Community Health Analysis: Rheumatic Fever in Maori Individuals

INTRODUCTION

Starting with a sore throat and eventually leading to a serious disease. Rheumatic Fever is one of the most preventable leading diseases amongst the community; beginning with ‘strep throat’; a throat infection caused by a bacteria called Group A Streptococcus; constant re-occurrence of untreated strep throats are the main cause behind Rheumatic Fever amongst the youth today (Ministry of Health, 2017).  Counties Manukau alone is the highest prevalent area being affected by this unfortunate disease, as the highest population being Maori and Pacific individuals; who are ultimately the most affected group in New Zealand (Ministry of Health, 2017).

Upon conducting research with current health education resources for Rheumatic Fever it is evident that there are many resources available to educate and inform the public of the disease and its context. Although you can notice an obvious gap when it comes to medication adherence; highlighting the importance and significance of this topic is essential as it’s the first step towards prevention of Rheumatic Fever. As to why the writer will create a health education resource in a form of an app where a reminder can be set in the commencement of antibiotics for GAS positive children as well as gaining knowledge on the importance of prevention; thus target audience being parents who have young children aged 4 – 15 years old in the most at risk area’s i.e. Counties Manukau. Rauemi Atawhai will be utilized in the development of this health education resource and presenting information in a manner that is easily comprehended by the community; the expected outcome being to increase awareness and improve medication adherence for GAS positive children.

STAGE 1: NEED

Rheumatic fever is a serious and preventable disease that has repeatedly mostly affected Pacific and Maori children aged between 4 – 19 years old (Heart Foundation, 2019). Rheumatic fever starts off with a strep throat infection caused by Streptococcus A bacteria, often when this bacterial infection isn’t treated properly with antibiotics it causes serious detrimental effects to the body like serious kidney diseases and heart diseases (Heart Foundation, 2019). Rheumatic fever is a delayed autoimmune reaction to the ‘strep bugs’ where an individual’s immune system begins to mistakenly attack parts of the body such as the heart, joints, brain and skin; often causing excessive inflammation (Heart Foundation, 2019).  This could lead to concerning effects with the heart valves; getting damaged and causing restrictions with blood flow (Heart Foundation, 2019). Depending on the severity; individuals suffering with rheumatic fever often become hospitalised from weeks to months to receive doses of penicillin injections or getting surgeries conducted if there are irreversible damages to the heart (Heart Foundation, 2019).

According to Ministry of Health (2019) the most recent statistics are in 2018 which is where Counties Manukau had the highest reported cases of rheumatic fever and hospitalizations in whole of New Zealand. The most pressing causes of this detrimental disease is inequalities within socio economic statuses and demographic structure amongst the Maori and Pacific population (Ministry of Health, 2017). Lack of health literacy amongst the target group is a major contributing factor towards poor adherence. According to The New Zealand Medical Journal, 2017 there are a consistent number of cases in terms of poor adherence to antibiotic courses in treatment for gas positive children; many times symptom improvement led individuals to believe that completion was unnecessary. As well as individuals living in low socio economic areas are the most affected due to contributing factors like low income, poor health literacy and overcrowded houses (Ministry of Health, 2019). The health education resource constructed by writer ‘Adhere 2 Clear’ will be prevalent to the current population as it focuses on the importance of medication adherence as well as health education. Pacific and Maori individuals are the most at risk group being affected by these contributing factors being the highest percentage population living in socioeconomic deprived areas (Ministry of Health, 2017). According to Stats NZ (2016) Pacific and Maori had the highest rates of unemployment in New Zealand; due to this the discussed population aren’t able to gain access to appropriate health care or housing due to insufficient funds. Housing plays a big role in terms of Rheumatic Fever being one of the most pressing causes of this disease; things like cold/damp and overcrowded homes are the most suitable environment for strep bacteria to spread from one person to another (Best Practice Advocacy, 2011). The Pacific and Maori population are most likely to have insufficient health outcomes than the overall population due to these obvious inequalities with accessing appropriate housing, income and health outcomes (Ministry of Health, 2019).

