More needs to be done to reduce a leading infectious cause of blindness in WA’s Indigenous communities, argues Dr Melissa Stoneham.

Australia, disappointingly, is the only developed country to have endemic trachoma, which is responsible for the blindness or visual impairment of about 1.8 million people worldwide and remains a public health problem in 42 countries. 

Dr Melissa Stoneham

Almost 100% of our trachoma cases occur in Aboriginal and Torres Strait Islander communities.

The World Health Organisation has set a target to eliminate trachoma worldwide and developed the SAFE strategy, which is a comprehensive approach including surgery, antibiotic treatment, facial cleanliness and environmental improvement.

The #endingtrachoma project focuses on prevention of trachoma by measures such as washing face and hands and being able to wash clothes and bed linen. Although this may sound relatively easy, there are several challenges, including the tyranny of distance for remote communities, which makes it difficult to access maintenance services or even basic hardware.

The level of disadvantage in remote communities also impacts on the social determinants of health, choice and options and the consequences of acculturation and the loss of cultural cohesion impact on communities. 

In 2019, the proportion of children aged 5-9 with active trachoma in screened communities was 15% in WA. Traditionally, the WA Trachoma Program focused on reducing infection rates by screening school children and providing treatment in line with national guidelines, as well as addressing behavioural barriers and raising awareness of facial cleanliness (such as promotion of trachoma and the “clean faces” concept in schools). 

This approach has been effective in reducing trachoma to a point, but unless environmental conditions inside homes change, such as having a functional bathroom in homes, trachoma is unlikely to be eradicated.

The Environmental Health Trachoma Project was created to fill this gap. We aim to reduce the incidence of trachoma in 41 ‘trachoma at risk’ Aboriginal communities in remote WA through environmental health. 

We specifically address risk factors inside the home with a combination of long-term planning processes that support the development of community-led prevention plans combined with hands-on service provision delivered by Aboriginal environmental health workers (AEHW) who are employed in remote communities.

The #endingtrachoma team builds capacity, mentors and supports the AEHWs. It also accesses and provides tailored resources for remote communities including videos, local messaging, community events and more substantial resources such as washer-dryer trailers, health hardware such as shower roses, soap, towels and towel hooks, mirrors, light bulbs and hygiene kits.

Our key message is Six Steps to Stopping Germs, which was produced by the Indigenous Eye Health Centre at the University of Melbourne. They include blowing the nose until empty; washing hands with soap and water; washing face to clean mucous and discharg eyes; brushing teeth with toothpaste morning and night; having a shower with soap every day and not sharing towels.

We have reproduced and refreshed this message in videos using local community members, which is shown in Aboriginal Medical Services’ waiting rooms, on regional TV and used as learning tools; on stickers left in people’s bathrooms and laundries; and on as many community resources as possible. It is important for us to repeat our key message as often and in as many settings as possible.  

Over the past few years, the project has focused on preventing trachoma through auditing and ensuring functional health hardware in bathrooms and laundries in remote homes. Although this prevented trachoma, it also addressed risk factors for a range of other environmental health-related conditions such as skin sores, RHD, gastroenteritis, otitis media and of course, COVID-19.

To amplify this, given 30-50% of health inequalities experienced by Aboriginal and Torres Strait Islander peoples can be attributed to poor environmental health, we expanded our training and mentoring to integrate a whole-of-house assessment. This allows AEHWs to take a more holistic approach to reducing transmission or the prevention of disease and have a soft conversation about the importance of hygiene in the home. 

As important as it is to fix tapware and other health hardware, it is equally important to ensure tenants are aware of what they can do to keep their family and friends healthy. 

A series of healthy homes workshops linking disease risk factors to houses and providing skills and confidence in having soft conversations about hygiene have been provided in six regional locations, with the most recent in Warakurna in the Ngaanyatjarra Lands (NG Lands).

The #endingtrachoma project will continue to build the skills of the AEHWs. It is an important part of our job so that when our funding runs out, we leave behind a skilled and confident workforce who can continue this important work.  

ED: Dr Melissa Stoneham is lead of the #endingtrachoma project which is run out of the Public Health Advocacy Institute affiliated with Curtin University.