Addressing Community Health Issues: Experiences from the Field

### **Chapter 1**

## Lessons Learned from Implementing a Community Health Worker-Initiated Referral Strengthening Intervention in Haiti: A Mixed-Methods Program Case Study

*Alain Casseus, Kenia Vissieres, Tracy L. McClair, Chery Maurice Jr, Charlotte Warren and Pooja Sripad*

### **Abstract**

Referral processes linking communities to facilities are under-appreciated and lack evaluation, particularly in humanitarian settings. Community health workers or agents de santé communautaire polyvalent (ASCPs) in Haiti refer communities to health facilities for a range of services. This program case study assessed implementation of a public-private referral strengthening intervention within on-going community health programming, including a triplicate referral form, supportive training, and follow-up structures. We applied mixed methods to describe referral trends using routine programmatic data, factors affecting implementation and referral completion through a pre-intervention referred patient survey (n = 525), meeting observations, and interviews with ASCPs, supervisors, and key stakeholders (n = 88). We found that the intervention demonstrates little influence on referral trends, but qualitatively enhances the referral process for ASCPs and supervisory stakeholders in Haiti. It improves supervision relationships and shows promise for enhanced communityintegrated patient monitoring systems – when supported by financial support and non-governmental and governmental partners, but is vulnerable to sociopolitical, geographic, and insecurity challenges preventing referral completion. Integrating intervention activities within existing programming and scaling the triplicate referral form in Haiti can strengthen the national ASCP curricula. Globally, we suggest adapting the triplicate referral form as a promising job-aid and data-reporting tool within community health worker programs.

**Keywords:** community health workers, community-based referral, case study, referral processes, Haiti

### **1. Introduction**

Referral processes linking communities to facilities for an array of health services, though critical are often under-appreciated and challenging to measure globally. In part this is due to measurement gaps given limited community inputs into integrated health information systems and the challenges of monitoring referral completion [1–3]. Facilitating linkages through functional referral and counter-referral mechanisms demands that community health workers (CHWs) are able to correctly identify when to refer patients; patients are able to access the referral facility; and the referral facilities provide sufficient counter-referral information to patients for follow-up with CHWs in their communities [4]. Global estimates of adherence to referral guidelines, defined broadly as both CHW adherence to guidelines and referral completion by patients, range from 9 to 83% [4]. Few studies have evaluated the effectiveness and comprehensiveness of CHW referral in low- and middle-income country (LMIC) settings, nor assessed the influence of context and programming on CHW-activated referral processes and completion [2, 3, 5].

Exploring referral processes in the context of expanding community health programming to support CHWs as they reduce service coverage gaps and improve outcomes is critical. In countries like Haiti that struggle with frequent political transition, decreasing economic resources, and environmental and disease outbreaks, all of which have left it with the worst health indicators in the Western Hemisphere, CHWs are often the only source of care for many [6–9]. Haiti's ratio of physicians and nurses to individuals is 2.5 and 1.1 to 10,000, respectively, has led CHWs, to serve as the primary health workforce in delivering care and counseling to communities [10]. CHWs in Haiti, known as agents de santé communautaire polyvalent (ASCPs) make approximately 100 home visits per month during which they provide direct services (e.g. medicines, vaccination, and some family planning methods), health education, and referrals. ASCPs link communities to health facilities for a range of services by referring for a variety of health issues: tuberculosis, HIV, malnutrition, women's health, maternity care, child health, non-communicable diseases, mental health, and other emergencies. ASCPs refer patients to facilities for care as needed and document referrals in paper-based registers. Generally, the referral process involves ASCPs interacting with individuals in the community and referring, and at times, accompanying clients to the appropriate facility – a dispensary, health center or hospital, and following up with the clients once they return home. Sociopolitical and contextual factors influence ASCP-initiated referral processes [11]. To-date, however, documentation of how to strengthen referral processes in practice is weak in the absence of data reporting tools to aid ASCPs and their supervisors, among other factors.

This program case study describes learnings from the introduction of a public-private referral strengthening intervention, consisting of the introduction of a triplicate referral form and supportive programmatic structures. We draw on multiple perspectives – ASCPs, ASCP supervisors, and key policy/program stakeholders to assess how the referral strengthening intervention (e.g. introduction of a triplicate referral form and associated-trainings for adoption) affected the community-initiated referral process in all sites. Referral "completion", in our study, refers to whether a patient who was referred by an ASCP for a service went to a facility received the intended service. We investigate:


*Lessons Learned from Implementing a Community Health Worker-Initiated Referral… DOI: http://dx.doi.org/10.5772/intechopen.109687*


### **2. Program development and adaptation**

### **2.1 Program development and description**

Zanmi Lasante (ZL), a non-governmental local organization in Haiti has been working in community health for decades in collaboration with the Ministère de la Santé Publique et de la Population (MSPP). Under the Integrating Community Health Partnership (2016–2020), ZL supported the MSPP in the introduction and orientation of ASCPs in Central and Artibonite regions, through the development and implementation of a comprehensive curricula. The curricula included five modules: Organization of Health Services, the ASCP Work Process, Health at Different Life Stages, Prevention and Control of Common Diseases, and ASCP Actions in Crisis Situations. Despite the various contextual disruptions including political volatility and generalized insecurity, ZL supported implementation of curricula, integrated with on-going programming efforts, over 4 years, to inform scaling a ASCP capacitybuilding approach country-wide.

Within this program context, in 2018, there was recognition of the need to further strengthen and support referral and counter-referral processes embedded within the ASCP's core functions. ZL, in collaboration with the Department de la Promotion de la Sante et Protection de l'Environnement in the MSPP, developed and implemented a triplicate referral form, a related training, and a supportive feedback mechanism to pilot as a tool for tracking and enhancing referrals, referral completion, and follow up. The triplicate referral form – comprised of three carbon copy slips that can be shared with clients, CHWs and health facilities – allows for better documentation around health areas that ASCPs normally counsel and refer (**Figure 1**). Following a week-long training in November 2019 in Mirebalais, the triplicate referral forms were implemented across Central and Artibonite Departments, including in Mirebalais, Le Petit Rivière Artibonite (PRA) and Verrettes communes. Upon referral of a client to a facility, an ASCP documented the referral in his/her register, provided a referral sheet to the client, and shared in aggregate a monthly referral report to their supervisor. The feedback mechanism, coordinated by ZL program managers, included health teams discussing referral challenges and enablers during on-going monthly meetings between a community health nurse (program oversight), ASCPs, and their supervisors.

Several adaptations affected program development and application. First, while initially a technological component (digital triplicate referral form) to complement the paper-based form was explored, various organizational, political, and logistical challenges prevented its integration. Second, a Community Health Nurse and Auxiliary Nurse intended to review and cross-reference ASCP registers and reports with the referral lists at the dispensaries, health centers, and hospitals to identify complete and incomplete referrals. However, in practice, only referrals made – rather than completed– were able to be checked. Third, COVID-19 pandemic-related restrictions prevented feedback sessions to occur at in their anticipated frequency –four sessions were held before lockdowns ensued; not all three communes resumed sessions as the pandemic wore on. These restrictions, along with persisting socio-political


### **Figure 1.**

*Triplicate referral form used in Haiti (English version).*

fluctuations and insecurity in Haiti, prevented the application of some of our original learning tools (e.g., survey with referred patients) in a formal evaluation.

### **2.2 Learning tools**

Our program case study draws on quantitative and qualitative data sources to learn about the piloting process of the triplicate referral form in practice. Trends in referrals across the three communes were ascertained through routine programmatic referral tracking data, including registers and referral reports verified by health teams. Factors associated with referral completion were assessed by self-report through 525 referred patients surveyed in a pre-intervention assessment and qualitatively from ASCPs following implementation. Semi-structured monthly meeting observational checklists recorded by trained research assistants qualitatively informed how supervisory

*Lessons Learned from Implementing a Community Health Worker-Initiated Referral… DOI: http://dx.doi.org/10.5772/intechopen.109687*


**Table 1.**

*In-depth interview sample.*

processes affected the community-activated referral mechanisms. Eighty-eight in-depth interviews with ASCPs, ASCP supervisors, and community health policy/ program stakeholders, conducted before (n = 49) and after (n = 39) the implementation, provided rich perspectives on the referral processes, completion and related factors (**Table 1**).

### **3. Piloting**

### **3.1 Did the referral strengthening intervention affect the referral trends in all sites?**

Referral data from ASCP records indicate that over 12 months of active implementation from December 2019 to November 2020, referrals by ASCP in the Central and Artibonite Departments were similar (**Figure 2**). Referrals appear slightly higher in the Central Department, with a slight increase over time in both groups. There is a notable spike in referrals in September 2020 in the Artibonite Department and dips in referrals, across all sites, in April and November 2020, notably affected by

the COVID-19 pandemic. Referral peaks reflect the easing of COVID restrictions around movement. At these times, people moved freely from different areas within the country and across the border from the Dominican Republic. Dips in referrals are related to increased COVID restrictions, including social distancing guidelines, mask wearing, and limits to gathering at assembly posts and hospital waiting rooms.

### **3.2 How did the referral strengthening intervention affect referral processes?**

We qualitatively assessed what the referral process looked like before and after the introduction of the triplicate referral form and associated trainings. Our pre-implementation assessment showed that the referral process involved an ASCP providing a verbal or simple referral slip to the patient. The referral slip included the name, phone number of the ASCP, and patient information. Facilities were not notified of referrals. ASCPs stated that they never or rarely received counter-referral slips after referrals were completed. ASCPs were not notified if patients completed their referrals; however, ASCPs recorded the date of referral in their notebooks, and often followed up 4–5 days later to see if the patient completed the referral.

*'The referral is usually done informally; the patient is told to go to a health center, no documentation, whatsoever… The Department's "referral" form …[though]… printed and distributed at departmental level, is rarely available in the field, at least, not on a regular basis. Community workers therefore simply tell the patient to" go to a health facility and tell the nurse that you have such a problem"."*

– National Policymaker

After the implementation of the triplicate referral form, ASCPs commented that the new forms are detailed and helpful for assessing if people are in urgent need of care, since there are limited resources at health centers. They mentioned receiving training on how to fill out the forms and found the forms easy to use. ASCPs generally did not have any additional recommendations for the forms. Similar to our pre-intervention assessment, ASCPs confirmed that they typically follow up by phone or inperson a few days after they make referrals, and people usually received the intended services. ASCPs commented that triplicate referral forms allow other members of the medical community to better serve their patients. One ASCP describes their modified process for referral:

*"When I make a referral to a Health Center, the referral form guides me. It includes the place to write the date, the service [referral type], the place to take the service the nearest hospital or dispensary. I write the name, signature, date of birth, gender. After that, there is a place that says why you refer the person who has signs like big headache or shortness of breath. As an ASCP, I put my code, name and phone number in case of needed follow-up."*

*–* ASCP, Central, Mirebalais

While consistent across setting, ASCPs and ASCP supervisors describe how the referral process has changed and been made easier after implementing the triplicate referral form.

*"It has rendered the process easier. At one time, we did not have a form, we would use a sheet of paper from a notebook or pad. When the patient showed up at the hospital,*  *Lessons Learned from Implementing a Community Health Worker-Initiated Referral… DOI: http://dx.doi.org/10.5772/intechopen.109687*

*the staff did not really know what to do with the sheet of paper or they would drop it somewhere, it could have been written by anyone. Now it is more structured, formal, and the hospital staff receive the patients."*

*–* ASCP, Central, Mirebalais

*"It [referral process] changed in that it gives you more motivation, because now it is a reference form that represents a registry. So when making the referral, the remaining source [copy] allows us to verify the referral was well done. [Previously it]… was a small sheet that was given and the person went with it, there was no source [copy] left. We can follow up on the referrals as supervisors."*

*–* ASCP Supervisor, Artibonite, PRA

### **3.3 What factors affected implementation of the intervention?**

Supervisors and ASCPs describe the importance of supportive supervision as critical to ASCP's work, including the use of the triplicate form. Specifically, the value of supervision arises in technical support, training, and correcting ASPC's behaviors and practices as needed on the job. Monthly group supervision on various topics including referral, allows for ASCPs to work out challenges with the referral process and allows for upward and downward communication between the department and central MSPP through to ASCP supervisors and ASCPs. Our sample's ASCPs and supervisors describe supervisory meetings as opportunities for receiving encouragement by supervisors and peers.

*"There are changes [over the last year]… My supervisor is always present, he is always on time, he is a supervisor that I love very much. When I have concerns… he tells me to look how he does it, gives me strength, and says, 'Let me see.' Sometimes he tells me, 'it's not this, come let's go on.' He always encourages me."*

*–* ASCP, Artibonite, PRA

Supervision on applying the triplicate referral form was similar across all settings and reportedly helpful from the perspective of most ASCPs and supervisory stakeholders. ASCPs and supervisors noted that supervisors provide support with filling out triplicate referral forms when challenges are encountered.

*"He always double-checked if I keep record of the reference forms that I delivered to patients… Sometimes it happens that we remove them both and the supervisor couldn't trace the reference. To prevent this, he always keeps an eye on the reference forms we are using, trying to ensure that we give the first one and keep a copy, to be able to report on the number of references we give."*

*–* ASCP, Artibonite, PRA

Observational notes from monthly meetings showed that despite the usefulness of the triplicate referral form, one complaint voiced by ASCPs included the difficulty in receiving counter referral information from facilities. Often there was lack of information shared by supervisory facility-based staff on patients completing their referrals, a result of fragmented and delayed data-reporting systems.

ASCPs noted that the modeled communication between ASCPs and their supervisors translates into how ASCPs mobilize their clients, underlining the downstream benefits of the ASCP-supervisor relationship. Supervisors also back up and/or

accompany ASCPs as needed, particularly in emergencies and when ASCPs experience difficult client refusals. In some cases, supervisors provide corrections personally after a group session to not embarrass or offend ASCPs in front of their peers.

*"It is a good relationship, everyone knows their role and the hierarchy - as such, no one dominates another, we each have tasks to accomplish. If there is a problem, I may make a recommendation; if something needs my changing, I oblige. I also do the training [monthly meeting] sessions, our relationship is based on our set objective that we work together to attain."*

*–* Nurse, Artibonite, Verrettes

There are mixed perspectives as to how accessible supervisors are to ASCPs. Most ASCPs say that supervisors are accessible when you need them and are often close to the field, however, a few describe limited accessibility in situations of political turmoil and roadblocks. ASCPs and ASCP supervisors alike describe the importance of having individual phone-based communication, particularly when ASCPs have quick questions or need clarification while in the field. ASCP supervisors also provide in-person on-site visits and/or accompany ASCPs to homes and posts, especially when health workers and communities are in remote areas.

*"We work together and when there is something that does not work well, I always reach out to tell them [ASCPs] how things should be. I always hold meetings with them based on our activities… I create my calendar based on their calendar and I would go to them to complete the fieldwork."*

– ASCP Supervisor, Artibonite, Verrettes

Financial and non-financial support also affects implementation of the triplicate referral form and ASCPs work. ASCPs describe the need for salary increase given their current salary is not motivating and they suffer increasing expenses due to inflation and sociopolitical insecurity. ASCPs and supervisors also mention the need for additional funds for transportation (e.g. motorbike taxis, buying gas) and phone cards with sufficient minutes to enable them to conduct their duties effectively. Several ASCPs mentioned needing to borrow money to travel long distances work and some expressed frustration with discontinued transportation fee support. In some cases, the association of ASCPs with government and non-governmental organizations led to a veiled financial stability of ASCPs at the community level.

*"As a health worker you have a family to care for, you have responsibilities. People think that you work for this giant organization…[and] come to you for money all the time, and there are times you are only able to buy only a loaf of bread… I brought 2 packets of crackers, I did not even get a chance to eat them, I gave them to 2 children who were asking me for money."*

*-* ASCP, Central, Mirebalais

Though ASCPs maintained access to the triplicate referral form, they expressed limited access to other necessary materials and vaccines to conduct their duties – particularly when it comes to community distribution activities. Some mentioned an inability to give people relevant medications. Supervisors mention similar concerns about materials – supervisors put in many requisitions but claim they have not received items to distribute to ASCPs such as vitamin A pills, iodine pills, folate, vaccines, and menstrual pads.

*Lessons Learned from Implementing a Community Health Worker-Initiated Referral… DOI: http://dx.doi.org/10.5772/intechopen.109687*

*"The role of the government is to provide us with support… they need to provide us more materials, such as notepads, notebooks, and a manual containing the data we need. Sometimes you think you will work on an activity for 2 hours but then you end up working 8 hours; we tend to write extensively, we need other materials to store our documents, bags, and raincoats also."*

*–* ASCP, Artibonite, PRA

ASPCs expressed that they would like more training for areas that they are less familiar with, such as new or less common diseases. Observation of monthly meetings showed, for example, that ASCPs had some difficulty referring children for problems other than prevalent malnutrition. Community health nurses similarly expressed that they need more training to take advantage of technology innovations in their work. Some ASCPs mentioned that they would like better healthcare treatment for themselves, because even though they are in the health field, when they are sick, it is difficult for them to get are.

The referral process is not without challenges. ASCPs explained that triplicate referral forms are easier than the previous process, but some non-state hospitals do not accept the forms. They explained that it is easier when they refer people to Zanmi Lasante-supported hospitals where the forms are received. When the triplicate referral forms are not recognized nor received, ASCPs feel ashamed, and in some cases blamed, that their patients are not able to get care. An additional challenge is that facilities are not reliably tracking referrals.

*"When we make referrals, it is very stressful because sometimes the person spends the whole day in the hospital with the referral in his hand, he never is given an appointment… We even accompany the person even though they [facility staff ] do not receive us… The references we provide become of no value to the community."*

*–* ASCP, Central, Mirebalais

### **3.4 What factors affect referral completion?**

We found consistency in the factors affecting referral completion before and after implementation of the referral strengthening intervention.

Our pre-intervention quantitative assessment examined sociodemographic factors associated with referral completion including gender, age, education, marital status, and religion (tabulated data not shown). Referral completion was significantly associated with were gender and religion. Of 525 respondents who were referred by an ASCP in the last 6 months, men were more likely than women to complete a referral at baseline (62 vs. 49%) as were those with no religion compared to those who were Catholic, Protestant, or other (69 vs. 45%, 20, and 51%, respectively). We also examined several interpersonal factors within the respondent-ASCP interaction including number of visits in the last 6 months, whether or not the ASCP asked questions or gave health information to other family members, service satisfaction, whether or not the information provided by the ASCP was easy to understand, and whether or not the ASCP asked the respondent questions about family members' health. Factors significantly associated with referral completion were whether or not the ASCP asked questions or gave health information to other family members (63 vs. 45%), and whether or not the ASCP asked the respondent questions about family members' health (62 vs. 42%).

Our qualitative pre-intervention assessment showed several factors affected referral completion. First, ASCPs stated that referral institutions are sometimes too far for patients. The cost associated with referral completion are prohibitive for some patients. Some patients do not accept the advice of the ASCPs – for example, some people do not accept that their child is malnourished if the ASCP tells them that this is the case. Some people decide to go to a voodoo priest instead of a health facility, though alternative care seeking emerged less salient at endline.

Following implementation, many of qualitative factors described in the preintervention assessment – delayed decision making because of distance, cost, socio-political barriers, and perceived quality – persist. An additional challenge was patients' misunderstandings of the triplicate referral form as it relates to perceived quality of a hospital's responsiveness to a referral. For example, patients believe a referral means they do not have to pay for treatment. Patients think the triplicate referral form means that they are "VIP" and should be treated as such, so they do not want to wait for the doctor.

*"When we make the referral, the patients always ask us, firstly, to accompany them… secondly, they always complain about not having money for transportation to go to the hospital and that it is difficult to find a service even if they have the referral form." –* ASCP, Central, Mirebalais

*"I don't know if this come from the ASCP or if it is a misunderstanding from the patients - patients think that the referral could be used as a pass for everything. A referral doesn't give any right to ["express" care for] the patient -it only indicates that this his problem is identified and the intended service … Most of the time, [at] the referral institutions, patients with the referral think that they are "VIP" and should be treated as such. They do not want to wait for the doctor… They refuse to pay even their dossier fee… a referral is not a dossier."*

*–* ASCP Supervisor, Artibonite, PRA

Observational notes from monthly meetings showed that ASCPs raised the more information related to experiences of patients that did not complete referrals. For these patients, the main concerns voiced included wait times at the hospital and the sup-optimal hospital reception, where they felt unwelcome and spoken to in a bad manner.

### **4. Lessons learned**

Implementation of a referral strengthening intervention – a triplicate referral form, supportive training, and monthly troubleshooting meetings – as a part of routine community health programming demonstrates little influence on overarching referral trends, but promising qualitative effects on the referral process for ASCPs and supervisory stakeholders in Haiti. Our piloting shows that despite the persisting challenges to the referral completion at the patient level that further link to the country's extreme poverty and limited emergency and routine relief in the protracted insecurity [12], high quality of supervisory relationships were instrumental in mitigation and reinforced the use of the triplicate referral form. This suggests the value of a streamlined referral form extends beyond the merit of improved communityintegrated patient tracking as part of health care monitoring systems, but also to the

*Lessons Learned from Implementing a Community Health Worker-Initiated Referral… DOI: http://dx.doi.org/10.5772/intechopen.109687*

motivational aspects around individual community health stakeholder goal-setting and achievements.

We glean several lessons around sustaining implementation beyond the project timeline – and in the face of further disaster (e.g. COVID-19 pandemic). First, implementing the intervention demands a nominal cost associated with producing the triplicate referral form and that of personnel to oversee its distribution, collection, and validation. These costs may be reduced if digital tracking were enabled, though such solutions require high preliminary investment and regular updates for failed technology. Second, collaborative development of the triplicate referral form by Zanmi Lasante and the MPSS, enabled its successful integration into on-going referral processes, though further technical assistance and advocacy may be required for its full recognition in non-state hospitals. Third, there is a need to strengthen counter referral processes, including tracking referral completion at the facility level. Communicating care features and monitoring needs back to ASCPs routinely through functional supervisory feedback mechanisms described in this paper can help better follow up with communities over time. Finally, navigating politics to sustain gains in community-integrated referral strengthening is crucial in contexts with shifting and unstable ministerial and policy landscapes. As intervention implementation progressed over time in Haiti, we had to accommodate changes in community health governance and financial investments that re-prioritized aspects of ASCP hiring, training, and retention.

### **5. Recommendations and conclusions**

Community health stakeholders in Haiti find the referral strengthening intervention acceptable – given it can be easily integrated into routine workflows of CHWs, supervisors, and program managers. We recommend integration of the triplicate referral form, training, and follow up meetings as a quality assurance mechanism to strengthen community-facility linkage and equitable communication between supervisors and CHWs. In Haiti, we advocate for scaling the triplicate referral form across the country, as part of the national ASCP curricula; over time transitioning the referral tracking system to a digital platform can be considered. Scaling the form alongside further research is needed, especially around the disaggregation of referral trend effects by distance to a facility and linked trends in referral completion. Globally, particularly in similar fragile humanitarian settings where CHWs carry out much of the primary health care service delivery, we suggest adapting the triplicate referral form as a promising job-aid and data-reporting tool.

### **Acknowledgements**

We want to thank all who contributed to this work, particularly Sarah Kennedy, Smisha Agarwal and Ralph Ternier, for their roles during the early phases of design and implementation. We also thank Guerline Bayas, a member of the Haitian Ministry of Health, for her support of the study.

### **Funding statement**

This study was supported by the Bill & Melinda Gates Foundation [OPP1174594].

### **Author details**

Alain Casseus1 \*, Kenia Vissieres1 , Tracy L. McClair2 , Chery Maurice Jr1 , Charlotte Warren3 and Pooja Sripad<sup>2</sup>

1 Zanmi Lasante, Port-au-Prince, Haiti

2 Independent Contributor, Washington, USA

3 Population Council, Washington, USA

\*Address all correspondence to: acasseus@pih.org

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Lessons Learned from Implementing a Community Health Worker-Initiated Referral… DOI: http://dx.doi.org/10.5772/intechopen.109687*

### **References**

[1] Agarwal S, Sripad P, Johnson C, Kirk K, Bellows B, Ana J, et al. A conceptual framework for measuring community health workforce performance within primary health care systems. Human Resources for Health. 2019;**17**(1):1-20

[2] Kok MC, Dieleman M, Taegtmeyer M, Broerse JEW, Kane SS, Ormel H, et al. Which intervention design factors influence performance of community health workers in low- and middleincome countries? A systematic review. Health Policy Plan. 2015;**30**(9):1207-1227

[3] Nigussie Z, Zemicheal N, Tiruneh G, Bayou Y, Teklu G, Kibret E, et al. Using mHealth to improve timeliness and quality of maternal and newborn health in the primary health care system in Ethiopia. Global Health: Science and Practice. 2021;**9**(3):668-681

[4] Lal S, Ndyomugenyi R, Paintain L, Alexander ND, Hansen KS, Magnussen P, et al. Community health workers adherence to referral guidelines: Evidence from studies introducing RDTs in two malaria transmission settings in Uganda. Malaria Journal. 2016;**15**(1):1-13

[5] Kok MC, Kane SS, Tulloch O, Ormel H, Theobald S, Dieleman M, et al. How does context influence performance of community health workers in low- and middle-income countries? Evidence from the literature. Health Research Policy and Systems. 2015;**13**(1):1-14

[6] Atun R, De Andrade LOM, Almeida G, Cotlear D, Dmytraczenko T, Frenz P, et al. Health-system reform and universal health coverage in Latin America. Lancet. 2015;**385**(9974):1230-1247

[7] Zeng W, Cros M, Wright KD, Shepard DS. Impact of performancebased financing on primary health care services in Haiti. Health Policy and Planning. 2013;**28**(6):596-605

[8] Cavagnero EDV, Cros MJ, Dunworth AJ, Sjoblom MC, America L, Caribbean DD. Better Spending, Better Care: A Look at Haiti's Health Financing: Summary Report. Washington DC: The World Bank Group, ed; 2017

[9] Sripad P, Casseus A, Kennedy S, Isaac B, Vissieres K, Warren CE, et al. "Eternally restarting" or "a branch line of continuity"? Exploring consequences of external shocks on community health systems in Haiti. Journal of Global Health. 2021;**11**:07004

[10] Jerome & Ivers. Community Health Workers in Health Systems Strengthening: A qualitative evaluation from rural Haiti. AIDS. 2010;**24**(Suppl 1): 1-9

[11] Project FH, Lasante Z. Assessing the performance of community health workers in Haiti: Key findings from a mixed-methods study. Reproductive Health [Internet]. 2021;(October 2019:1-4. Available from: https:// knowledgecommons.popcouncil.org/ departments\_sbsr-rh/1383

[12] Leaning J, Guha-Sapir D. Natural disasters, armed conflict, and public health. The New England Journal of Medicine. 2013;**369**(19):1836-1842

### **Chapter 2**

## Perspective Chapter: Integrating Traditional Healers into the National Health Care System – A Review and Reflection

*Bamdev Subedi*

### **Abstract**

This paper reviews and reflects on the policy efforts to integrate traditional healers in Nepal. Most people in rural Nepal rely on traditional healers for their primary health care needs, not only because health facilities in rural areas are poorly functioning but also because these healers meet various health care needs. The kind of traditional medicine provided by traditional healers (such as herbalists, bone setters, faith healers, and traditional midwives) is much more accessible to them than the practitioners of biomedicine and scholarly traditional medicine (such as Ayurveda, Unani, and Homeopathy). However, traditional healers have not been recognized as legitimate practitioners. Policy initiatives are needed to facilitate recognition, accreditation, or licensing of traditional healers so that they can be integrated into the formal structure of the health care system. Nepal's recent initiative of registration of traditional healers is an important policy effort in this direction.

