Working in partnership with communities at risk: the potential of integrated public health action during an outbreak of APSGN in remote AustraliaOriginal article (peer reviewed)
Custodio J, Kelly G, Haenga M, Bell C, Bond T, Prouse I, Eastwood A* (2016)
Working in partnership with communities at risk: the potential of integrated public health action during an outbreak of APSGN in remote Australia. Australian Indigenous HealthBulletin 16(4). Retrieved [access date] from http://healthbulletin.org.au/articles/working-in-partnership-with-communities-at-risk-the-potential-of-integrated-public-health-action-during-an-outbreak-of-apsgn-in-remote-australia
* Corresponding author’s contact details: Ashley Eastwood, Kimberley Population Health Unit, Department of Health, 5/9 Napier Terrace, PO Box 525, Broome 6725, email: Ashley.Eastwood@health.wa.gov.au
Abbreviations for authors: Custodio J – (JC), Kelly G – (GK), Haenga M – (MH), Bell C – (CB), Bond T – (TB), Prouse I – (IP), Eastwood A – (AE)
Objective: To share the findings of a service-based ‘healthy skin initiative’ implemented during an outbreak of Acute Post-Streptococcal Glomerulonephritis (APSGN) in the Kimberley.
Methods: There were four consecutive visits to a remote Aboriginal community in the Kimberley over six months combining environmental health (EH), health promotion (HP) and public health (PH) alongside on-site primary health care (PHC). Activities and key findings were documented. Clinic data were independently retrieved from a de-identified administrative database to compare skin presentations to the PHC clinic before and after this initiative.
Results: PH team achieved high rates of assessment of children aged 1-17 years, seeing 176 children (median age, 11 years) in total and completing 371 assessments. Forty-four comprehensive home health hardware assessments identified 242 repairs for referral (range per home assessment 1-15; median 5). Of these, all but one was completed within six months (<1%). Clinic data showed significant decrease before and after this initiative in presentations to the local clinic for scabies (9.5% v 2.2%) (p<0.0001).
Conclusions: This service-based initiative adopted a partnership approach, respected community empowerment and demonstrated positive yields that the community has endorsed as a ‘good news story’.
Implications: Achieving skin integrity for Aboriginal children requires genuine partnership between community leaders, PHC clinic staff, EH, HP and PH. This initiative, galvanised in an APSGN outbreak, required considerable planning and resource reallocation. These achievements invite consideration of long-term investment in community-based environmental health, health promotion and primary health care services beyond the outbreak itself.
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Acute Post Streptococcal Glomerulonephritis (APSGN) is a delayed inflammatory condition affecting the kidney that occurs after an infection of the skin or throat with Group A Streptococcus (GAS) . One percent of patients with APSGN have short-term but life-threatening kidney failure. At least 15% of patients with APSGN will have permanent evidence of kidney dysfunction, high blood pressure or both . Aboriginal adults with a childhood history of APSGN are significantly more likely than those without to have proteinuria . Proteinuria predicts the rate of permanent loss of kidney function . APSGN is another among many accumulating risk factors for kidney disease [3, 4]. Ten years ago, APSGN was pronounced ‘rare’ in developed countries . Yet APSGN still occurs in cycles among Aboriginal people [6-8]. Remote Aboriginal communities have a higher prevalence of GAS infections than non-Aboriginal communities . New GAS strains spread especially quickly in remote Aboriginal communities with high rates of scabies, skin sores and overcrowded living conditions [10-11]. Skin integrity resistant to GAS is vital for health and wellbeing especially for Aboriginal children [12-17].
APSGN is not notifiable in Western Australia (WA). After a gap of seven years without APSGN, 23 cases occurred in succession across the Kimberley in 2014, heralding an outbreak. A regional APSGN Task Force was convened. Immediate attention focused on developing resources to standardise practice across the region. For example, the Kimberley skin infection protocol had not been updated since 2010. Revision of this protocol was prioritised to incorporate specific diagnostic criteria for skin infection; the role of GAS as a cause of skin infection in the Kimberley; evidence-based treatment and an updated section on scabies treatment. This revision was released in December 2014 . A 16-page resource about public health strategies was developed: initially released in an interim form and finalised in November 2014 . This included sections on the role of the clinician in APSGN; the role of primary health care (PHC) in standardised contact identification and tracing; epidemiological criteria for invoking population-wide community screening and delegations to authorise this decision .
