The evaluation was planned and implemented collaboratively between a health research institute and Territory and State Government agencies. A survey questionnaire was developed taking account of key social, economic, cultural and environmental factors previously identified as barriers to, or promoting of, handwashing with soap in remote communities [2, 21, 25] and based on the principals and constructs of the TPB [31]. Survey activities were planned to occur immediately before and on completion of the intervention. The scope of project activities was restricted due to having only 12 months to develop and deliver the intervention and complete the evaluation.
The intervention
Three new television commercials were developed with the input of Aboriginal people living in remote communities. The television commercials were filmed in regional and remote locations and feature Aboriginal people from these areas. One of commercials targets primary school aged children and focuses on handwashing with soap prior to eating. This commercial utilises humour and the motivational factor of disgust to promote behaviour change with the goal to promote new normative behaviour [33]. This commercial reinforced the NGoM key message of preventing faeco-oral spread of disease as in the original commercials. The other two commercials focus on family members taking action to help interrupt child-to-child transmission of respiratory and other infections by teaching and assisting young children to wash their hands with soap and have clean faces (faces free of nasal discharge) before touching babies. The behaviour change motivational factor of nurture informs these commercials with the overall aim being to promote new normative behaviours [33]. All commercials are freely available on the internet [34].
Five television channels (four ‘free-to-air’ and one satellite) were contracted to intensively televise the three commercials over a four week period (11 May 2014 to 8 June 2014). Adult viewers were the target audience and the commercials were televised multiple times on a rotational basis during peak viewing periods including during Australian Football League and National Rugby League games and during programs such as Home and Away, X Factor, dancing shows, family movies, weekend specials, afternoon news and afternoon game shows. Additional ‘bonus’ screenings at non-peak viewing times were provided by all networks. The broadcast area covered was vast and included remote and rural communities across the NT and Western Australia, northern South Australia and central and far west Queensland and New South Wales. Following the period of intensive screening the commercials were withdrawn for four weeks to allow for the post intervention surveys to be completed. Televising of the commercials recommenced on the completion of data collection.
Setting
Six remote Aboriginal communities representing three different geographical regions agreed to participate in the evaluation. Two communities are located in the Top End (TE) of the NT; two are in Central Australia (CA), and two in the Kimberley region of Western Australia (WA). All six communities are disadvantaged across all measurable social determinants of health.
Essential infrastructure and services are available in all the communities, for example, reliable water supply, sanitation and refuse management systems. Public housing of western design is provided to families that consist mostly of two to four bedrooms with one or two bathrooms with flush toilets and showers. Household crowding is common, caused by the general shortage of housing and this is exacerbated by the preference to live in extended family units and the frequent presence of relatives visiting from other communities.
Common to all communities are high rates of infection among young children and the need to improve hygiene practices to improve child health [12]. Characteristics that vary between the communities include degree of remoteness, level of access to services, population size and climatic conditions (sub-tropical, semi-arid and arid). The two TE communities are coastal communities that have populations in excess of 2000 people. Both communities are considered isolated, having limited access to a regional centre and services due to long distance and unsealed roads. Both communities are only accessible by air for approximately six months of the year due to monsoonal weather conditions, high rain fall and road closures. In the Top End the climate is characterised as generally being hot and humid. One CA community has a population of approximately 1900 and the other of approximately 500. Sealed roads are available for both communities to access the closest regional centre and services. The larger community having good access (approximately 10–20 km to travel), and the smaller community limited access owing to the need to drive approximately 400 km to access services. In CA, the climate is characterised as generally being dry and dusty and having extremes of heat and cold. Both the WA communities have populations of approximately 300. These communities are located in the far north of WA and experience not dissimilar climatic conditions to the TE of the NT. One WA community is a coastal community and is an approximately 20 min drive on a sealed road to the nearest regional centre. The other community is inland and the regional centre is located approximately 300 km away. The populations of all six communities fluctuate in size due to families travelling between communities and regional centres for cultural, social, family and sporting reasons. However, population mobility is greater in the CA and WA communities owing to having smaller distances to travel between communities and generally better road conditions.
Participants
Convenience sampling was used to recruit survey participants. Potential participants who were meeting or transiting though public places in communities, for example, outside the community store or at the child care centre, were invited to take part in the evaluation. All Aboriginal persons aged 16 years or more who were currently residing in the community were eligible to participate. The choice of sampling method and eligibility criteria took account of a) current child care practices in communities, for example older siblings and extended family members all care for children and that infants and children move and live between households; b) the importance of not to be intrusive or to cause offence when recruiting participants; c) the limited resources and time available; and d) conducting an evaluation for purposes of evaluating a program offered by services providers and not a research study per se. The aim was to recruit a minimum of 80 persons from each community for both pre and post intervention survey rounds. This sample size based on the minimum number of participants advised as needed to test the internal validity of the constructs as determined by the developers of the TPB tool [31] and considered feasible by the EHOs. Participants were provided with a gift of toiletry and grooming products for completing the survey questionnaire. Purposive sampling was used to recruit two key informants from each community for informal interviews.
