: Hygiene behaviours and community members’ knowledge, attitudes and practices: methods and
process.
46
E. McDonald et al.
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 ,22SD 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
An ecological approach to health promotion
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).
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
47
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
Fig. 2: PRECEDE/PROCEED model and HIF: integrated model. Adapted from [(Green and Kreuter,
1999), p. 50], and [(Bateman and McGahey, 2004), p. 10].
48
E. McDonald et al.
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 ¼ 38), provision of
inappropriate technology (23%, n ¼ 32) and
general damage (considered to be caused by
residents trying to do repairs themselves;
13.7%, n ¼ 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 ¼ 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.
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,
Table 1: Observed household contamination in one
Aboriginal community: IHANT survey, May 2002
Environmental health indicatora
Kitchen bench tops showed obvious signs of
contaminated surfaces
Faeces or other decaying matter observed on
surfaces inside the house (not kitchen
bench tops)
Faeces or other decaying matter observed on
sealed surrounds of the house
Any contaminated surfaces observed inside
or on sealed surrounds of the house
a
Houses
No.b
%
13
28.8
9
20.0
8
17.8
19
42.2
Contaminants observed inside or on the sealed surrounds
of houses where children ,7 years lived (n ¼ 45).
b
Data missing for two houses.
An ecological approach to health promotion
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.
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:
(i) the positive effects of regular bathing with
soap to prevent skin infections were not
well recognized in the study community
(ii) participants did not recognize the health
risks associated with the faeces of infants
and young children
49
(iii) all participants were unaware of the concept
of toilet training children from a young age
(iv) the role of flies and dogs in transmitting
infections appeared to be exaggerated
(v) some participants were familiar with the
concept of germs and the role they play
in causing disease
(vi) 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
(vii) there appeared to be a high level of tolerance towards seeing children with nasal
discharge
(viii) 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
Fig. 3: Mother sleeping with her children: three-pile sorting card image.
50
E. McDonald et al.
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
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
Multifaceted approaches required to reach
all community members to accommodate
traditional child-rearing practices such as
shared mothering
Some community members have found
solutions to important hygiene challenges
The model and approach taken needs to incorporate capacity building
at the organizational and individual levels
Most young children do not receive personal
or domestic hygiene education at home
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
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
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
Use and build on solutions that are already present in a community to
increase the chances of feasibility, acceptability and appropriateness
of interventions
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
Interventions should be designed and implemented using
community-based participatory research methods to ensure cultural
and social appropriateness
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)
An ecological approach to health promotion
51
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
Interventions need to promote an awareness of the transmission
infection transmission mechanisms of
mechanisms and likely immediate and long-term consequences of
common childhood infections
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
Acceptable and feasible methods need to be identified to counter
in the open poses an ongoing health
the negative effects of this practice (or change the behaviour);
risk to all children
achieve this by using participatory methods to develop
interventions
Low level of awareness exists around the
Health education and hygiene promotion programs should aim to
risks posed by common childhood
raise the level of awareness around the potentially infectious
infections and the potentially infectious
nature of faeces and most body fluids
nature of discharge and exudates due to
respiratory and skin infections
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
operates across sectors to focus on practical strategies that raise awareness and achieve behaviour
change in communities (Table 3).
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 victimblaming 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.
52
E. McDonald et al.
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.
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.
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