Elizabeth L. McDonald

Skin infection, housing and social circumstances in children living in remote Indigenous communities: testing conceptual and methodological approaches

BackgroundPoor housing conditions in remote Indigenous communities in Australia are a major underlying factor in poor child health, including high rates of skin infections. The aim of this study is to test approaches to data collection, analysis and feedback for a follow-up study of the impact of housing conditions on child health.MethodsParticipation was negotiated in three communities with community councils and individual participants. Data were collected by survey of dwelling condition, interviews, and audit health centre records of children aged under seven years. Community feedback comprised immediate report of items requiring urgent repair followed by a summary descriptive report. Multivariate models were developed to calculate adjusted incidence rate ratios (IRR) for skin infections and their association with aspects of household infrastructure.ResultsThere was a high level of participation in all communities. Health centre records were inadequate for audit in one community. The records of 138 children were available for development of multivariate analytic models. Rates of skin infection in dwellings that lacked functioning facilities for removing faeces or which had concrete floors may be up to twice as high as for other dwellings, and the latter association appears to be exacerbated by crowding. Younger children living in older dwellings may also be at approximately two-fold higher risk. A number of socioeconomic and socio-demographic variables also appear to be directly associated with high rates of skin infections.ConclusionThe methods used in the pilot study were generally feasible, and the analytic approach provides meaningful results. The study provides some evidence that new and modern housing is contributing to a reduction in skin infections in Aboriginal children in remote communities, particularly when this housing leads to a reduction in crowding and the effective removal of human waste.

Are hygiene and public health interventions likely to improve outcomes for Australian Aboriginal children living in remote communities? A systematic review of the literature

BackgroundAustralian Aboriginal children living in remote communities still experience a high burden of common infectious diseases which are generally attributed to poor hygiene and unsanitary living conditions. The objective of this systematic literature review was to examine the epidemiological evidence for a relationship between various hygiene and public health intervention strategies, separately or in combination, and the occurrence of common preventable childhood infectious diseases. The purpose was to determine what intervention/s might most effectively reduce the incidence of skin, diarrhoeal and infectious diseases experienced by children living in remote Indigenous communities.MethodsStudies were identified through systematically searching electronic databases and hand searching. Study types were restricted to those included in Cochrane Collaboration Effective Practice and Organisation of Care Review Group (EPOC) guidelines and reviewers assessed the quality of studies and extracted data using the same guidelines. The types of participants eligible were Indigenous populations and populations of developing countries. The types of intervention eligible for inclusion were restricted to those likely to prevent conditions caused by poor personal hygiene and poor living environments.ResultsThe evidence showed that there is clear and strong evidence of effect of education and handwashing with soap in preventing diarrhoeal disease among children (consistent effect in four studies). In the largest well-designed study, children living in households that received plain soap and encouragement to wash their hands had a 53% lower incidence of diarrhoea (95% CI, 0.35, 0.59). There is some evidence of an effect of education and other hygiene behaviour change interventions (six studies), as well as the provision of water supply, sanitation and hygiene education (two studies) on reducing rates of diarrhoeal disease. The size of these effects is small and the quality of the studies generally poor.ConclusionResearch which measures the effectiveness of hygiene interventions is complex and difficult to implement. Multifaceted interventions (which target handwashing with soap and include water, sanitation and hygiene promotion) are likely to provide the greatest opportunity to improve child health outcomes in remote Indigenous communities.

Exploring cross-sectional associations between common childhood illness, housing and social conditions in remote Australian Aboriginal communities

