Background and Development

Developing unified hygiene health promotion resources

The aim of the development of the ‘Milpa’s Six Steps to Stop Germs’ suite of resources was to create a unified approach to hygiene-related illness by expanding the steps to include actions that help prevent a range of childhood infections, not just trachoma. This meant having the key action of eliminating trachoma – ‘wash faces whenever they have eye or nose secretions’, alongside other actions such as ‘having a shower with soap everyday’ which helps to prevent conditions such as scabies other skin infections.

Repeated infections of trachoma can lead to blindness. Many other acute infections can lead to disability and chronic and life-threatening diseases these include; acute otitis media, tooth decay and gum disease, respiratory, gastrointestinal and skin infections.

It is unacceptable that young children in remote Indigenous communities have high attendance rates at clinics with infectious conditions being almost two-thirds of presentations in some regions1.  Indigenous babies and children also bear a disproportionate burden of serious infections2 with higher hospital admission rates for infection in children under two, than non-Indigenous children.

To make lasting change for the elimination of trachoma and reduce other infections, health programs must increase knowledge, change social norms and behaviour change (the ‘software’) and provide the safe bathrooms infrastructure (the ‘hardware’) to conduct positive hygiene practices.

The ability to carry out positive hygiene practices is also limited by inadequate and poorly maintained health hardware, over-crowded housing, unaffordable soap, towels and cleaning supplies.

The health system must be supported by housing, education and environmental health sectors to address the underlying social determinants of infectious disease.

Community Consultation and Endorsement

During 2019 IEH conducted a widespread consultation to discuss the six steps images and key messages with Indigenous community members, and both Indigenous and non-Indigenous staff members from health, environmental health, education and language services in SA, WA and the NT.

The participants views were very considered and wide ranging, yet it was clear that Indigenous community members and staff held some similar views across SA, WA and the NT. In general, their input was similar to the advice of the Ngumbin Reference Group in 2010 “keep it simple”, “tell us exactly what to do” and “describe the action clearly in everyday language”. The input from Indigenous individuals and organisations was given greater weight than that of non-Indigenous input.

These recommendations brought together a way to communicate the best, evidence-based key messages for hygiene behaviour change, helped refine the images and select the final title. The title “Milpa’s Six Steps to Stop Germs” was preferred, being very specific, was about stopping germs and could be linked to the popular No Germs on Me campaign.


Four Steps

  • The unified hygiene resource originated in the Alice Springs Trachoma Health Promotion Group in 2013 to join simple steps for clean faces and hands as many hand-washing messages at that time did not include face washing.
  • Group members consulted with community members and stakeholders3 and created the Four Steps for Good Hygiene.
  • This was incorporated into the Families as First Teachers Health Hygiene and Safety Standards NT 20134 and taught by trachoma programs and in school hygiene routines in the NT, SA and WA.

Five Steps

  • In addition to nose blowing, hand and face washing, many schools include tooth-brushing in their morning routine.
  • Oral hygiene was included as a tool to support teachers and teacher assistants with this daily practice in 2016.
  • The resources were also widely distributed to community members for their homes and used in clinics, stores, youth services and many community programs.

Six Steps

  • The health promotion resources were reviewed in 2018 and a sixth step included to encourage good skin health by having a daily shower with soap.
  • The resources incorporate the well-known and accepted Milpa the Trachoma Goanna mascot and branding and the call to action for eliminating trachoma and other infections.
  • A review of the unified hygiene resources was conducted in 2019 to ensure images and key messages communicated current best practices clearly and consistently to audiences in remote Indigenous settings.
  • Indigenous community members, Indigenous organisations and health/hygiene networks had input and endorsed the final set of key actions with imagery.
  • Milpa’s Six Steps to Stop Germs suite of resources are part of a new suite of health promotion resources and multimedia available in 2020.
  1. Kearns T, Clucas D, Connors C, Currie BJ, Carapetis JR, Andrews RM. Clinic Attendances during the First 12 Months of Life for Aboriginal Children in Five Remote Communities of Northern Australia. PLoSONE. 2013; 8(3): e58231.
  2. Carville KS, Lehmann D, Hall G, Moore H, Richmond P, de Klerk N, Burgner D. Infection is the major component of the disease burden in Aboriginal and non-Aboriginal Australian children: a population based study. Pediatric Infectious Disease Journal. 2007; 26(3) 210–216
  3. IEHU Trachoma Newsletter July 2013
  4. FaFT Health Hygiene and Safety Standards 2013, Office of Children and Families Northern Territory. NT Government. 2013

2 April 2020