Indigenous Environmental Health: Report of the Fifth National Conference 2004

Impact of Swimming Pools on Health of Aboriginal Children in Remote Western Australian Communities

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Mary Tennant, Epidemiology, Telethon Institute for Child Health Research, Western Australia

The swimming pool study began in May 1999 when the Western Australian Department of Housing and Works asked the Telethon Institute for Child Health Research to determine whether pools that were to be built in remote Aboriginal communities would have any effects on the health of children in those communities. Three swimming pools were opened in the communities of Jigalong, Burringurrah and Yandeyarra in September 2000. We undertook to follow the children in two of these communities - Jigalong and Burringurrah.

We looked at the impact on ear and skin health of these children. In addition we monitored morbidity among children enrolled in the study, by collecting information from the medical files in each community. We also took an interest in the social impact of the pool and conducted regular interviews with adults in the communities to find out what their impressions were.

Results from the first two years were published in the British Medical Journal.¹

Introduction

Indigenous Australian children have very high rates of pyoderma (pus-producing skin lesions) and otitis media (glue ear). In some communities as many as 70 per cent of children have been found to have skin sores, at any one time. The major pathogen of pyoderma is group A streptococcus, which is also associated with chronic renal failure and rheumatic fever, both of which have high incidence rates in Indigenous communities in Australia.

Impaired hearing, a symptom of otitis media, can seriously affect performance at school, subsequent employment, and social circumstances in adulthood. Between 10 per cent and 67 per cent of Aboriginal school age children have perforated tympanic membranes, and between 14 and 67 per cent have some degree of hearing loss; remote communities have the highest prevalence.

Drowning occurs at a higher rate in the Aboriginal population in Western Australia than in the non-Aboriginal population. With the introduction of the Royal Life Saving Societies ‘swim and survive’ program (conducted by Royal Life Saving Societies pool managers) all school age children in the communities currently have swimming lessons.

People in remote Aboriginal communities have little or no opportunities for physical exercise, and changes in diet and lifestyle have made Aboriginal people more prone to the group of conditions know as ‘syndrome X’—obesity, Type 2 diabetes, cardiovascular and renal disease.

Method

We compared disease prevalence before and after swimming pools were opened in the two communities (total population approximately 180 in Burringurrah and approximately 250 in Jigalong) located in semi-arid environments 1200 and 1600 kilometres north of Perth, respectively. During the summer, daily temperatures range from 15ºC to 45ºC, and fall to freezing at night in winter. The swimming pools were opened in September 2000 and are open annually from September to April.

Children were examined four times at approximately six-monthly intervals between July 2000 and March 2002 and a fifth examination was done in the winter of 2003 (August–September 2003). During the winter visit to Jigalong we found a large number of children with ear disease - it was reported that the pool had been under-utilised during the previous summer, and the pool was closed from September 2003 until late January 2004, due to management problems - so we made an extra visit to Jigalong in March 2004.

All children younger than 16 years present in the community were eligible for inclusion in the study if informed consent was obtained. At each survey a paediatrician examined all enrolled children who could be located and children who moved into the communities were also given the opportunity to enrol. In winter 2003, new recruits made up almost 50 per cent of children examined in both communities.

Skin sores were graded according to severity (the ‘sore score’) based on the total number and severity of sores (crusty, pus-producing or dry flat lesions). A sore score of 1-4 was classified as non-severe and 5 or greater as severe. The presence and severity of scabies, abscesses and fungal lesions was also recorded. Experienced paediatricians performed ear examinations. If otorrhoea (seepage from the ear) was found the ear was irrigated with 1:20 Betadine solution to obtain a good view of the tympanic membrane. Colour and position of the tympanic membrane (retracted, bulging or normal) was recorded, as was presence of wax, cholesteatoma (a tumour-like mass of cholesterol and tissue in the ear), perforations and otorrhoea. Pathology indicative of past disease, such as healed perforations and tympanosclerosis (thickening and calcification of the tympanic membrane), was also noted. Two ear, nose and throat specialists examined children with serious ear disease or to confirm the paediatrician’s diagnosis.

We examined the health records of children enrolled on the study and recorded clinic visits for the year prior to pool opening and each year after. The information obtained was in reference to skin, ear and eye disease and the frequency and type of antibiotic prescriptions. In this way we were able to compare health visits in the year prior to pool opening and afterwards.