**Keywords:** integration, traditional healers, primary health care, traditional medicine, Nepal

### **1. Introduction**

Traditional medicine is widely used and the world today sees its relevance for health and well-being [1]. The issue of integration of traditional healers into the national health care system got prominence around the time of Alma-Ata Conference in Primary Health Care in 1978 [2–5]. The Alma-Ata Declaration not only highlighted the wide existence of traditional healers including traditional birth attendants but also the importance of engaging them in the formal health system to meet primary health care needs. The Declaration stated that

*"With the support of the formal health system, these indigenous practitioners can become important allies in organizing efforts to improve the health of the community. Some communities may select them as community health workers. Therefore, it is worthwhile exploring the possibilities of engaging them in primary health care and training them accordingly" [6].*

Following the recommendation of the Alma-Ata Declaration, many nationstates explored the possibilities of integrating them. Those traditional healers who were practicing scholarly traditional medicine (such as Ayurveda, Unani, and Homeopathy) or qualified in any stream of these systems were recognized as practitioners and integrated into the formal health care system. Those traditional healers (who were practicing "folk", "popular," or "indigenous" traditional medicine) largely remained outside the state's purview and regulation. Only 36 countries have regulated "indigenous traditional medicine providers" that include "traditional healers, bone setters, herbalists, and traditional birth attendants" [7].

Though the integration of traditional medicine into the general public health system has been recognized as a "pressing need" [8], no such laudable efforts were made in bringing traditional healers into the fold of the formal health system. Scholars have recognized the important role traditional healers play in primary health care and often they are described as "the principal health care providers", "primary source of health care", "first point of contact", "first treatment of choice", etc. and appreciated for their healing prowess and herbal knowledge. The contribution of traditional healers in primary health care has been highlighted and scholars argue for their inclusion in the formal health care system [9]. Despite all this, the integration of traditional healers remains to be an unfinished dream in many nation-states.

The scholarly emphasis seems much on traditional medicine, medicinal practices, and medicinal herbs rather than the traditional healers who practice medicine and who have the knowledge of using herbs as medicine. This is something that recognizes the value of medicinal herbs but not the traditional healers who have been using them. This is something that tends to recognize the knowledge but not the (original) knowledge holder.

In many developing countries, health facilities are largely concentrated in urban areas [10] and rural populations are poorly served by the formal healthcare system. Traditional healers are providing at least some form of health care to the rural populations who are underserved by the formal healthcare system [11]. Even in urban areas, formal healthcare services are expensive, and traditional healers work as an affordable substitute. The kind of traditional medicine provided by traditional healers (such as herbalists, faith/spiritual healers, bone setters, and traditional midwives) is much more accessible to them than practitioners of biomedicine and scholarly traditional medicine. Moreover, some traditional healers address the different healthcare needs that patients cannot avail from formal healthcare providers.

Traditional healers, in many settings, lack legitimacy and are practicing informally. The issue of traditional healers' legitimacy has drawn the attention of scholars and activists. In this context, this chapter looks into Nepal's efforts to integrate these healers based on the literature, policy documents, periodic plans, and programs. However, some of the descriptive information about the healers are backed by my field experience [12–14]. The chapter begins with a short note on the health care system of Nepal, looks into the difference between scholarly and popular traditional medicine, and then describes the volume and types of traditional healers and then examines their place in the policy documents and periodic plans. The last part of the paper reviews the recent development of registration standards for traditional healers, reflects on challenges and opportunities, quality concerns, and how government can support traditional healers to provide quality traditional medicine services, and emphasizes the need for the policy initiatives as concluding remarks.

*Perspective Chapter: Integrating Traditional Healers into the National Health Care System… DOI: http://dx.doi.org/10.5772/intechopen.109885*

### **2. Health care system of Nepal**

Healthcare services are provided by both public and private facilities. The public sector provides health services from 201 public hospitals, 189 primary health care centers (PHCC), and 3,794 health posts (HP), and the private sector provides from 2082 facilities [15]. After entering into the federal system of government in 2017, Nepal has three levels of government (a federal, seven provincial, and 753 local) and the local level governments' role has become very important in the delivery of health care services. The local government plays an important role in the administration of PHCC and HP and the provision of services to local communities [16].

Traditional medicine services are also provided by both public and private health facilities. Public facilities include a total of 382 Ayurveda facilities (2 Ayurveda hospitals, 14 Zonal Ayurveda Dispensaries, 61 District Ayurveda Health Centers, and 305 Ayurveda Dispensaries), 1 Homeopathy hospital and an Unani dispensary [17]. Several private facilities (hospitals, clinics, and pharmacies) provide Ayurveda, Homeopathy, Sowa-Rigpa, and Naturopathy services.

Nepal is ranked 143 (out of 192 countries) on the Human development index [18] and 98 (out of 163) on the SDG index [19]. Nepal has relatively low health expenditure (around 5% of GDP) and high out-of-pocket spending (around 57% of the total health expenditure) [20] and only 21.35% of the population has been covered by the national health insurance program [21]. People have to pay from their own pockets for traditional medicine services because traditional medicine facilities are yet to be included in the list of service provider institutions.

Nepal has high poverty headcount ratio (32.8% at \$3.20/day), high maternal (186/100,000 live births) and under-5 mortality rates (28/1000 live births), and high prevalence of stunting (31.5%) and wasting (12.0%) in under-5 children, and low life expectancy at birth (70.9 years) and low subjective wellbeing score (4.4 in the scale of 0–10, worst-best) [19].

The total population of Nepal is 29.1 million, according to the 2021 census. There are a total of 2,67,891 registered human resources for health (including 28,477 medical doctors, dentists, and specialists; 96,430 nurses and auxiliary nurse midwives; 77,605 health assistants and auxiliary health workers; 14,720 pharmacists, 790 Ayurveda physicians, and 4281 Ayurveda practitioners; 71 Naturopathy and Yoga practitioners, 174 Acupuncture practitioners, and 228 Homeopathy and Unani practitioners) [22]. The Sowa-Rigpa practitioners have not been registered yet but it is likely that they will be registered soon.

The doctor-to-population ratio (0.9 physicians/1000 population) and nurse-topopulation ratio (2.1 nurses/1000 population) in Nepal are far less than the SDG index threshold of 4.45 physicians, nurses, and midwives per 1000 population [23]. The concentration of the health workforce in urban areas resulted in an unequal distribution of human resources for health. Although traditional healers are widespread in rural areas, they remain an untapped resource. Traditional healers hold the possibility to contribute to achieving SDG 3, which is about "ensuring healthy lives and promoting well-being for all at all ages." Moreover, their service is in line with the spirit of universal health coverage in the sense that people can access traditional healer's services at their doorstep whenever they need, without financial hardship [24].

### **3. Traditional medicine: scholarly and popular**

Following Dunn [25], traditional medicine can be divided into two groups: (i) Scholarly traditional medicines which are distributed over a relatively large area such as Ayurveda, Unani, and traditional Chinese medicine, and (ii) popular traditional medicines, also known as "folk" medicine, are the local or small-scale medicine rooted in the ethnocultural traditions. Scholarly traditional medicines represent the textual tradition and are codified and institutionalized whereas popular traditional medicines represent oral tradition and largely remain in non-codified and noninstitutionalized forms.

The practitioners of scholarly traditional medicine in Nepal hold academic degrees and are registered with Nepal Ayurveda Medical Council (NAMC) or Nepal Health Professional Council (NHPC). Traditional healers lack such degrees and certificates and practice without getting registered. To date, only 19 traditional healers have been registered with NAMC. This means all the healers, except those registered with NAMC, are practicing without being registered. NAMC is the autonomous body to regulate Ayurveda medicine, practitioners, courses, institutions, and traditional healers in Nepal.

Traditional healers in Nepal do not have a formal status. They are not institutionally trained, accredited, or licensed. The current legal framework does not recognize them as legitimate health practitioners. It is important to bring traditional healers into the regulatory framework in order to ensure the safety and efficacy of their practices. The healers have also felt pressure to be registered to serve as valid practitioners and get needful support from the state [26]. Scholars have continuously pointed to the need for the registration of traditional healers. There is an ongoing policy debate to recognize their knowledge and integrate their practices into the formal health care system.

### **4. The types of traditional healers**

Though traditional healers form a major source of health care for many people, they are not a homogeneous category. Various types of traditional healers are catering to people's health care needs. In this chapter, the term "traditional healers" has been used to refer to herbal healers, bone setters, traditional midwives, massagers, faith healers, or any such practitioners who are experienced enough and recognized as healers by the community people. These healers are the informal providers who are not trained in academic institutions but provide health care services based on traditional knowledge and experience. They hold knowledge of medicinal herbs, healing mantras, traditional midwifery, and massage and are consulted for physical, psychosocial, and emotional health problems. They learn the healing knowledge as a family tradition or work under their gurus, the senior traditional healers. Some of them have expanded their knowledge through long-term practice and self-study. They represent the oral tradition and treat patients with herbal remedies and/or healing mantras, based on lineage inheritance of knowledge and experience. Despite the expansion of healthcare services throughout Nepal, a large number of people take recourse to these healers [27]. These healers command the trust of the community in which they live. The healers and patients share the same culture and worldview. In the villages, they are treated with respect and are consulted for a range of physical, emotional, spiritual, and psychosocial problems.

*Perspective Chapter: Integrating Traditional Healers into the National Health Care System… DOI: http://dx.doi.org/10.5772/intechopen.109885*

Traditional healers are invariably described as folk healers, indigenous healers, native healers, or indigenous traditional medicine providers. There is no Nepali equivalent term to refer to traditional healers [28]. They are known by different names in different communities. These healers can be categorized into three broad groups:

### **4.1 Herbal healers**

Herbal healers are informal providers who exclusively rely on medicinal plants for the treatment of different health problems. Though they are also known as *vaidya* (informal Ayurveda practitioner), *amchi* (informal Sowa-Rigpa practitioner), and *hakim* (informal Unani practitioner) but are not qualified from academic institutions. They follow textual tradition by learning privately in the family or with the *guru* and, therefore, hold no certificates or degrees. There are other categories of herbal healers who do not follow textual tradition but hold the knowledge and know-how of medicinal herbs and deal with specific health problems such as jaundice or bone fracture. These healers use medicinal plants and plant parts, mineral substances, and animal products as medicine. Some of them also purchase manufactured herbal medicine and dispense them keeping a margin of profit. The herbal healers are consulted for physical illnesses and injuries. Some specialist traditional healers are consulted for specific illness problems such as bone fractures, snake bites, jaundice, stomach pain, and joint pain.

### **4.2 Faith/spiritual healers**

Faith/spiritual healers use nonmaterial means for diagnosis, prevention, and treatment, invoking unseen/spiritual forces. Some of them may combine healing mantras with herbal medicines. They are known as *dhami-jhankri* (shamans), *jannne-manchhe* (those who know herbal and faith healing), *jhar-phuke* (healers who sweep down or blow out evil spirits), *mata* (a woman healer possessed by Goddess), *jyotish* (an astrologer who foretells star and suggest rituals like *grah-shanti*), *pundit, pujari, lama, gubhaju, or guruwa* (who do faith healing and priestly work). Faith/spiritual healers largely follow the ritual methods of treatment. They are consulted for the illnesses, which are locally understood and explained such as *daraune* (frightening), *jhaskine* (startling), *nidra nalagne* (sleeplessness), *chhatpati hune* (restlessness), and similar other illnesses of emotional, spiritual, and psychosocial nature [12].

### **4.3 Traditional midwives**

Traditional midwives are known as *sudeni*, who assist in homebirth and provide postnatal care and massage. Traditional midwives also use medicinal herbs and oils, treated with ingredients such as fenugreek, for massage.

### **5. The size of traditional healers**

Traditional healers are found in every village and town in Nepal. Scholars and planners often quote a study [29] that had estimated the number of traditional faith healers to be around four to eight hundred thousand. The number also shows that faith healing is the most widely prevalent tradition in Nepal [30]. The number got an entry in the Ninth Five Year Plan [31], which stated: "to encourage about 800,000 traditional healers *(dhami, jhankri, lama, and vaidya)* to provide health services." Till today, no such study has been done to estimate their precise number and types. However, a common understanding is that the number of traditional healers is dwindling, as the young generation is not interested in taking up the profession of traditional healing. In recent times, formal healthcare services are being expanded. Health awareness is increasing and faith healing is fading. There are instances of faith healers who have left their long-standing faith-healing professions. Similarly, traditional midwives' role has been shrunk with the promotion of institutional deliveries [13]. However, herbal healers have retained their relevance, and even today, traditional healers have a robust presence in Nepal, especially in rural areas. They outnumber the medical practitioners and "85% of the rural population turns to traditional healers as their first point of care" [28].

### **6. Traditional healers in policy and periodic plans**

Ayurveda Medical Council Act 1988 allowed registration for those traditional healers who were 50 years and above and practicing herb-based Ayurveda medicine as a family tradition for the last three generations and [32]. The Section 5.1.1B of the Act states that "In the case of a person who is Fifty years of age, and having obtained recommendation from the concerned District Office with the certification of experiences being involved in the Ayurveda medical science since three generations, such person may carry on Ayurveda medical profession by obtaining permission under separate provisions as specified by the Council within one year from the date of commencement of this Act." The Act also barred the unregistered traditional healers to practice as this was made punishable offense with "a fine not exceeding 3000 rupees or with imprisonment for a term not exceeding six months or with both." This provision was criticized as "ridiculous and humiliating" [33]. Indeed, this provision was restrictive for those who were below 50 years of age and even for the eligible healers it was just a one-time opportunity to get registered. This may be the reason why there are only 19 traditional healers registered with the NAMC. The Act illegitimated many traditional healers but they kept practicing without getting registered. Rather, they continued to advocate for their rights and recognition. The scholars and activists also argued in favor of traditional healing/healers and questioned the government's reluctance, inaction, and skepticism (see **Box 1** below). The issue of registration and integration invited much debate and discussion among scholars, activists, planners, and policymakers.

**Box 1.** *Activists and scholars speaking in favor of traditional healers.*

<sup>&</sup>quot;The government cannot remain silent about those who are providing health care to the people in one way or another. Either it [government] should say that there is no use of traditional healer's service, with strong reason; otherwise, it should investigate and open a way to legalize traditional healing"—Shantalal Mulmi, RECPHEC

<sup>&</sup>quot;The knowledge received from their forefathers, the treatment method of preparing medicine at home from naturally obtained herbs and other things is the original method of Nepal and it is the responsibility of the state to build it and properly manage it"—Dr. Sarita Shrestha

<sup>&</sup>quot;Such treatment methods which are used for the sake of service rather than financial gain are cheap and accessible as well as being close to the way of life should be mainstreamed"—Madhubajra Bajracharya

<sup>&</sup>quot;Therefore, in order to register the traditional healers, the government should take an initiation to formulate plan and policies focusing on traditional healers" [26].

<sup>&</sup>quot;Traditional healing deserves its due share in government budgetary allocation" [28] .

<sup>&</sup>quot;The roles and responsibilities of traditional healers must be identified and clearly defined" [34].

*Perspective Chapter: Integrating Traditional Healers into the National Health Care System… DOI: http://dx.doi.org/10.5772/intechopen.109885*

### **6.1 Healers in the periodic plans**

An examination of national policies and planning documents reveal inconsistent and insignificant efforts to recognize and integrate healers. In 1998, Nepal Human Development Report [35] wrote, "Traditional healing received little direct support from the state, but in the last 15 years there have been efforts to integrate it with the public health system. But such efforts were peripheral and lukewarm." This shows that there was only a half-hearted effort to integrate traditional healers. Though some of the periodic plans emphasized traditional healers' training. For example, the Sixth Five Year Plan [36] had a program to provide training to traditional healers (such as *vaidya* and *jhankri*) and then the Eighth FYP [37] also repeated to provide training to traditional healers including birth attendants and mobilize them. The Ninth FYP [31] specified the number of healers and planned to encourage them to provide health care services. Subsequent periodic plans did not mention traditional healers but repeated government's commitment to protect and expand Ayurveda and other alternative systems. Thus, in the planning documents, traditional healers sometimes got a mention and sometimes did not. Nevertheless, traditional healers' training remained one of the regular activities of DOAA and at times NGOs also included traditional healers' training in their programs. The training events were mostly intended to increase knowledge of the formal treatment processes and seek referral support rather than to enhance their knowledge and skills in traditional healing (for example, see [38–40]).

### **6.2 Healers in the health policy**

National Health Policy 1991 emphasized the participation of women volunteers and birth attendants (Sudeni). National Ayurveda Health Policy 1996 also emphasized the training of traditional healers and the protection of their knowledge. National Health Policy 2014 continued to repeat "develop, protect, and promote Ayurveda and other complementary medicine." However, the National Health Policy 2019 states that "the existing traditional health care system shall be enlisted, managed, and regulated as per the standard" [41]. This policy provision seems developed from the Nepal Health Sector Strategy [42], which had iterated the government's commitment to the protection and promotion of traditional medicine. The strategy accepted the popularity of traditional practices that are being provided by traditional healers and showed the need to study the effectiveness of this method by bringing them into the mainstream. Similarly, the second long term health plan was to provide traditional healers with appropriate training in health, nutrition, and family planning, and use them in health education activities at the local level [43].

### **7. Registration standard for traditional healers**

After a long debate and series of discussions, the Department of Ayurveda and Alternative Medicine (DOAA) drafted registration standard for traditional treatment providers [44] to facilitate local governments in the registration of traditional healers. The registration standard recognizes traditional healers as *Paramparagat Upacharak*. This Standard has been adopted, approved, and published in the Local Gazette by some municipalities (*Palika*), the local government body. The Standard provides guidance and criteria for the registration of traditional healers. The Standard aims to provide a regulatory framework to ensure the efficacy, safety, and quality of

traditional healing; to provide for the management and control over the registration, training, and conduct of practitioners.

The registration standard is based on the provision of Article 22 of the Public Health Service Act, 2018. Article 22 states that it is mandatory to obtain a license to provide health services. Article 22 (3) of the Act states that "In the case of the traditional treatment service, service shall be provided after obtaining approval pursuant to the standards prescribed by the Local Level" [45]. While the practitioners of Ayurveda, Unani, Homeopathy, Yoga, and Naturopathy are registered with the NAMC or NHPC, traditional healers (except those 19 traditional healers) are practicing without being registered. Since the existing legal framework and regulatory body do not recognize them as legitimate health practitioners, the Standard addresses the registration issue, at least for those traditional healers who meet the requirements.

The registration standard defines traditional healers as "those persons who provide treatment at their home based on the knowledge, skills, technology, and experience acquired from their ancestors or *gurukul* traditions, examining the patients looking at the cause, nature, and condition of the disease, and using or processing various herbs, minerals, and animal products available naturally at the local level" [44]. The registration standard also recognizes the three categories of healers: (i) Herbal healers, (ii) Spiritual healers, and (iii) Traditional midwives (*Sudeni*).

### **7.1 Objectives of the registration standard**

The main objective of the registration standard (see **Box 2**) is to bring traditional healers into the regulatory framework. The Standard recognizes those healers who are involved in providing treatment for certain diseases by using certain herbs or sources, those who have acquired healing knowledge through at least 15 years of closeness to ancestors or gurus, and those who have adopted traditional healing as their main occupation. In addition to having a clear knowledge of the cause and symptoms of the disease to be treated, in case of using herbs or materials, the healers should have a genuine knowledge of the place and source along with properties, process, collection method, and time, processing, storage, preservation, supply, and usage. In the case of those who manufacture medicine from herbs and use it, they should properly follow the manufacturing method, use local resources and prepare medicine themselves, and provide health care services.


**Box 2.** *Objectives of the registration standard for traditional healers.*

*Perspective Chapter: Integrating Traditional Healers into the National Health Care System… DOI: http://dx.doi.org/10.5772/intechopen.109885*

### **7.2 Rights and duties of healers**

The Standard defines the functions, duties, and rights of traditional healers. The healers are required to keep records, not only of the method of collection of herbs, the place of collection, and the manufacturing process but also of patients' symptoms, conditions, services provided, and medicines dispensed, including the quantity and dosage. The healers should be able to identify herbs well and prepare medicines at home from such herbs and should have provided treatment services by making medicines from herbs without using the classical or patent medicines manufactured by different companies. The Standard prohibits healers from using classical or patent medicines of various companies, manufactured by using modern technology or knowledge and skills or those readily available in the market. The Standard allows healers to make medicine required for the treatment but forbid them to produce to sell in the market. The Standard does not allow them to advertise their services and products.

The healers are required to contact and coordinate with the Ayurveda dispensary or municipality in case they have specific knowledge, skill, technique, or original manuscript for verification, protection, enrichment, or printing support. Traditional healers who provide health services without being registered will be prosecuted according to prevailing Nepali laws. The Standard gives authority to the municipality to explain the clause of the Standard, to change and modify the schedule of the Standard, and to issue a notice for the registration of the traditional healers.

### **8. The challenges and opportunities**

Traditional healers are not a homogenous category. Integration of diverse forms of traditional healers is a challenge. There are a variety of traditional healers, classified into three groups, and their practices differ considerably. Some practice herb-based medicine, while others mix with shamanistic and spiritualistic practices making it difficult for scientific validation of their practices. Some healers have adopted healing as their main profession and many others continue as a part-time voluntary service. Some do charge for their sustenance and some accept the nominal amount as an offering, yet others do not accept money as they think charging those who are ill is morally wrong. Some are consulted by their extended family members, relatives, and neighbors but some are also consulted by far-away patients. Some follow oral tradition and some follow textual tradition by doing self-study or learning from gurus or senior practitioners. Some healers specialize in herbal treatment, some in midwifery and massage, some in faith healing, shamanism, and magico-religious and spiritual healing. Some others are consulted for specific health conditions such as jaundice, joint pain, and stomach problem. And there is a mismatch of practices, for example, some of the traditional *dhami-jhankri*, they are known for faith healing also possess knowledge of herbs and include herbal treatment along with ritual treatment. The registration standard as it appears is favorable to those healers who practice herbal medicine and restrictive to those who provide faith healing.

Another challenge is that we do not have a good understanding of the number and types of these healers. And, we have no idea about the extent of use of traditional healers by the population, the kind of health care needs these healers address, the number of illness episodes they treat, and the quality of care they provide. There is no such mechanism to collect periodic data on traditional healing and healers' activities. One of the points often gets mentioned is the declining interest in traditional

healing and the dwindling number of traditional healers. The young generation is not interested in taking up their parents' occupation, because healers get neither official appreciation nor any incentives. Traditional healing largely remains an unattractive profession because there is no monetary benefit. Though some healers have started to charge for the services and the medicine they dispense. But a very large number of healers give crude herbs and do not charge or charge nominally or take whatever is given out of happiness.

The young generation lacks knowledge and skills regarding medicinal herbs and traditional healing. The educational system has distracted students away from traditional health knowledge. Most of the healers are elderly, and the young generation is not willing to learn traditional healing (because it takes a long time to learn) and this is leading to the inter-generational loss of health knowledge [12].

Opportunity for integration exists when looked at from two different angles. The first is that ethnic communities form one-third of Nepal's population and the ethnic communities do have their own healing traditions. The UNDRIP recognizes the importance of indigenous knowledge, and indigenous people's "right to their traditional medicines and to maintain their health practices" [46]. Similarly, the ILO Convention (169) states that indigenous people's "traditional preventive care, healing practices, and medicine" shall be taken into account while planning and administering health services. WHO encourages member states to integrate traditional and complementary medicine into health systems "by developing national policies, regulatory frameworks, and strategic plans for T&CM products, practices, and practitioners" [7]. The state policy as enshrined in the Constitution of Nepal is to protect and promote the traditional knowledge and experience of the indigenous people and local communities [47]. These international conventions, WHO strategy, and national constitution also work as background reasons to move towards recognition of traditional healing. Moreover, traditional healers are appreciated for their role in conserving traditional knowledge, biodiversity, and plant resources. Another important opportunity for Nepal is that a large number of traditional healers have been serving informally and struggling for recognition and integration. Moreover, traditional healers have community support and cultural legitimacy to their practice, and many scholars and activists see the potential of popular traditional medicine and traditional healers.

### **9. The question of quality in traditional healing**

One of the questions often asked is the quality of treatment services traditional healers provide. If we accept that the kind of medicine people use should be of sufficient quality, it is reasonable to ask about the quality of medicine and services traditional healers provide. Since traditional healers lack academic training, doubt over their prowess, experience, and wisdom exists. Though some studies have found medicinal herbs that are being used by herbal healers are consistent with the principles of Ayurveda [26], their practices have not been validated scientifically and the risk of inappropriate use of herbs exists. Traditional healing is not free from harmful practices and needs extra attention and effort to discourage harmful practices and promote beneficial practices. Beneficial practices "should be scientifically validated and integrated into the health system" [26]. As Dr. Margaret Chan stated, "traditional medicines, of proven quality, safety, and efficacy, contribute to the goal of ensuring that all people have access to care" [1], the quality question is far more important

### *Perspective Chapter: Integrating Traditional Healers into the National Health Care System… DOI: http://dx.doi.org/10.5772/intechopen.109885*

when it comes to traditional healing. From the equity perspective, traditional healing needs additional attention and effort from the state to increase its quality. Steps should be taken to validate traditional healers' knowledge and practices as well as enhance their knowledge and skills.

Popular traditional medicine is the primary source of care for the socioeconomically poor who live in rural areas, and from the equity perspective, it should get priority [48]. However, governments seem reluctant to make a budgetary allocation to address the issue of quality. Traditional healers can be provided with training and modular courses. The registered healers can be recognized by awarding a certificate of appreciation and/or monetary incentives for their outstanding service. They can be incentivized with training, equipment, seed, and saplings to grow medicinal herbs in their home gardens. They can be facilitated to form their associations at local, provincial, and national levels. These associations can be supported to work as a selfregulatory body of traditional healing. An institution can be established to document traditional healing practices and herbal knowledge to build the capacity of traditional healers and promote research activities. Some of the healers can be selected and mobilized as traditional medicine volunteers or Ayurveda health volunteers like the female community health volunteers. There are many things government can and should do to increase access and to enhance/ensure the quality of popular traditional medicine.