During 2014, one community met epidemiological criteria for population-wide screening as agreed by the APSGN Task Force twice in less than six months (July 2014 and October 2014). Because 75% of APSGN in the Kimberley is environmentally attributable , we were concerned that 60 residential houses in Community B were each likely to be occupied by at least seven people [21, 22]. As a consequence, children living there remained at risk of ongoing GAS transmission and preventable APSGN. Although 20 initial home assessments were completed in October 2014, there was little published evidence at that time to inform an integrated approach in this context . Our public health response would need to respect community autonomy and support without sidelining PHC staff working on site and residing in Community B. As elsewhere in remote Australia , remote PHC staff turnover is high and the legacy of historical trauma and diminished pride further disempowers communities.
This article describes the way we worked to bring resources from environmental health, public health and health promotion together as integrated public health action in conjunction with PHC clinic staff over a nine-month period. This intensive ‘healthy skin initiative’ was designed to reduce factors in Community B that placed children at risk for APSGN, specifically scabies and skin infections. After sharing our experiences with Community B in May 2016, we earned their permission to describe the significance of this initiative for ongoing activities in the Kimberley and offer recommendations for others promoting skin integrity.
Integrating environmental health (EH), public health (PH) and health promotion (HP) action with primary health care (PHC)
Planning and logistics meetings began in late 2014. AE (senior author) initiated contact with Community B leaders and on-site PHC staff to understand their expectations of integrated public health action on the ground. JC and MH (the PH team) would be redeployed from scheduled duties to prioritise this initiative: both are experienced public health nurses with expertise in skin screening, scabies treatment and community engagement. GK (Aboriginal Public Health Liaison Officer) leads implementation of the No Germs on Me health promotion campaign in the Kimberley . GK would be supported to tailor this and other programs in Community B (HP component). CB and TB (the EH team) are experienced environmental health staff who have worked long-term in the Kimberley: both would be able to focus on Community B by rescheduling other competing work. Co-ordination with PHC occurred at two levels: one, between senior managers at Kimberley Population Health Unit (KPHU) and, the other, at local level with on-site PHC clinic staff. We focused on the contribution of skilled Aboriginal staff: CB and GK were male and female Aboriginal staff respectively and both had further support from IP, a senior Aboriginal EH manager. Four ‘fly in / fly out’ visits to Community B were agreed. Details are presented below (see also Box 1).
Environmental health (EH) component
Our EH team has a deep cultural knowledge of Community B and respect for the community, their history, customs, culture and practices. They have an expert understanding of the complexities of living conditions, social issues and hardships as well as community strengths and resilience. During all four visits, comprehensive home health hardware assessments by the EH team would be augmented by the presence of one of the PH team. Assessments were completed using a seven-page form (Appendix 1 shows the summary page) (the full form can be obtained from the authors). Permission would be obtained before entering the home. If any issue was identified, this would be explained to the residents and prioritised for referral by the EH team to the relevant service provider such as Community Housing Limited (CHL) for plumbing repairs within the fenced boundary of a house; Kimberley Regional Service Providers (KRSP) for plumbing outside the fenced boundary including larger jobs such as sewerage outflows needing large earth-moving machines or a community-based service known as the Support and Tenant Education Program (STEP) managed by Nirrumbuk Aboriginal Corporation which could offer follow-up support with voluntary sign-up depending upon available capacity . In addition, our EH team is equipped to deliver a Dog Health program. The EH team would repeat home visits if required.