Due to the severity of this particular disease many initiatives and resources have been made available for the community to decrease rates of rheumatic fever within New Zealand. According to Ministry of Health (2017) The Rheumatic Fever Prevention Programme was initiated until July 2017 to increase awareness of rheumatic fever, reduce household crowding, and improve access to timely and effective treatment for strep throat infections in priority communities. According to recent statistics “In the 12 months ending on 31 December 2018, there were 171 people diagnosed for the first time with rheumatic fever in New Zealand – a rate of 3.6 per 100,000. The rate is now almost at the level seen prior to the beginning of the Rheumatic Fever Prevention Programme (2012) when there were 177 cases, a rate of 4.0 per 100,000 (Ministry of Health, 2019)”. The following statement highlights that although there are specific interventions put in place there is still a significant gap with health education amongst the community leading to a concerning amount rheumatic fever cases in New Zealand. Upon further research writer identified a variety of health resources available for health education amongst the community, many visual aids; like posters for “Steps of rheumatic fever”, family guide booklet “sore throats and rheumatic fever”, cards and videos for “key tips to a warmer home” (Ministry of Health, 2017). One main thing common with all resources available is prevention, all resources focus on the importance of preventing strep throat from occurring or giving information on rheumatic fever and the damages it causes to the body which is essential. Although an obvious need for health education on adherence is essential, many individuals don’t understand the importance of medication adherence as to why Adhere 2 Clear is the ideal resource as it mainly focuses on adherence alone to prevent rheumatic fever.

The health resource constructed by writer ‘Adhere 2 Clear’ will display the importance of adherence, providing reminders and health education on all information in terms adherence. The resource will come in an App for mobile devices as to why target audience are parents of young children in low socio economic areas. The app will mainly consist of being able to set a reminder on mobile devices upon the commencement of gas positive child’s antibiotics, receiving reminders in an alarm form on mobile devices to help parents remember to administer antibiotics to their child. As the days go the app is able to track progress and inform parents of how many days are remaining to complete course thus encouraging adherence. The app also consists of essential information in terms of strep throat, signs/symptoms, causes, prevention, importance of adherence and rheumatic fever to cater to all parents in Counties Manukau area. As well as listing free support services available for strep throat prevention as well as treatment and key tips for a drier home. The reasoning behind choosing an app was mainly derived from being in a technological era, many parents carry mobile devices that are able to download this app and gain essential information required in terms of Rheumatic Fever prevention.

STAGE 2: AUDIENCE

According to Ministry of Health, 2019 the largest population for Counties Manukau are Pacific and Maori individuals who are also the main sufferers of Rheumatic Fever; having the highest reported cases of hospitalisations in 2018 New Zealand wide. With the combination of overcrowded housing conditions and socio-economic deprivation; Maori and Pacific are leading to higher rates of rheumatic fever due to untreated strep throats (Ministry of Health, 2019). Young Maori and Pacific children both male and female aged between 4 – 15 years old are suffering with this unfortunate disease due to living in poor conditions (Ministry of Health, 2019). As to why in the making of ‘Adhere 2 Clear’ health resource the primary audience are Pacific and Maori parents with young children aged between 4 – 15 years old within Counties Manukau. Due to the evidence based research these are the most at risk groups and require health education on adherence to avoid repetition of untreated strep throats. Secondary audience being health professionals who will emphasize the importance on adherence and educate parents on the app.