People in Nepal often consult traditional healers before consulting formal practitioners [49]. Traditional healers have been making an important contribution to primary healthcare [40] and for the benefit of the community, these healers need to be recognized and integrated into the formal healthcare systems. Integration of traditional healers into the formal healthcare system is likely to contribute to the health and well-being of rural communities. Popular traditional medicine is struggling with the changing socio-economic, educational, legal, and regulatory requirements. The erosion of traditional health knowledge, the young generation's declining interest in the healing profession, the negative attitude towards traditional practices, and the question of safety, efficacy, and quality are some of the challenges traditional healing faces today. The identification of healers, recognition of their practices, promotion of beneficial practices, registering them as treatment providers, and providing them with necessary support can contribute to the integration process.

### **10. Concluding remarks**

Many nations are struggling with the issues of the integration of traditional healers. Nepal is not an exception. Though scholarly traditions have got official legitimacy and academically qualified traditional medicine practitioners have been authorized to practice, traditional healers, the practitioners of popular traditions, have been struggling to secure a legitimate space in the formal structure of the health care system. The issue of integration of traditional healers is complicated. However, Nepal has at least moved ahead from inaction and skepticism towards a more inclusionary health care system in which traditional healers will have a role to play. The recent development suggests Nepal's approval of the idea of recognizing and integrating traditional healers. However much remains to be done to see traditional healers integrated into the health care system. Nepal's example can be a good one if it moves in the desired direction. Policy initiatives are necessary to address issues of recognition, accreditation, or licensing of traditional healers and to help integrate them into the national healthcare system.

### **Acknowledgements**

I would like to thank anonymous reviewer of this chapter who greatly helped to shape this paper in this form. I have received no funding support from any organization for this research. I thank IntechOpen for a publication fee waiver.

### **Conflict of interest**

I declare no conflict of interest.

### **Author details**

Bamdev Subedi Medical Anthropologist (Doctorate from Jawaharlal Nehru University, New Delhi), Kathmandu, Nepal

\*Address all correspondence to: bamdevsubedi@gmail.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Perspective Chapter: Integrating Traditional Healers into the National Health Care System… DOI: http://dx.doi.org/10.5772/intechopen.109885*

### **References**

[1] WHO. WHO Traditional Medicine Strategy: 2014-2023. World Health Organization, Geneva [Online]. 2013. Available from: https://www.who.int/ publications/i/item/9789241506096 [Accessed: July 08, 2021]

[2] WHO Meeting on the Promotion and Development of Traditional Medicine (1977, Geneva) and World Health Organization. The promotion and development of traditional medicine: report of a WHO meeting [held in Geneva from 28 November to 2 December 1977] [Online]. 1978. Available from: https://apps.who.int/iris/ handle/10665/40995

[3] Rubel AJ, Sargent C. Parallel medical systems: papers from a workshop on 'the healing process': introduction. Social Science & Medicine. Part B. 1979;**13**(1):3- 6. DOI: 10.1016/0160-7987(79)90013-9

[4] Good CM. Traditional medicine: an agenda for medical geography. Social Science & Medicine 1967 1977;11(14):705-713. DOI: 10.1016/ 0037-7856(77)90156-1

[5] Newell KW, editor. Health by the People. Geneva: World Health Organization; 1975

[6] WHO and UNICEF. Primary Health Care: Report of the International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978. World Health Organization, Geneva, 1978

[7] WHO. WHO global report on traditional and complementary medicine 2019. World Health Organization [Online]. 2019. Available: https://www.who.int/publications/i/ item/978924151536. [Accessed: March 24, 2022]

[8] World Health Organization. Regional Office for South-East Asia, Traditional medicine in the WHO South-East Asia Region: review of progress 2014-2019. World Health Organization. Regional Office for South-East Asia [Online]. 2020. Available from: https://apps.who. int/iris/handle/10665/340393. [Accessed: December 05, 2022]

[9] Lyngdoh JP. In: Kaushik A, Suchiang A, editors. Contribution of Traditional Medicine Toward Primary Health Care in Meghalaya. In: Narratives and New Voices from India: Cases of Community Development for Social Change. Singapore: Springer Nature; 2022. pp. 203-214. DOI: 10.1007/978-981-19-2496-5\_14

[10] Tamang AL, Broom A. The practice and meanings of spiritual healing in Nepal. South Asian History and Culture. 2010;**1**(2):328-340

[11] Priya R, Saxena SA. Status and Role of AYUSH and Local Health Traditions under the National Rural Health Mission. New Delhi: National Health Systems Resource Center; 2010

[12] Subedi B. Socioeconomic disparities in access and utilization of health care services in Nepal. In: Christopher S, editor. Caste, COVID-19, and Inequalities of Care, Acharya SS. Singapore: Springer Nature Singapore; 2022. pp. 355-373. DOI: 10.1007/978-981-16-6917-0\_18

[13] Subedi B. Medical pluralism among the tharus of Nepal: legitimacy, hierarchy and state policy. Dhaulagiri Journal of Sociology and Anthropology. 2019;**13**:58- 66. DOI: 10.3126/dsaj.v13i0.26197

[14] Subedi B. Whose knowledge counts? a reflection on the field narratives

of indigenous health knowledge and practices. Dhaulagiri Journal of Sociology and Anthropology. 2022;**16**(01):59-69. DOI: 10.3126/dsaj. v16i01.50947

[15] DoHS. Annual Report 2020/21. DoHS, Ministry of Health and Population, Government of Nepal, Kathmandu, Nepal. 2022

[16] Lewis TP, Aryal A, Mehata S, Thapa A, Yousafzai AK, Kruk ME. Best and worst performing health facilities: a positive deviance analysis of perceived drivers of primary care performance in Nepal. Social Science & Medicine. 2022;**309**:115251. DOI: 10.1016/j. socscimed.2022.115251

[17] DoHS. Annual Report 2019/20. DoHS, Ministry of Health and Population, Government of Nepal, Kathmandu, Nepal. 2021

[18] UNDP. Human Development Report 2021-22: Uncertain times, unsettled lives: shaping our future in a transforming world. 2022. Available from: https://hdr. undp.org/content/human-developmentreport-2021-2022 [Accessed: January 05, 2023]

[19] Sachs J, Kroll C, Lafortune G, Fuller G, Woelm F. Sustainable Development Report 2022. Cambridge University Press; 2022

[20] MoHP. Nepal National Health Accounts 2017/18. Ministry of Health and Population (MoHP), Kathmandu, 2022

[21] Health Insurance Board. Health Insurance Board policy and program for the financial year 2022/23 [Swasthya Bima Bord 2079/80 BS ko Niti tatha Karyakram]. Health Insurance Board, Government of Nepal [Online]. 2022. Available from: https://hib.gov.np/en/

detail/b-b-aa. [Accessed: January 06, 2023]

[22] MoHP. Nepal's National Strategy for Human Resources for Health 2021- 2030 [Nepalko Swasthya Janashakti Sambandhi Rananiti 2076/77-2078/88 BS]. Ministry of Health and Population (MoHP), Kathmandu, Nepal. 2022

[23] WHO. Global Strategy on Human Resources for Health: Workforce 2030. Geneva: World Health Organization; 2016

[24] Bode M, Hariramamurthi G. Integrating folk healers in india's public health: acceptance, legitimacy and emancipation. eJournal of Indian Medicine. 2014;**7**:1-20

[25] Dunn F. Traditional Asian medicine and cosmopolitan medicine as adaptive system. In: Leslie C, editor. Asian Medical System: A Comparative Study. Berkeley: University of California Press; 1976. pp. 133-158

[26] Aryal K, Dhimal M, Pandey A, Pandey A, Dhungana R, Khaniya B. Knowledge Diversity and Healing Practices of Traditional Medicine in Nepal. Kathmandu: Nepal Health Research Council; 2016

[27] Patel B et al. An assessment of local use pattern and traditional knowledge on medicinal and aromatic plants in Kapilvastu district Nepal. The Healer. 2021;**2**(1):17-41. DOI: https://doi. org/10.51649/healer.54

[28] Pham TV, Koirala R, Kohrt BA. Satisfaction in the soul: common factors theory applied to traditional healers in rural Nepal. Ethos Berkeley Calif. 2020;**48**(1):93-128. DOI: 10.1111/ etho.12263

[29] Shrestha R, Lediard M. Faith Healers: A Force for Change. Kathmandu: Educational Interprises; 1980

*Perspective Chapter: Integrating Traditional Healers into the National Health Care System… DOI: http://dx.doi.org/10.5772/intechopen.109885*

[30] Subedi MS. Healer choice in medically pluralistic cultural settings: an overview of Nepali Medical Pluralism. Occasional Papers in Sociology and Anthropology. 2003;**8**:128-158

[31] NPC. Ninth Five Year Plan (1996/97-2000/01). National Planning Commission, Government of Nepal. 1997

[32] The Ayurveda Medical Council (First Amendment) Act, 1999 [Online]. 1999. Available from: https://lawcommission. gov.np/en/?p=16371. [Accessed: December 08, 2022]

[33] Bajracharya MB. Traditional ayurveda, the indigenous knowledge and health practice in Nepal. Education and Development. 2006;**22**(Special issue):90-97

[34] Phuyal N. Indigenous people of Nepal and their healing practices. Education and Development. 2006;**22**:69-74

[35] NESAC. Nepal Human Development Report, 1998. Nepal South Asia Center (NESAC), Kathmandu, 1998

[36] NPC. Sixth Five Year Plan (1980- 1985). National Planning Commission, Government of Nepal. 1980

[37] NPC. Eighth Five Year Plan (1992/93-1996/97). National Planning Commission, Government of Nepal. 1993

[38] Sharma A, Ross J. Nepal: integrating traditional and modern health services in the remote area of Bashkharka. International Journal of Nursing Studies. 1990;**27**(4):343-353. DOI: 10.1016/0020-7489(90)90093-X

[39] Oswald IH. Are traditional healers the solution to the failures of primary health care in rural Nepal? Social Science & Medicine. 1983;**17**(5):255-257

[40] Poudyal AK, Jimba M, Murakami I, Silwal RC, Wakai S, Kuratsuji T. A traditional healers' training model in rural Nepal: strengthening their roles in community health. Tropical Medicine & International Health. 2003;**8**(10):956-960. DOI: 10.1046/j.1365-3156.2003.01094.x

[41] MoHP. Raastriya Swasthya Niti 2076 (National Health Policy 2019). Ministry of Health and Population, Government of Nepal, Kathmandu, Nepal. 2019

[42] Ministry of Health. Nepal Health Sector Strategy: Implementation Plan 2016-2021. Ministry of Health, Government of Nepal, Kathmandu, 2017

[43] MoHP. Second Long Term Health Plan 1997-2017: Perspective Plan for Health Sector Development. Ministry of Health and Population, GoN, Kathmandu. 1997

[44] DOAA. Paramparagat Upacharakko Suchikaran Maapdand 2077 BS (Namuna Masyauda) [Registration Standard for Traditional Healers 2020 (Sample Draft)] [Online]. 2020. Available from: https://doaa.gov.np/notices/%e0%a4% aa%e0%a4%b0%e0%a4%ae%e0%a5% 8d%e0%a4%aa%e0%a4%b0%e0%a4 %be%e0%a4%97%e0%a4%a4-%e0% a4%89%e0%a4%aa%e0%a4%9a%e0 %a4%be%e0%a4%b0%e0%a4%95% e0%a4%95%e0%a5%8b-%e0%a4%b8% e0%a5%82%e0%a4%9a%e0%a4%bf-2/ [Accessed: September 23, 2021]

[45] The Public Health Service Act, 2018 [Online]. 2018. Available from: https://www.lawcommission.gov.np/ en/wp-content/uploads/2019/07/The-Public-Health-Service-Act-2075-2018. pdf [Accessed: September 23, 2021]

[46] UN General Assembly. United Nations Declaration on the Rights of Indigenous Peoples: resolution/adopted by the General Assembly, 2 October 2007, A/RES/61/295. United Nations [Online]. 2007. Available from: https:// www.refworld.org/docid/471355a82.html [Accessed: February 26, 2020]

[47] GoN. The Constitution of Nepal 2015. Constitution Assembly Secretariat, Simha Darbar, Kathmandu, 2015

[48] Subedi B, Joshi LR. (Un) popular traditional medicine community perceptions, changing practices, and state policy in Nepal. eSocial Sciences and Humanities. 2018;**1**(2):157-167

[49] Jimba M, Poudyal AK, Wakai S. The need for linking healthcare-seeking behavior and health policy in rural Nepal. The Southeast Asian Journal of Tropical Medicine and Public Health. 2003;**34**(2):462-463

### **Chapter 3**

Implementation of the Posyandu Program and Healthy Living Behavior of Mothers and Children in Sidomulyo Village, Godean District, Sleman Regency, Yogyakarta Special Region

*Umar Nain*

### **Abstract**

This study aims to: (1) analyze the continuity of healthy behavior of mothers and children even though their involvement in *Posyandu* is low due to poor *Posyandu* services; (2) analyze the healthy behavior of mothers and children in the community that is institutionalized by the community itself, although at the initial level, it was introduced by *Posyandu*. This research uses a descriptive survey approach. The population of this research is 348 mothers who have babies and toddlers, who are the target of the *Posyandu* service program. The number of samples taken was 100 respondents with a simple random sampling technique because the population was homogeneous. Data were obtained through questionnaires, in-depth interviews, and direct observation. The results showed that the low involvement of mothers in Posyandu was not an obstacle for mothers to behave in a healthy manner on an ongoing basis. This is because in the community there are various formal, semiformal, and village institutions that institutionalize healthy living accompanied by the availability of service facilities outside the *Posyandu* that can be used by mothers to meet the needs of a healthy life. The healthy behavior of mothers and children in the family is included in the high category seen from the frequency of mothers providing nutritious food for the family, maintaining food hygiene, boiling water before drinking, providing complete immunizations to their babies, baby clothes and utensils, conducting pregnancy checkups 7–9 times during pregnancy, using modern health care facilities for childbirth, as well as actively participating as an acceptor for independent family planning.

**Keywords:** Posyandu program, healthy lifestyle, mother and child, healthy behavior, Indonesia health system

### **1. Introduction**

There are still many obstacles in the way of Indonesia's health development and its goal of improving maternal and child health. Still high rates of maternal and child mortality, as well as malnutrition in babies and toddlers, are indicative of these difficulties. The 2012 IDHS maternal mortality rate (MMR) in Indonesia was calculated to be 359 per 100,000 live births due to complications during or immediately after delivery [1, 2].

Deaths among infants (IMR) and young children (under-5 mortality rate, AKBAL) occur at a rate of 32 and 29 per 1000 live births, respectively (www.depkes. go.id). Since 1982, the government of Indonesia has used the primary health care (PHC) plan to pursue health development with the aim of lowering maternal and infant mortality rates. Community health centers (Puskesmas) use a primary health care approach, seeing patients as their first point of contact when they are ill and acting as a referral hub for more advanced medical care [3].

The government established the integrated service post program (Posyandu) in response to geographical challenges, a shortage of medical professionals, and the community health center's expansive service area, all of which made it difficult to provide accessible public health services, especially those focused on mothers and children [4, 5].

Family planning services (KB), maternity and child health (KIA), vaccination, nutrition enhancement, and diarrhea prevention make up Posyandu's basic service package as a health care institution offered by the government to rural communities. Nutrition counseling, family development for toddlers, dengue hemorrhagic fever, child care, food processing, and the promotion of healthy living are only some of the other initiatives carried out *via* counseling [6, 7].

It seems that the strategy of relying on the target population's (mothers and children) visits to the Posyandu to achieve service program coverage has not been successful. Visits to Posyandu by pregnant women, babies, and toddlers, as measured by the Ministry of Health's own data collection methods (1997 report), indicate that Posyandu is still not widely used in the community. Coverage for family planning services is 32.40%, with 8.99% of pregnant women seeing Posyandu, 23.51% of newborns, and 67.51% of toddlers [8].

Because the Posyandu service program places an emphasis on preventative health services, including vaccination, pregnancy checkups, and child weighing, community participation in Posyandu has dwindled. The unpredictability and lack of consideration for the activities of the local community in setting the Posyandu's service schedule is a major factor in the low rate of mother participation. We may, thus, infer that subpar Posyandu services will work against efforts to boost citizen participation in Posyandu.

The success of a development program depends on three factors aligning perfectly: the needs of the beneficiary and the outcomes of the program; the requirements of the program and the actual capabilities of the auxiliary organizations; and the recipients' ability to express needs and the decision-making processes of the auxiliary organizations. If Posyandu is able to tailor its services to the need of the local population, it will play a part in enhancing the community's health, as shown by this research [9].

Affordability, timeliness, and precision in medical care are all indicators of rising service quality. The capacity, outlook, and demeanor of service officers in their dealings with members of the community as service receivers are decisive in ensuring *Implementation of the Posyandu Program and Healthy Living Behavior of Mothers… DOI: http://dx.doi.org/10.5772/intechopen.109770*

the execution of excellent service. Police personnel may demonstrate courtesy and friendliness in these encounters. Posyandu's decision-making process, as well as the ease with which demands may be communicated, will influence the extent to which the organization can gain public support [10].

The democratic method, which places a great deal of responsibility above the community, and the autocratic approach, which holds that people are fully responsible, work together to ensure that those with the right to act and educate the community are the ones who do so. Since the success of development depends on community engagement and the support of local resources, including labor, finances, and facilities [11], Posyandu will obtain support from the community if it employs a democratic method in decision making.

At the community level, development success may be gauged by how well the Posyandu program has been ingrained into people's daily routines. Institutions in the community and other groups may help with the institutionalization process. The organization is a set of official and informal roles that everyone understands and plays. The institution, however, is understood to be a social standard and pattern of conduct that occurs in order to accomplish certain ends. Meanwhile, various constraints on institutions make patterned behavior a sequence of social connections that occur in communities or groups. Patterned behavior is now a shared feature of our society as a whole [12].

Promoting healthy lifestyles is the ultimate aim of health initiatives, such as Posyandu. There are three types of influences on behavior: (i) predisposition, which includes individual knowledge, attitudes, traditions, and social norms; (ii) enabling factors, which include the accessibility of health service facilities; and (iii) reinforcing factors, which include the attitudes and behaviors of health workers. The high expense of transportation and treatment, as well as the difficulty in accessing medical facilities, are two examples of nonbehavioral issues. There are many different types of healthy lifestyle choices, including those that affect one's physical and mental health, as well as one's approach to food and the environment [13, 14].

The presence of Posyandu, a health service institution, is an indicator that people in rural regions have access to health care resources. Both governmental and grassroots institutions have contributed to shaping modern civilization. Community health centers, sub-health centers, village maternity boarding schools (Polindes), village drug posts, village midwives, and skilled traditional healers are all examples of those who actively participate in delivering health services. Village Community Empowerment Institutions (LPMD), Family Welfare Empowerment (PKK), Dasa Wisma Group, Toddler Family Development Groups, Craftsmen Groups, arisan, and so on all serve to inculcate and encourage villagers to live healthily [15, 16].

Given the above, the study's primary concern is whether or not mothers and children's healthy behavior would persist in the face of their low engagement in the Posyandu as a result of the poor quality of Posyandu services. Second, even if Posyandu was the one who first presented the concept of good parenting to society, how is it being institutionalized by the community itself?

### **2. Methods**

The purpose of this research was not to test hypotheses but to provide a descriptive survey. This study also included in-depth interviews with respondents and many informants to supplement the data collected through questionnaires. Researchers not only conduct in-depth interviews but also actively participate (observer as participant) in Posyandu services in order to observe, comprehend, query, and document all phenomena that emerge throughout the course of a Posyandu service [17]. Sidomulyo Village in Godean District in Sleman Regency in Yogyakarta, a special province, was the site of the study. Firstly, Sidomulyo Village is highly typical for other villages in Godean District due to its relatively homogenous degree of Posyandu development and community features; and secondly, Sidomulyo Village has never been employed as a comparable study site before.

In this study, the population was mothers who had newborns and children under five at the time the research was carried out, with the consideration that they were the focus of the Posyandu service program. There are 348 individuals in all, living in eight different Posyandu (hamlet). Random sampling was used for the sampling process. The sample size collected from the population is 30%, which is carried out proportionately for each Posyandu by lottery. A total of 100 participants were included in the sample. The study variables associated with the issue and the unit under investigation were described by the processing of descriptive statistical data (descriptive statistics). In this research, the mother-child dyad serves as the unit of analysis. So, the mother is the unit of analysis at the individual level, since the child's healthy behavior mirrors the mother's good conduct [18, 19].

### **3. Results and discussion**

### **3.1 Implementation of the Posyandu service program**

Each Posyandu is required to carry out at least five different program packages as part of the implementation of the Posyandu service program. These program packages are collectively referred to as minimum service activity packages. Improving nutrition is one of these five programs, along with mother and child health (MCH), family planning (KB), vaccination, and preventing diarrheal illnesses. The supplemental feeding package (PMT) is also a part of the nutrition improvement program (P2-Diarrhea). It is clear from the findings of the field study conducted in Sidomulyo Village that not every Posyandu is capable of doing each and every one of these basic service activity packages [20].

Participant observations led to the discovery that the types of Posyandu services in Sidomulyo Village that were carried out by 40% consisted of two types of services: nutrition services (20%) and maternal and child health services, particularly services for weighing toddlers (20%). The findings of this discovery were based on the fact that 40% of the village's residents were surveyed. Family planning and diarrhea prevention were not included among the three categories of services that were not provided since they were not implemented. The insufficient nature of the Posyandu service, which places the utmost emphasis on weighing toddlers, gives the impression that Posyandu is primarily a weighing station for children under three years old.

The results of field research can be used to get an idea of what people think of Posyandu as a post for weighing toddlers. The results showed that 85% of respondents stated that it was not suitable, while only 3% stated that it was suitable. This gives the impression that Posyandu is not an appropriate post for weighing toddlers. The number of respondents who claimed that it was suitable was made up of responses from mothers who had toddlers; hence, the most clear need was to manage the health progression of toddlers *via* activities including weighing. Even while the vast majority

### *Implementation of the Posyandu Program and Healthy Living Behavior of Mothers… DOI: http://dx.doi.org/10.5772/intechopen.109770*

of respondents (85%) said that they were qualified, they in fact need additional sorts of services, including counseling on family planning, vaccination, extra food (nutrition parks), and counseling on environmental health. According to the findings of the poll, an overwhelming majority of respondents (88%) claimed that the service for the registration desk went well, while just 5% of respondents stated that the service was not smooth. On the other hand, with regard to the second table (weighing), as many as 97% of the respondents claimed that the service was operating well, while just 1% of the respondents stated that it was not operating smoothly.

As for the recording of the findings (table three), the majority of respondents indicated that they were up to date, which is represented by the percentage 90% of respondents who stated that they were current and the percentage 3% of respondents who stated that they were not current. Posyandu gives the appearance of being a toddler weighing station due to the fact that registration, weighing, and the recording of results all go through without a hitch [21].

It was discovered that as many as 38% of respondents stated that it was not operating smoothly for the fourth table (individual counseling/referring), and it was discovered that as many as 38% of respondents stated that it was not operating smoothly for the fifth table (KB-Health services). In the meanwhile, according to the responses of those who were asked about the sufficiency of the Posyandu amenities in Sidomulyo Village, it would seem that the facilities that are enough are mostly those that are administrative in nature. In the meanwhile, essential facilities or equipment, such as cooking utensils, contraception, as well as tables and chairs, are in short supply. Even the respondents themselves expressed their opinion that these amenities were inadequate in some way. As many as 65 respondents indicated that there was an insufficient supply of cooking utensils, as many as 35% of respondents stated that there was an insufficient supply of contraceptives, and as many as 33% of respondents stated that there was also an insufficient supply of table and chair facilities [7].

### **3.2 Mother and child involvement in Posyandu**

The involvement of mothers and children in Posyandu activities can be seen from the frequency of mother and child visits in utilizing the services available at the Posyandu. This can be seen from the variations in the answers of mothers (respondents) to the frequency of visits to Posyandu. The results of the study explained that as many as 57% of respondents stated that the utilization of family planning services at Posyandu was very low; this was related to the quality of family planning services provided. The low quality of family planning services causes mothers to be more inclined to carry out family planning services at the local doctor, midwife, or health center.

For prenatal checks, most of the respondents stated that they were very lacking in utilizing the service, namely 55%. The lack of utilization of this service is not due to the reluctance of Posyandu participants but rather due to inadequate service factors such as the absence of technical staff at the Posyandu (e.g., midwives) to examine mothers, lack of adequate facilities, and infrastructure, for example, a blood pressure measuring device. The lack of quality of antenatal care services has caused most mothers to use the services of doctors, midwives, or Puskesmas as a place to carry out prenatal checks [22].

For immunization services, it was shown that the majority of respondents stated that the quality of immunization services was very poor, namely as much as 50%. This lack of immunization services is mainly caused by the dependence of immunization

services on the presence of midwives at the Posyandu who bring vaccines as needed. Because the vaccines are stored at the Puskesmas, and if on Posyandu open days the midwives do not bring the vaccines, the immunization services are abolished [23].

In the case of giving ORS, the majority of respondents also stated that their visit to this type of service was lacking, namely as much as 48%. The low involvement of mothers in this type of ORS service is due to a lack of ORS supplies at the Posyandu. This is also due to the fact that the supply of ORS at Posyandu is highly dependent on distribution from the Puskesmas. The types of Posyandu services that show the high involvement of respondents in utilizing the service are weighing children under five, giving vitamin A for toddlers, and providing additional food.

The involvement of mothers and children in Posyandu activities can also be seen from the participation of mothers in the payment of health fund contributions (IDS). The results of the study explained that 48% of the respondents paid contributions to the health fund (IDS). While mothers who do not make IDS payments are as much as 38%. The amount of health fund contributions (IDS) among Posyandu varies, but field findings show that health fund contributions (IDS) range from IDR 1000.00 to IDR 1500.00 for each mother.

Mothers' involvement in Posyandu activities can also be seen from the frequency with which mothers provide donations/assistance in procuring service facilities needed by Posyandu. The results of the study found that most of the respondents had never contributed to the provision of Posyandu service facilities, namely 62% and there were 22% of respondents who stated that only occasionally, while 16% stated that they often made donations to procure Posyandu service facilities. Forms of donations include money, food, medicines, and vitamins.