BackgroundThere is limited epidemiological research that provides insight into the complex web of causative and moderating factors that links housing conditions to a variety of poor health outcomes. This study explores the relationship between housing conditions (with a primary focus on the functional state of infrastructure) and common childhood illness in remote Australian Aboriginal communities for the purpose of informing development of housing interventions to improve child health.MethodsHierarchical multi-level analysis of association between carer report of common childhood illnesses and functional and hygienic state of housing infrastructure, socio-economic, psychosocial and health related behaviours using baseline survey data from a housing intervention study.ResultsMultivariate analysis showed a strong independent association between report of respiratory infection and overall functional condition of the house (Odds Ratio (OR) 3.00; 95%CI 1.36-6.63), but no significant association between report of other illnesses and the overall functional condition or the functional condition of infrastructure required for specific healthy living practices. Associations between report of child illness and secondary explanatory variables which showed an OR of 2 or more included: for skin infection - evidence of poor temperature control in the house (OR 3.25; 95%CI 1.06-9.94), evidence of pests and vermin in the house (OR 2.88; 95%CI 1.25-6.60); for respiratory infection - breastfeeding in infancy (OR 0.27; 95%CI 0.14-0.49); for diarrhoea/vomiting - hygienic state of food preparation and storage areas (OR 2.10; 95%CI 1.10-4.00); for ear infection - child care attendance (OR 2.25; 95%CI 1.26-3.99).ConclusionThese findings add to other evidence that building programs need to be supported by a range of other social and behavioural interventions for potential health gains to be more fully realised.

Water supply and sanitation in remote indigenous communities: priorities for health development

Objective:To review available national and State/Territory survey data on water supply and sanitation in remote Indigenous Australian communities and to discuss the findings in terms of priorities for health and infrastructure development.

A case study of physical and social barriers to hygiene and child growth in remote Australian Aboriginal communities

BackgroundDespite Australias wealth, poor growth is common among Aboriginal children living in remote communities. An important underlying factor for poor growth is the unhygienic state of the living environment in these communities. This study explores the physical and social barriers to achieving safe levels of hygiene for these children.MethodsA mixed qualitative and quantitative approach included a community level cross-sectional housing infrastructure survey, focus groups, case studies and key informant interviews in one community.ResultsWe found that a combination of crowding, non-functioning essential housing infrastructure and poor standards of personal and domestic hygiene underlie the high burden of infection experienced by children in this remote community.ConclusionThere is a need to address policy and the management of infrastructure, as well as key parenting and childcare practices that allow the high burden of infection among children to persist. The common characteristics of many remote Aboriginal communities in Australia suggest that these findings may be more widely applicable.

An ecological approach to health promotion in remote Australian Aboriginal communities

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 childrens 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.

Making systematic reviews more useful for policy-makers

Editor – The Mexico Summit has high-lighted the need to improve evidence for informed policy-making about health concerns in low- and middle-income countries (LMICs). We agree with Volmink et al. who, in a recent article published in the Bulletin, asserted that systematic reviews provide the most useful type of evidence for determining the effectiveness of health care interven-tions (1). Other authors have focused on how policy-makers can interpret systematic reviews (2), and have called for more reviews of health problems in LMICs (1, 3).However, as highlighted by Langer et al. in another recent Bulletin article, the evidence in most systematic reviews originates from high-income countries (4). This is likely to continue to be the case for the foreseeable future. Evidence-based policy-making in LMICs would benefit if the applicability of reviews con-ducted elsewhere could be maximized.Use of health-care interventions in LMICs often depends on factors such as the resources available, the organization of health services, cultural norms, and the physical environment. Considering such contextual factors can enhance the generalizability of sys-tematic reviews and their usefulness to policy-makers in diverse settings. This process is analogous to that of improv-ing the internal validity of systematic reviews by considering inter-study variations in participants, study design, and analytic methods (5). A structured approach for dealing with contextual variation can be either extrinsic or intrinsic to the review process.An extrinsic approach requires re-viewers to give some context-dependent guidance for applying a review’s findings. Although the reviewers may not have an in-depth knowledge of all circumstances, they often have considerable expertise in the intervention and alternatives. Furthermore, reviews often provide an opportunity to evaluate studies con-ducted in a variety of settings. Generaliz-ability can be tackled by considering the following questions:1. Relative importance of the health problem: Do the occurrence and se-verity of the health problem vary sig-nificantly between settings and how might this affect the intervention’s potential benefit to the population? 2. Relevance of outcome measures: Are there different outcome measures that might be more or less meaningful in different settings? 3. Practicality of the intervention: What factors, if any, might significantly affect the feasibility of the interven-tion in different settings? 4. Appropriateness of the intervention: Are there other interventions for achieving the stated goal that might be more appropriate in some settings? 5. Cost-effectiveness of the intervention: Are the costs and benefits of the intervention likely to differ signifi-cantly across settings?Addressing these questions may take as little as one or two paragraphs. Using the example of the effect of streptoki-nase for the treatment of myocardial infarction, such a paragraph could read: “Acute myocardial infarction is an im-portant problem in all populations and cultures. Streptokinase is an interven-tion that can be effectively provided in settings where medications can be given intravenously. Alternative treatments do exist, some of which are considerably cheaper (e.g. aspirin), while others are considerably more expensive (e.g. tissue plasminogen activating factor, angio-plasty, etc). Other reviews have com-pared the effectiveness of some alterna-tives with that of streptokinase. The relative beneficial effect of streptokinase compared to no treatment is likely to be consistent across different risk groups in a range of populations. The cost of streptokinase (around US