Public health (PH) component
We liaised with on-site PHC staff in advance of all visits. In addition to organising supplies and locations, PHC staff obtained written parental or guardian consent for skin examinations and treatment prior to the arrival of the PH team. This process explained why the PH team was performing skin checks and initiating treatment. Parents/guardians could consent for their child to be screened (or not), for their child to be treated with permethrin if required (or not) and penicillin injections without their presence (or not). Our PH team completed skin assessments of every Aboriginal child aged between one and 17 years as recommended . All appropriate places where children of eligible age could be seen and screened were used, including the remote school, and with permission, facilitated through the EH team’s residential homes. Any unaccompanied child requiring treatment who did not have parental consent was referred to the PHC clinic. Our PH team recorded the name, date of birth and skin integrity of every child examined and, where possible, location seen. Assessment of the presence of skin sores was standardised using relevant criteria . For any child with scabies, the PH team was authorised to initiate a course of permethrin topically; for those with head lice, the PH team was authorised to initiate maldison topically. For those with skin sores requiring treatment such as oral or intramuscular antibiotics, the PH team referred the child to the on-site PHC clinic staffed by remote area nurses (RANs) whose responsibilities include comprehensive primary health and emergency care. When RANs are credentialed in pharmaco-therapeutics, standing orders describe clinical conditions for which they can administer pharmacological treatment including antibiotics without a doctor’s order. PHC staff also completed a seven-day follow-up of any child treated with topical medication by the PH team and any household member of a child with scabies also received a course of topical permethrin through the clinic. New RANs were orientated to the APSGN outbreak prior to arriving in Community B. Follow-up meetings occurred with PH team during each of the four visits particularly to reinforce relevant guidelines [18, 19]. Continuous dialogue about specific patients and families further promoted a sense of shared responsibility for children’s outcomes between PHC staff and our visiting PH team.
Health promotion (HP) component
GK prepared a comprehensive health promotion (HP) plan as a central component of this initiative to engage community members, grannies, mums and carers, in understanding the links between healthy skin, poor skin, disease and the home. Strategies included general community education; assisting PH and EH teams in walking around the community and using culturally appropriate resources. GK is an acknowledged Aboriginal expert in health promotion and community engagement. Where possible, PHC staff joined HP sessions, adding healthy nutrition and other HP topics.
Extent of community access to skin checks
According to the Australian Bureau of Statistics (ABS), there are 172 Aboriginal children aged 1-17 years in Community B . As it is extremely uncommon for a non-Aboriginal child to reside in Community B, we counted all children seen as Aboriginal. At a minimum, all Aboriginal children needed to be seen at least once as part of this integrated initiative.
PH, HP and EH team descriptive data collection
Data were collected for all visits by all team members. PH screening data sheets were de-identified, assigning a unique code number to every individual child. The EH team recorded the number of houses that were assessed, the number of repairs relating to skin health required per household and the number of housing referrals completed within six months. Staff logged hours worked.
Before/after clinic data comparison
We accessed a de-identified administrative database used throughout the Kimberley known as HCARE  to determine any change in clinic presentations for scabies or skin infection before and after our initiative. Our ‘before’ period was set as September to November 2014 inclusive and our ‘after’ period as September to November 2015 inclusive (exactly a year later). HCARE obviates the need to access individual clinical medical records. We compared the percentage of all consultations in PHC with children 0-17 years in Community B in which ‘scabies’ was coded as either a ‘primary’ or ‘additional’ reason for attendance before and after our initiative. We also compared the percentage of all consultations in PHC with children 0-17 years in Community B in which ‘skin infection’ was coded as either a ‘primary’ or ‘additional’ reason before and after our initiative. While this approach avoided seasonal variation, we were unable due to limited resources to obtain HCARE data for a control group from elsewhere in the Kimberley. To compare proportions, we used Yates corrected Chi Square on Epi Info .
KPHU maintains regional public health databases during disease outbreaks as part of its statutory obligations. This allowed APSGN notifications to KPHU for Community B and the rest of the Kimberley to be monitored.
This integrated initiative was instigated as part of an outbreak response conducted by an authorised public health team. Evaluation was exempt from ethics committee approval. No identifying information was shared with any person outside the team. These findings were presented to Community B in May 2016. Feedback was incorporated into this manuscript. Their permission to publish was obtained.
Four visits to Community B integrating PH, HP and EH components alongside on-site PHC clinic services were completed in December 2014, January 2015, March 2015 and May 2015. CB, TB and GK were already especially well-known to Community B and were highly visible. JC and CB missed one visit each, otherwise the teams were stable throughout. Considerable logistic planning ensured that all team members met and worked together with local community leaders and PHC clinic staff as envisaged. Excluding travel time to reach Community B, 437 hours were expended on the ground by EH, PH and HP staff that would have been otherwise dedicated to service provision elsewhere.