The involvement of Posyandu participants in service activities can also be seen from their involvement in discussing Posyandu issues. The results of the field findings revealed that the respondents' answers varied quite a lot in terms of involving these members. As many as 40% of respondents feel that they are always involved in discussing problems in the Posyandu. Meanwhile, another 40% feel that they are only occasionally involved in discussions about the ins and outs of Posyandu service activities. Meanwhile, there were 20% of respondents who said they had never been involved in discussing problems in Posyandu services. This means that the decisionmaking system has not run democratically so it can affect their involvement in Posyandu.

### **3.3 Healthy behavior of mother and child**

Field data showed that the majority of respondents in this survey lead healthy diets and diet-related lifestyles, with 71% of participants reporting that they regularly serve healthy meals for their families. Rice, tempeh, tofu, pork, fish, eggs, carrots, beans, kale, and fruits, as well as vegetables, milk, and iodized salt, are all eaten to provide for his family's nutritional requirements. Most people already have a good grasp on the value of a healthy diet, therefore it is not commonly questioned whether or not to provide wholesome meals. Most respondents also had incomes above Rp. 750,000.00, which means they are able to afford to regularly serve healthy meals. They will be able to afford enough food to suit their dietary requirements with this sum of money. In contrast, 29% of respondents said they only sometimes supplied healthy meals for their family, and 0% said they never did. It is not that they do not understand the need of maintaining a healthy lifestyle by eating well, but rather that financial constraints at home make it difficult to do so. A mother's involvement

### *Implementation of the Posyandu Program and Healthy Living Behavior of Mothers… DOI: http://dx.doi.org/10.5772/intechopen.109770*

in family planning programs is an indicator of her commitment to healthy lifestyle choices, especially those that promote her reproductive health (KB).

The majority of respondents (74%) actively accepted family planning, according to the data from the field. Eleven percent, however, reported being less active, while 15% indicated they did not exercise at all. Most of the respondents at the research sites were now independent family planning participants; that is, they could afford to pay for services from private midwives or practicing physicians, which explains the large number of active family planning acceptors at the study sites.

A mother's propensity to attend prenatal visits is another indicator of her overall health throughout pregnancy. Women who are expecting children are offered prenatal care at regular intervals. During pregnancy, women should see a Puskesmas or midwife at least four times (K1–K4) for checkups (antenatal care). According to the data collected in the field, just 8% of pregnant women went in for between one and three prenatal checkups, while 35% went in for between six and seven and 57% went in for between seven and nine. This indicates that expecting women are well aware of the need of prenatal care. This indicates that the mother is practicing exemplary prenatal hygiene [24].

When it comes to delivering their children, field data indicated that as many as 7% of respondents used a traditional birth attendant, 80% used a midwife, and 13% used a doctor or medical professional in some capacity. Due to the fact that most respondents have given birth with the assistance of a midwife or doctor and just a small number have sought the services of a dukun beranak, it is evident that the mother's healthy behavior is high.

Immunizations against diseases, including diphtheria, pertussis, and tetanus (DPT), hepatitis-B, polio, measles, and Bacillus Calmette Guerin (BCG), are a good indicator of a mother's dedication to keeping her child healthy. Findings from the field showed that almost nine in ten respondents vaccinated their infants and toddlers entirely, with 3% providing just partial vaccinations and 8% reporting that they did not vaccinate at all.

Mothers' healing behavior may be inferred from the lengths they go to in order to treat their children, just as it can be from the measures they take to protect them from illness. When respondents' children were under the age of five and unwell, the majority took them to a midwife (64%), a community health center (64%), or a community health center (80%). Midwives, health centers, and auxiliary health centers are frequently visited by parents who have brought their sick children there because they are reliable, accessible (*via* walking or public transportation), inexpensive (relative to other medical options), and open to people of all socioeconomic backgrounds.

The results of the fieldwork indicated that all respondents boiled their drinking water before ingesting it, which is a healthy practice for families. In addition, research from the field shows that 42% of people who have latrines at home utilize them. Those who fall within this group of respondents understand the significance of maintaining a clean environment and taking measures to eliminate potential health hazards in the comfort of their own homes. However, 13% of respondents reported using a public restroom and 45% reported not having access to a private lavatory in their homes.

The respondents' high socioeconomic status, represented in their education and income levels, is a key factor in the achievement of the aforementioned healthy behavior of mothers and children. Findings from this research show that the vast majority of respondents are well educated, with 43% having completed high school and 7% having completed college or university, and that over half (52%) earn more than IDR 750,000.00 per year. Mothers with higher incomes will have an easier time affording the costs of a healthy lifestyle, and mothers with higher levels of education will be better able to appreciate the significance of maintaining a healthy lifestyle.

### **4. Conclusion**

Subpar service hindered the Posyandu program's rollout. The inability of Posyandu to provide all sorts of services, poor quality service systems, and insufficient service facilities and equipment all contribute to the quality of service that customers get. Because Posyandu only provides weighing services for toddlers and nutrition services, whereas women additionally require prenatal care, vaccination, family planning, and treatment for diarrhea, poor mother participation in Posyandu might be attributed to this mismatch. Posyandu only captures a fraction of the community's mothers and children's healthy behaviors. Most of their knowledge about how to live a healthy life comes from sources other than the Posyandu, such as community health centers, sub health centers, private midwives, and medical professionals. The high levels of education and wealth within the family help to prove this. Even if mothers are not actively participating in Posyandu, this does not prevent them from exhibiting positive health habits in the long run. This is due to the availability of service facilities outside the Posyandu that mothers may utilize to satisfy their daily requirements, as well as the presence of numerous formal, semiformal, and rural institutions that institutionalize healthy living.

But the regularity with which mothers offer nutritious meals for the family, maintain food hygiene, boil drinking water first, give their newborns full vaccines, and bathe their babies twice a day all fall into the "high" category of healthy family behavior, as well as being independent-KB participants, who practice cleanliness in all aspects of their lives (eating, drinking, dressing, and caring for baby equipment), who visit their doctors 7–9 times during pregnancy, who utilize contemporary health service centers for delivery assistance, and who actively engage in these practices.

Since Posyandu is not the only health care facility available to mothers, the healthy behavior of mothers and children will persist even with minimal participation. In rural areas with a high standard of living, residents choose not to employ Posyandu services in favor of more contemporary medical options.

### **Author details**

Umar Nain Institute of Home Affairs Government, Indonesia

\*Address all correspondence to: umarnain1388@ipdn.ac.id

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Implementation of the Posyandu Program and Healthy Living Behavior of Mothers… DOI: http://dx.doi.org/10.5772/intechopen.109770*

### **References**

[1] Halfon N, Larson K, Lu M, Tullis E, Russ S. Lifecourse health development: Past, present and future. Maternal and Child Health Journal. 2014;**18**(2):344-365

[2] Organization, W. H. World Health Statistics 2016: Monitoring Health for the SDGs Sustainable Development Goals. World Health Organization; 2016

[3] MacDorman MF, Mathews TJ, Mohangoo AD, Zeitlin J. International Comparisons of Infant Mortality and Related Factors. United States and Europe; 2010

[4] Nirwana MD, Utami IH, Utami HN. The cadre of integrated health service post (Posyandu) as an agent in the socialization of cervical Cancer prevention in Malang regency, Indonesia: A cultural approach. Procedia-Social and Behavioral Sciences. 2015;**211**:681-687

[5] Pratono AH, Maharani A. Long- term care in Indonesia: The role of integrated service post for elderly. Journal of Aging and Health. 2018;**30**(10):1556-1573

[6] Apanga PA, Adam MA. Factors influencing the uptake of family planning services in the Talensi District, Ghana. Pan African Medical Journal. 2015;**20**(1):1-9

[7] Gavin L, Moskosky S, Carter M, Curtis K, Glass E, Godfrey E, et al. Providing quality family planning services: Recommendations of CDC and the US Office of population affairs. Morbidity and Mortality Weekly Report. Recommendations and Reports. 2014;**63**(4):1-54

[8] Kadarina TM, & Priambodo R. Preliminary design of internet of things (IoT) application for supporting mother and child health program in Indonesia. 2017 International Conference on Broadband Communication, Wireless Sensors and Powering (BCWSP). 2017. pp. 1-6

[9] Julian R. Is it for donors or locals? The relationship between stakeholder interests and demonstrating results in international development. International Journal of Managing Projects in Business. 2016;**2016**

[10] Syed SB, Leatherman S, Mensah-Abrampah N, Neilson M, Kelley E. Improving the quality of health care across the health system. Bulletin of the World Health Organization. 2018;**96**(12):799

[11] Lunenburg FC. The decision making process. National Forum of Educational Administration & Supervision Journal. 2010;**27**(4)

[12] Fosu AK. Achieving Development Success: Strategies and Lessons from the Developing World. Oxford University Press; 2013

[13] Grembowski D. The Practice of Health Program Evaluation. Sage Publications; 2015

[14] Schell SF, Luke DA, Schooley MW, Elliott MB, Herbers SH, Mueller NB, et al. Public health program capacity for sustainability: A new framework. Implementation Science. 2013;**8**(1):1-9

[15] Abuse S. Mental health services administration. Results. 2013;**2**:13

[16] Bowling A. Research Methods in Health: Investigating Health and Health Services. McGraw-hill Education (UK); 2014

[17] Showkat N, Parveen H. In-depth interview. Quadrant-I (e-text). 2017;**2017**

[18] Acharya AS, Prakash A, Saxena P, Nigam A. Sampling: Why and how of it. Indian Journal of Medical Specialties. 2013;**4**(2):330-333

[19] Emerson RW. Convenience sampling, random sampling, and snowball sampling: How does sampling affect the validity of research? Journal of Visual Impairment & Blindness. 2015;**109**(2):164-168

[20] Closa-Monasterolo R, Gispert-Llaurado M, Canals J, Luque V, Zaragoza-Jordana M, Koletzko B, et al. The effect of postpartum depression and current mental health problems of the mother on child behaviour at eight years. Maternal and Child Health Journal. 2017;**21**(7):1563-1572

[21] Gatto NM, Ventura EE, Cook LT, Gyllenhammer LE, Davis JN. LA sprouts: A garden-based nutrition intervention pilot program influences motivation and preferences for fruits and vegetables in Latino youth. Journal of the Academy of Nutrition and Dietetics. 2012;**112**(6):913-920

[22] Agha S, Tappis H. The timing of antenatal care initiation and the content of care in Sindh, Pakistan. BMC Pregnancy and Childbirth. 2016;**16**(1):1-9

[23] Assija V, Singh A, Sharma V. Coverage and quality of immunization services in rural Chandigarh. Indian Pediatrics. 2012;**49**(7):565-567

[24] Perry GS, Patil SP, Presley-Cantrell LR. Raising awareness of sleep as a healthy behavior. Preventing Chronic Disease. 2013;**10**

### **Chapter 4**

## The Kongsi Covid: A Cultural and Religious Belief Approaches for Covid-19, Battling Stigma and Strengthening Family Resilience for Villagers in Padang, Indonesia

*Rizanda Machmud, Finny Fitry Yani, Feri Mulyani Hamid, Yuniar Lestari, Irvan Medison, Emilzon Taslim and Bestari Jaka Budiman*

### **Abstract**

Background: The stigma of Covid-19 is culturally rooted in health beliefs and practices in Padang-Indonesia. The aim of this intervention project is to develop cultural & religious belief approaches for Covid-19 battling stigma and strengthening family resilience for villagers. Intervention: The Kongsi Covid-19 is community-based preparedness and response strategy preventing the transmission of Covid-19. The sub-village RT/RW is subordinate to the village as a cluster that has supervision directed in the community and requires 10–14 volunteers. All activities are monitored, coordinated, and supervised by the village leader, sub-district, community health centers, and city health offices. Results and Impact: Padang had developed 1,252 Kongsi Coovid-19 covering 100% of sub-villages. More than 3000 people with positive confirmed cases with asymptomatic or mild symptoms, doing self-isolation under Kongsi COVID-19 local monitoring. The government of Padang was awarded the Best rating II due to its policy for preparing strategic planning which includes efforts to deal with the COVID-19 pandemic through the innovations of the Kongsi COVID-19. Conclusions: Kongsi Covid-19 strengthens existing partnerships to reach and engage with wider community networks. It has an active role to resolve the health issue of Covid-19 battling stigma and strengthening family resilience for villagers in Padang-Indonesia.

**Keywords:** cultural religious approach, empowerment, family resilience, social, Covid-19

### **1. Introduction**

The Covid-19 pandemic has led to cause large-scale morbidity and mortality globally. During the early Covid-19 pandemic, positive numbers of Covid-19 patients in Padang continued to increase every day [1, 2]. The proportion of positive

numbers due to Covid-19 increased from 484 cases on June 15, 2020, to 488 cases on June 16, 2020, and on June 17, 2020, to 492 cases [2]. Thus, the city of Padang was designated as a red zone category prone to the transmission of the Corona Disease Virus (Covid-19). Another problem is that the health protocol and self-isolation protocol, which are government programs to control the increase in Covid-19 cases, have not been socialized properly, and what is worrying is the existence of stigma in society, which hinders the control of Covid-19 [1–3]. The Covid-19 pandemic has distanced people from the healthcare system due to excessive fear.

The high number of cases in the Padang requires a new strategy and order to increase this achievement in the New Normal era [3]. In New Normal conditions, according to the Ministry of Internal Affairs No. 440-830 of 2020, in the end, society must live side by side with the threat of the coronavirus, as an effort to restore community life activities and administration of government conditions such as before the occurrence of Covid-19, so that people become productive and safe in carrying out their activities [3, 4]. As for the activities in this New Normal era, what needs to be done is to carry out activities based on the principles of Covid-19, namely wearing a mask when leaving the house, washing hands with soap and running water, and keeping distance [5–7]. The activities of this new order should be community-based. This means that this community-based activity is expected to eliminate the stigma against Covid-19.

Meanwhile, the community is the vanguard that has been forgotten so far; it has more impact and builds social solidarity and mutual cooperation. Community engagement plays a role in maximizing the effectiveness of Covid-19 preparedness and response strategies and preventing transmission at the community level.

The communities, when engaged, are the front line in detecting and managing epidemics. They are the most affected and have the greatest influence in anticipation and preparedness as new diseases emerge or old ones re-emerge [6–8].

By engaging communities in the preparedness and response to Covid-19, the health sector can avoid the emergence of cases that will worsen the pandemic. It can also give the health sector more time to prepare to respond in realistic, relevant, and appropriate ways to the needs and challenges of every population group. Further, community engagement can serve to address and prevent health and gender inequities during the Covid-19 pandemic.

Therefore, we need a community-engaged communication strategy that focuses on Covid-19 messaging in a cultural context that can be a potential channel for responding to the Covid-19 pandemic. Efforts are being made to involve a culture-based community that is already inherent in the Minangkabau community by modifying it to suit the handling and control of Covid-19 in the community. The focus of activities on Covid-19 at this time can be a positive synergy.

### **2. Rationale: cultural and religious approaches for Covid-19, battling stigma and strengthening family resilience for villagers**

Research in another setting has shown the need to address cultural health beliefs about the locus of control in the design and development of programs. In this sense, the word "community participation" is the key word for increasing access to make it easier to detect cases, the socialization process for each stage of the action, as well as community participation in handling Covid-19.

People in West Sumatera are mostly of the Minang tribe and have culturally rooted health beliefs and practices. This activity is based on the sub-village. Every time

### *The Kongsi Covid: A Cultural and Religious Belief Approaches for Covid-19, Battling Stigma... DOI: http://dx.doi.org/10.5772/intechopen.109446*

someone dies in the sub-village, it will be held together in mutual cooperation by the local sub-village residents. It is such as a community bereavement service which is initiated by community in favor to support the loosing family by the neighbourhood where they lived. The community is homogenous and solid. It is called Kongsi Kematian.

Leveraging existing networks and community forums in sub-village. We have modified a strategic approach for addressing the preparedness and response strategies and preventing the transmission of Covid-19 in the community. We modified a community engagement that has been rooted in Minang Kabau devise such as Kongsi Kematian.

It is hoped that this concept can be applied in the preparedness and response strategies and preventing transmission of Covid-19 at the community level, which is called the "Kongsi Covid".

We also had already identified and reviewed Kongsi Covid as the terms of reference for previously established partnerships that could be of value in reaching and engaging solid communities.

Strong existing networks in Padang have established a platform to facilitate discussions among the community about how they can support one another and come up with their own solutions that would be beneficial in Covid-19 promotion and prevention. Kongsi Covid, with the principle of mutual cooperation, removes stigma, increases family resilience, and raises awareness and mental health of the community.

The assignments of the Kongsi Covid are to keep negative cluster areas negative; to monitor clusters, if there are positive people, to become negative; to remove stigma; to raise public awareness; and to work on mental health. The community empowered by the principle of working together means that the concern of promoting and preventing behaviors becomes and is controlled by society itself.

### **3. The intervention and implementation of the Kongsi Covid**

The 'Kongsi Covid-19' concept is a micro lockdown unit in a sub-village, called RT/RW, where the RT/RW sub-villager community serves as a sharing center for food, medicine, and information. Its establishment requires 10–14 volunteers.

Therefore, the RT/RW sub-village is a Covid-19 Consortium Cluster. The clusters as a micro lockdown unit are smaller and more numerous, in fact, minimizing the risk of transmission and making it easier to monitor and evaluate the handling of Covid-19. The role of the sub-village RT/RW in the Kongsi Covid-19 is that of supervision at the community level, no longer at the family nor at the regional government level.

For this reason, for the success of the Kongsi Covid-19, we cannot rely on the role of the health sector alone, but cross-sectoral roles, such as RT/RW, youth organizations, NGOs, the head of village, the head of district, and the presence of academics also play a decisive role. One of the real supports from academics in the success of this partnership is through community empowerment, together with students and lecturers, to improve the management of Covid-19.

We selected Mata Air Village, Padang Selatan District, as the pilot project of the implementation of Kongsi Covid-19. Mata Air has the highest cases among the subdistricts in Padang Selatan District and tends to increase the cases of Covid-19. It has 20 positive cases, 9 people recovered, and 2 people died. The challenge of Mata Air Village is the area that has a dense population, making it easier for Covid-19 transmission to occur [9].

The activity model that will be carried out is as follows: socialization regarding health protocols during the Covid pandemic and the self-isolation protocol. Collaborating with cross-sectoral partners such as villages, Youth Organizations, NGOs, Head villages, Head sub-district, and Health Offices.

The activity model that will be carried out is as follows: 1. Socialization regarding Health Protocols during the Covid Pandemic and the Self-Isolation Protocol; 2. Collaborating with cross-sectoral partners such as villages, Youth Organizations, NGOs, Head villages, Head sub-district, and Health Offices; 3. Preparing the Establishment of the Kongsi Covid-19 at the sub-village level, and its organizational structure and duties and responsibilities; 4. Make periodic reports that describe conditions in each RT/RW sub-village using the Google form or application; 5. Form socialization by using print media and online media; 6. Create an RT/RW WhatsApp (WA) group for monitoring; 7. Monitoring and evaluating the implementation of the RT/RW Kongsi COVID-19 activities through regular virtual meetings; 8. Creating a Covid Positive community monitoring system; 9. Create a monitoring and reporting system through an application that contains: case identification, reporting of suspected Covid-19, recording of suspected Covid-19, and monitoring of independent isolation that occurs in each sub-village [10, 11].

### **4. Flow and stages of the implementation of Kongsi Covid-19 activities**

The activity indicators are the formation of the RT/RW Kongsi Covid-19; activities of the Covid-19 partnership, discovery of new cases of Covid-19, and self-isolation patients are well monitored (**Figure 1**).

If there are people with symptoms of COVID-19:


*The Kongsi Covid: A Cultural and Religious Belief Approaches for Covid-19, Battling Stigma... DOI: http://dx.doi.org/10.5772/intechopen.109446*


### **Figure 1.**

*The flow of Kongsi Covid-19 concept and platform [10, 11].*

### **5. Result**

The Kongsi COVID-19 has been developed after all set in Mato Aia Village as a pilot project model. There are 1.252 Kongsi Covid-19 in other sub-villages in Padang. It covers 100% of sub-villages which has an incident of Covid-19. It spreads in all eleven districts in Padang city.

There are more than 3000 people with positive confirmed cases, but with asymptomatic or mild symptoms, doing self-isolation under Kongsi Covid-19 local monitoring. Several of Kongsi Covid-19 societies have quarantine houses that can be used by the local citizen for self-isolation. This Kongsi Covid-19 has collaborated with the health care workers from the health center in managing and reporting the suspected cases and facilitated doing contact tracing to persons who have had contact with the confirmed cases.

We advocate the stakeholder—the mayor of Padang city—to make a local regulation concerning guidelines for the implementation of Kongsi COVID-19 in Padang city and a guideline book with ISBN.

The innovation of the Kongsi Covid-19 has been rewarded by the national government for the success in preparing quality planning in order to achieve better regional development. The award from the Ministry of National Development Planning-Bappenas was handed over virtually at the National Development Conference, which was opened directly by the President of the Republic of Indonesia Joko Widodo, in Jakarta, Tuesday (4/5/2021).

The city of Padang was awarded the Best rating II in the city category, because from a planning perspective, it has a policy for preparing strategic planning, which includes efforts to deal with the Covid-19 pandemic through the innovations of the Kongsi Covid-19.

The villagers in Padang City developed deep relationships within the community and organizations to work together to address Covid-19 issues. It promotes and prevents behaviors to decrease morbidity and mortality due to Covid-19. The principle of mutual cooperation removes the stigma and raises awareness, strengthening the family resilience and mental health of the community. It has established a platform to facilitate discussions among the community about how they can support one another and come up with their own solutions that would benefit in healthcare and treatment.

### **6. Conclusion**

A community-engaged communication strategy that focuses on Covid-19 messaging in a cultural context, which is called Kongsi Covid-19, can be a potential channel for responding to the Covid-19 pandemic. Efforts are being made to involve a culturebased community that is already inherent in the Minangkabau community by modifying it to suit the handling and control of Covid-19 in the community. It is a modified activity that has existed for a long time in the city of Padang, where this activity is based at the sub-village level.

Kongsi Covid-19 is a local community-based social restriction that is more sustainable or supportive because it requires constant vigilance. This intervention in the community made the front line in preventing Covid-19.

Kongsi Covid in the Mato Air Village, Padang Selatan District, became a pilot model, which was followed massively in other villages in the city of Padang. It has been held jointly in cooperation with local sub-village residents to help eliminate stigma in society and raise awareness and community mental health and family resilience.

*The Kongsi Covid: A Cultural and Religious Belief Approaches for Covid-19, Battling Stigma... DOI: http://dx.doi.org/10.5772/intechopen.109446*

### **Acknowledgements**

Thank you to our Dean Faculty of Medicine Andalas University give us full support on Kongsi Covid project. And especially to our collages Irvan Medison MD, Dr. Emilzon Taslim, MD have a huge contribution to the implementation.

### **Conflict of interest**

The authors declare no conflict of interest.

### **Notes/thanks/other declarations**

Thank you to our Major of Padang City Mahyeldi Ansharullaah, District Health Office of Padang Feri Mulyani Hamid, MD, M.Biomed, head sub-district of Padang Selatan, and head of sub-villages, head of Primary Health Cares in Padang and community where Kongsi Covid implemented, with all collaboration that made Kongsi Covid had a national level reward.

### **Author details**

Rizanda Machmud1 \*, Finny Fitry Yani2 , Feri Mulyani Hamid3 , Yuniar Lestari1 , Irvan Medison4 , Emilzon Taslim<sup>5</sup> and Bestari Jaka Budiman6

1 Department of Public Health/Community Medicine Medical Faculty of Universitas Andalas, Padang, Indonesia

2 Department of Child Health, Dr. M. Djamil General Hospital, Padang, Indonesia

3 Padang City Health District, Padang, Indonesia

4 Department of Pulmonologist, Dr. M. Djamil General Hospital, Padang, Indonesia

5 Department of Anesthesia, Dr. M. Djamil General Hospital, Padang, Indonesia

6 Department of Ear Nose Throat-Head Neck Surgery, Dr. M. Djamil General Hospital, Padang, Indonesia

\*Address all correspondence to: rizandamachmud@med.unand.ac.id

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Online News. Kasus COVID-19 Sumbar Kian Landai, Kini Peringkat 15 Setelah Sempat Nomor 8 Nasional [Internet]. 2020. Available from: https:// langgam.id/kasusCOVID-19-sumbarkian-landai-kiniperingkat15setelahsemp atnomor-8-nasional/ [Accessed: June 17, 2020]

[2] Padang Departement of Health. Situasi dan Perkembangan COVID-19 [Internet]. 2020. Available from: http:// corona.padang.go.id/ [Accessed: June 17, 2020]

[3] Ministry of the Internal Affairs Repubkic of Indonesia. Keputusan Menteri Dalam Negeri No 440 – 830 Tahun 2020 tentang Pedoman Tatanan Normal Baru Produktif dan Aman Corona Virus Disease 2019 Bagi Aparatur Sipil Negara di Lingkungan Kementerian Dalam Negeri dan Pemerintah Daerah. Kepmendagri, Jakarta; 2020

[4] Directorate General of Disease Prevention and Control. Pedoman Pencegahan Dan Pengendalian Coronavirus Disease (COVID-19). Jakarta: Ministry of Health Republic of Indonesia Directorate General of Disease Prevention and Control; 2020

[5] World Health Organization. Naming the Coronavirus Disease (COVID-19) and the Virus that Causes it [Internet]. Geneva: World Health Organization; 2020. Available from: https://www.who.int/emergencies/ diseases/novelcoronavirus2019/ technicalguidance/naming-thecoronavirusdisease-(COVID-2019)-andthe-virus-thatcauses-it

[6] World Health Organization. Coronavirus Disease 2019 (COVID-19) Situation Report-70 [Internet]. WHO;

2020. Available from: https://www.who. int/docs/defaultsource/coronaviruse/ situationreports/20200330sitrep70- COVID-9.pdf?sfvrsn=7e0fe3f8\_2

[7] Fotterl Q. Here's How Here's How the Mysterious Coronavirus has Spread Around the World so Rapidly.[Internet]. 2020. Available from: https://www.marketwatch. com/story/howthemysteriouscoronavirus-fromchinahasspread-soquickly-2020-01-21

[8] Ministry of the Health Republic of Indonesia. Situasi dan Perkembangan COVID-19 [Internet]. 2020. Available from: http://corona.padang.go.id/ [Accessed: June 16, 2020]

[9] Provincial Government of West Sumatra. Situasi dan Perkembangan COVID-19 [Internet]. 2020. Available from: http://corona.padang.go.id/ [Accessed: June 16, 2020]

[10] Minisitry of Villages. Development of Disadvantaged Regions, and the Transmigration Republic of Indonesia. Protokol Relawan Desa Lawan COVID-19. Kemen Desa, PDT, dan Transmigrasi RI, Jakarta; 2020

[11] Provincial Government of DKI Jakarta. Pedoman RT/RW dalam Menanggulangi Penyebaran COVID-19. Kementerian Kesehatan RI Direktorat Jenderal Kesehatan Masyarakat Direktorat Promosi Kesehatan dan Pemberdayaan, Masyarakat. Jakarta; 2020

### **Chapter 5**

## Poverty and Disease Burden: Reflection on the Rural Community Health Services of the 'Natives' in the Former Northern Transvaal of South Africa, 1930s–1980s

*William Maepa*

### **Abstract**

The twentieth-century period in South Africa was characterised by social-, political- and economic disparity between blacks and whites. Poor socio-economic conditions of blacks resulted in subjection to tuberculosis and other poverty-related diseases. This study explores rural exposure to diseases due to segregationist and subsequent state of racial disparity in all spheres of live. Focus is particularly thrown at incidents of malaria and tuberculosis in the rural communities of the Transvaal. This study also considers efforts forged by government in an attempt to abate and arrest the spread of these and other epidemics through rudimentary health services. The study relies on the use of published sources, archival materials and data collected through interviews. It is the position of this study that the escalated incidence of these diseases had immense impact on the lives of the rural than urban population. Other related pandemics, such as HIV-AIDS and COVID-19 will be explored. Lastly, the study will argue that evidence of ill health and death continued to surface irrespective of invented vaccines and other related medications.

