Introduction

Trachoma is the world’s leading cause of infectious blindness. Globally, trachoma is linked to poverty, household crowding, limited access to water and poor hygiene [1,2]. Active infection with Chlamydia trachomatis is usually found in young children and transmitted by infected eye and nose secretions. A child may have between 30 and 40 episodes of reinfection during their childhood and up to 160 to 180 infections may occur in total. The resultant scarring and in-turned eyelashes (trichiasis) damage the cornea leading to blindness in older people [3].

Australia is the only high-income country with endemic trachoma, one of four eye conditions leading to vision loss and blindness in Indigenous Australians [4,5]. Trachoma disappeared from most of Australia in the early 1900s when water and sanitation infrastructure improved living conditions [6]. Yet it persists in remote Aboriginal communities where limited and overcrowded housing, lack of working bathrooms and poor hygiene, are still common [7,8,9]. Additionally, children with persistent eye and nose secretions sometimes go unnoticed and is not always commonplace to wash a child’s face whenever it is dirty [10,11].

Australia is committed to the “Alliance for Global Elimination of Trachoma by 2020” utilising the World Health Organization’s SAFE strategy to eliminate trachoma. The four elements are; Surgery for trichiasis (S), Antibiotics for active trachoma infection (A), Facial cleanliness to reduce transmission (F) and Environmental improvements (E) [12,13].

The association between facial cleanliness, nasal discharge and trachoma is well established [14,15,16,17]. In Australia, the prevalence of clean faces (without nasal or ocular discharge) is a mandatory reporting indicator for trachoma surveillance and promoting facial cleanliness is central to the public health management of trachoma [18]. ‘Clean face, strong eyes’ is the key message in trachoma health promotion [19].

Government programs increased in 2009 providing coordinated, visiting screening and antibiotic treatment programs in communities at risk of trachoma. Trichiasis screening and referral for surgery are provided by staff in remote community clinics [18]. Identified barriers to implementing the SAFE strategy include a lack of culturally appropriate resources and that trachoma was not considered a priority by staff in remote clinic work settings [20]. Multiple component trachoma resources, based on the SAFE strategy, were developed for working with individuals and for use at the population level. In the early stages of the program reported in this study, resources were used directly with staff members to develop and support a workforce for trachoma elimination within remote communities. The health promotion strategy used the established settings-based health promotion approach [21]. The goal of working with local staff was to increase their trachoma related knowledge, attitudes and practice making it possible for them to become intermediaries and agents of change with the community population.

The expanded trachoma screening and control activities 2010 resulted in trachoma rates declining considerably from 14% in 2009 (1–9 yrs.) to 4% in 2012 (5-9yrs) in the NT. However, of the 82 communities considered at risk in the NT in 2010, 28% remained with endemic trachoma and 37% were considered hyper-endemic in 2012 [22]. This study examines changes in the trachoma-related knowledge, attitudes and practice of staff in clinic, schools and community work settings in 63 of the 82 communities at risk of trachoma in the NT, following exposure to the new health promotion initiatives.

Methods

Health promotion resources and initiatives

Health promotion initiatives were based on the ‘Trachoma Story Kit’ developed in response to lack of culturally appropriate material for Australia. Input came from Aboriginal Health Services, Departments of Health and Education, NGOs, community programs and environmental health. The Ngumbin Reference Group of Elders and Aboriginal Health Workers from the Katherine West region of the NT advised throughout the development phase on cultural safety and acceptability of the resources^. They recommended the resources be placed in clinics, schools and community work-places because they viewed trachoma elimination as everyone’s business [27]. All resources featured the program mascot—Milpa (eye in Warlpiri language) the Trachoma Goanna and the slogans "Clean Faces, Strong Eyes" and “Wash your face whenever its dirty” to support new social norms for facial cleanliness. Clinic materials included clinical training tools and patient education material. Additionally, an e-learning module—based on the Trachoma Story Kit—was developed by Remote Area Health Corps and Indigenous Eye Health for urban health practitioners doing short-term contracts in remote Indigenous communities [28]. Schools are a key setting for trachoma education globally, and as children can be change agents for trachoma elimination [29,30]. lesson plans were developed in line with the school curriculum [19]. Community workplace materials featured realistic images, stories and multi-media to engage family support services. Population level initiatives included public football events [31] and television and radio adverts reinforced the key messages with Milpa the Trachoma Goanna. The multi-media strategies maximised program reach through the wide footprint of digital media channels in remote Indigenous communities across the NT and the multiple health promotion activities were designed for a complementary and synergistic effect. Table 1, shows the suite of health promotion initiatives that make up ‘the intervention’. Participants were asked if they had seen or heard one or more activity. Prior to the intervention, no known population-based trachoma health promotion had been introduced across the NT.