Skin check component
In total, 176 children were seen for skin checks by the PH team (median age, 11 years). Twenty-four children were seen at every visit (four times); 32 children were seen three times; 56 twice; and 64 only once. In total, 371 skin checks were completed (see Table 1). The PH team saw 103 children in the target age group in Visit 1. Of these, 65 (63%) were disease-free. For the remaining 38 children, nearly 10% had scabies with or without another skin condition at the first visit (9.7%). Five (5%) children with skin conditions required referral. By Visit 4, 3% of children seen by the PH team had scabies with or without another skin condition. At no visit was there a child with ‘crusted scabies’.
Table 1 Skin conditions among children 1-17 years in Community B by visit
|Skin condition||Number (%)||Action|
|Visit 1 (Dec 2014)|
|Clear skin||65 (63%)||Nil required|
|Head lice only||13 (12%)||All treated by PH team|
|Skin sores*||11 (11%)||Three referred to clinic; two received penicillin by intramuscular injection (IMI)|
|Scabies and head lice||4 (4%)||All 4 treated with permethrin topically and maldison topically. One child with infected scabies was referred to clinic for penicillin IMI.|
|Skin sores and head lice||4 (4%)||None required referral to clinic.|
|Scabies only||3 (3%)||All treated. None referred.|
|Skin sores and scabies||2 (2%)||Both treated. None required referral to clinic.|
|Skin sores, scabies and head lice||1 (1%)||Full treatment by PH team and referral to clinic|
|Visit 2 (Jan 2015)|
|Clear skin||43 (54%)|
|Head lice only||19 (24%)||16 treated with maldison topically. Three had no parental or guardian consent and required referral to clinic for this treatment.|
|Skin sores||10 (12%)||One required referral to clinic|
|Scabies and head lice||0 (0%)|
|Skin sores and head lice||6 (7%)||Three had no parental or guardian consent and required referral to clinic for treatment.|
|Scabies only||2 (3%)||Two treated with permethrin topical|
|Skin sores and scabies||0 (0%)|
|Skin sores, scabies and head lice||0 (0%)|
|Visit 3 (Mar 2015)|
|Clear skin||51 (50%)|
|Head lice only||31 (31%)||21 treated by PH team. 10 others had no consent.|
|Skin sores||10 (10%)||Two required referral to PHC clinic.|
|Skin sores and head lice||5 (5%)||Three were treated by PH team. One had no parental or guardian consent and required referral to clinic for treatment. Another had parental consent but there was appropriate place at the school to administer full treatment.|
|Scabies only||2 (2%)||Two treated by PH team with permethrin topically.|
|Skin sores and scabies||1 (1%)||Scabies treated with permethrin topically. Referred to PHC for treatment of skin sores.|
|Scabies and head lice||1 (1%)||Treated with permethrin and maldison topically.|
|Skin sores, scabies and head lice||0 (0%)|
|Visit 4 (May 2015)|
|Clear skin||66 (76%)|
|Head lice only||13 (15%)||9 treated with maldison topically. Four children had no parental or guardian consent and required referral to PHC clinic for treatment.|
|Skin sores||4 (5%)||All four required referral to clinic|
|Scabies and head lice||1 (1%)||Treated by PH team with permethrin and maldison topically.|
|Skin sores and head lice||2 (2%)||Both referred to clinic for skin sores and head lice treatment. One was reviewed and evacuated with a provisional diagnosis of APSGN (later confirmed).|
|Scabies only||0 (0%)|
|Skin sores and scabies||1 (1%)||Had been treated for skin sores a week ago but still required referral to clinic for review|
|Skin sores, scabies and head lice||0 (0%)|
Environmental health house assessments proceeded with CB, TB, GK and JC travelling door-to-door through the community (Box 1). Excluding unoccupied houses, 31 homes were assessed and re-assessed. In total, 44 housing assessments were completed which doubled the number of assessments completed before December 2014. In total, 242 household issues were identified for referral ranging from one to 15 per assessment (median 5). Required repairs were wide-ranging, including blocked toilets, leaking roofs, no hot water, blocked kitchen sinks, cracked septic tanks lids, blocked external drains causing water to pool in the rear of residents’ yards, faulty toilet cisterns or broken or faulty taps in showers, laundry, bathroom or kitchen. As plumbing defects must be repaired according to current WA plumbing licensing legislation , a plumber visits Community B regularly depending upon demand. If a clothes-line needed repair however, this could be done by the EH team to ensure laundry could be dried and blankets exposed to sunlight. Household access to functioning washing machines was variable. Of the 242 issues referred for repair, all but one (<1%) was completed within six months. Other issues were identified even though not directly affecting skin health because our EH team listened attentively to household residents. For example, multiple power short-outs were traced back to a crumbling electricity pole. This was reported immediately by the EH team to the relevant public utility provider. CHL added solar panel inspection as a routine item in their own home inspections because this initiative reinforced links between hygiene, regular showering, healthy skin and availability of hot water through functioning solar hot water power systems to household occupants and CHL.