**Keywords:** rudimentary, black/African healthcare, preventative primary healthcare, rural-urban migration, South Africa/Transvaal, unequal health, disease burden

### **1. Introduction**

The chronic prevalence of pandemics has been a toxic threat to the lives of South Africans and the world in general. Over many decades after the establishment of the union government, the killer diseases such as malaria, tuberculosis, HIV-AIDS and lately COVID–19 had been a 'headache' to the Department of Health and the World Health Organisation, respectively. It was upon these challenges that blacks found themselves vulnerable due to their state of poverty and other socio-economic defects. The Northern Transvaal, which included the so-called 'native areas or reserves' and later the 1960s ethnic-based homelands of Lebowa, Venda and Gazankulu, became

victims of disease diffusions. At times these conditions compelled many young and adult to migrate to the white farms and mining towns where poor living conditions, marginalisation, poor wages and ultimate disease infections were common. The deterioration of health of the blacks compelled the state to come up with measures to deal with the diseases through the establishment of native health, which was followed by popularisation of the concepts such as preventative, progressive and communitybased primary health care. The killer diseases such as HIV-AIDS and COVID-19, which erupted in the early 1980s and early 2020s, respectively also continued to inflict ill health and death among the blacks in the country.

### **2. Malaria in the transvaal and its impact on health care provision**

Malaria has been a life-threatening disease that affected Africa and other world countries. As a seasonal disease, in South Africa, it starts to appear in October and reaching its peak in January and February. The disease is usually transmitted through a bite by a female mosquito that carries this disease. It targets mostly the humid hightemperature regions of the world. The Lowveld areas of the former northern and eastern Transvaal, with extreme high annual temperature and rainfall, are popularly known to have favourable breeding ground for malaria-carrying mosquitoes. It has generally been noticed that the intensity of this disease decreases from east to west [1] as reflected in **Figure 1** of the map. One can, therefore, also realise that there is a positive correlation between the rate of malaria, temperature and rainfall, with serious risk areas followed by moderate and light risk areas.

**Figure 1.** *Malaria risk areas in South Africa, 1938 [1].*

*Poverty and Disease Burden: Reflection on the Rural Community Health Services of the 'Natives'… DOI: http://dx.doi.org/10.5772/intechopen.110266*

The effect of malaria was witnessed during the *Voortrekker* movement to Mozambique when Louis Trichardt, as a leader of the movement, his wife and 20 members were killed between 1837 and 1838 [2]. As a precautionary measure, farmers in the entire area of Transvaal Lowveld considered choosing the high-lying slopes and dry areas for settlement as they were deemed free from malaria-carrying mosquitoes [3].

It was in the midst of the growing malaria challenges that the state saw it fit to come up with workable measures to control and prevent the disease. *Gambiae* and *Funestus* were the mosquitoes typologies that were causing malaria in the area. The Department of Public Health was assigned to carry out this duty through the efforts of N.H Swellengrabel. Meanwhile, malaria continued to worsen in the Lowveld area of the Transvaal, Swellengrabel recommended the establishment of a malaria station in Tzaneen. His influence led to building of the station in 1932 by the South African Institute of Medical Research (SAIMR) under the leadership of De Meillon and Annecke, to carry out research and control of the disease. This effort encouraged the establishment of another station in Eshowe, Natal, in 1934 [2]. Annecke recommended the spraying of indoors and roof surfaces using Quinine Hydrochloride to the Tzaneen Malaria Station in 1939 to control the disease [4, 5]. Traditional leaders were visited and supplied with quinine for distribution to Thabina and the entire Lowveld region [3]. The utilisation of native commissioners through effective depot system was considered critical through constant supervision in the affected areas (**Figure 2**) [7].

Meanwhile, malaria showed an upward trend in the 1940s and 1960s, and the state continued to resort to other additional measures. Educating the communities through the engagement of Tzaneen malaria station staff was crucial as lecturing was presented to black school teachers in the districts of Waterberg, Potgietersrus and Groblersdal [8]. This effort was supplemented by the recommendations of the Tzaneen magistrate, who saw the need for the control malaria depots in Tzaneen and the surrounding countryside [7]. Other areas included Mphahlele's location in the Pietersburg district, municipalities of Potgietersrus, Naboomspruit, Nylstroom and Warmbaths [9]. Towards the end of the Second World War, Annecke endorsed the use of *dichlorodiphenyltrichloroethane* (DDT), which was recommended internationally as effective in the control and prevention of malaria. The reported cases were also dealt with at Giyani area of the Letaba District, the Shingwedzi area of the Letaba District and the Shingwedzi area of the Sibasa District [7].

### **Figure 2.**

*The two malaria transmitter mosquitoes in southern Africa [6].*

When DDT was banned in 1970, followed by its complete replacement in the mid-1980s, the disease once more reflected an upward trend. The banning was influenced by the poisonous impact of this insecticide to the biotic and abiotic environment. Although the public concern was justified, the malaria trends started to increase again, reaching the highest peaks between 1996 and 2015 [10]. Since millions of people throughout the world, including South Africa are currently at risk of contracting this disease, the National Department of Health considered it as a matter of urgency. Its impact as a barrier on social and economic development in the country compelled the state to prioritise meaningful measures to prevent its escalation.

### **3. Tuberculosis and health services**

Tuberculosis (TB), which is caused by a virus called mycobacterium tuberculosis, was unknown to South African blacks until the arrival of whites of European descent in the nineteenth century [11]. People with tuberculosis can be detected by symptoms, such as excessive coughing, physical or body weakness, weight loss, shortness of breath and continuous stress. The discoveries of minerals during the early 1800 in the TVL had a significant impact on the rural-urban migration by the impoverished blacks. As such, blacks became targets of this disease [1]. Researchers such as Shula Marks and Neil Anderson associate poverty and racial discrimination with the high rate of tuberculosis in the rural areas.

In the industrial towns and cities like in the Witwatersrand, the black migrants found themselves vulnerable to the tuberculosis infections caused by unfavourable living conditions. These migrants could easily spread it to their rural environments where health services were poor and inadequate. The soaring ill health and mortality appealed to those in power as well as the employers in the domestic, mining and industrial environments to remedy the situation. They feared the dwindling of labour force and ultimate negative impact on the country's economy. One of the measures initiated by the state was the National Health Service Commission during the early 1940s, which recommended the increase of hospital nurses, doctors, beds and health education for the rural black communities [12]. Apart from the state's request for local authorities to increase hospital beds as a way of overcoming the challenges, immunisation through vaccination was considered the most effective preventative measure. The efforts to combat tuberculosis were made easier when the radiological services were improved with several authorities and mission hospitals having acquired X-Ray units suitable for other health services [13].

The need to increase a number of beds for tuberculosis patients in hospitals coincided with the acute increase of black population during the 1950s and 1960s. Statistics in **Table 1** show the highest incidence of tuberculosis for *Bantu* (blacks) as compared to whites, coloureds and Asiatics in all six regions in 1964 [14].

The Northern Transvaal homelands of Lebowa, Transvaaal and Gazankulu continued to experience increasing reported cases of tuberculosis in the 1970s, with the north-eastern Transvaal in the Mhala district of Gazankulu recording the highest trend. Attempts by the state to deal with this challenge led to the testing of tuberculosis in primary schools including those formerly owned by the missionaries, with subsequent immunisation through vaccinations and distribution of tuberculosis tablets [14]. The forced removal of blacks by the state and subsequent inception of homelands or Bantustans, rural-urban migration, overpopulation, unemployment, poverty and ill health mitigated infection rate. The homelands became breeding grounds for TB and

*Poverty and Disease Burden: Reflection on the Rural Community Health Services of the 'Natives'… DOI: http://dx.doi.org/10.5772/intechopen.110266*


### **Table 1.**

*South African tuberculosis infected patients in 1964.*

other poverty-related diseases. For example, in the Transkei homeland tuberculosis notification growth was at the rate of 489 per 100,000 in 1975 [1].

Alarming notification of tuberculosis encouraged meaningful efforts of educational researches through conferences and symposiums by various institutions of high learning. Attempts at dealing with the challenges of increasing infections in the homelands and developing countries were highlighted during the symposium held at the then University of the North (now the University of Limpopo) on 28–29 October 1976. Pulmonary tuberculosis, which is the tuberculosis of the lungs, was singled out as still by far the most common threatening disease in the homelands [15]. A wide range of recommendations was initiated based on the idea of primary health care approach, with emphasis on preventative and community-oriented care. The reported findings of the health officials from the Pietersburg Regional Directorate of Health Service on the 1978/79 after Lebowa hospitals, such as Knobel, Mogalakwena and Kgapane, were visited revealed increasing notifications. Similar findings were reported from other homelands from the findings by the Medical Research Council during the early 1980s.

Challenges associated with tuberculosis continued to surface in South Africa and worldwide. The disease is currently one of the killer diseases with non-HIV tuberculosis as commonly reported at Waterberg district in 2018. It was here that 1.1 million cases have been estimated [16]. Other districts in Limpopo experienced cases of illnesses and deaths caused by this disease.

### **4. The relation of disease patterns since 1980**

The changing patterns of malaria and tuberculosis continued in the country and elsewhere in the African countries in the 1980s until recent times. The government found itself challenged by these fluctuating incidents of mortality resulting from these diseases. At times the emergence of the new pandemics, such as HIV-AIDS in the early 1980s and COVID–19 in the late 2019 became repeatedly linked to tuberculosis. The Limpopo Province, which embraced previous homelands of Lebowa, Venda and Gazankulu, is largely rural, with high rate of poverty and unemployment.

The first cases of HIV/AIDS were reported in South Africa during the early 1980s and evoked mixed perceptions as many people believed that it only affected European and American homosexuals. As a result, the public did not take enough precautions in the earlier stages. Similarly, the government believed that it was easy to control the

homosexuals as they were handful and easy to contain. As for the HIV/AIDS in the black townships and rural communities, lack of sufficient interest by the state was motivated by the racial policy of apartheid. As a result, intervention through preventative measures during the first 5 years after the incidence of the disease was reported was deliberately ignored [17].

The rapid spread of HIV/AIDS can certainly be linked to the migrant labour system and poverty. The long-entrenched labour system had a huge impact on the spread of HIV/AIDS in most rural areas of the former Northern Transvaal, most particularly in the former homeland areas of Lebowa, Venda and Gazankulu and other rural homelands in the country during the 1980s. The tendency of having multiple sexual partners among the blacks, which was deemed culturally acceptable, accelerated the spread of the disease. Most of these migrants established second families in urban areas [18]. This practice also escalated the spread of infections to the entire rural and township black communities, both within South Africa and other neighboring states.

Although the AIDS awareness campaigns were launched for years since the early 1980s, the post-1994 elections in South Africa strengthened the need for the full implementation of community-oriented primary healthcare system. The production of numerous drugs in recent years did not help much to cure the disease completely but contained it as chronic through utilisation of antiretroviral dugs. The scientific discoveries revealed that the disease aggravates in patients with tuberculosis and the two became comorbidities that continued to inflict ill health and death. When COVID-19 emerged towards the end of 2019, focus was shifted, and the disease once more escalated.

The outbreak of COVID-19 created fear and panic in the country, leading to ultimate closure of all public, recreational, private and state institutions, forcing people to stay at home through the 'lock-down' regulations [19]. The challenge with the disease was its rapid rate of infection and death due to the absence of medicine to cure it. The changing structural pattern of this disease made it difficult for health scientists to deal effectively with it as they continued to wrestle to find appropriate vaccine. In Limpopo and other provinces of South Africa, the government initiatives were at times hampered by reluctance of most of the rural populations to comply with precautionary preventative measures and the general attitude of distrust against vaccines during the lockdown alert levels. The controversies surrounding the taking of vaccines and some evidences of government officials' breaking of the lockdown regulations in their gatherings and stealing of personal protective equipment also hampered the government's efforts of effectively dealing with the disease.

Violet Chewe, a Sub-district COVID-19 Coordinator in Mankweng located east of Polokwane and surrounding rural areas, noted that most of the patients diagnosed positive with excessive sickness were found to have other diseases, such as sugar diabetes, tuberculosis, HIV-AIDS, excessive flu and other related communicable diseases. She further stressed that common challenges were experienced during the tracing of people with this disease as most of rural people were in denial as well as being afraid of victimisation and hatred from other members of the communities. She indicated that these conditions were common to other districts of Limpopo Province and countrywide [20].

As for the role played by the traditional healers in the treatment of this disease, Nani Ramalepe, who is one of the well-known traditional healers in the rural area of Tickyline outside Tzaneen confessed that she successfully treated many patients who had similar symptoms of COVID-19 by using plant-based traditional medicines [21]. It is indeed clear that apart from the current reliance on vaccines, which at times raised controversial issues, more scientific research to improve the available vaccines and effective involvement of traditional healers should be encouraged.

*Poverty and Disease Burden: Reflection on the Rural Community Health Services of the 'Natives'… DOI: http://dx.doi.org/10.5772/intechopen.110266*

### **5. Conclusion**

Certainly, over the years Malaria, tuberculosis, HIV-AIDS and COVID-19 as communicable diseases, continued to pose health challenges to the rural areas and nationwide, forcing the governmental and non-governmental organisations to implement various measures based on the precepts of primary health care. However, with the period following the inception of democratic South Africa in 1994, the whole efforts were at times hampered, among others by lack of effective administration, insufficient medications, ever-increasing black population, laxity and corruption. The rural blacks continued to suffer as most of them could not easily access the quality and expensive health services offered by private health institutions. It is despite the intervention measures from the Department of Health that health challenges continued to threaten the lives of the South Africans, most particularly poverty-stricken black population in the rural areas as it happened with its recent aftermath of COVID-19 pandemic. Although the recent the level of infections showed a significant decline in the late 1921, forcing the government to lift the National State of Disaster on 05 April 2022, COVID-19 has joined malaria, tuberculosis and HIV-Aids as a killer diseases. These diseases continued to be a cause for concern for the Department of Health and the World Health Organisation because of their fluctuating patterns.

### **Author details**

William Maepa University of Pretoria (UP), Pretoria, South Africa

\*Address all correspondence to: maepawilly@webmail.co.za

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Van Rensburg HCF et al. Health Care in South Africa: Structure and Dynamics. Pretoria: Academica; 31 August 1992

[2] Coetzee M et al. Malaria in South Africa: 110 of learning to control the disease. South African Medical Journal. October 2013;**103**(10)

[3] Kruger P. Face-to-Face Interview on Migrant Work and Immunization during the Period Under Study. Polokwane, South Africa: Malaria Control Directorate, Limpopo Provincial Department of Health; 24 March 2016

[4] South African National Archives, GES, Box 2659 File37/56b, Department of Public Health, Malaria, Tzaneen, South Africa. 15 July 1939

[5] South African National Archives, GES, Box 2659 File45/26, Malaria Distribution of Sale of Medicines and Materials, Malaria, Tzaneen, South Africa. 2 December 1939

[6] Gear JHS et al. Malaria in Southern Africa. Johannesburg: University of Witwatersrand; 1989

[7] South African National Archives, GES, Box 2659 File45/26, Malaria Distribution of Sale of Medicines and Materials, Malaria, Tzaneen, South Africa. 27 November 1939

[8] South African National Archives, GES, Box 2659 File45/26, Malaria Distribution of Sale of Medicines and Materials, Malaria, Tzaneen, South Africa. 01 August 1939

[9] Limpop Provincial Archives, Medical and Preventative Services, Tuberculosis Consultative Report. July 1978/June 1979 [10] Mabunda QE. Malaria Trends in Limpopo Province: Presentation of MRC Malaria Conference, South Africa. August 2015

[11] De Beer C. The South African Disease: Apartheid Health and Health Services. Johannesburg: Southern African Research Service; 1984

[12] Packard RM. White Plaque, Black Labor: Tuberculosis and Political Economy of Health and Disease in South Africa. University of California Press; 1989

[13] Annual Report of the Department of Health, Year ended 31 December 1959. Government Printer, Pretoria 28/1962

[14] Wilson F, Ramphele M. Uprooting Poverty: The South African Challenge. USA: David Philip; 1989

[15] Grous J. Physical Factors which Influence Health : International Symposium on Health Services for Developing Community. South Africa: University of the North; 28 and 29 October 1976

[16] Ramaliba TM et al. Tuberculosis risk factors in Lephalale Local Manucipality of Limpopo Province. South African Family Practice. 2017;**59**(5)

[17] Grunglingh L. Government response to HIV-AIDS in South Africa as reported in the Media, 1983-1994. South African Historical Journal. 2001;**45**(127)

[18] Coovadia et al. The Health and Health of South Africa: Health in South Africa. 5 September 2009;**374**(9692):817-834. Available from: www.thelancet.com

*Poverty and Disease Burden: Reflection on the Rural Community Health Services of the 'Natives'… DOI: http://dx.doi.org/10.5772/intechopen.110266*

[19] Mercer A, Chinchen G. Available from: https://neuroemploy.com/2022/10/ 09/benefits-of-covid-19-tot-theworkplace

[20] Chewe MV. Face-to-face interview about the link between COVID-19 and other communicative diseases. 2022

[21] Ramalepe N. Face-to-Face Interview about the Contribution of Traditional Healers in the Treatment of COVID-19. Tickyline Village, Tzaneen, Limpopo Province of South Africa. 8 January 2021

Section 2

## Reducing Inequities in Access to Health and Social Services

### **Chapter 6**

## Perspective Chapter: Health Facilities and Services in Rural Sierra Leone – Implication for Longevity and Well Being of Her Citizenry

*Roland Suluku, Abu Macavoray, Moinina Nelphenson Kallon and Joseph A. Buntin-Graden*

### **Abstract**

Sierra Leoneans face multiple barriers to accessing health facilities and services in rural communities leading to morbidity and mortality. The objective of this paper is to identify some of these challenges and proffer possible solutions to mitigate morbidity and mortality in rural communities and prolong the lives of their citizenry. The lack of money, the use of cheaper traditional medicines versus expensive medicines at health centers, lack of confidence in health workers, and transportation access to reach health facilities are barriers to accessing health facilities and services by rural community people. The above barriers outline was obtained through thirty years of interaction, discussion, and observations with people and health workers in rural communities. Possible solutions include the provision of free health care, ambulances to ease transportation, the integration of traditional medicine into the national health system, and the encouragement of rural community people to engage in multiple cropping every year. The above solutions and many others will encourage the citizenry in rural communities to attend health facilities and services in the country's rural towns and villages.

**Keywords:** rural, health, well-being, citizenry, long-life

### **1. Introduction**

Sierra Leone had limited health facilities in rural communities before the rebel war in 1991. This was partly due to low health expenditures by the government due to the reduced tax collection base of the country. In 2001, the African government agreed to allocate 15% of its annual income to health known as the Abuja declaration [1]. However, most countries have not achieved this African objective due to low gross domestic product, low tax collection, and low budget allocation to the health sector as a result of many competing priorities [2]. However, health requires intensive capital

investment, as it increases labor efficiency and productivity, increases income, and improves the standard of living of her citizenry [3]. Current health expenditure by the government of Sierra Leone in 2019 was 8.75%, and out-of-pocket expenditure was US\$25.47 [4]. This is far well below the WHO recommended US 30–40 per person needed to cover essential health care in low-income countries [5]. Low-income countries currently spend US\$8.00–US\$129 per capita compared to US\$4000.00 for high-income countries However, many countries in Africa have not been able to meet the Abuja declaration, except Botswana, Rwanda, and Zambia [6], while Equatorial guinea who has not achieved toe the Abuja declaration, but has high health per capita [7].

Rural communities' health infrastructures were destroyed, and only 86% of district headquarters health facilities remained functional during the elevenyear-old civil war. In 2003, the government rehabilitated and made 631 available peripheral health units (PHU) across the country [8]. Most communities' peripheral health facilities were 5 miles apart, so distance will not limit people from seeking medical attention. However, the major bottleneck is the need for more trained and qualified health personnel to operate these health facilities in rural communities. United Nations reported that only 38% of nurses and 25% of medical doctors work in health facilities in rural communities [9]. Five of the fourteen districts lacked access to primary health services after the civil war. The government reintegrated ex-combatants who were treating rebels and civilians as vaccinators. The strategy increased the number of health workforce but limited progress in the health sector due to a need for a clear political vision. Despite this improvement in the country's health facilities, most of the population residing in rural communities could not afford the cost, which also contributed to the high maternal mortality rate of 1800/100,000 in 2002 [8].

In 2010, the government introduced free healthcare to increase access to health facilities and services for pregnant and breastfeeding women and young children [10]; at this time, most births in rural communities were done by traditional birth attendants. The government engaged conventional birth attendants and trained them to work with health workers, thereby increasing attendance at health facilities. By-laws were formulated to discourage home birth but to encourage the use of health facilities. The objective was to reduce maternal morbidity and mortality [11].

Free health care and funding performance-based increased coordination in the health system and brought a paradigm shift in the health sector in the country [12]. The government also introduced performance-based financing as a way of motivating health workers. Compounding the situation further was the high death rate of health personnel, which eroded patients' convenience in attending these facilities and accessing the service [13, 14].

In July 2015, the President of Sierra Leone launched the Ebola Health Recovery Plan to attain a resilient sustainable health system to reduce maternal and child mortality and morbidity [4]. However, the presidential recovery initiative was for 24 months, with a critical focus on IDSR, strengthening IPC, Community engagement, enhancing Human Resources for Health, and Improving Management for Health and a Resilient Health System. The government needed help translating this novel initiative into an effective maternal health system. It was, therefore, the plan of the Ministry of Health and Sanitation to design an appropriate and effective program that is economically, socially, and culturally acceptable to the rural population of Sierra Leone.

*Perspective Chapter: Health Facilities and Services in Rural Sierra Leone – Implication… DOI: http://dx.doi.org/10.5772/intechopen.111717*

The WHO designed the External Joint Evaluation to address the health challenges and build a sustainable, resilient health system to reduce maternal morbidity and mortality. Moreover, the Ministry of Health and Sanitation, with international partners and the One Health secretariat, prioritizes zoonotic diseases to improve the health situation in the country. Aside from these strides, people in rural communities face numerous challenges in accessing these health facilities and services.

### **2. Challenges and constraints in accessing health facilities and services in rural communities**

The primary source of income in rural communities is agriculture and mining contributing to employment and gross domestic product [15, 16]. In time past, people in rural communities were engaged in all-year-round income generation. They harvest and sell coffee, cocoa, and piassava from October to January in the southern and eastern provinces. Ginger was harvested and sold from January to march, orange from February to May, and rice was harvested from June to November. Other assorted crops planted and sold include cassava, benne, yam, groundnut, maize, millet, sweet potato, and other multiple crops cultivated on the rice farm [17]. During the dry season in some communities, there are several water catchments and rivers where the women fish and prepare dishes for the evening meals. The men set traps, hunt animals for home consumption, and sell some for emergencies. All these multiple sources of income make it possible for people in rural communities to easily pay medical bills.

Today, massive destruction of the environment through lumbering, charcoal burning, and mining has destroyed the farming environment in rural communities [18] reported that human activities in the environment in which they live have shown a negative impact on the forest ecology in the last 2800 years. Morie Sam [19] confirmed for Sierra Leone that people depend on forest vegetation as a major source of energy. Soils are no longer fertile, yields are low, and the current population is unwilling to farm. Sam and Zhiqiang [20] said, removing the vegetation cover of the forest decreases the forest and soil stability and biosphere and thus impacts the normal environment. Moreover, the massive destruction of the environment has drastically reduced the income of people in rural communities [21]; as such, the majority can no longer afford to pay for basic essential commodities and services. What are the Challenges and constraints of accessing health facilities and services in rural communities?

i.**Lack of money:** most rural people have narrowed their income sources to single or sole cropping or few activities. IFAD [22] reported that the yields of all major crops cultivated in Sierra Leone are significantly lower than most countries in the subregion of West Africa. The government of Sierra Leone estimated that rice yields are 0.97 t/ha far below other countries in the region. The Government attributes the low yields to the unavailability of improved seeds, lack of access to fertilizers, mechanization, crop protection products, weak extension services, and water control in lowlands [22]. Other contributing factors in rural communities are deforestation and charcoal burning, leading to the reduced organic matter in the soil, low fertility, and crop yield, which cannot meet their daily household or domestic needs. About two-thirds of people in rural communities now grow multiple crops to mitigate against crop failure and reduce the risk of cash income failure [23, 24]. Animal rearing is another source of income, but its compounded with numerous disease

outbreaks such as PPR, New Castle Disease, Rift valley fever, rabies, and theft. Most animal rearers drop out of animal rearing which decreases their sources of income. The average Sierra Leonean earns less than 1.90 dollars daily. This has led to many deaths and others being unable to access these medical facilities and services.

The lack of money to pay for consultancy services and transportation to reach these facilities has led to the situation where most pregnant women give birth at home. At the same time, others die on the way to these facilities on foot or bikes.

Sometimes, family members are taxed to contribute and pay the medical expenses before a person goes to these facilities. Some members find it challenging to raise their contributions leading to delay or death of the patient.