Upon various different discussion with stakeholders a decision was made final to make an app as well adjustments within the app to best suit the target audience. In a discussion, I. Kakala (personal communication, April 30, 2019) had conversation about current resources available, Kakala (Preceptor) referred to ‘Sticker Charts’ being a great interactive resource for kids to get interested in adherence; further elaborated on how there are many visual resources available i.e. pamphlets, posters, fridge magnets but nothing of a different approach which may be the gap within health education amongst the community. In another discussion, K. Pearson (personal communication, May 7, 2019) carried out conversations based on what information may be critical in terms of the target audience, Person (PHN) mentioned it is important relay the consequences of non-adherence must be made aware to parents; when introduced to the idea of a mobile app; Pearson mentioned that it will be keeping up to the new generation of technology and easy access to information. In another discussion, I. Kakala (personal communication, May 15, 2019) carried out conversations on the importance on involving contributing factors, the most important factor being overcrowded or damp housing conditions; sharing advice with parents on tips to improve that would be a great asset to the app. Also involving visual aids to make information more understandable by reader, having the app available in different languages to help the target audience better understand the information displayed. In discussion, Client A (personal communication, May 2, 2019) carried out conversation about how effective app may be, discussed the importance of ‘pictures’, also explained that an idea of the App would be quite fitting as majority of most individuals time is spent on their phone and the reminder alarm would help in terms of not forgetting to administer daily dose of antibiotics. In phone call, Client B (personal communication, May 4, 2019), while conducting follow up phone calls for medication adherence for a gas positive child parent discloses stopping antibiotic course half way through as the parent believed that the bacteria has gone due to child being asymptomatic; this displayed the lack of understanding in terms of adherence amongst the community which is constantly leading to repeated strep throat infections amongst young children in Counties Manukau. All these discussion had contributing factors in terms of the changes to be made within the mobile app ‘Adhere 2 Clear’ to best suit the community and effectively display all the information in a comprehensive manner.

STAGE 3: HEALTH LITERACY

Health literacy is the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make informed and appropriate health decisions (Health Navigator, 2018). This in the most important factor in terms of effectively processing information and interpretation of health services to make well informed decisions for health and wellbeing (Ministry of Health, 2015). Interpretation of information is important especially in terms of prevention, which is the most uninstructed area within Counties Manukau; not fully grasping or understanding the importance of adherence is the leading cause of Rheumatic Fever (Ministry of Health, 2019). Individuals who have poor health literacy often oversight resources available thus not achieving positive health outcomes; this could mean an oversight of free sore throat checks at school or free medication treatments provided at certain schools (Best Practice Advocacy Centre, 2012).  Low health literacy levels have a major contributing factor towards health disadvantages amongst the Pacific and Maori community (Best Practice Advocacy Centre, 2012). According to Ministry of Health, 2018 “Māori have poorer health literacy skills compared to non-Māori across all of the measured variables; eighty per cent of Māori males and seventy five per cent of Māori females were found to have poor health literacy skills”. Education a plays a big part on the comprehension of health literacy according to Stats NZ, 2018 pacific students tend to have poorer education outcomes that other students from the same communities; which is a result from combination of factors including lower levels of participation in learning practices throughout schooling. Many times language is the biggest barrier in terms of understanding information provided by health professionals; many pacific families that migrate over are still learning to adapt to a new lifestyle and many times learning English is the biggest challenge they face post migration (Stats NZ, 2018).

Reducing health literacy is as simple as communicating effectively, understanding the barriers and providing information in sustainable way for the client to understand (Stats NZ, 2018). Avoidance of medical jargon when providing health education is important health professionals are very familiar with terminology used on a daily basis but for the client it would be harder to comprehend thus leading to ineffective management of health disparities (Ministry of Health, 2015). When presenting the health resource ‘Adhere 2 Clear’ the writer will ask questions in terms of information provided to see how much is comprehended by target audience. As well as interacting audience to present information back to writer to see how much was understood in terms of health education provided within the app. ‘Adhere 2 Clear’ will incorporate these findings by providing information that is easily understandable, utilising visual aids for better understanding and providing app in different Pacific and Maori languages to over step language barrier.

STAGE 4: HEALTH EDUCATION RESOURCE SCOPE

The main purpose of this health education resource is to educate on the importance of antibiotic adherence in terms of strep throat infections. Also to bring awareness on the importance of preventing rheumatic fever amongst young Pacific and Maori children between 4 – 15 years old within Counties Manukau. Recent statistics as previously evidence have showed the lack of health literacy amongst this specific group and the increasing rates of poor health outcomes amongst this specific group. According to The New Zealand Medical Journal, 2017 Rheumatic fever is a rare but significant complication of group A streptococcus (GAS) pharyngitis; causing compelling morbidity and mortality rate amongst young Maori and Pacific people. According to The New Zealand Medical Journal, 2017 there are a consistent number of cases in terms of poor adherence to antibiotic courses in treatment for gas positive children; many times symptom improvement led individuals to believe that completion was unnecessary. Which ultimately led to repeated cases of strep throat infections amongst young children, making  a major risk factor for others surrounding like peers in school or siblings at home (Ministry of Health, 2018). In between 20/04/19 – 20/05/19 ‘Adhere 2 Clear’ will be constructed and presented to a few members of the target audience as well as health professionals in order to receive constructive feedback in terms of the changes to be made. The plan is to construct a mobile app directed towards parents; the app will contain a reminder that displays a notification on the device to remind parents to administer daily dose of antibiotics, as well as providing basic information on the importance adherence, support available, tips for prevention or spread and risk factors with poor adherence.
 