Box 1 Structure of combined PH and EH four-day visits to Community B
PH team commenced screening at school until midday then pre-school screening in the afternoon. For community screening in the afternoon, JC teamed up with EH team. MH joined GK to prepare community education venues. EH team updated maps of streets, public amenities and residential houses (occupied or unoccupied). During EH home visits, families with children that didn’t attend or were absent that day from school were informed about the initiative. During home visits, EH team provided house assessments to residences with concerns regarding hardware or plumbing issues. EH organised referrals to appropriate agency for action and repair. MH and GK were based at central location for parents/carers to bring children for skin check by MH. Any child of concern referred to clinic with follow up from EH team to assess home hardware and plumbing. At the end of the day, teams returned to on-site PHC clinic to catch up with clinical staff regarding outcome of children referred to them.
Teams met briefly with clinic regarding plan for the day. Any new PHC staff unfamiliar with Kimberley skin infection protocol was informed. School-based screening continued. Activities largely as for Day 1.
To ensure a closer focus on children with unhealthy skin and their families to build knowledge and understanding, a brief update with clinic was followed by follow up of children and families identified at risk earlier in the visit to review the child and provide family 1:1 education and discussion. EH continued to conduct comprehensive house and yard assessments. Interactions with families reinforced the importance of household repairs and the causal links between health hardware, children’s health and skin disease. Any clinical questions asked of the EH team could be answered by JC. In the afternoon, teams continued with home visits to connect with babies, toddlers and children missed from previous 2 days of screening. Education sessions by GK continued in locations convenient to the community using relevant resources. People seen during their daily activities such as their daily shopping could approach any team members. Teams returned to clinic to catch up with clinical staff regarding outcome of children referred to them.
There was no skin screening on Day 4 as this day was dedicated to wrap up, entry into clinical notes, liaison with clinic staff regarding children requiring follow up and review and debriefing the visit. EH team ensured all referrals in train before leaving the community until the next visit.
Anecdotally, the EH team’s pre-existing familiarity with community members not only facilitated their own access to homes for health hardware assessments but also facilitated entry to homes by the PH team to assess the skin of children too young for school. Families were comfortable to suggest other families whose homes needed to be visited. In addition, referral forms were introduced for on-site PHC staff (Appendix 2).
Health promotion and community education
GK was pivotal in engaging community members with this initiative. Culturally appropriate HP resources were developed specifically for Community B including posters and flyers about scabies and APSGN. One poster used photos taken in the community with permission. Photos from an existing health skin flip chart were adapted . GK also assisted with education of families about basic wound management, cleaning of skin sores, observing wound healing and how to watch for complications. This approach became ‘loving them up, walking towards healthy skin’ . CB and TB also had existing resources on dog health and other EH issues that were used in community education sessions. Various locations were used including the local community resource centre, open air school facility and other community buildings. Two BBQs were held, when agreed with the community, to engage families who may have been missed in door-to-door contacts. Informal questions could be asked by anyone. Semi-structured surveys gauged community understanding and knowledge of this initiative and identified ways to improve or adjust from Visit 1 to 4. GK noticed increasing engagement with school students and self-referral by school students to the PH and EH teams for skin problems. Services of the PHC clinic were explained. Children and adults were encouraged to attend the clinic for diagnosis and treatment if their condition was not encompassed in the PH scope of practice. GK also accompanied the EH team as planned for home visits to connect with community and answer questions. Because of this visible Aboriginal leadership, there was greater community confidence in its purpose. Anecdotally, the benefits of these visits for the community spread quickly by word of mouth. We encouraged people to not be frightened of attending the PHC clinic. One older woman said she had itchy skin: even though she was not in our target age group, she was accompanied to the PHC clinic for treatment she might otherwise not have sought. Community HP events also allowed our visiting teams to acknowledge and thank the community for their involvement.
