This study is concerned with the vision and eye health problems of indigenous children living in remote communities of far north Queensland in Australia. Those living in remote areas often have little or no access to the services that urban communities take for granted. There are also cultural differences which may inhibit access and further disadvantage indigenous communities. Since a screening service is the first step in determining whether treatment is required, there are strong equity reasons for undertaking a screening program in these communities.
The most comprehensive screening of indigenous Australians was initiated as the National Trachoma and Eye Health Program (NTEHP) two decades ago. This program found that trachoma was endemic in some communities with many older persons suffering a substantial loss of vision. The relationship of eye health to climate and hygiene was also noted in older adults. Although chemotherapy was undertaken in some areas, ongoing treatment and changes to the environment to destroy the persistence of Chlamydia infections were advocated as continuing action.
Despite these recommendations, there are only a few recent reports of relevant treatment and environmental changes and of these, most concern communities in the arid centre of Australia. The study reported in this thesis focussed on children in far north Queensland because there is little recent information about their vision and eye health and some of the major problems reported for adults may be prevented if screening and treatment is undertaken during childhood. Taylor (1997) compared the prevalence of follicular trachoma among Aboriginal children in the NTEHP surveys (1976-1979) with current data (1989-1996). Although he showed that substantial numbers of children were still affected by follicular trachoma in many areas of Australia, he could not make the comparison for Queensland as no current data were available.
This study was undertaken in five communities on Cape York Peninsula and in one community on a Torres Strait Island. The communities were: Lockhart River, Coen, Aurukun, Pormpuraaw, Bamaga and Thursday Island.
These regions are more than 3000 km from Brisbane, the capital city of Queensland, and up to 1500 km from Cairns, the regional administration centre for ATSIC programs and for health services. The communities were selected because they are remote from cities and towns, are isolated through distance and weather conditions, are composed mainly of indigenous people, and lack ready access to eye care centres.
In choosing the tests and equipment to be used in screening the children's vision, the usefulness of the total kit to para-professionals was kept in mind. It seemed more useful to devise a screening program which could be recommended later to paraprofessionals than to recommend frequent specialist visits to these remote areas.
Since several flight and road transfers were involved in the study, it was necessary to choose material and equipment which would withstand multiple transfers. There would be no possibility of repair or replacement in the communities visited so that factors such as strong construction and portability were important considerations.
Another consideration was ease of administration. As I was the sole examiner,-responsible for the assessment, recording and interpretation of results for large groups of children, it was not advisable to use equipment requiring complex operation. This is also relevant if the screening kit is to be used in the future by para-professionals. Along with less complex equipment, familiar settings help to ensure that testing procedures do not seem threatening to children. With this in mind, the possibility that some assessment would be given outdoors was also considered in choosing equipment.
A final consideration was the suitability of the material for the children's culture and experience. The material needed to be age appropriate and not heavily biased towards urban or non-indigenous backgrounds.
The Snellen chart was selected to measure the far vision of children who could read, write and communicate verbally. The use of this chart for children who can read the Roman alphabet avoids cultural bias. The dimensions of the chart make it portable. It is suitable for use in indoor or outdoor lighting conditions in the person's natural environment. For young children and those unable to read, the Pictorial chart was selected as it fulfils the same requirements as the Snellen chart. The E cube was also included in the kit but reserved for verification or indecisive circumstances. It has a special advantage for children who can neither read nor communicate verbally.
The Maclure Bar Reading Type for Children was selected as the most suitable near vision test for children aged six years and older who can read. The Sheridan Gardiner Letter Test Card was chosen for children who are less proficient in reading but who know the letters of the alphabet or who can match letters.
The Ishihara Test for Colour Blindness and the Colour Vision Test for Infants were selected for colour vision screening.
After testing a variety of cameras and their accessories, a Pentax spotmatic F camera with 70 mm extended zoom lens, a 20 mm extended tube and a flash was chosen to take records of the eyes and lids of the children. The portability of this equipment, its ease of use and the objective record of the physical characteristics are desirable features.
A portable slit lamp was included in the screening kit. The use of a slit lamp to examine the eye health of children is non intrusive. Children can cooperate and participate without any medication to the eyes or any need of contact between the examiner and child. The compact size of the portable slit lamp enables easy transport.
The equipment and materials were transported in two compact parcels. In one, the slit lamp was housed in a 40 x 30 x 20 cm carry case. The other was a medium size back pack carrying the remaining test materials.
A total number of 596 (290 boys) traditional indigenous children were screened. Their ages ranged from 2 years 6 months to 14 years 8 months but the majority (n=568) were in age bands ranging from 4 to 12 years. The sample is believed to be close to 100% of indigenous school children in this age range in these communities.
In each community, most children were found to have good near and far vision. A number in each community, however, showed eye lid problems, pterygia, or other eye health conditions. The highest prevalence of eyelid problems, observed specifically as possible precursors to trachoma, was 12.8% over the 10 and 11 year age bands. Pterygia and other eye health conditions were also frequent at these ages (9.6% and 5.8% respectively). The community with the highest prevalence of eyelid problems was Aurukun (20.3% overall and 26% in children 10 or 11 years of age). A number of features were observed in the children's environment which were detrimental to eye health. Dusty conditions were common as few roads in the communities were sealed, community members spent much time outside in the bright sunshine, and packs of dogs in poor condition and many flies contributed to hygiene problems in some areas.
A notable result of the screening was the absence of colour vision deficiencies. Those who live in these remote communities on Cape York are Aborigines or Torres Strait Islanders whose culture differs from that of mainstream European Australia. Social organisation and social structure is based on a group rather than a nuclear family. It is suggested that although a long process of natural selection may have endowed hunter-gatherer communities with good colour vision, during recent history the marriage and kinship systems of the Aborigines and Islanders have minimised the incidence of inherited conditions such as colour blindness.
It was concluded that there is a need to re-invigorate the education of the indigenous communities in primary health care, with a special focus on education for prevention. Many eye problems can be averted through knowledge and practices related to eye care and eye hygiene. The cultural origin of the group needs to be considered when selecting and implementing a program. Reports in the literature have suggested that effective services for remote communities in other countries are implemented by members of the community who have undergone "hands on" training in education or health, supported and monitored by specialist personnel. Such training would allow selected members of the Aboriginal and Torres Strait Islander communities to learn primary health provision or primary teaching skills without being away from their communities for a significant length of time. Brief periods in major centres will always be necessary for community members to gain wider knowledge and experience in health and education, especially for those who seek professional qualifications.
Although there are some limited programs in Queensland for training health workers, the indigenous staff in the communities visited for this study were not well qualified and were mainly employed as teacher aides or community health workers with restricted responsibilities. If communities are to be encouraged to take more responsibility for their own health and education programs, some changes in the current system are desirable. Changes seem especially desirable in education services since many lifestyle practices are learned early in life and become well engrained by adulthood. The education system could be playing a much greater role in coordination with health personnel to help children to learn new practices regarding hygiene, exposure to sun, and nutrition. Effective preventive programs need to be developed using the knowledge and skill of both education and health personnel and respecting a high level of community participation.
It was also concluded that because the scattered nature of the indigenous communities increases the difficulty of providing services, cooperation among communities is essential for prudent organisation and use of human and material services.