Gantt Chart

Short Term Goal: A significant increase in antibiotic adherence within four weeks on launch and distribution of ‘Adhere 2 Clear’ amongst Pacific and Maori children aged 4 – 15 years.

Medium Term Goal: A significant decrease of repeated strep throat amongst Pacific and Maori children aged 4 – 15 years within three months on launch and distribution of ‘Adhere 2 Clear’

Long Term Goal: A decrease in rates of hospitalisations due to Rheumatic Fever for Maori and Pacific children aged 4 – 15 years old due to good adherence within two years on launch and distribution of ‘Adhere 2 Clear’.

STAGE 5: DRAFT AND TEST

Adhere 2 Clear was drafted in a two minute presentation within a power point, summarising key points and actions of the app. The power point was presented in front of a small group of public health nurses and whanau support workers in Clendon Kids First Community. A small anonymous feedback form was constructed to easily summarise the changes in order to effectively display information on the app. Many individuals believed that the app must have more pacific languages available, show importance of proper living conditions, add in support services available in the area and limit information on screen to make it more visual. All the following amendments were made within the app to best suit target audience and display information more effectively. The feedback questionnaire will be attached within appendices.

According to Boyte, 2016 in an average week, 3.1 million New Zealanders aged 15 and over spend 14 hours online; with 70% of New Zealanders now owning a mobile device. With the up and coming age of technology the app would be a beneficial way to deliver the message across to target audience. Also considering already available resources there are many visual aids i.e. posters, pamphlets, fridge magnets, online reading material etc. ‘Adhere 2 Clear’ would be a fresh and new way to provide information keeping up with the fast changing technological community. Upon assessing target audience it was evident nearly each parent carried a smart phone, which would be an easy, fast and assessable way to provide information daily. Keeping up with health literacy for Maori and Pacific individuals the information provided on the resource ensures avoidance of medical jargon and providing different languages to avoid language barriers.

REFLECTION
Description:

This is a reflection on the process of developing an effective health education resource for Rheumatic Fever prevention by emphasizing on the importance of medication adherence. Upon research there was a lot of useful information found within the placement sector alone, due to setting being in the most deprived areas resources were readily available for prevention of rheumatic fever. Although the repeated cases coming back to clinics was concerning as this was the leading cause of young children suffering from rheumatic fever. The gap was clearly identified as the parents were quite unsure on the importance of adherence, many mentioned stopping course midway due to disappearance of symptoms. Many parents were unaware that even if the symptoms are clear bacteria may be still active causing another gas positive and risk of spread to siblings or peers. Statistics were quite easily accessible as this was a fast growing issue in New Zealand, many reliable sources had endless discussions, articles and resources readily available on the rates and causes of rheumatic fever. A clear decision was made to develop an app as it was an idea that hasn’t been utilised and a new way to engage audience in to health education about medication adherence.

Feelings:

Writer strongly believed that the lack of knowledge on adherence was the main cause for repeated strep throat within a household. Also raised a major issue as often gas positive children would pass on the illness to their siblings or class mates unknowingly. Thus led to the development of ‘Adhere 2 Clear’ where information will readily available for parents to take correct steps in terms of eliminating strep throat infections completely.

Evaluation:

While presenting ‘Adhere 2 Clear’ idea to preceptor gained more insight on contributing factors like housing conditions and low socio economic statuses. Lack of knowledge of support available often lead parents to avoid contact with health services. Also briefly discussing idea with lecturer helped to gain perspective as the original idea was a video but after gaining feedback from both parties’ changes were made and a firm decision was made to develop a mobile app.