Additional short-term funds were obtained through the WA Health Child Health Investment Project to engage an additional project officer for six weeks from mid-May to the end of June 2015, enabling further communication and consultation with the local Aboriginal Corporation, community groups, individuals and service providers to ascertain the main health needs of the community to help KPHU better plan strategically over the long-term. This consultation identified social and emotional wellbeing, and social determinants of health as core underlying concerns for Community B including food insecurity, housing that was inadequate for the size of the community, addictions, job opportunities and infrequent services for common problems. This consultation also identified the confusion experienced by local people when service provision by visiting services was poorly coordinated. Accountability of service providers to communicate and co-ordinate with each other and also the community could be better facilitated through the local Aboriginal Corporation [Collins, unpublished report, August 2015].
Findings from clinic attendance database
Before this initiative to reduce APSGN risk in Community B during an outbreak, the percentage of all PHC consultations for children 0-17 years in which scabies was coded as either ‘primary’ or ‘additional’ reason for attendance was 9.5%. After this initiative, the percentage was 2.2%. This difference is statistically significant (9.5% v 2.2%)(chi square 14.22; df1; p<0.0001). Before this initiative, the percentage of all PHC consultations for children 0-17 years in which skin infection was coded as either ‘primary’ or ‘additional’ reason for attendance was 8.5%. After, it was 8.2%. This difference was not significant (8.5% v 8.2%)(chi square 0.0001; df1; p=0.98).
Trends in APSGN notifications
In 2014, the first four APSGN cases in Community B had all occurred in June; then one in July; three in September; three in October and two in November. This pattern was extinguished commencing December 2014 when there were no cases (Visit 1). In 2015, there were no APSGN cases until May 2015 when one isolated case was reported. This was the only case for the entire 2015 calendar year in Community B (compared with 13 in 2014). APSGN continued elsewhere in the Kimberley (102 cases as at March 2016). While denominators are too small to examine whether there were significantly different APSGN rates between Community B and elsewhere, these data suggest the reduction was achieved in Community B as intended.
Senior managers in KPHU obtained resources and reallocated staff as best feasible over nine months to implement this intensive ‘healthy skin initiative’ to halt an unprecedented APSGN outbreak through integrated public health action. By working hard to achieve cultural security, our reach in screening children, assessing homes and coordinating repairs exceeded our expectations. Serious consequences of seemingly harmless skin conditions were explained during home assessments and community education sessions whenever people were curious (‘These skin sores can really do you damage’, ‘Do you know people on kidney machines?’ ‘The bugs in skin sores can damage your kidneys’). Other stakeholders including non-health services also became more familiar with risk factors for APSGN. Having this clear risk-based rationale for housing repairs was very effective. Local liaison between services achieved high rates of repair completion: all but one of 242 (<1%) referred repairs was completed within six months.
Our most convincing health outcome revealed by analysing HCARE data was a significant before / after reduction in scabies among children seen at the PHC clinic (9.5% v 2.2%)(p<0.0001). We were surprised however to discover a low percentage of skin infections coded in HCARE before our initiative. Documentation of skin infections at that time was likely inconsistent as the previous Kimberley Skin Infection Protocol was ambiguous in defining skin infection and vague in providing quantitative criteria for treatment. This version was rescinded and replaced during the outbreak. Intensive educational follow-up reinforced the need to document skin infections. After our initiative, skin infections as a percentage of PHC consultations with children were 8.2%. If we speculate that accuracy of documentation after our initiative was higher than before it, then a true but unmeasured change may have occurred. Skin infections are generally poorly reported . We accept that pragmatic observational studies remain the ‘workhorse’ of environmental health research and evaluation design . In selecting three-month blocks exactly a year apart for evaluation, seasonal variation was not explored. The picture for seasonal variation in skin infections in Aboriginal communities is also mixed [13, 33]. Consistent provision of skin examinations into routine PHC through child health check schedules should be supported. Clinical audits to improve diagnosis and treatment could be developed with PHC staff.
