Report of the 6th National Conference

Identifying appropriate environmental health interventions to reduce the transmission of pathogenic organisms that cause diarrhoea, skin and respiratory infections: Hand washing Project

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Nicola Slavin and Annette Fuller, NT Department of Health and Community Services

Impact of Childhood Infections

Infectious diseases such as respiratory and intestinal infections are the leading causes of hospitalisation for Aboriginal infants and children in the NT, with rates many times higher than in the non- Indigenous population. Skin infections are also a major contributor to the burden of illness experienced by Aboriginal babies and children in the NT.

These infections impact not only on the health of children in the short term but may also contribute to chronic disease in adulthood. Research indicates that repeated infections during infancy and early childhood can also result in impaired growth, which may lead to long-term health repercussions. Growth in the first year of life, as well as in utero, has been shown to impact not only on somatic growth but also on the development and function of specific organs which in turn has been found to have direct consequences for adult chronic disease particularly cardiovascular disease and hypertension (Barker: 1991; Maguire: 2004).

Preventative Interventions

Primary barriers such as sanitation and hand washing after faecal contact have been found to be the most effective means of reducing diarrhoeal disease. Curtis and Cairncross’ (2003) recent systematic review of the effect of hand washing with soap indicated that hand washing with soap can reduce the incidence of diarrhoeal disease by 42-47%.

Whilst it has long been accepted that hand washing provides an important means of preventing the spread of diarrhoeal disease, it is only relatively recently that the connection between hand washing and respiratory infections has been recognised. Several studies have shown that hand washing is effective at reducing the rate of respiratory infections in a range of populations. The Karachi Soap Health study found that children younger than five living in households which had received intensive hand washing promotion and who where provided with free soap had a 50% lower incidence of diarrhoea and pneumonia than controls (Luby et al 2005). The same study also found that children younger than 15 had a 35% lower incidence of impetigo.

A number of international studies conducted in a variety of settings including childcare centres and in the homes of urban families in the UK (Curtis et al: 2003), have shown that people often do not adequately wash their hands after key junctures such as going to the toilet and cleaning up after children who have defecated.

Global Focus on Handwashing

The determinants of hygiene behaviours such as hand washing are complex and research indicates that simply teaching people about the health benefits of hand washing does not result in substantial behavioural change. Internationally there is an increasing awareness that in order to change handwashing behaviour on a large scale, the principles of industrial marketing need to be applied.

The Public Private Partnerships for handwashing with soap is a global initiative developed by a number of government and non- government organisations including the World Bank, the Water and Sanitation Program, the London School of Hygiene and Tropical Medicine, USAID, UNICEF, Unilever and Colgate Palmolive. The aim of the initiative is to foster productive partnerships between private industry and the public sector, utilising the unique skills and expertise that each sector has to offer. In particular, the private sector has a wealth of marketing expertise which can be utilised to promote hand washing with soap to the public, and increase the likelihood of hand washing becoming a habitual practice.

The underlying belief behind the Public Private Partnership for hand washing with soap is that hand washing needs to be tackled on the scale of vaccination programs where population coverage in any given area is almost total (Curtis 2002). The Public Private Partnership model was first trialled in Ghana and in Kerala, India. Since then the model has been successfully applied in a number of countries including Senegal, Peru and Indonesia.
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Project Description

The long term goal of the project is to reduce the person-to-person, and environment-to-person, transmission of pathogenic organisms which cause diarrhoea, skin sores and respiratory disease. The project is being trialled on an Indigenous community in both Central Australia and in the Top End of the NT. There is also a designated comparison community in both regions.

We hope to implement the project divided into three stages, each to be run over approximately a year. The focus of stage one is on identifying effective means of promoting hygiene in Indigenous communities. The second stage of the project will involve the development and implementation of a repair and a maintenance strategy for essential plumbing, and the third stage will reinforce key health messages. We are currently in the process of implementing stage one of the project.

One of the key strategies of stage one is the development of a social marketing campaign, central to which is the target audience’s identification of the perceived barriers to, and benefits of, the desired behaviour. The function of a social marketing program is to change the ratio of benefits and barriers so that the target behaviour becomes more attractive.

Baseline Data

The following baseline data was collected at the trial and comparison communities:
  • Housing surveys were conducted to identify the maintenance needs of community-managed houses.
  • Administered questionnaires were delivered to each household. The questionnaires were aimed at identifying the current knowledge, attitude and behaviour in relation to washing hands with soap.

Questionnaire Findings

Many respondents in the Top End community said that they usually used soap when washing hands. However, most homes did not have soap at the time of doing the questionnaire. In Central Australia, nearly all homes did not have soap at the time of doing the questionnaire. Several respondents stated that they did not believe it was important to wash your hands.

In the Top End trial community, many respondents understood the importance of washing hands and nominated key times to wash hands as being after going to the toilet and before preparing or eating food. Many understood that washing hands could stop germs from spreading. However, in Central Australia, respondents had a limited understanding of germ theory.

Focus Groups

A social market research company was engaged to research the primary barriers and motivators to washing hands with soap. The researcher used focus groups and in-depth stakeholder interviews to explore what are the barriers to people washing hands with soap as a routine behaviour, and what sorts of things would motivate people to adopt that behaviour.