Analysis:

While presenting the actual draft to various different public health nurses and whanau support workers more perspectives were gained. Feedback allowed writer to make essential adjustments that were oversighted. Like the importance of having different languages available on app due to the target audience as well as adding some visual aids to avoid information being “too wordy”.

Conclusion:

Many amendments were made within the app to best suit the target audience. Although would’ve preferred to make further adjustments in terms of visual aids; adding few more pictures to grasp readers attention a lot more. As well as adding a few extra colours to make the app visually pleasing to the audience. End result was positive as the feedback provided showed the effectiveness of the idea although in future instances these are the elements to keep in mind.

CONCLUSION

Rheumatic Fever is a highly preventable diseases amongst young Maori and Pacific children aged 4 – 15 years old. High rates of poor adherence amongst this group is a leading cause of rheumatic fever in New Zealand; as well as contributing factors like living in low socio economic area, poor housing conditions and poor health literacy amongst the specific target group. According to the findings it is essential to have ongoing health education amongst clients to ensure positive health outcomes as well as increasing on knowledge on risk factors of non-compliance to treatment. In order to improve and benefit the community it is a must to provide sufficient services to the target audience as well as providing sufficient teaching in order for clients to make informed decisions in terms of health and wellbeing.

REFERENCES

• Best Practice Advocacy Centre. (2011). Rheumatic Fever in Maori: what can we do better.
• Retrieved from https://bpac.org.nz/BPJ/2011/august/rheumatic.aspx

• Best Practice Advocacy Centre. 2012. Upfront: Understanding health literacy. Retrieved from https://bpac.org.nz/bpj/2012/august/upfront.aspx

• Boyte, T. (2016). Mobile Keeping Kiwis Connected. Retrieved from https://www.nielsen.com/nz/en/insights/news/2016/nz-mobile-keeping-kiwis-connected.html

• Heart Foundation. (2019). Rheumatic Heart Disease. Retrieved from https://www.heartfoundation.org.nz/your-heart/heart-conditions/rheumatic-heart-disease

• Health Navigator, 2018. Health literacy. Retrieved from https://www.healthnavigator.org.nz/clinicians/h/health-literacy/

• Ministry of Health, 2015. Health literacy. Retrieved from https://www.health.govt.nz/our-work/making-services-better-users/health-literacy

• Ministry of Health. 2018. Maori health. Retrieved from https://www.health.govt.nz/our-work/populations/maori-health

• Ministry of Health. (2019). Reducing Rheumatic Fever. Retrieved from https://www.health.govt.nz/our-work/diseases-and-conditions/rheumatic-fever/reducing-rheumatic-fever

• Ministry of Health. (2017). Rheumatic Fever. Retrieved from https://www.health.govt.nz/your-health/conditions-and-treatments/diseases-and-illnesses/rheumatic-fever
• Ministry of Health. (2017). Rheumatic fever resources for health professionals. Retrieved from https://www.health.govt.nz/our-work/diseases-and-conditions/rheumatic-fever/rheumatic-fever-resources/rheumatic-fever-resources-health-professionals#education
• Ministry of Health. (2017). TRFPP. Received from https://www.health.govt.nz/our-work/diseases-and-conditions/rheumatic-fever/rfpp-strategies
   
• Stats NZ. 2018. Health and Pacific Peoples in New Zealand. Retrieved from http://archive.stats.govt.nz/browse_for_stats/people_and_communities/pacific_peoples/pacific-progress-health/influences-on-health-well-being.aspx
• Stats NZ. (2016). Unemployment. Retrieved from http://archive.stats.govt.nz/browse_for_stats/snapshots-of-nz/nz-social-indicators/Home/Labour%20market/unemployment.aspx
• The New Zealand Medical Journal. (2017). Clinical management and patient persistence with antibiotic course in suspected group A streptococcal pharyngitis for primary prevention of rheumatic fever: the perspective from a New Zealand emergency department. Retrieved from https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2017/vol-130-no-1457-16-june-2017/7281

APPENDIX 1 – [Health Education Resource Validation Form]

APPENDIX 2 - [Feedback Questionnaires]