Since parents were concerned about truancy, the community introduced a ‘no school no pool’ policy (see p. 138) as an incentive for children to attend school. In addition to having swimming lessons at school, school attendees are given passes permitting them to use the pool after school.
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Results

Figures 13-16 show a reduction in prevalence of skin infection and eardrum perforations, particularly in Burringurrah.

Figure 13: Skin infections in Burringurrah



Figure 14: Skin infections in Jigalong



Figure 15: Ear infections in Burringurrah



Figure 16: Ear infections in Jigalong



Among children who remained in Jigalong throughout the study, an average of 6 courses of antibiotics per child were prescribed in the year prior to the pool opening and then 4, 2. 5 and 1. 3 courses per child, respectively, in each subsequent year. This clearly shows a decrease in the need for antibiotics.

Pool-related incidents

There have been no reported disease outbreaks and only occasional faecal accidents in the pools. In each community, there was one pool-related accident - a broken arm and mild concussion.
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Recommendations and feedback to community councils

We have received comments that people would like better access to the pool for the elderly, disabled and obese. This might come in the form of a larger stairway into the pool or a hydraulic lift.

Very few adults use the pool. The reasons they gave for not using the pool were:

• I used to swim in a pool when I was a child but not now.
• I do not have the right clothing.
• I go there to watch kids.
• It’s not fresh water.
• I’m not used to swimming in a pool.
• I panic when kids are around water.
• I don’t swim in salty water it hurts my eyes.

Adolescent children in Jigalong attend the pool either as a group of girls or a group of boys; this is something that they arrange among themselves. The majority of people reported that the pool was a good thing for the children as they had somewhere safe to swim, the water was not polluted and swimming lessons were beneficial.

Maintaining interest in the pool is vital to the success of this project. Children are certainly keen to learn to swim and to participate in the carnivals the Royal Life Saving Societies run yearly. An added interest might be inter-community carnivals between the three communities, advanced swimming classes where the keener children could improve their stroke and fitness levels. Similarly it would be advantageous if there was a mother-and-child swimming program which would start children in the pool earlier than when they reach school. These added activities are beyond the scope of the pool managers who, in addition to maintaining pool water standards and cleanliness, run the ‘swim and survive’ program and supervise children after school hours.

The issue of payment to enter the pool has presented problems for some children. In order to enter the pool a child needs a pool pass after all day attendance at school, a responsible person to supervise while they swim and a dollar for the entry fee. In one community this was too much for the younger children and pool attendance dropped as a result. Another community has consulted families and, with their agreement, a fortnightly levy of $2.50 is imposed on all families so children do not have to be carrying money for pool entry.

To date, no-one in any community has been identified to take on the role of pool manager. At the outset it was agreed by the Department of Housing and Works and the Royal Life Saving Societies that, in the longer-term, it would be desirable for someone from each community to undergo pool manager training and take over management of the pool. The obstacle to this has been finding someone with the level of literacy and numeracy skills to undergo training.

Conclusion

Swimming pools in remote communities have been associated with reduced prevalence of perforations of the tympanic membranes and skin sores, which could result in long-term benefits through reduction in chronic disease burden and improved educational and social outcomes.

Research team

Dr Deborah Lehmann, Dr Desiree Silva, Mary Tennant, Helen Wright (RA), Daniel McAullay, Jacinta Johnston, Kate Butler, Irene Nannup, Sharon Weeks, Manda Hollins, Harvey Coates, Francis Lannigan, Dr John Stuart, Dr Peter Richmond, Dr Helen Wright, Pamela Kelly, Lorateen Garlett, Ashwini Arumugaswamy, Georgia Werna, and Claire Gordon. Associate investigators: Professor Fiona Stanley and Dr Anne Read.


For further information
Mary Tennant
Epidemiology,
Telethon Institute for Child Health Research
PO Box 855,
West Perth, Western Australia 6872
Phone: 08 9489 7788
Fax: 08 9489 7700
Email: maryt@ichr.uwa.edu.au

Footnotes
1. Lehmann, D, Tennant, M, Silva, D, McAullay, D, Lannigan, F, Coates, H & Stanley, F 2003, ‘Benefits of swimming pools in two remote Aboriginal communities in Western Australia: intervention study’, British Medical Journal, 327: 415-19.

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