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Table 1. Health promotion initiatives and delivery timelines.

https://doi.org/10.1371/journal.pntd.0005503.t001

Results

Table 2 shows the distribution of correct questions by 272 participants pre- and 261 participants post-intervention in three work place settings and for the group as a whole. The majority of pre- and post- participants were from clinics n = 272(73.5%) and n = 148 (56.7%) respectively. The response from schools and community work places was much lower but increased in the post-intervention survey after the introduction of resources kits and other health promotion in their area. Most participants (94.8%) from the three settings overall could correctly define trachoma and knew it could lead to blindness (96.1%), yet one in five (17.9%) did not know they lived and worked in a trachoma endemic area. Over four in five (84.6%) reported that trachoma could be spread from person to person (the main transmission route) yet only 70.5% understood that contamination by towels or bedding is possible.

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Table 2. Distributions of correct questions by work setting: Pre- and post- intervention.

https://doi.org/10.1371/journal.pntd.0005503.t002

Discussion

In this study, the trachoma related KAP of staff who provided education and support to families and children was assessed during the early stages of health promotion in trachoma endemic communities. The multi-faceted interventions for trachoma health promotion were established in the settings where people engaged in daily activity, with the aim of attaining synergistic effects and sustained population-wide behaviour change. There is renewed interest in the settings-based approach to facilitate health promotion and public health action [21] and it was anticipated that embedding trachoma related KAP in work settings may redress a previous finding that trachoma was not considered a priority in remote health services [20]. Trachoma elimination in vast areas of remote Australia is an enormous challenge and the workforce for trachoma elimination in the NT is small. During this study, visiting trachoma nurses conducted annual screening and treatment and provided education sessions mainly with children in schools and with local staff in clinics and community work places. It was anticipated, local staff could support trachoma elimination as intermediaries with families to support trachoma elimination, an approach used with an Indigenous children’s ear-health program [32]. Local staff have a unique capacity to engage with resources, facilitate interaction and stimulate discussion with children and carers in an everyday, supported context [33], such as exists in remote work places. Importantly they can encourage supportive practices and encourage behaviour change for children and families. However, while the KAP of staff will generally improve after health education in most workplaces, a significant limitation in remote communities is the considerable level of staff turnover. In clinics about 60% of staff change annually [34] and in schools, staff retention is commonly measured in months rather than years [35]. Embedding trachoma related KAP into workplace practices was a priority to establish and operationalise trachoma elimination in supportive work places, beyond staff tenure.

Underlying the ill health and health related behaviours of Indigenous Australians are many historical, geographical and socioeconomic determinants [36,37,38,39]. In addition, past assimilation policies included the forcible removals of Indigenous children from their families often occurring with allegations of child neglect and poor hygiene [40,41]. Subsequently, addressing hygiene related health is complex. A key barrier to eliminating trachoma and addressing other hygiene-related health issues, is normalisation of dirty faces in young children in some remote Indigenous communities [42,43]. Indigenous and non-Indigenous staff and community members do not always notice children’s dirty faces or help to clean eye or nose secretions from the faces of small children [10]. Non-Indigenous staff may be hesitant to assist or discuss clean faces for fear of shaming, being rude or intrusive, or they may simply not know how best to help. A direct, non-blaming, practical approach is crucial when addressing hygiene/health issues with Indigenous children and families [44]. Staff can educate and provide respectful, practical and immediate support to children and families for clean faces and hygiene practices to eliminate trachoma and reduce infectious disease in Indigenous children.

The multiple components of the health promotion intervention are shown in Table 1. This comprised of clinical education, community performances, football, Trachoma Story Kits, large safety mirrors, posters, television and radio adverts. The study found that despite the high levels of staff turnover and in a relatively short time, 70% of participants in all three settings reported they used or observed a health promotion intervention. This suggests trachoma resources and health promotion activities were associated with increased trachoma-related KAP as no other trachoma health promotion was functioning during the study period.

Trachoma programs in Australia and worldwide must bear in mind, that while increasing knowledge can occur in the short term, changing social norms, such as attitudes and behaviour, is a long-term process in any culture. Annual trachoma and clean face prevalence data from 2008–2015 in Table 3 shows a considerable reduction in trachoma prevalence over time. The study period of 2010–2012 is highlighted, during which trachoma prevalence reduced from 15% to 4%, possibly explained by widespread antibiotic treatment. The slight increase in trachoma prevalence after 2013 must be interpreted cautiously, but is thought to have been influenced by extended delays in program funding and activity. There was a marginal increase in clean face prevalence during the study period, which is not surprising as it should not be expected that meaningful and lasting behaviour change could occur within 1–2 years. From 2010 to 2015 however, a gradual but steady increase of clean face prevalence is clearer. Behaviour change takes time.