Questionnaire development
Drawing on the principles and constructs of the TPB [28–30] (Fig. 1), the questionnaire consisted of items intended to measure change concerning individuals’ beliefs, attitudes, and behavioural intentions about teaching and assisting young children to wash their hands with soap and have clean faces (faces free of nasal discharge).
Health promotion ecological theory [32] principles informed developing questions to ascertain if the key physical, social and cultural supports identified previously as important for individuals to successfully undertake the desired behaviours were present at the time of the surveys (Fig. 2) [2, 21, 25, 32].
The pre intervention questionnaire consisted of a total of 40 items. Ten items focused on demographic and other information that might influence the way an individual responds to questions, for example – gender, age, relationship of participant to children living in the house, level of schooling, and about the level of access to a functioning health hardware and the availability or soap, toilet paper or facial tissues at the time of the survey. Toilet paper frequently used in remote communities as a cheaper and more accessible option than facial tissues for nose blowing and for cleaning nasal discharge from young children’s faces. Thirty questionnaire items were designed to measure individuals’ beliefs, attitudes, and intentions about assisting and teaching young children to wash their hands with soap and keep their faces free of nasal discharge. For example, participants were asked to score how strongly they disagreed or agreed with the following sentences:
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If you help kids to wash their hands with soap you will help stop germs spreading to babies. (Belief)
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It would make a lot of extra work for you if you were to make sure that kids always wash their hands and always have clean faces. (Attitude)
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In the future, you will make sure the kids you care for have clean faces and wash their hands with soap. (Behavioural intention)
Questions were written in such a way that some might be grouped to analyse for the four direct constructs of the TPB; Attitude Overall, Perceived Behavioural Control, Generalised Intention and Subject Norm (Figs. 1 and 2) [31]. Attitude Overall measuring if the person is in favour of doing the promoted behaviour; Perceived Behavioural Control if the person feels in control and they can undertake the behaviour; Generalised Intention if the person expects, wants or intends to comply with the promoted behaviour; and Subjective Norm measuring how much the person feels social pressure to teach and support children to wash their hands with soap and have a clean face. Internal reliability testing for the TPB constructs Attitude Overall, Perceived Behavioural Control, and Generalised Intention was satisfactory-good (Cronbach’s alpha coefficient value 0.6 or higher [35]) but poor for the construct Subjective Norm. Additional file 1: Table S1 and Additional file 2: Table S2 provide a summary of TPB questionnaire items and the internal reliability testing analysis plan and results. Questionnaire development and internal reliability and validity testing are the focus of another paper submitted for publication.
The post intervention questionnaire contained additional questions pertaining to access in the home to a functioning television; whether participants had viewed the new commercials; which commercials were seen; if the commercials were easy to understand; which commercial they liked the most; and did they learn anything new from the commercials.
Questionnaire items were written in plain English so individuals with good levels of English literacy and numeracy could complete the survey unaided and also so the questionnaire might be verbally administered to others. Likert scales were used to score TPB items and tick box responses were required for other items.
Qualitative data
Informal interviews were conducted in each of the communities with key persons such as the manager or staff at the community store, health service staff and child care workers. The information collected focussed on what community member behaviours had generally been observed as it concerned the purchase of soap, toilet paper and facial tissues.
Data collection
The EHOs who regularly visited and provided services in each of the communities led survey activities. They also completed the informal interviews and reported on their observations, and the key issues that arose when generally chatting with participants. The EHOs taking this role allowed for successful community engagement and also assisted later when interpreting survey findings. In all communities we endeavoured to employ one or more Aboriginal research assistants to guide evaluators in their conduct while working in their community; to provide interpreting services if required; to help recruit participants; and to administer questionnaires. EHOs and Aboriginal research assistants received instruction in the correct administration of the questionnaire.
Data analysis
SPSS Version 22 was used to analyse the data [36]. Data was de-identified prior to any analysis and all analysis was at the population level. Analysis was conducted at community, regional and total population levels so the different geographical conditions, population size and other features, for example climatic conditions, degree of geographical isolation, may be compared. TPB constructs previously shown to have good internal reliability (Attitudes Overall, Perceived Behavioural Control and Generalised Intention) to be compared between pre and post intervention survey results using the Independent Sample t-test, and for the participants who completed both pre and post surveys the Paired Sample t-test was used [37].
Information from informal interviews and gathered when generally chatting or ‘yarning’ with participants to be examined to identify key themes to assist contextualise and explain quantitative findings.
Ethics
Ethical approval was obtained from the Human Research Ethics Committee of the NT Department of Health and Menzies School of Health Research, the Central Australian Human Research Ethics Committee and the Western Australian Aboriginal Health Ethics Committee. Participants provided written, informed consent prior to participating in the evaluation.