The focus groups explored:
  • What current opinions and attitudes exist towards handwashing?
  • What are the existing handwashing behaviours?
  • What influences people’s opinions generally?
  • Channels of communication within the community.
  • General media consumption habits.
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Barriers to Washing hands with Soap

Primary barriers and motivators to washing hands with soap that were identified through the focus group discussions included:
  • Handwashing is not a social norm. Washing hands with soap is not a routine behaviour, and there is no social expectation of one another in terms of washing hands.
  • Soap is not available in homes. Most of the households we talked with did not have soap, although some households said that they sometimes used alternatives such as dishwashing detergent and shampoo
  • Handwashing is not seen as useful. Many people didn’t understand the link between washing hands and stopping the spread of germs. Hence, there is limited belief about the benefit of routinely washing hands.
  • Health hardware is not maintained. While structurally many of the houses have appropriate health hardware, at the time of doing the housing surveys, many houses needed routine plumbing maintenance.
  • Low self efficacy. Sometimes people don’t believe that they have control of their own situation and events that affect their lives.

Motivators/Drivers

Factors that motivate people include:
  • Overall, people expressed a positive attitude towards washing hands with soap.
  • People did not consider that soap was expensive to buy.
  • Nurturing and wellbeing. Keeping children healthy is considered important.
  • Image and appearance are cited as important with men and women taking care to present themselves, wearing clean clothes, combing and dying hair, etc.
  • People are keen players and spectators in many sports.

Creative Concepts

An advertising agency was engaged to develop concepts based around motivating factors identified through the social market research. These are currently being tested.

Community Activities

Community activities will be developed and run on communities to coincide with a possible media campaign. To date we have run educational activities within the schools highlighting how, when and why to wash hands. A major activity planned is the engagement of professional Hip Hop artists to develop hip hop music that incorporates the hygiene message. The music will be professionally produced and will also feature on community service announcement ads on Imparja Television. Other activities will include soap making, t-shirt printing and possibly home hygiene activities in conjunction with homemaker and housing maintenance programs.

Lessons Learnt

While the project is not yet completed, a number of lessons have already been learnt including:
  • The need to allow adequate time for the ethics approval process in project timeframes.
  • The importance of providing consultants with very detailed briefs.
  • Recognising that the timeframe of the project and project milestones will not always coincide with community priorities.

References

Barker, D. 1991. Relation of birth weight and childhood respiratory infection to adult lung function and death from chronic obstructive airways disease. British Medical Journal; 303: 671 – 675.

Curtis, V. and Cairncross, S. 2003. Effect of washing hands with soap on diarrhoea risk in the community: a systematic review. The Lancet Infectious Diseases; 3: 275 – 281.

Luby, S.Agboatwalla, M., Painter, J., Altaf, A., Billhimer, W. and Hoekstra, R. 2004. Effect of intensive hand washing promotion on childhood diarrhea in high risk communities in Pakistan. JAMA 291; 2547 – 2554.

Maguire, G. 2004. Respiratory Health and Disease in Aboriginal Australians in the Northern Territory. Menzies School of Health Research and The University of Sydney, Doctor of Philosophy Thesis.
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Questions:

Q1. “What if people are allergic to soap? What can they use, because a lot of them suffer from allergies”?

A1. Nicola Slavin - “We haven’t explored that one much yet. In central Australia there were issues around not liking to wash their hands because soap irritated their skin. We will now look into alternative soap such as soap-free washes that work the same as soap, but don’t have the same sort of allergens as soap. We will also look at alternatives for soaps that are good for hard water, because that is a bit of a problem down in Central Australia where soap won’t lather nicely for people. If that’s an issue we will explore the sort of stuff around allergies, but I don’t think anyone has raised that as a big point so far”.

Q2. “Another point I noticed was you said it would take 12 months to implement. Why will it take so long when people should be told now about washing their hands”?

A2. Nicola Slavin - “The first stage will run for 12 months, where we focus on promoting hand washing. For the whole 12 months Annette will be out in the bush talking with people. We will have the ads on TV and all the other stuff that goes with it - it just takes time to get things up and running”.

Q3 Craig Steel – “Good presentation, ladies. Central Australia also includes a lot of our remote areas. If I heard you right, you said that the majority of your households do not have soap in them and nor do a lot of impoverished communities in Central Australia. From our point of view, how are you going to get soap into households? Could perhaps some of the funds you spend on advertising and social marketing not have gone to actually providing the soap into the households so they could have at least had the opportunity to wash their hands whilst you go through your 12 months, which is largely project- oriented for consideration”?

A3. Nicola Slavin - “As Annette highlighted a little when she did the questionnaire, one of the questions was did people think soap was expensive. The majority of people said that they didn’t find soap expensive to purchase, so I am not sure cost was a major factor. Nonetheless, we are trying to get soap out there but we didn’t just want to provide free soap to all households because the project was meant to be sustainable in that in the long-term nobody would be providing free soap - the idea was that we would also be marketing soap more intensively in the shops. Annette was going to explore with the shops that maybe if you buy a certain amount of groceries you get a bonus bar of soap with grocery purchases in some ways that potentially could be sustainable. We have been talking to the community and looking at ways that they can keep this going in the long-term. Also, with the community activities there are giveaways, competitions, workshops, the prizes and ‘thank yous’ that are toiletries and soap products. We are trying to get more soap out there as well, but I’m not sure the cost of soap is a major inhibitor, really.

Q4. “I am interested in your housing survey and the data on the number of houses that had soap. Did the survey record which of those houses had soap holders”?

A4. Nicola Slavin - “No, it didn’t”. “Certainly in my house you can’t keep soap - it ends up everywhere but where it should”.

Nicola Slavin - “No, we didn’t specifically identify soap holders. We only looked at hand basins and if people had a hand basin there would be a space to put the soap”.

For Further Information

Nicola Slavin

PO Box 40596, Casuarina, NT 0811

Ph: 08 8999 2580 Email: nicola.slavin@nt.gov.au
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