*Perspective Chapter: Health Facilities and Services in Rural Sierra Leone – Implication… DOI: http://dx.doi.org/10.5772/intechopen.111717*

v.**Lack of transportation fees for vehicles and bikes:** most rural towns and villages in the country are not accessible either by cars, vehicles, or in some cases, motorbikes [31]. Some people trek on foot to access health services in those facilities. Families who lost their strong and abled-bodied relatives during the war stayed in the villages with no one to take them to the medical facilities. Some with strong relatives have to travel with them on a hammock, while others die on the way. With the advent of motorbikes, traveling to health centers has become much easier, as these bikes move faster on bad roads, thereby reducing transportation constraints in rural communities. The disadvantage is the high cost which most people cannot afford in rural communities. The same is true of the ambulance government has introduced in the country.

Due to the challenging economic status of people in rural communities, providing funds to make use of ambulance services even when available is a major issue. The people not only resort to risky alternatives but also seek spiritual help from traditional herbalists or religious sources. A typical example is in Lumponga village located in Kamajei chiefdom, Moyamba district, the southern province, where a lady suffered for three days before giving birth because of financial constraints. The people have to seek the attention of church members for prayers until the lady gave birth to a bouncing baby boy three days later. So, although the government has provided ambulances, many people, especially in rural communities cannot use them. Alternatively, they also seek the help of traditional herbalists. This is one factor that has increased the use of conventional medicine in these communities.


Some health personnel have good interpersonal relationship with patients, and this encourages patients to attend such health facilities. The patient in such a community informs others of the good attitude of the health staff. The health worker, in turn, receives gifts from the community, such as rice, chickens, fish, yam, palm oil, or whatever agricultural commodity they have. In some cases, because of the bond, rural community people who do not have money pay in kind, and the health worker sells the items received into money, thus increasing access to health facilities and services.

On the other hand, where health workers' relationship with community people is poor, the rural community people run away from these facilities and rely on traditional herbalists for treatment.

ix.**Case study**: during the Ebola outbreak, most sick people ran away from hospitals and medical facilities around the country because the government announced that there were no drugs to cure Ebola. People suspected of or infected with Ebola refused to attend health facilities but instead went to nurses. They had good relationships. My daughter was one such person who received many patients due to her relationship with the communities she worked. In the end, she, too, contracts the virus and dies.

Rural community people believe in friendship and encourage health professional who loves, promotes, and empathizes with their situation.

x.**Lack of bye-laws:** these are effective constitutional instruments, if judiciously used, can increase attendance in rural health facilities. During the Ebola outbreak, all the paramount chiefs formulated by-laws and circulated them in their respective chiefdoms. These were later digested by the chiefdom authorities and became chiefdom by-laws. It was fully implemented, which helped reduce the epidemic in those communities where it was enforced.

In some communities during the Ebola outbreak, people were asked to report to the hospital if they fell sick. Fines were levied against those who refused to report to health facilities.

xi.**Technical and social infrastructure:** the type of health infrastructure built in the rural areas will attract both technical staff and patients to access the facilities. Medical doctors and other highly trained personnel will stay in rural communities if they have the equipment to work with. Many people would like to stay in rural areas if provided with the necessary infrastructure. Such facilities include hospital services, preventive care, and emergency services. At Njala University hospital, a medical doctor resigned because there was no theater to conduct operations on patients.

### **3. How do we make people in rural communities attend health facilities and access services to prolong their lives**

In many low-income countries, several factors prevent people from equal access from attending health facilities which leads to morbidity and mortality. Particularly so in rural communities [32]. Sierra Leone is one such country where medical bills are

### *Perspective Chapter: Health Facilities and Services in Rural Sierra Leone – Implication… DOI: http://dx.doi.org/10.5772/intechopen.111717*

paid by the individual, lack of skilled medical staff, and services provided are poor and not to the satisfaction of the patient [33]. Compounding the situation further is the concentration of more than half of the medical staff concentration in the capital city leaving the majority of communities at the mercy of mother nature [34]. The government increased access to health facilities by introducing free health care in 2010 to reduce maternal and neonatal mortality by waiving all medical fees for pregnant and breastfeeding women, children under the age of five years, and those who survived the Ebola pandemic. st as a means of reducing [35].

Another method used to increase access to health facilities was the introduction of the ambulance system known as the National Emergency Service. The government aimed to provide a free-of-charge ambulance service coordinated by a center in all 14 districts [36].

Other strategies used to increase attendance or access to health facilities and services include:

### **3.1 Encourage rural community people to cultivate multiple crops**

In Sierra Leone, multiple crops include rice intercropped with cassava, yam, beans, millet, sorghum, benni, garden eggs, bitter balls, pepper, egusi, cucumber, and maize. After harvest, the farmer will sell some of these crops and use the money for multiple purposes including accessing health facilities and services. Planting multiple crops will militate against crop failure. In Sierra Leone, two-thirds of household families cultivate 12 different types of crops on 2 acres of land [37]. Household plan against food security strategy to prevent crop failure and reduces the risk of income shortage over cash income. An increase in crop production will lead to surplus, and excess crops produced will be sold to earn additional income which they will use to pay for medical bills when they attend health facilities, settle domestic issues and emergencies relating to initiation into secret societies, naming ceremonies, school fees, and unresolved problems within the families or neighbors [38]. The lack of income will prevent many people from accessing health facilities and services thereby leading to increased morbidity and mortality.

### **3.2 Cultivation of permanent crops**

Cultivation of permanent crops such as coffee, cacao, cashew, organ, palm trees, rubber plantation, coconut, guava, kola trees, banana, and plantain. These crops were grown by our rural people for development such as the construction of dwelling houses, payment of school fees, initiation into secret societies, hiring of farm labor, settling bush conflicts, and emergencies such as payment for medical bills. Illnesses that require emergency operations cannot be settled with income from rice farming. These permanent crops were like savings banks and have been used for centuries. Today, the young generation does not grow crops but harvests what their parents have grown, and the yield of crops has drastically reduced. This has led to a shortage of income within the families and hence unable access health facilities. Tree crops currently employ 100,000 rural cacao producers in the country [39] with a total acreage of 235,749 ha, with Kailahun cultivating 114.125 ha, Kenema 58,086 ha, Kono 43,23 ha and Bo district 11,715 ha respectively [39]. This has forced the Government of Sierra Leone to develop long-term planning for expansion, modernization, and improved management to increase income and enhance [40].

### **3.3 Rotational sources of income**

As time passed, rural community farmers had all-year-round income from their farming activities in Sierra Leone. They will plan at the end of the year what they intend to achieve the following year. The plan is based on the income they receive from various crops, animals, or activities they undertake as a family.

### **3.4 Case study**

In the South and Eastern provinces of Sierra Leone, families plant coffee, cacao, ginger, orange, and rice. Rice is harvested between September, and November to the end of December. The rice is sold to buy clothing, shoes, and household condiments for the Christmas celebration. Coffee and cacao are harvested from November until the end of February; Ginger is harvested in the month of November to February end, while orange is harvested in the month of March and April. The harvest is sold, and proceeds are used for house construction, sometimes paying school fees, initiation into secret societies, and settling emergency medical bills. In some families, they will keep or set aside some amount of funds for emergencies. When a family member falls sick, money set aside will be used to send the ill person to health facilities, thus increasing access to health facilities and services. The current generation of abledbodied men no longer follows this pattern of income generation, thereby reducing access to these facilities and services. Sometimes a portion of the proceeds is plowed back into farming and used to buy food during the lean period.

### **3.5 Rural transportation**

Transportation is a significant bottleneck in accessing rural health facilities and services. About one billion people in rural communities are three miles or 2 km away from a regular road [41]. Aside from the availability of good roads, a large segment of the rural population needs help to afford the cost of transportation. Patients die in rural communities or on the way to medical facilities because they cannot afford the cost of paying for bikes, lorries, and taxis. Lack of safe access roads causes devastating effects on communities leading to high infant mortality in isolated communities [42]. Though the government has provided ambulances in all districts, only a few people can afford the cost. Providing transportation at a subsidized price will increase access to these facilities.

### **3.6 Education of rural organizations**

Organizations raising awareness and educating rural communities on healthcare issues should be provided with adequate education on community social, traditional, and cultural norms. Understanding social behavior and traditional and cultural norms will help them to interact and live with people amicably. Such social cohesion will help increase access to health facilities and services because of the level of awareness of their health in the community. Health education will empower people to improve health care, disease prevention, and control [43]. Such knowledge gained will allow people to adopt healthier behaviors to attend health facilities when sick and use the services provided. Empowerment of this nature will not only help the individual but families, communities, and the nation to contribute to the achievement of the millennium development goal.

*Perspective Chapter: Health Facilities and Services in Rural Sierra Leone – Implication… DOI: http://dx.doi.org/10.5772/intechopen.111717*

### **3.7 Training community health workers' socio-cultural lives in rural communities**

Training community health workers on how to live in rural communities will be a step in the right direction. There are reports of healthcare workers, especially nurses using abusive language against and beating patients. In South Africa, patients refused to give birth in a hospital because they were beaten and scolded by nurses and discriminated against Kruger and Schoombee [44]. Understanding rural people's traditions and socio-cultural customs, will them appreciate you, and either party can live harmoniously. Some of the health workers today are from rural communities, but grew up and spend all their time in the cities or district headquarters towns. As such see rural people as inferior and discriminate against them. Dapaah [45] reported that some nurses discriminate and give preferential treatment to those they love. Such behavior scares people away from attending such health facilities because of a lack of respect [46, 47]. On the other hand, community health workers who understand community life put on a good attitude and live in peace with the people. Small and large health centers are most often flocked with people. Regular training on traditional and socio-cultural behavior will improve personal interaction between health workers and community people.

### **3.8 Increase incentives for professionals working in rural communities**

Most people dislike working in rural communities. The provision of incentives will go a long way in retaining health workers. Retaining health workers in such a community will lead to a strong professional relationship between the healthcare giver and patients thereby improving the relationship between people in rural communities [48, 49]. In many parts of the world, the government and the private sector find it extremely difficult to retain health workers in rural communities [50]. It is vital to retain health workers in rural communities to provide health care and develop a professional relationship between the patient and the health worker to improve the health outcomes of the most defenseless population in the country [49].

### **3.9 Integrating traditional medicine into national health systems**

The integration of traditional medicine into the national health care system will not only help people in rural communities but will meet the health care needs of people in developing and developed countries [51, 52]. In Africa, 80% of the population uses traditional medicine as their first line of healthcare [53]. In Ghana, for example, studies conducted on traditional medicine show treatment of different ailments such as diabetes, fever, foot rot, and stroke [54]. Aside from low-income countries, it is widely used in high-income countries such as France, the USA, Austria Canada, and Belgium [54]. Developing policies, by-laws, and regulations for providers and professionals will enhance rural community access to health facilities and assess services in remote communities.

### **3.10 Outreach or extension of the internship programs of health care students to rural communities**

Students studying medicine and other health care professionals will be better able to convince people in rural communities to attend health facilities and access the services available. Rural community people believe and develop confidence in young people who know how to talk to them when sent on such missions. The rural people do admire the health workers and even try to persuade their children to choose such a vocation. The bond between the two parties sometimes becomes so strong that the community people invite the health personnel into their homes. Such a relationship will boost confidence and increase the attendance of the rural people in the health facilities. Training community children to become healthcare professionals will increase attendance at health facilities and the use of health services.

### **3.11 Improved infrastructure**

People in rural communities easily believe and trust the medical personnel and facilities they have in their communities. When the health center is well constructed and capacitated with adequate equipment, drugs, and trained personnel, rural people tend to frequent such facilities because they are assured of getting the needed services. It is a common saying in rural communities that the medical structure is fine when it has well-trained staff, equipment, and drugs In my village, people prefer seeking medical attention at the Masanka health facilities and Segbwema hospital because they have Europeans who know how to talk to patients and treat them well. People often find money to visit these health centers because of their outstanding performance. Once the trust has been established, they create a friendly relationship with the health personnel and frequently visit them when they are sick.

### **4. Conclusion**

Diversification of income sources, improved infrastructure, and basic services, which include transportation facilities, and reduced cost of out-of-pocket medical bills in rural communities will help them access health facilities and services and increase life expectancy among people.

### **Acknowledgements**

Thanks to members of the serology and molecular diagnostic Laboratory staff who join us to collect information during our visits to animal sample collection throughout the country. Special thanks to health personnel for spearing their time during the interview. The team also thanks all the people in rural communities who visited during the sample collection. Special thanks to my wife who took care of the home during my visits to various communities, and Njala university for using their facilities during this write-up. No fund was received for this write-up.

*Perspective Chapter: Health Facilities and Services in Rural Sierra Leone – Implication… DOI: http://dx.doi.org/10.5772/intechopen.111717*

### **Author details**

Roland Suluku1 \*, Abu Macavoray1 , Moinina Nelphenson Kallon1 and Joseph A. Buntin-Graden<sup>2</sup>

1 School of Agriculture and Food Sciences, Animal Science Department, Njala University, Sierra Leone

2 Directorate of Health Security and Emergencies, Ministry of Health and Sanitation, Sierra Leone

\*Address all correspondence to: rsuluku@njala.edu.sl

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Piabuo SM, Tieguhong JC. Health expenditure and economic growth—A review of the literature and an analysis between the economic community for central African states (CEMAC) and selected African countries. Health Economics Review. 2017;**2017**:7. DOI: 10.1186/s13561-017-0159-1

[2] Gatome-Munyua A, Olalere N. Public Financing for Health in Africa: 15% of an Elephant is not 15% of a Chicken. African Union's 2001 Abuja Declaration on Funding National Health Budgets. 2020. Available from: https://www.un.org/ africarenewal/magazine/october-2020/ public-financing-health-africa-when-15-elephant-not-15-chicken [Accessed: March 23, 2023]

[3] World Health Organization. Make Every Mother and Child Count. The World Health Report 2005. 2005

[4] The World Bank Current Health Expenditure. Sierra Leone. 2023. Available from: https://data.worldbank. org/indicator/SH.XPD.CHEX. GD.ZS?locations=SL&most\_recent\_value\_ desc=false [Retrieved: May 21, 2023]

[5] Ali EE. Health care financing in Ethiopia: Implications on access to essential Medicines. Value in Health Regional Issues. 2014;**4**:37-40

[6] Piabuo SM, Tieguhong JC. Health expenditure and economic growth— Review of the literature and an analysis between the economic community for central African states (CEMAC) and selected African countries. Health Economics Review. 2017;**2017**:7. DOI: 10.1186/s13561-017-0159-1

[7] Dye C, Boerma T, Evans D, Harries A, Lienhardt C, McManus J, et al. The world health report. Research for Universal Health Coverage. 2013. Ref # ISBN 9789240690837

[8] National Recovery Strategy. Sierra Leone 2002-2003. 2002

[9] United Nations. Population Facts Department of Economic and Social Affairs Population Division. 2010 No. 2010/2/E/Ref

[10] UNICEF Annual Report. Covering 1 January 2009 through 31 December 2009. 2009

[11] Edoka IP, Stacey NK. Estimating a cost-effectiveness threshold for health care decision-making in South Africa. 2016. DOI: 10.1093/heal/czz152

[12] Bertone M, Witter S. The development of HRH policy in Sierra Leone, 2002-2012 Report on key informant interviews. Center for Disease Control and Prevention. 2014-2016 Ebola Outbreak in West Africa. 2002-2012. Available from: https://www.cdc.gov/ vhf/ebola/history/2014-2016-outbreak/ index.html [Accessed: January 2022]

[13] Elston JW, Moosa AJ, Moses F, Walker G, Dotta N, Waldman RJ, et al. Impact of the Ebola outbreak on health systems and population health in Sierra Leone. Journal of Public Health (Oxford). 2 Dec 2016;**38**(4):673-678. DOI: 10.1093/pubmed/fdv158. PMID: 28158472

[14] Sochas L, Channon AA, Nam S. Counting indirect crisis-related deaths in the context of a low-resilience health system: The case of maternal and neonatal health during the Ebola epidemic in Sierra Leone. 2017. DOI: 10.1093/heal/czx108

*Perspective Chapter: Health Facilities and Services in Rural Sierra Leone – Implication… DOI: http://dx.doi.org/10.5772/intechopen.111717*

[15] Gboku MLS, Davowa SK, Gassama A. Sierra Leone 2015 population and housing census: Thematic report on agriculture. Statistics Sierra Leone, Freetown, October, 41. 2017. Available from: https://sierraleone.unfpa.org/ en/publications/sierra-leone-2015 population-and-housing-censusthematic-report-agriculture

[16] World Bank in Sierra Leone. The World Bank works closely with development partners to support Sierra Leone in fighting poverty, promoting economic development, and improving living standards. 2022. Available from: https://www.worldbank.org/en/country/ sierraleone/overview updated October 20, 2022 [Accessed: March 28, 2023]

[17] Amadu FO, Silvert C, Eisenmann C, Mosiman K, Liang R. Sierra Leone Landscape Analysis. 2017. Available from: https://www.g-fras.org/en/component/ phocadownload/category/93-reviews-andassessments.html?download=821:sierraleone-landscape-analysis

[18] Feurdean Angelica GF, Vanniere B, Tant I, O'Hara RB, Pfeiffer M, Hutchinson SM, et al. Fire has been an important driver of Forest dynamics in the Carpathian Mountain during Holocene. Forest Ecology and Management. 2017;**389**:15-26

[19] Morie Sam AS. Availability, accessibility, and the road map for clean, affordable, effective, and efficient energy for Sierra Leone. A six years analysis from 2006-2011. International Journal of Scientific and Research Publication. 2018;**8**(5):543-553

[20] Sam M, Zhiqiang Z. The trend of forest cover removal: Case study of Tonkolili district, Northern Sierra Leone. Journal of Environment and Earth Science. 2018;**8**(11). ISSN 2224-3216 (Paper) 2225-0948(Online)

[21] Oduntan OO, Soaga JAO, Akinyemi AF, Ojo SO. Human activities pressure and its threat on forest reserves in your division of Ogun state, Nigeria. Journal of Environmental Research and Management. 2013;**4**(5):260- 267. Available from: https://www. researchgate.net/publication/353757276\_ Effects\_of\_Deforestation\_on\_Rural\_ Household\_Income\_In\_Vandeikya\_ Local\_Government\_Area\_of\_Benue\_ State\_Nigeria [Accessed: March 29, 2023]

[22] IFAD. Sierra Leone agriculture value development project design completion report document date: 21-Oct 2018 project No. 1544 west and Central Africa division programmed management department. 2018

[23] Saravia Matus SL, Gomez y Paloma S. Farm viability of (semi) subsistence smallholders in Sierra Leone. African Journal of Agricultural and Resource Economics. 2014;**2014**(9):165-182

[24] Saravia-Matus S, Gomez y Paloma S. Implementation challenges to the National Sustainable Agriculture Development Plan (NSADP) for (semi) subsistence farmers in Sierra Leone. Cahiers Agricultures. 2015;**24**:240-245

[25] Abdullahi AA. Trends and challenges of traditional medicine in Africa. African Journal of Traditional, Complementary, and Alternative Medicines. 2011;**8**(5):115-123. DOI: 10.4314/ajtcam. v8i5s.5

[26] Antwi-Baffour SS, Bello AI, Adjei DN, Mahmood SA, Ayeh-Kumi PF. The place of traditional medicine in the African society: The science, acceptance and support. American Journal of Health Research. 2014;**2**(2):49-54. DOI: 10.11648/j.ajhr.20140202.13

[27] Tiffany A, Dalziel BD, Kagume Njenge H, Johnson G, Nugba Ballah R, James D, et al. Estimating the number of secondary Ebola cases resulting from an unsafe burial and risk 138 factors for transmission during the West Africa Ebola epidemic. PLoS Neglected Tropical Diseases. 2017;**11**(6):e0005491. DOI: 10.1371/journal.pntd.0005491

[28] Sabeti P, Salahi L. Outbreak Culture: The Ebola Crisis and the Next Epidemic. Cambridge, Massachusetts: Harvard University Press; 2018. 288 p

[29] Sochas L, Channon AA, Nam S. Counting indirect crisis-related deaths in the context of a low-resilience health system: The case of maternal and neonatal health during the Ebola epidemic in Sierra Leone. 2017. DOI: 10.1093/heal/czx108

[30] Elston JW, Cartwright C, Ndumbi P, Wright J. The health impact of the 2014- 15 Ebola outbreak. Public Health. Feb 2017;**143**:60-70. DOI: 10.1016/j. puhe.2016.10.020. Epub 2016 Nov 29. PMID: 28159028

[31] Munguambe K, Boene H, Vidler M. et al, Barriers and facilitators to health care seeking behaviors in pregnancy in rural communities of southern Mozambique. Reproductive Health. 2016;**13**(Suppl 1):31. DOI: 10.1186/ s12978-016-0141-0.

[32] Strasser R, Kam SM, Regalado SM. Rural health care access and policy in developing countries. Annual Review of Public Health. 2016;**37**:395-412

[33] Human Development Reports. Sierra Leone. 2020. Available from: http://hdr. undp.org/en/countries/profiles/SLE [Accessed: April 1, 2023]

[34] National Health Sector Strategic Plan. Ministry of Health and Sanitation. 2017-2021

[35] Donnelly J. How did Sierra Leone provide free health care? Lancet. 2011;**377**:1393-1396

[36] Ragazzoni L, Caviglia M, Rosi P, Buson R, Pini S, Merlo F, et al. Designing, implementing, and managing a national emergency medical service in Sierra Leone. Prehospital and Disaster Medicine. Feb 2021;**36**(1):115-120. DOI: 10.1017/S1049023X20001442. Epub 2020 Dec 1. PMID: 33256859

[37] Sesay A, Tejan-Kella M, Thompson A. Agricultural Sector, Background Review for the PRSP. Freetown, Sierra Leone: Government of Sierra Leone; 2004

[38] Suluku R et al. Investigate the uses of goats and socioeconomic impact of Peste des Petits ruminant on farmers engaged in diamond Mining in Tongo Field. International Journal of Zoology and Animal Biology. 2022;**5**(6):000415

[39] Sierra Leone Population and Housing Census. Thematic Report on Agriculture. Statistics Sierra Leone. Freetown. 2015:60

[40] Ex-post Evaluation of Agriculture for Development (A4D) Sierra Leone, Final Report. Freetown. 2018:10

[41] Transport & ICT. Measuring Rural Access: Using New Technologies. Washington DC, USA: Transport and ICT Global Practice; 2016

[42] Sustainable Mobility for All. Global Roadmap of Action Toward Sustainable Mobility: Universal Rural Access. Washington, DC, USA: Sustainable Mobility for All; 2019

[43] Sørensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z. (HLS-EU) Consortium Health Literacy Project European. Health literacy and

*Perspective Chapter: Health Facilities and Services in Rural Sierra Leone – Implication… DOI: http://dx.doi.org/10.5772/intechopen.111717*

public health: A systematic review and integration of definitions and models. BMC Public Health. 2012;**12**:80

[44] Kruger LM, Schoombee C. The other side of caring: Abuse in a South African maternity ward. Journal of Reproductive and Infant Psychology. 2010;**28**(1):84-101

[45] Dapaah JM. Attitudes and behaviours of health workers and the use of HIV/AIDS Health Care Services. Nursing Research and Practice. 2016;**2016**:5172497. DOI: 10.1155/2016/517249

[46] Umar N, Quaife M, Exley J, Shuaibu A, Hill Z, Marchant T. Toward improving respectful maternity care: A discrete choice experiment with rural women in northeast Nigeria. BMJ Global Health. 2020;**5**(3):e002135

[47] Afulani PA, Kelly AM, Buback L, Asunka J, Kirumbi L, Lyndon A. Providers' perceptions of disrespect and abuse during childbirth: A mixedmethods study in Kenya. Health Policy and Planning. 2020;**35**(5):577-586

[48] Maarsingh OR et al. Continuity of Care in Primary Care and Association with Survival in older people: A 17-year prospective cohort study. The British Journal of General Practice. 2016;**66**(649):e531-e539

[49] Pereira-Gray DJ et al. Continuity of care with doctors—A matter of life and death? A systematic review of continuity of care and mortality. BMJ Open. 2018;**8**(6):e021161

[50] Dolea C. Increasing Access to Health Workers in Remote and Rural Areas through Improved Retention: Global Policy Recommendations. Geneva: World Health Organization; 2010

[51] Hilbers J, Lewis C. Complementary health therapies: Moving towards an integrated health model. Collegian. 2013;**20**(1):51-60

[52] Payyappallimana U. Role of traditional medicine in primary healthcare: An overview of perspectives and challenges. Yokohama Journal of Social Sciences. 2010;**14**(6):724-742

[53] World Health Organization. WHO Traditional Medicine Strategy 2002- 2005. Geneva, Switzerland: World Health Organization; 2002

[54] Boadu AA, Asase A. Documentation of herbal medicines used for the treatment and management of human diseases by some communities in southern Ghana. Evidence-based Complementary and Alternative Medicine. 2017;**2017**:3043061

## Pathology Testing at the Point of Patient Care: Transformational Change for Rural Communities

*Mark Shephard, Susan Matthews, Corey Markus, Emma de Courcy-Ireland, Lauren Duckworth, Isabelle Haklar, Ellen Kambanaros, Tamika Regnier, April Rivers-Kennedy and Grant White*

### **Abstract**

Point-of-care (POC) testing is an innovative and revolutionary *in vitro* diagnostic (IVD) technology that enables the real-time conduct of pathology testing during a patient consultation, facilitating immediate clinical action. When conducted under a quality-assured framework, POC testing is an essential diagnostic tool, and is now well embedded, in primary health care settings in rural communities around the world. POC testing helps bridge the gap in health equity access that exists in geographically isolated rural communities and empowers patients to invest in understanding and improving their own health literacy. Using POC testing networks for chronic, acute and infectious diseases that are currently operating in rural and remote Australia, this chapter explores the operational, clinical and economic benefits that POC testing can deliver, and the lessons learned that have contributed to continuously improved quality of POC testing service delivery. Investment in POC testing and infrastructure by Australian governments, both federal and state, has reaped significant rewards for patients in rural communities. Additionally, translational research in this field has provided insight into how POC testing can be successfully scaled up for broad application in low- and middle-income countries.

**Keywords:** point-of-care testing, equity of access, patient-centered care, translational research, scalability

### **1. Introduction**

Point-of-care (POC) testing enables pathology testing to be conducted during a patient consultation in a primary care setting and facilitates timely clinical review and action for the patient. POC testing is the fastest growing sector of the pathology industry, with the global POC testing market worth US \$45 billion in 2022 and expecting to reach around US \$103 billion by 2030, with a compound annual growth rate of 10.9% [1]. As such, POC testing is referred to as a 'disruptive technology' [2], having transformed the way pathology testing is delivered for the care of patients with non-communicable (NCD) and infectious (ID) diseases, particularly in rural and remote primary care settings. This was particularly evident during the COVID-19 pandemic, where nucleic acid amplification, and later rapid antigen POC testing enabled rapid diagnosis and swift public health action and treatment [3]. Patientcentered care, with specimen collection, POC testing and informed treatment taking place during the consultation, is not only convenient and reduces loss to follow-up, but also enables the patient to become empowered and engaged in understanding and improving their own health and health literacy [4].