Community B was one of 106 Kimberley communities known since 2008 as having inadequate home design and equipment for healthy living . When reviewing Aboriginal programs in 2014, Professor Holman showed that environmental factors contributed to 13% of the gap in potential years of life lost but received 7.9% of funds, concluding ‘prima facie’ that environmental services were ‘under-allocated’ . Although an example of how resources can be mobilised for integrated public health action in an outbreak, our initiative was not routine. Primordial prevention of skin disease through concerted effort requires partnership . The importance we place on partnership is visible in the ratification in September 2015 of a Kimberley Skin Health Regional Partnership which describes governance and capacity building priorities for the Kimberley with six guiding principles (Box 2) . Evaluation through this agreement could monitor population impact. Research expertise has been secured by the Minister of Health . We agree with the World Health Organisation (WHO) that an important part of scabies control and elimination programs is their integration into existing systems . We are less convinced about the value of mass drug administration (MDA) in remote Kimberley communities . Postcolonial conditions in which Aboriginal populations with endemic scabies are forced to live in order to remain connected to land that for centuries was their forebears’ will not be addressed by MDA alone . Our results suggest MDA can be avoided.
Six guiding principles in the Kimberley Skin Health Regional Partnership 
Social, educational and economic conditions matter
Evidence-based approach is crucial
Effective governance will be delivered
Unique strengths and histories of communities will be respected
Outcomes will improve
Sustainable community empowerment matters
Changing community conditions and building the necessary capacity needs to be continued. Conversations about living conditions and health are private, sensitive and difficult. Impatience will not work but longevity and authenticity do. As one person reflected, ‘You can’t buy this rapport’. New resources have subsequently been identified to construct a community laundry in which token-operated washing machines capable of heavy loads return revenue to the community to subsidise costs of power bills. Other resources could be better tapped for effective primordial prevention including revitalising the Strong Women’s Centre, establishing an Aboriginal HP Officer for on-site community development and expanding the skills of Aboriginal staff in PHC. In May 2016, we ascertained from Community B their additional ideas about future directions. These included sustainable implementation of the community laundry, more job opportunities in community development, dog control and teaching young parents about the links between environment and children’s health.
To conclude, we are optimistic about the potential for ongoing community engagement to achieve skin health. Working together and sharing data further strengthens community re-empowerment and service accountability [42-43]. Tools exist [20, 44]. We also affirm the importance of Aboriginal employment as a social determinant including careers in environmental health for people who are personally invested in their community’s outcomes. As said by a member of Community B: ‘This is a good story to share. Nobody says anything good about Kalumburu.’
The authors thank Tom Bell, volunteer, for joining the EH team during the last visit; Monica Frain, Remote Clinic Coordinator and the nurses at Kalumburu Clinic for their commitment and significant contribution to the healthy skin initiative; Mel James, PH Manager for leadership and obtaining WA Health Child Health Investment Project funds to support further community consultation; Pippa Collins, Project Officer, for attentive community consultation; Di James, Regional Health Information Manager, for HCARE outputs; Prof Cate D’Este at the Australian National University (ANU) for statistical advice; Andrew Waters, KPHU Director for supporting internal resource reallocation and Prof Jeanette Ward for facilitating manuscript preparation. We acknowledge the vital role of the Kimberley Aboriginal Health Planning Forum (KAHPF) Environmental Health Subcommittee for promoting partnership and learning. Finally, we thank the Kalumburu Aboriginal Corporation for agreeing that Community B be named and authorising publication of these results.
KPHU offices are located on Yawuru land. We acknowledge the impact of Europeans in disturbing sovereign Aboriginal states in northwestern WA. We also pledge our commitment to local partnerships with Aboriginal people to achieve greater equity.
The authors declare they have no conflicts of interest.
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