Evaluation of an Australian indigenous housing programme: community level impact on crowding, infrastructure function and hygiene

30 per dose) may vary in different countries. While it is considered a cheap intervention in developed countries, it is relatively expensive in developing countries.”Alternatively, in an intrinsic ap-proach, important contextual dimen-sions are addressed through planned stratification or subgroup analyses. We recently used this approach in a Cochrane Review of the effectiveness of specialist outreach clinics compared with hospital outpatient clinics (6). A total of 73 studies were identified reporting outreach to nearby urban clin-ics, such as in the United Kingdom, or to rural communities, including remote populations in Africa, Latin America, Australia and Canada. In some studies outreach was targeted at general popu-lations and in others at disadvantaged subgroups such as indigenous commu-nities or homeless people. The nature of the intervention, the types of outcomes measured, and the effectiveness of out-reach all varied according to the setting and population, and we stratified studies accordingly. For example, outreach to urban clinics had minimal effect on access, but could improve health out-comes when combined with education sessions or joint consultations. Outreach to rural and disadvantaged populations led to improved access. We also identi-fied a paucity of high-quality compara-tive studies in rural and disadvantaged settings, where outreach has poten-tially the most to offer.Evidence-based public policy-making is a laudable goal in all settings, but relies on making the most of avail-able evidence. Authors, as well as users, can work towards this goal by produc-ing systematic reviews that are widely applicable. OCompeting interests: none declared.Russell L. Gruen

No germs on me: a social marketing campaign to promote hand-washing with soap in remote Australian Aboriginal communities.

Background and Aim Housing programmes in indigenous Australian communities have focused largely on achieving good standards of infrastructure function. The impact of this approach was assessed on three potentially important housing-related influences on child health at the community level: (1) crowding, (2) the functional state of the house infrastructure and (3) the hygienic condition of the houses. Methods A before-and-after study, including house infrastructure surveys and structured interviews with the main householder, was conducted in all homes of young children in 10 remote Australian indigenous communities. Results Compared with baseline, follow-up surveys showed (1) a small non-significant decrease in the mean number of people per bedroom in the house on the night before the survey (3.4, 95% CI 3.1 to 3.6 at baseline vs 3.2, 95% CI 2.9 to 3.4 at follow-up; natural logarithm transformed t test, t=1.3, p=0.102); (2) a marginally significant overall improvement in infrastructure function scores (Kruskal–Wallis test, χ2=3.9, p=0.047); and (3) no clear overall improvement in hygiene (Kruskal–Wallis test, χ2=0.3, p=0.605). Conclusion Housing programmes of this scale that focus on the provision of infrastructure alone appear unlikely to lead to more hygienic general living environments, at least in this study context. A broader ecological approach to housing programmes delivered in these communities is needed if potential health benefits are to be maximised. This ecological approach would require a balanced programme of improving access to health hardware, hygiene promotion and creating a broader enabling environment in communities.

Hygiene improvement: Essential to improving child health in remote Aboriginal communities

A social marketing campaign promoting hand-washing with soap was implemented to reduce the high burden of infection experienced by Australian Aboriginal children living in remote communities. Epidemiological evidence of effect and other evidence were used to identify the hygiene intervention and health promotion approach for the project. We drew on the findings of: (i) a systematic literature review to identify the intervention for which there is strong effect in similar populations and contexts; and (ii) a narrative literature review to determine our health promotion approach. This process provided practitioners with confidence and understanding so they could address a complex problem in a politically and otherwise sensitive context.