POC testing networks within remote Australia have demonstrated that when governments have the political will and are prepared to invest in POC testing and required infrastructure then clinical, operational, cultural and economic benefits can be derived for both the patient and healthcare system [5]. This is particularly evident for remote communities and marginalised populations, where access to centralised pathology laboratories is limited and loss to follow-up is high [6].

Following the rapid expansion of POC testing during the pandemic, current global research discussion in the field of POC testing is now focused on building high-quality, sustainable POC testing networks with the capacity to be scaled up to, for example, a national level; scale-up is defined by the World Health Organisation (WHO) as "the deliberate efforts to increase the impact of successfully tested health interventions [such as POC testing] so as to benefit more people and to foster policy and programme development on a lasting basis" [7]. This chapter explores the evolution of POC testing in rural and remote Australia using both qualitative and quantitative translational research, and highlights lessons learned, from established selected, working POC testing networks in this country. Commentary focuses particularly on the key quality and resource elements that must be embedded into POC testing to enable successful field translation, clinical utility and scale-up.

### **2. Investment by government in funding POC testing networks in Australia**

The Flinders University International Centre for Point-of-Care Testing (ICPOCT) is a specialist POC testing network provider that currently supports eight different NCD and ID POC testing models in primary care settings in Australia; five of these networks are managed solely by the Centre and three are managed in partnership with the Kirby Institute, University of New South Wales. A summary of these networks is provided (**Table 1**). All these networks are funded by either the Australian Government Department of Health and Aged Care or State/Territory governments within Australia. Funding is generally provided for a fixed time period, with recontracting occurring multiple times for many models, providing key performance indicators set by the government are met.

To illustrate how these models have been established and managed and to discuss the continuous quality improvements that have been made towards the goal of optimisation for scale-up, examples will be drawn from three specific models—one with a chronic disease focus (Quality Assurance for Aboriginal and Torres Strait Islander Medical Services [QAAMS] Program), one with acute care testing as *Pathology Testing at the Point of Patient Care: Transformational Change for Rural Communities DOI: http://dx.doi.org/10.5772/intechopen.109769*


*Aust. Govt. = Australian Government, NT Govt. = Northern Territory Government, WA Govt. = Western Australian Government.@Number of new operator certifications to November 30, 2022.*

*^Haemoglobin A1c.*

*# albumin: creatinine ratio.*

*~ Haemoglobin.*

*\* International Normalised Ratio.*

*\*\*POC testing program managed in partnership with the Kirby Institute, University of New South Wales. + Severe Acute Respiratory Syndrome Coronavirus 2.*

### **Table 1.**

*Summary of primary care POC testing networks managed by the ICPOCT (Flinders University) alone, or in collaborative partnership with the Kirby Institute (UNSW).*

its core activity (the Northern Territory [NT] Acute Care POC Testing Program) and one concerning infectious disease (the National Enhanced Syphilis Response [ESR] Program). Each of these models operates in rural and remote Australia and supports mainly Aboriginal and Torres Strait Islander peoples living in those geographically isolated areas. The lessons learned from these models have been important for, and have shaped, the development of government policy for POC testing in Australia [8].

### **3. Evolution of POC testing models: Building blocks underpinning POC testing and associated translational research**

### **3.1 The Quality Assurance for Aboriginal and Torres Strait Islander Medical Services (QAAMS) Program**

The Quality Assurance for Aboriginal and Torres Strait Islander Medical Services (QAAMS) Program was Australia's first national POC testing network in the primary care sector. The program emerged from a recommendation from the National Diabetes Strategy in 1998, which supported a trial of the Siemens (then Bayer) DCA 2000 POC testing device for haemoglobin A1c (HbA1c) in Aboriginal and Torres Strait Islander people with established diabetes [9]. Diabetes and associated renal disease were at the time, and continue to be, a major contemporary health problem for Aboriginal and Torres Strait Islander peoples who experience rates of diabetes that are three times the national average and up to 12% in remote areas [10, 11]. In these latter geographically isolated areas, testing through traditional pathology laboratories was characterised by long delays for turnaround of pathology results and high rates of patient loss to follow-up. Through funding provided by the (then) Australian Government's Office for Aboriginal and Torres Strait Islander Health, in partnership with the National Aboriginal Community Controlled Health Organisation (NACCHO)—the peak body representing the health of Aboriginal and Torres Strait Islander communities in Australia—the QAAMS Program began as a pilot in 45 Aboriginal and Torres Strait Islander health services across Australia in 1999; more than 80% of these services were in rural or remote Australia.

Since that time, the program has been scaled up to reach almost 200 health services at 238 testing sites across Australia and is now fully embedded in the mainstream diabetes diagnosis, monitoring and care of Aboriginal and Torres Strait Islander people.

### *3.1.1 Surveillance of analytical quality*

In 1999, POC testing was in its infancy in Australia. The principal focus of the Australian Government in funding QAAMS was to establish that POC testing in primary health care services, which was conducted principally by Aboriginal Health Workers who were trained by ICPOCT scientists, could meet analytical performance standards expected of a pathology laboratory. Aboriginal Health Workers are health professionals of Aboriginal and Torres Strait Islander descent who live in the community and have a qualification in primary health care. The importance of high quality, robust and culturally safe training for POC testing operators and the surveillance of analytical quality became the initial core elements of this pioneering POC testing model.

Analytical quality in QAAMS was assessed by trained operators regularly testing both commercially available quality control (QC) and blinded external quality assurance (EQA, also known as proficiency testing) samples. Both QC and EQA testing processes form part of mandatory medical testing requirements for pathology laboratories accredited to international standards but had never been implemented in an Aboriginal and Torres Strait Islander primary care setting, nor conducted by non-laboratory trained health professionals. In QAAMS, the QC material was supplied by Siemens and the EQA samples were provided by the Royal College of Australasia's Quality Assurance Programs (RCPAQAP), an accredited global EQA provider; the EQA samples for QAAMS POC testing were identical to those tested

### *Pathology Testing at the Point of Patient Care: Transformational Change for Rural Communities DOI: http://dx.doi.org/10.5772/intechopen.109769*

by 250 Australasian laboratories (employing 21 different analytical methods) in a separate national laboratory based EQA Program provided by the RCPAQAP. This has enabled a direct comparison of the analytical performance for HbA1c (as measured by imprecision, expressed as a coefficient of variation, CV), in the QAAMS Program versus Australasian laboratories. To enable clinically significant changes in serial patient HbA1c measurements to be detected and not be masked by poor-quality test performance, imprecision goals of 3% (desired) and 2% (optimal) have been set by professional bodies and expert panels [12, 13].

Twenty years of data (from 2002 to 2022) is now available on the comparative imprecision for HbA1c testing in QAAMS and laboratories, with 49,169 EQA samples having been tested in QAAMS (**Figure 1**). In a remarkable achievement, imprecision has continued to improve across time and there has been no significant difference in the imprecision for HbA1c testing observed in the QAAMS Program (mean 2.75% SD 0.46) versus Australasian laboratories (mean 2.68% SD 0.39) over this 20-year period (p = 0.435 on a two-tailed p test).

A major improvement to the QAAMS quality system involved the development of real-time entry of QC test results (in 2016) and blinded EQA test results (in 2020) by test operators on the QAAMS website (www.qaams.org.au). This initiative has allowed operators to receive immediate feedback on the results of the quality testing performed at their health service. Once a quality result is entered, operators receive an instant message as to whether their test performance (a) meets analytical standards,

### **Figure 1.**

*Comparative imprecision (median CV%) observed for HbA1c quality assurance testing in QAAMS (by POC testing) and Australasian laboratories (all methods) from 2002 to 2022. \*QAAMS sites and Australasian laboratories tested the same EQA material from 2002 to 2020, after which the supplier of EQA material for QAAMS changed (to an Australian-based rather than an international supplier). Three levels of analytical goals for imprecision have generally been recognised for HbA1c testing over the past 20 years—A minimum goal of 4%, a desired goal of 3% and an optimal goal of 2% [12].*

enabling them to continue to test patients, or (b) falls outside acceptable limits for quality, in which case patient testing should be ceased until the reason for poor performance can be identified and rectified through consultation between the operator and the ICPOCT scientific support team.

### *3.1.2 Training for POC operators*

The sound and sustained analytical quality observed in QAAMS is underpinned by a culturally safe training program, which provides flexible modes of training delivery and training resources. Across the 20-year-plus lifespan of QAAMS, variable training formats have been developed and expanded to include face-to-face training for individual services and at regional or annual training workshops; self-directed/ self-paced e-learning modules through password-protected access via the QAAMS website; and tele-, video- or now web-conference training sessions (formerly using videocassette, DVD and USB). ICPOCT considers face-to-face training to be the most effective means of training, as it provides an opportunity for operators and training staff to meet and form relationships which then enhance future communication when device troubleshooting, for example, is required. The annual training workshop, which offers attendance support via travel scholarships for remote POC operators from across Australia to meet centrally, is also highly valuable, as it provides a forum for cultural education, operator networking and fosters a sense of inclusion rather than having operators feel they are working in isolation. The training resource package for QAAMS includes a hard copy training manual in full-colour A3 format; a set of posters which provides simple step-by-step visual instructions for operators to conduct patient, QC and EQA testing; training aids on how to interpret patient and quality test results; training videos on the QAAMS website; and a PowerPoint presentation delivered by ICPOCT scientists. Once training is completed, all operators undertake a written and practical competency assessment to formally obtain a competency certificate as a qualified operator in the program. Competency certification lasts for a specified period, currently 2 years, after which a training update and renewal of competency is required. These core learnings from QAAMS training have been invaluable in shaping POC testing policy in Australia [7, 8].

Through this process, a significant workforce for conducting POC testing for chronic disease care has been built in rural and remote Australia, with more than 3200 operators having been trained and/or renewed their competency in the program over 20 years. Further aspects of training will be discussed later in this chapter.

There have been many key time points/significant events that have occurred in the optimisation and scale-up of the QAAMS Program over its lifespan. These will be described in chronological order and provide an insight into how the building blocks of this pioneering POC testing model were established.

### *3.1.3 Independent evaluation of the program*

The program has undergone two independent evaluations—by NACCHO in 2001 and by the Government-commissioned external consultancy company, Campbell Research and Consulting, in 2008. The major impact of the QAAMS Program reported from these evaluations included themes of improved community-based diabetes management, health worker empowerment and appropriate cultural sensitivity (**Table 2**). Continuing evaluation is an important component of a POC testing network and provides an insight into whether the program is fit for clinical purpose,

2002: Evaluation by the National Aboriginal Community Controlled Health Organisation (NACCHO).

"This new point of care technology [the DCA 2000] seems to represent a 'major opportunity' to better care for and manage clients with diabetes and for the clients themselves to better understand its impact on their health." …

"The machine served as a catalyst for communication to enhance self-management through the speedy return of results and its overall ease of use which led to health workers generally demonstrating a high level of acceptance of this new 'point of care technology'." …

"A key finding was that nearly two-thirds of services expressed … [that the DCA] had the effect of raising the esteem of health workers in their community contexts. That is, health worker competence in using this relatively sophisticated piece of technology and the subsequent opportunity this presented for health workers and clients to work together to deal with the multiple effects of diabetes, demonstrated their communities' capacity to take control of the management of [diabetes]." …

"… a sense of community control was enhanced as a result of the way in which the management of persons with diabetes became more focused within most services."

2008: Campbell, Research and Consulting

"The QAAMS model is firmly rooted in accepted approaches to Aboriginal healthcare. QAAMS has consistently maintained a high level of cultural appropriateness and acceptability …"

"Aboriginal health professionals and clients alike hold QAAMS in high esteem."

"The program has always been very consultative and culturally sensitive and empowering; those are the things that have made it such a success."

"All sources of evidence suggest that QAAMS is meeting best practice standards in the areas of Indigenous healthcare, diabetes management and Point of Care testing."

"QAAMS is one of the few programs to successfully navigate the cultural complexities and potential pitfalls of chronic disease management in Indigenous communities."

### **Table 2.**

*Summary of findings from independent evaluations of QAAMS.*

how the program is viewed by its stakeholders, in what areas improvement to the program can be made, and where the program may be failing.

### *3.1.4 Validation of test performance*

Urine ACR POC testing was added to the program in 2003, following the test's approval for use in Australia, demonstration of its clinical use for the detection of microalbuminuria in peer-reviewed international literature, and an independent evaluation of its analytical performance both in the laboratory [14] and the field [15]. Indeed, ICPOCT have maintained the philosophy consistent with best practice that, where possible, laboratory and field evaluations of new POC tests and devices should be conducted before their introduction into a new network [16, 17]. Similar to HbA1c, sound long-term analytical performance has been observed with urine ACR testing in the QAAMS Program [18].

### *3.1.5 Integration of POC testing into clinical pathways*

It is critical that POC testing is not performed in isolation but is integrated formally to improve clinical pathways for the care of patients, who are focus of the program. In QAAMS, POC test frequency was aligned with established Australian clinical guidelines for the use of the tests concerned; for HbA1c, up to four tests per annum are conducted for the management of patients with diabetes while, for urine ACR, tests

are performed three- to six-monthly depending on clinical need for those patients with microalbuminuria and annually on patients without microalbuminuria [19, 20]. A new clinical pathway incorporating the use of the HbA1c test for the diagnosis of diabetes was developed and approved by the Australian Government in 2015 [21].

### *3.1.6 Assessment of clinical effectiveness*

The clinical effectiveness of POC testing in facilitating improvements in the glycaemic control of patients with established diabetes was confirmed early in the evolution of the QAAMS Program [22]. Later, a statistically significant reduction in HbA1c of 2.7% was observed in a cohort of 40 diabetes patients across the NT who had access to POC testing in QAAMS for 15 months, while no significant reduction in HbA1c was seen in these patients when laboratory testing was used as part of their care for the 15 months prior to POC testing. In addition, the mean turnaround time for HbA1c test results was 42 hours when laboratory services were used and less than 10 minutes for POC testing, while the mean time for patient follow-up and clinical consultation was 24 days following laboratory testing and less than 15 minutes post the implementation of POC testing [23].

### *3.1.7 Ensuring POC testing is cost effective*

Significantly, in 2002, the QAAMS Program was the first POC testing program outside an accredited laboratory in Australia to be granted a rebate under the Australian Government's Medical Benefits Scheme (MBS). The rebate was approved directly by the Federal Health Minister and enabled services in the QAAMS Program to claim for a POC HbA1c test conducted for the management of established diabetes. (Medicare rebates are usually restricted to medical testing in pathology laboratories accredited to international quality standards by the National Association of Testing Authorities [NATA]). The QAAMS rebate has ensured that the HbA1c POC test is paid for through the national public health system in Australia and not by the health services participating in the network. Subsequently, MBS rebates have also been approved in QAAMS for the ACR test for detection of microalbuminuria in 2006 and for HbA1c for the diagnosis of diabetes in 2015. These rebates have ensured sustainability and growth of the program, as the cost remains neutral for participants. **Figure 2** summarises the numbers of MBS claims for the three item numbers currently available in QAAMS.

Outside of QAAMS, processes for supporting MBS rebates for POC tests remains a significant barrier for the field in Australia and more support and flexibility is required by Governments in this area, particularly if there is a strong clinical need and evidence base to support the clinical, cultural, operational and cost benefits of utilising POC testing in rural and remote environments. The demonstration of the cost benefit of POC testing is now a critical area of research for the field, as predictive cost savings from mathematical modelling for diagnosis and intervention and evidence-based value propositions of diagnostic tests are essential tools for incentivising government investment [24].

### *3.1.8 Acceptability of POC testing by stakeholder groups*

Surveying the views and satisfaction levels of key stakeholder groups such as clinical staff, POC test operators, and patients who are the consumers of the POC service

*Pathology Testing at the Point of Patient Care: Transformational Change for Rural Communities DOI: http://dx.doi.org/10.5772/intechopen.109769*

### **Figure 2.**

*Total number of MBS items claimed per year by services enrolled in the QAAMS Program—For the HbA1c items for the management of established diabetes and for the diagnosis of diabetes, as well as for the UACR item for microalbuminuria.*

is an important component of assessing a model's acceptability, cultural safety and suitability to scale-up.

Surveys has been regularly conducted through the lifespan of QAAMS (as early as 2004 and as recently as 2016) [22, 25]. Ideally, stakeholder satisfaction should be embedded as a core element at the initiation of a new network where, ideally, acceptability can be assessed for example prior to, during and post implementation of a model.

### *3.1.9 Clinical governance of a network*

The governance of the QAAMS Program was initially administered by a small management committee comprising the QAAMS Program Manager and QAAMS Training Coordinator, reporting directly to the Government. However, a more multidisciplinary and inclusive governance structure was implemented in QAAMS in 2006, which included representatives from the following stakeholder groups: RCPA QAP (responsible for EQA support), Medicare Australia (to support services with MBS rebate claims) and Siemens (as an industry representative responsible for logistical supply of devices, cartridges and QC material). A Clinical Support Officer role was also created at this time to provide clinical advice and support to doctors and allied health professionals from participating sites on the appropriate clinical use of the HbA1c and urine ACR tests, as well as interpretation of POC testing results for these analytes. While this was a pioneering appointment in QAAMS at the time, the importance of systematic and integrated clinical governance is now considered paramount for all large-scale POC testing networks in Australia. The clinical governance portfolio can be assigned to a single individual (such as with QAAMS [and the NT POC

Testing network—see next section]) where the Clinical Support Officer is a member of the program's management committee or to a Clinical Advisory Group which act as an advisory panel that sits separate to, and hierarchically above, a management committee. The importance of clinical governance for POC testing networks, with designated and accountable clinical responsibility, is now embedded within the latest *Requirements for POC Testing in Australia* and will become an integral component of future accreditation frameworks for POC testing in this country [8].

### *3.1.10 Indigenous leadership for QAAMS*

In 2006, a QAAMS Indigenous Leadership Team was established. This initiative recognised the ongoing contribution of Aboriginal Health Workers (now also known as Practitioners in some parts of Australia) and their commitment to the success and viability of the program. One representative from each State/Territory of Australia was appointed to the initial leadership team. The Leaders Team act as cultural ambassadors for the program, provide an ongoing Indigenous voice and viewpoint on all aspects of QAAMS, advise on the cultural safety of program's training resource package and, increasingly, participate in training workshops and the development of training resources. The national leader of this group was also appointed to the program's expanded management committee. This initiative has proven one of the most important success stories for the program and continues to the present day, with the group renamed the QAAMS National Leadership Forum in 2021. There is no doubt that any POC testing network that supports the health of Aboriginal and Torres Strait Islander people must include strong Indigenous leadership, co-designed programs, and community engagement.

### *3.1.11 Connectivity and the electronic capture of POC test results*

Most early models of POC testing devices had the capacity to print out a set of POC test results that could be manually placed in a patient's clinical record. However, the importance of connectivity—the capacity to electronically capture POC test results and securely store them in the patient's electronic medical record has now become an essential post-analytical component of a modern POC testing network.

In the past, connectivity has been a challenge for QAAMS due to issues with individual services' firewalls and different patient management systems used by different groups of health services. Connectivity was first trialled and established in QAAMS in 2010, when a group of 40 new POC testing devices were introduced into the state of Queensland (Qld), following the receipt of a grant from the Queensland government (an initiative approved by the Australian Government at the time). The transition from the Siemens DCA to the Atellica (see Section 3.1.13), which offer improved connectivity functionality combined with the current range of open POC testing middleware solutions available on the market, may enable full connectivity of QAAMS devices to be realised in the future. However, the costs associated with connectivity software implementation, device driver development and licencing for large scale networks remain prohibitive.

For some of our Centre's ID networks, the connectivity system also extends to remote access of the POC device for troubleshooting, real-time POC test dashboard and alert systems, and jurisdictional electronic notification of encrypted positive test results [3].

*Pathology Testing at the Point of Patient Care: Transformational Change for Rural Communities DOI: http://dx.doi.org/10.5772/intechopen.109769*

### *3.1.12 Scale-up of QAAMS achieved after 11 years*

Following the sequential implementation of the building blocks outlined, QAAMS had been systematically scaled up to almost 150 sites by 2010. It had taken the best part of 11 years to achieve what was considered an optimised POC testing chronic disease model. Given QAAMS had been a pioneering, best practice model for POC testing outside the laboratory in Australia and acknowledging the quantitative and qualitative translational research conducted, the quality improvements continually made, and the lessons learned along the journey, this time frame was not unexpected.

However, with an accumulated knowledge of the building blocks required for a POC testing network to be scaled-up, the growth and optimisation of future models (as later outlined) could now be facilitated in shorter time frames.

Before concluding the section on QAAMS, two other aspects deserve brief commentary.

### *3.1.13 Transitioning to new/updated models of POCT devices*

With QAAMS operational across a 23-year period, it was inevitable that changes/ upgrades to the POC technology used in the program would occur. For the first 9 years of operation, the Siemens DCA 2000 was used in the program. In 2008, Siemens introduced a newer model known as the DCA Vantage. Fortunately, the method principle did not change, only the external appearance and electronic display features were modified. This facilitated a smooth transition to the new device over the ensuing three-year period, when the existing DCA 2000 devices were systematically exchanged for the Vantage model. Before introducing the Vantage, an independent evaluation of the new device's analytical performance was conducted by ICPOCT scientists. Support from both the industry vendor (where discounted prices were offered in flexible changeover packages) and government (who facilitated the purchase of new devices for nearly half of the enrolled participants) greatly enhanced the transition to the new device. In 2021, Siemens announced the approval of the Atellica® DCA Analyser by the Therapeutics Goods Administration (TGA)—the peak regulatory agency for IVDs, medicines and therapeutics—and availability to the Australian IVD market. A similar transition to the new device has commenced. The method principle has again not changed, albeit there is a reduction in time for result for the HbA1c test from 6 to 4 minutes and progression to a more versatile and smaller device. A further analytical evaluation of this new device has also been completed by ICPOCT scientists. The introduction of both these new devices 13 years apart has necessitated the redevelopment of updated training resource packages, a process which requires co-design and time to complete.

### *3.1.14 Impact of COVID-19 on test usage in QAAMS*

The world has been grappling with the spread of the SARS-CoV-2 virus since late 2019. The COVID-19 pandemic has resulted in severe disruption to the provision of basic health services in many communities, with a focus on isolation of patients with COVID and prioritisation given to the testing for this new disease, especially prior to widespread vaccination. Australia (and QAAMS) have been no exception [26, 27]. As described above, the quality of testing in QAAMS has not been impacted but the number of POC tests performed on diabetes patients has. In the year before the pandemic struck (2019), there were approximately 16,864 MBS claims for HbA1c POC testing for the management of diabetes. At the end of the first full year of the pandemic (2020), MBS claims for this item had fallen to 14,053 (a decrease of 17%) while, by the end of 2021, only 13,030 tests were conducted (a total reduction in test numbers from pre-pandemic levels of 23%). Similarly, a 32% reduction in MBS claims for ACR testing was seen from 2019 to 2021, while there was a 19% decrease in MBS claims for the HbA1c diagnosis item over the same period.

Across the pandemic, the role of Aboriginal Health Workers changed significantly with a range of other COVID-related tasks preoccupying their role; these included contact tracing; swabbing patients for laboratory COVID testing and/or in some cases conducting molecular-based POC testing for SARS-CoV-2 in remote communities (through the Flinders-Kirby COVID POC Testing network—see **Table 1**); conducting telephone follow-ups and welfare checks; issuing COVID-19 vaccinations (when available), delivering medications, COVID isolation packs and food supplies; promoting COVID-safe health messages and explaining isolation/quarantine requirements. These conflicting roles no doubt contributed to decline in testing rates in remote Indigenous communities.

QAAMS continues to be a landmark and ground-breaking POC testing network in Australia. The fact that QAAMS has operated sustainably for more than 23 years is a testament to the commitment of Government, the National Indigenous Leadership Forum, the QAAMS governance and operational teams, and the Aboriginal and Torres Strait Islander health professionals who deliver the program at the rural and remote coalface.

### **3.2 The Northern Territory acute care POC testing program**

The Northern Territory (NT) of Australia covers an area of 1.3 million square kilometres (km) and represents the third largest state/territory in Australia. It comprises some of the most challenging environments for conducting POC testing in Australia. The landscape is harsh and environmental extremes of soaring temperatures, excessive humidity and tropical monsoonal rains make living and working conditions difficult. Outside of three major towns (Darwin, Katherine and Alice Springs), the vast majority of communities in the Territory are geographically isolated and classified as remote or very remote by the Australian Statistical Geography Standard (ASGS) Remoteness Area Structure [28]. Health services are often spartan, with large road and air distances (often hundreds of kilometres) to reach the nearest regional hospital facilities. Health professional staff (notably remote area nurses) are often transient and overworked. The nature of health care delivery is mainly opportunistic, with multiple daily medical emergencies being a common occurrence among the predominantly Aboriginal and Torres Strait Islander peoples that live in these remote communities.

The NT Acute Care POCT program began in 2008, after the collapse of NT medical retrieval air services meant that pathology tests were unable to be transported to either of the two main pathology laboratories in the Territory. The NT Government investigated POC testing as a possible solution to address the issue and engaged ICPOCT to establish and manage a POCT service, initially in 33 remote health services administered by the Government. The Abbott i-STAT® device was employed due to its capacity to perform a range of acute care tests, notably sodium, potassium, creatinine, glucose, haemoglobin (on a test cartridge known a CHEM8+); blood gases and lactate (CG4+ cartridge), and troponin I. In addition, the i-STAT could test for Prothrombin Time (PT)/International Normalised Ration (INR) on a separate cartridge. The PT/INR test had specific clinical application in the Territory, as Aboriginal *Pathology Testing at the Point of Patient Care: Transformational Change for Rural Communities DOI: http://dx.doi.org/10.5772/intechopen.109769*

and Torres Strait Islander people living in the Territory have one of the highest rates of rheumatic heart disease (RHD) in the world and INR is used routinely to monitor warfarin levels, an anticoagulant used to treat RHD [29]. By placing the i-STAT into a downloading cradle, patient and quality test results can be instantaneously transferred to a central data repository. A more detailed and recent review of the NT POCT program has been published elsewhere [30].

Through lessons learned from the research conducted in QAAMS, the NT program was established using the same core building blocks which had proven successful in QAAMS.

In terms of governance, a NT POC Testing Management Committee was initially established which comprised scientific representatives from ICPOCT (including the chair of the Committee and senior scientist overseeing the program), a clinical support officer (the District Medical Officer for the NT Government's Remote Health Branch), regional POC testing supervisors from Central Australia and the Top End [the northern half of the Territory] (both professional practice nurses), and representatives from the Remote Health Branch's quality and safety committee. Over time, this structure has been modified with more scientific representatives from ICPOCT and a representative from the Aboriginal Medical Services Alliance NT (AMSANT), the peak body representing the Aboriginal community controlled health service sector in the NT, now part of the Committee.