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Table 3. The prevalence of trachoma and clean faces in children aged 5–9 years in screened communities in the NT.

https://doi.org/10.1371/journal.pntd.0005503.t003

In Australia, to support the F of the SAFE strategy, the health promotion priority was to increase trachoma awareness, provide culturally relevant health promotion approaches and create a workforce with the capacity to support changes in remote communities. To do so however, staff and community members require environmental improvements (E of SAFE). In many remote communities, there is a lack of properly installed and regularly maintained washing (bathroom) facilities in houses, schools, preschools, sporting areas and other community settings. Safe and functional bathroom facilities have sinks and showers with working taps and drains and include soap, paper towels and child height mirrors.

Strengths and limitations

Strengths of the study include having a wide geographical reach, covering three-quarters of the remote communities at risk of trachoma in the NT. The KAP survey provided high utility with difficult to reach participants in a program with very limited resources. Remote communities in Australia are especially difficult to survey due to research fatigue, high mobility of community members, language barriers and difficulty in accessing participants in busy, remote work places. Sufficient pre- and post-sampling rates were achieved by delivering surveys in person, following up when required by telephone and email and by the short questionnaire design. The program and study reach within the community was widespread with participants drawn from three key settings with daily contact and influence with community members and their children.

However, self-report KAP surveys have known weaknesses and several limitations must be considered when interpreting the results of this study. This survey relied on the participant’s introspection and interpretation of questions which may have resulted in over-reporting of KAP. There was also potential for response bias/courtesy bias where participants may have respond with answers they believe acceptable. The question “Are children’s dirty faces normal in your community?” is ambiguous and a weakness in the study. Every-day English was used in the survey to encourage participation by Indigenous community staff members. Although ‘normal’ is frequently used to mean commonly observed in colloquial language, the term could have been interpreted by some as either ‘common’ or ‘acceptable’. Nevertheless, either interpretation indicates a serious risk factor for trachoma. The question “I am able to teach others about trachoma prevention” should have been independently verified/assessed through supervision. Due to the turnover of staff, the program depended less on the retention of information by individual staff but in the implementation of an ongoing system to induct new staff and inculcate the information into the work setting. The resources and activities were a method of addressing the need for ongoing orientation and teaching about trachoma for new staff. Incorporating community-level evaluation was not possible due to resource limitations but the use of qualitative methods could have revealed important contextual and cultural factors and strengthened the study by validating results and reducing possible bias. The mobility of community and staff may have resulted in some participants being exposed to the health promotion intervention prior to baseline data being collected. It is anticipated that such exposure was limited due to the restrictions on mobility imposed in these communities by the wet season. While increased knowledge was noted and some changes to attitudes and practice, it cannot be assumed that it leads to a direct increase in health behaviour action. Equally, improved KAP among staff members may not positively influence or improve the health behaviours in trachoma endemic communities. It is recommended that further evaluation is planned to assess change in community level knowledge, attitude and practice.

Conclusion

It is true that many health and social issues are more pressing than the elimination of trachoma in remote Indigenous communities, yet resolving them will take considerable time, resources and commitment by Indigenous and non-Indigenous Australians working across multiple sectors. Trachoma elimination does require resources, inter-sectoral commitment and working together, but it is more discrete than most other issues and can be addressed in a reasonably short time using the SAFE strategy. Importantly, improving safe and functional bathroom facilities and hygiene behaviours could reduce the unacceptably high burden of infectious disease.

The health promotion interventions in this study contributed to improved trachoma knowledge, attitudes and some practices of staff members in key work settings in remote communities. These results were found despite persistent staff turnover, which may indicate that some practices had been operationalised within the work settings rather than dependent on individual staff. The multiple approach, settings-based health promotion should be continued and community engagement and leadership increased, for sustainable, behaviour change for trachoma elimination. Longer term, the social determinants contributing directly to trachoma, including poorly functioning bathroom facilities and overcrowded housing, must be addressed at every level of government. These environmental improvements must be supported by health education for community-wide benefit and reduction in transmission of infection.

The findings of this study may provide some general lessons with wider relevance for trachoma elimination, yet it is recognised there is no ‘one-size-fits-all’ approach. Each region and each country has its unique culture, language, political settings, financial resources, administrative capacity and historical context. In Australia in the early stages of the trachoma elimination program, it was important to lay a foundation of support with culturally relevant health promotion and increased workforce skills and capacity. This study illustrates that one cannot assume clinic, school and community-support staff are well informed about trachoma and can guide the behaviour of communities without the support of tailored trachoma education, health promotion resources and strategies.

Supporting information

Acknowledgments

The authors give special acknowledgement to the cultural oversight and advice from the Ngumbin Reference Group, David Lines, and Emma Baunach at Katherine West Health Board Aboriginal Corporation, whose work provided a strong foundation for trachoma health promotion in Australia. This study was made possible due to the dedicated support of Cate Coffey, Heather Wilson and trachoma nurses at the Centre for Disease Control, Northern Territory Department of Health. The assistance of individuals and organisations did not include financial support for the research project.