### *3.2.1 Integration into clinical pathways*

Emphasis on clinical aspects of governance has included specified clinical uses for each test measured and the development of NT-based paediatric reference intervals for each test. The integration of POC testing into clinical pathways has been continuously enhanced with POC testing protocols now embedded within the NT Remote Primary Care Manuals, a series of four clinic manuals for primary health care practitioners and allied health professionals in remote and Indigenous health services in central and northern Australia [31].

### *3.2.2 Growth of the program towards scale-up*

The program has undergone rapid growth across the past 14 years. The number of health service enrolled in the program remained between 30 and 35 from 2008 until 2014. However, following the initial success of the program and after a coroner's case found that a patient death may have been avoided if an i-STAT device had been available, the NT Government purchased sufficient i-STAT devices to service every remote NT community in 2015, effectively doubling the size of the program to a total of 72 devices. Since then, and with the support of the NT Government, the program has extended across the NT border into additional remote health services in the Ngaanyatjarra (Ng) Lands, which comprise an approximate 250,000 km2 area of Western Australia (WA) adjoining the NT and South Australian (SA) borders, bringing the current number of enrolled services to 86 (**Figure 3**).

The total number of operators trained (mainly remote area nurses) has steadily increased across the lifespan of the program to now reach 2104, of which 1340 have undergone at least one competency recertification (**Figure 4**). More than 253,000 POC tests have been performed, rising from just 700 in 2008 to 36,675 in 2021 (**Figure 5**). The CHEM8+ and PT/INR cartridges are the most frequently performed test types (**Figure 6**).

### **Figure 3.**

*Number of remote health services enrolled per year in the NT acute care POC testing program using the i-STAT device.*

### **Figure 4.**

*Cumulative growth in the number of operators trained (new and recertifications) in the NT acute care POC testing program using the i-STAT device.*

### *3.2.3 Analytical quality (and evaluation of test performance)*

Quality testing has underpinned the program since its inception. Participation in QC testing has averaged 90% since 2009, and 95% or better for the past 7 years since 2015. The imprecision for QC testing for a representative selection of critical i-STAT analytes–sodium, potassium, creatinine and pH—is shown in **Figure 7**. The average imprecision across the past 6 years for each analyte was: sodium 0.6%, potassium 1.0%, creatinine 3.5% and pH 0.2%, with each analyte meeting or being close to the imprecision goals currently achieved by participants in the RCPAQAP condensed POC testing program, survey 6, 2022 (of 0.5, 1.0, 4.6 and 0.2%, respectively) [30].

*Pathology Testing at the Point of Patient Care: Transformational Change for Rural Communities DOI: http://dx.doi.org/10.5772/intechopen.109769*

### **Figure 5.**

*Total number of tests performed on the i-STAT per annum in the NT acute care POC testing program.*

### **Figure 6.**

*The number of patient tests performed in the NT acute care POC testing program using i-STAT blood gas (CG4+), cardiac troponin I (cTnI), basic chemistry (CHEM8+), or prothrombin time/international normalised ratio (PT/INR) cartridge types, differentiated by year of test.*

This data highlights the remarkably consistent and analytically sound performance of these tests in the hands of remote area POC testing operators.

There have also been continuing evaluations of the analytical performance of the test analytes as part of the broader research and surveillance undertaken across the lifespan of the program [32, 33].

### *3.2.4 Clinical effectiveness*

During the early years of the program, a log of clinical cases where POC testing had resulted in beneficial clinical outcomes was developed. Among these was the case

### **Figure 7.**

*The average between-site imprecision for selected i-STAT analytes in the NT acute care POC testing program from 2016 to 2021, as assessed by QC testing.*

of a 46-year-old male with a history of RHD who had a coronary bypass surgery and was on warfarin to reduce his risk of stroke. In the year prior to the introduction of POCT, the average time between PT/INR tests was 67 days and time in therapeutic range (TTR) was 31% (well below the desired TTR of 60–70%). However, in the year post the introduction of POC testing, the average time between tests was 14 days and his TTR was 74% [29].

In 2015, the ICPOCT was awarded a research grant to investigate the clinical and economic effectiveness of POC testing in the NT. The study investigated 200 patient cases with three acute medical presentations at six remote health services: patients with acute chest pain (n = 147), patients with acute diarrhoea (n = 25) and patients with acute exacerbation of renal failure due to a missed dialysis session (n = 21). POC testing enabled more informed triaging of acutely ill patients requiring evacuation to a tertiary hospital as well as ruling out the need for evacuation for patients who could remain in the community and be stabilised [34].

### *3.2.5 Cost effectiveness*

Perhaps the most compelling evidence for the benefits of acute POC testing came from a cost-benefit analysis that was conducted as part of the 2015 research study. POC testing prevented 60 unnecessary medical retrievals from the cohort of 200 patients. The cost savings for the Northern Territory Government were (AUD) \$13.7 million per annum (for chest pain patients), \$6.45 million per annum (missed dialysis) and \$1.57 million per annum (diarrhoea), translating to an annual total saving of (\$21.75 million) for the NT health system [35].

### *3.2.6 Scale-up complete in 7 years*

Applying previous research conducted and lessons learned in QAAMS, the NT acute care POC testing program had been optimised and scaled up to a Territory-wide program in effectively 7 years.

*Pathology Testing at the Point of Patient Care: Transformational Change for Rural Communities DOI: http://dx.doi.org/10.5772/intechopen.109769*

Since 2015, the program has continued to grow in terms of number of services, tests and operators. Despite doubling the size of the program, the robustness and resilience of this optimised model has been sustained, with no diminution of analytical quality (see **Figure 7**). Indeed, in 2021, the NT Acute Care POC Testing program received an Engagement Australia Award in the category of 'outstanding engagement for research impact'.

### *3.2.7 White blood cell count and differential (WBC DIFF) POC testing network*

The success of this program led the NT Government to expand the suite of POC testing devices available to support other acute care presentations by introducing POC testing for white blood cell count (WBC) (including a 5-part differential (DIFF)) on the HemoCue WBC DIFF® device.

An extensive pre-evaluation of both the analytical performance and clinical utility of the WBC DIFF device was initially undertaken. Analytical performance was sound [36], while the clinical effectiveness study demonstrated the WBC DIFF device positively influenced decision making; enhanced patient safety for a range of clinical presentations, including undifferentiated sepsis, appendicitis and meningitis; and produced positive economic benefits (cost savings of approximately \$5 million per annum) through reducing numbers of unnecessary aeromedical evacuations [37].

Based on this evidence-based research, the NT Government supported and funded a WBC DIFF network of 20 remote health services in the Top End of the NT in 2020.

Services were prioritised for recruitment by NT Health's Top End Quality and Safety Team, with input from senior District Medical Officers and the Care Flight air service, based on how useful the tests would be for decision-making regarding medical retrieval and which sites would benefit the most from this decision-making capability.

A Primary Health Care Remote Guideline was developed for the clinical use of the device and its operation. This document is an NT Health Policy Guidelines Centre (PGC) Approved and Controlled document.

A workforce of over 175 trained and competent operators has been established, while approximately 1160 WBC DIFF tests have been conducted in just over 2 years (547 in 2021 and 611 to date in 2022).

This albeit smaller POC testing network has been scaled up in a two-year window (having been based on learnings and translational research from the NT Acute Care model). The 20-site program has recently been extended in duration to mid-2024 by the NT Department of Health.

In a more recent development (2021), ICPOCT, in partnership with the NT Government and other researchers, was the lead organisation in a successful Medical Research Future Fund (MRFF) grant awarded by the National Health and Medical Research Council (NHMRC) (Application ID 2016006). This 5-year research grant will investigate whether the availability of a full blood examination (measuring both red and white cell parameters using the HemoScreen [Pixcell Medical] POC device), can further enhance the clinical benefits of conducting acute care POC testing in the Territory, notably for patients with sepsis. The grant will research the analytical quality, clinical, operational, cost and cultural effectiveness of this new technology as well as build an Indigenous workforce competent in using this device before, if successful, making an evidence-based decision to supersede the WBC DIFF device.

### **3.3 The national Enhanced Syphilis Response program involving POC testing**

An outbreak of infectious syphilis (*Treponema pallidum*) has been progressively spreading across Qld, the NT, WA and SA, disproportionately affecting young Aboriginal and Torres Strait Islander peoples predominantly aged between 15 and 29 years [38]. In response to the outbreak, an Australian Government-commissioned working group was established to develop effective community-based strategies to tackle and mitigate the outbreak. The subsequent Enhanced Syphilis Response (ESR) program was established in 2018. Using a co-design approach, NACCHO were engaged to provide advocacy and leadership in the design and delivery of the ESR program, to establish and strengthen partner and stakeholder relationships, to support the enrolment of ACCHOs, to build a 'community of practice', and to increase the uptake of POC testing for syphilis by ACCHOs [38]. The ICPOCT was separately contracted by the Australian Government to establish and deliver a training and quality management system to support safe and accurate syphilis POC testing, as a screening tool, for the ESR program in affected communities. In terms of logistics, NACCHO is responsible for the distribution and stock management of syphilis POC test strips for their participating services. A complimentary program was later initiated by the WA Department of Health in 2020 to expand the reach of syphilis POC testing beyond ACCHOs, and into peri-urban maternal health services and community outreach screening in that state.

### *3.3.1 The POC test used to screen for syphilis*

The Abbott Determine™ Syphilis TP immunochromatographic test strip was chosen as the rapid, screening test of choice for the ESR (and WA) program, as it was (and remains) the only POC test approved by the TGA and has a clinical sensitivity and specificity of at least 96% in a capillary (fingerstick) sample type [39]. The Abbott Determine™ Syphilis TP test detects antibodies to *Treponema pallidum*.

The syphilis screening test is one of simple complexity (being suitable since 2021 as a syphilis self-test) and differs from the moderate complexity POC testing devices used in the QAAMS and NT Programs. The syphilis test provides a qualitative test result ('non-reactive' or 'reactive') rather than a quantitative (numerical) result. Being a manual test (where the operator loads 50 μL of capillary or venous whole blood on to the test strip), electronic capture of test results can only be recorded via digital photographs or imaging software. As such, many participating ACCHOs have created specific clinical items in their patient management systems for the POC syphilis test, with results able to be entered manually. Results can also be incorporated into other general health check data sets that are available for Aboriginal and Torres Strait Islander people in Australia. Nonetheless, these differences between the POC testing technologies used in the three networks outlined in this chapter highlight the broad methodological diversity of POC testing devices and applications which are now available on the global market. Following the advent, wide global usage and eventual definitive case identification of COVID-19 by rapid antigen testing, there is now a broader public awareness, competence and inclusion of lateral flow POC tests for sexually transmitted infections within a self-testing and broader policy environment [40].

A limitation of the Determine™ Syphilis TP test strip is that it is unable to distinguish between an active infection and a past, treated infection, infectious activity or progression of associated complications. Operators are made aware of this limitation as part of their extensive training delivered by ICPOCT scientists for the program.

*Pathology Testing at the Point of Patient Care: Transformational Change for Rural Communities DOI: http://dx.doi.org/10.5772/intechopen.109769*

Patients with 'reactive' POC test results for syphilis antibodies are checked against syphilis registers (available in most jurisdictions) and a serology sample is then sent to the laboratory for confirmation of positivity. The jurisdictional registers and laboratory testing therefore enable services to assess whether an infection is active or not.

In order to respond to the outbreak and build capacity for ACCHO engagement and support, there have been five phases in the rollout of the ESR program since its inception. The first phase commenced in June 2018 in Darwin (NT) and Townsville and Cairns (Qld). The second phase started in October 2018 in the Katherine Region, Nhulunbuy (NT) and the East Kimberley Region (WA). The third phase commenced in April 2019 in West Arnhem Land (NT), Western, Eyre, Far North and Adelaide Regions (SA), and the Pilbara and Western Kimberley Regions (WA). The fourth phase began in May 2020 in Mt. Isa (Qld) and Tennant Creek (NT). A fifth phase commenced in July 2021. In total, 111 services have been engaged in the rollout (**Figure 8**).

### *3.3.2 Training for syphilis POC testing*

The simplicity of the syphilis POC screening test enabled a new model of training to be adopted for the ESR program—that of 'advanced operator training', where local experienced 'POC testing champions' were identified and took part in a higher level of training from the ICPOCT primary training team and were then able to on-train other operators at their health service or surrounding regions. This was particularly advantageous during the initial phases of the COVID-19 pandemic, where face-to-face training sessions delivered by ICPOCT were not possible due to jurisdictional border closures and community lockdowns enforced in many participating services. The use of advanced operators enabled the workforce capacity for syphilis POC testing to be scaled up quicker as part of this emergency response program. Up to November 2022, a total of 872 operators have achieved basic operator certification since the ESR program commenced, while 171 advanced operators (representing 20% of the workforce on the ground) have been certified during this period (**Figure 9**, top). In the WA Syphilis

### **Figure 8.**

*The number of health services enrolled in the enhanced syphilis POC testing program during the five phases of recruitment from 2018 to 2021.*

### **Figure 9.**

*The number of operators undertaking advanced and basic training in the enhanced syphilis POC testing program (top) and Western Australian syphilis POC testing program (bottom) since the inception of these programs.*

program, 263 healthcare staff have obtained basic operator certification, while 106 (39%) have obtained advanced operator certification (**Figure 9**, bottom).

### *3.3.3 Use of advanced operator training depends on test complexity and patient risk*

A critical distinction needs to be made regarding the usefulness of the advanced operator training or 'train-the-trainer' approach. Syphilis POC testing is a relatively simple POC test of low technical complexity (i.e. suitability for a self-test) and relatively low patient risk if analytical performance characteristics are satisfactory. For this type of test, advanced operator training is appropriate, particularly when other forms of training may be limited or rapid scale-up of such a simple test is needed. However, advanced operator training is not appropriate for other POC test methodologies which are more complex and have higher patient and/or operator risk; for example, devices using molecular-based technologies that involve thermal cycling and have associated software packages (both for test ordering and result

### *Pathology Testing at the Point of Patient Care: Transformational Change for Rural Communities DOI: http://dx.doi.org/10.5772/intechopen.109769*

interpretation). In relation to our ICPOCT networks, the latter category includes tests such as Hepatitis C performed on the GeneXpert device, with the test being classified as Class IV IVD by the TGA, which carries the highest level of patient risk; and the Class III IVD, the SARS-CoV-2 and/or multiplex SARS-CoV-2, Flu A/B and RSV tests, also conducted on the GeneXpert system (in the Australian Government's national respiratory infection program), where operators are required to wear full personal protective equipment and risks of pre-analytical, analytical and post-analytical errors causing false positives or false negatives are high.

### *3.3.4 What elements of training are not negotiable and which can be consumer driven?*

In terms of developing a training framework for POC testing that is compliant with Australian POC testing requirements [8], ICPOCT have identified key elements of POC operator training which are mandatory and thus non-negotiable. These include, but are not limited to, work health and safety requirements which may be specific to the disease type, method or device; clinical governance requirements; competency registers; quality system compliance; and cultural co-design. The only negotiable elements of training are those relating to different modes or formats of training resources and delivery (i.e. allowing advanced operator training), but these should be applied specifically with the POC test and device complexity and thus patient risk at the forefront. Quantitative metrics, including error rates, error types, QC and EQA performance data and comprehensive, embedded qualitative end-user training surveys may be interdependent on training format offered and provide an evidence base for continual quality improvement of POC operator training. Continual quality improvement strategies should be adopted where possible; however, patient safety considerations, international standards and best-practice requirements may not be able to facilitate all end-user training feedback or change requests (**Figure 10**).

### *3.3.5 Analytical quality of syphilis POC testing*

Since late 2018, services enrolled in the ESR program have participated in 17 EQA testing events, with four events per year and two samples tested per event. The EQA material is prepared and distributed by the RCPAQAP (as part of their serology program) and contains both non-reactive and reactive samples with varying concentrations of syphilis antibodies and therefore degrees of reactivity. Concordance with the expected EQA result has averaged 98% (range 93–100%) in the ESR program. For the WA program, which commenced in late 2020, concordance (using the same EQA material and event sequence) has averaged 96% (range 80% during the initial set up of the program to 100%).

Similar to elements of training and competency (described above), assessment of POC test performance via specific requirements for QC and EQA are non-negotiable. Robust quality systems, capable of detecting false negatives or false positives (or quantitative performance at clinically important decision points) underpin POC test result quality and patient safety.

Important to ID POC testing models, where disease prevalence can change from low to high in geographical populations over time, is consideration of the monitoring of QC performance and adoption of individualised QC plans (IQCP) [41]; these plans provide flexibility with changing patient risk (i.e. false negatives and false positives) and permit the customisation of QC plans according to test method and

### **Figure 10.**

*A framework for the design and continual quality improvement of POC operator training, with elements that should be considered as negotiable, non-negotiable and interdependent.*

use, environment, and personnel competency while providing for equivalent quality testing. IQCP could potentially be considered as an additional regulatory option for POC testing in Australia.

### **3.4 Concluding remarks: implications for POC testing moving forward**

Many lessons have been learned from 25 years of implementing POC testing networks in rural and remote Australia. The building blocks to optimise a POC testing network have come together in somewhat of a jigsaw (**Figure 11**) but are now well established following a strong evidence-base of original research and quality improvements carried out along the journey. The optimisation and scale-up of POC

*Pathology Testing at the Point of Patient Care: Transformational Change for Rural Communities DOI: http://dx.doi.org/10.5772/intechopen.109769*

### **Figure 11.**

*Building blocks for the development, implementation and ultimate scale-up of a POC testing network—Compiled from lessons learned from ICPOCT experience over nearly 25 years.*

testing models remains a 'hot topic' in research conducted around the world in the field [42–44].

Where possible, POC testing scale-up should be accelerated to meet the time frame deemed necessary for the model—depending for example on whether it is a test for NCD versus an ID test that may be required for a disease outbreak or global emergency response. In this regard, ICPOCT remains at the cutting edge of this field through (a) its partnership with the Kirby Institute in an NHMRC-funded Centre for Research Excellence looking at scale-up of POC testing systems (now known as RAPID) and (b) its designation as a World Health Organisation (WHO) Collaborating Centre working *inter alia* on POC testing for sexually transmitted diseases and current gaps in health literacy for NCDs.

There remains considerable blue sky for methodological advancement, technological miniturisation, personalised scope and application of POC testing systems, particularly in rural and remote settings of the world and to service disadvantaged populations. But, as mentioned in the opening remarks for this chapter, success is dependent on policy change and support from governments. Our Australian models have benefitted from continuous funding from governments, albeit with contractual agreements needing to be negotiated repeatedly in time frames as short as 6 months. Ideally, successful models which can demonstrate clinical, operational, economic and cultural benefits as well as sustained analytical quality equivalent to a laboratory, should be underpinned by long-term, integrated funding where possible. This includes ongoing support for the cost of POC testing devices and cartridges; in this regard within Australia, MBS rebates to cover costs of these essential consumables should be in place for models where clinical need is high and laboratory services are lacking. Until recently the QAAMS Program was the only POC testing network with its own rebates. Recently, an MBS item was approved for the performance of POC HbA1c testing in the general practice (family doctor) sector in Australia. The rebate took effect after many years of negotiation with, and repeated submissions to, the main Government authority responsible for approving new rebate items (the Medical Services Advisory Committee, MSAC). When there is an overwhelming evidencebase to support the need for and quality of POC testing, the discipline of POC testing should be expeditiously supported with sustainable funding models.

### **Acknowledgements**

The authors acknowledge and thank the Australian Government Department of Health and Aged Care for their support in funding the QAAMS and ESR POC testing networks. The Northern Territory Government is also acknowledged for funding the NT acute care POC testing program and the WBC DIFF POC testing program, as is the Western Australian Government for supporting the WA Syphilis POC testing network. The authors acknowledge the contribution to these networks of many stakeholders including the National Aboriginal Community Controlled Health Organisation (NACCHO); participating Aboriginal community controlled and government health services; national, jurisdictional and local Aboriginal Community Controlled Health Organisations; national, State and Territory health departments, and other government services; our industry and academic partners; and most importantly, the dedicated health professional staff working as POC testing operators in our networks.

### **Conflict of interest**

The authors have no conflict of interest to declare.

*Pathology Testing at the Point of Patient Care: Transformational Change for Rural Communities DOI: http://dx.doi.org/10.5772/intechopen.109769*

### **Author details**

Mark Shephard\*, Susan Matthews, Corey Markus, Emma de Courcy-Ireland, Lauren Duckworth, Isabelle Haklar, Ellen Kambanaros, Tamika Regnier, April Rivers-Kennedy and Grant White Flinders University International Centre for Point-of-Care Testing, Adelaide, Australia

\*Address all correspondence to: mark.shephard@flinders.edu.au

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Precedence Research, Ottawa, Canada. Healthcare: Point-of-Care Testing Market. Report Code 2270 [Internet]. 2022. Available from: https:// www.precedenceresearch.com/pointof-care-testing-market [Accessed: December 7, 2022]

[2] Hayden O, Luppa PB, Min J. Point-of-care testing—New horizons for cross-sectional technologies and decentralized application strategies. Analytical and Bioanalytical Chemistry. 2022;**414**:3161-3163. DOI: 10.1007/ s00216-022-03987-8

[3] Hengel B, Causer L, Matthews S, Smith K, Andrewartha K, Badman S, et al. A decentralised point-of-care testing model to address inequities in the COVID-19 response. The Lancet Infectious Diseases. 2020;**21**(7):e183-e190. DOI: 10.1016/S1473-3099(20)30859-8

[4] Shephard M. An introduction to point-of-care testing and its global scope and application. In: Shephard M, editor. A Practical Guide to Global Point-of-Care Testing. Melbourne, Australia: CSIRO Publishing; 2016. pp. 1-14

[5] Spaeth B, Matthews S, Shephard M. Patient-centred point-of-care testing: A life-changing technology for remote health care. In: Onal A, editor. Primary Health Care. United Kingdom: London, UKIntechOpen; 2021. pp. 1-15. DOI: 10.5772/intechopen.100375

[6] Shephard M, Shephard A, Matthews S, Andrewartha K. The benefits and challenges of point-of-care testing in rural and remote primary care settings in Australia. Archives of Pathology and Laboratory Medicine. 2020;**144**(11):1372-1380. DOI: 10.5858/ arpa.2020-0105-RA

[7] World Health Organization, editor. Practical Guidance for Scaling up Health Service Innovations. Geneva, Switzerland: World Health Organization; 2009

[8] National Pathology Accreditation Advisory Council (NPAAC). NPAAC Requirements for Point of Care Testing (Second Edition 2021). Australian Government Department of Health. [Internet]. 2021. Available from: https:// www1.health.gov.au/internet/main/ publishing.nsf/Content/35DE5FC47 86CBB33CA257EEB007C7BF2/\$File/ DT0002469%20-%20NPAAC%20-%20 Requirements%20for%20point%20 of%20care%20testing%20Second%20 edition%202021%20-%2020211215.pdf [Accessed: November 30, 2022]

[9] Colagiuri S, Colagiuri R, Ward J. National Diabetes Strategy and Implementation Plan. Canberra: Diabetes Australia; 1998

[10] Hare MJL, Zhao Y, Guthridge S, Burgess P, Barr ELM, Ellis E, et al. Prevalence and incidence of diabetes among Aboriginal people in remote communities of the Northern Territory, Australia: A retrospective, longitudinal data-linkage study. BMJ Open. 2022;**12**:e059716. DOI: 10.1136/ bmjopen-2021-059716

[11] Australian Bureau of Statistics. National Aboriginal and Torres Strait Islander health survey, 2018-19. Ref: 4715.0. Canberra: ABS, [Internet]. 2019. Available from: https://www.abs. gov.au/statistics/people/aboriginaland-torres-strait-islander-peoples/ national-aboriginal-and-torresstrait-islander-health-survey/2018-19 [Accessed: December 1, 2022]

[12] Shephard M. Analytical goals for point-of-care testing used for diabetes *Pathology Testing at the Point of Patient Care: Transformational Change for Rural Communities DOI: http://dx.doi.org/10.5772/intechopen.109769*

management in Australian health care settings outside the laboratory. Point-of-Care: Journal of Near-Patient Testing and Technology. 2006;**5**:177-185

[13] Liddy AM, Grundy S, Sreenan S, Tormey W. Impact of haemoglobin variants on the use of haemoglobin A1c for the diagnosis and monitoring of diabetes: A contextualised review. Irish Journal of Medical Science. 2022. DOI: 10.1007/s11845-022-02967-2

[14] Shephard MDS, Barratt L, Simpson-Lyttle W. Is the Bayer DCA 2000 acceptable as a screening instrument for the early detection of renal disease? Annals of Clinical Biochemistry. 1999;**36**:393-394

[15] Shephard MDS, Allen GG. Screening for renal disease in a remote Aboriginal community using the Bayer DCA 2000. Australian Journal of Medical Science. 2001;**22**:164-170

[16] Tabrizi S, Unemo M, Golparian D, Twin J, Limnios A, Lahra M, et al. Analytical evaluation of GeneXpert CT/ NG, the first genetic point-of-care assay for simultaneous detection of Neisseria gonorrhoeae and chlamydia trachomatis. Journal of Clinical Microbiology. 2013;**51**:1945-1947. DOI: 10.1128/ JCM.00806-13

[17] Causer LM, Guy RJ, Tabrizi SN, Whiley DM, Speers DJ, Ward J, et al. Molecular test for chlamydia and gonorrhoea used at point of care in remote primary healthcare settings: A diagnostic test evaluation. Sexually Transmitted Infections. 2018;**94**:340- 345. DOI: 10.1136/sextrans-2017-053443

[18] Regnier T, Shephard M, Shephard A, Graham P, DeLeon R, Shepherd S. Results form 16 years of quality surveillance of urine albumin to creatinine ratio testing for a national Indigenous point-of-care testing program. Archives of Pathology and Laboratory Medicine. 2020;**144**:1199- 1203. DOI: 10.5858/arpa.2020-0106-OA

[19] Australasian Association of Clinical Biochemists. Pathology Tests Explained. HbA1c [Internet]. 2022. Available from: https://pathologytestsexplained.org.au/ learning/test-index/hba1c [Accessed: December 6, 2022]

[20] Kidney Health Australia. Chronic Kidney Disease (CKD) Management in Primary Care (4th edition). Melbourne: Kidney Health Australia; 2020. p. 90. Available from: https://kidney.org.au/ uploads/resources/CKD-Managementin-Primary-Care\_handbook\_2020.1.pdf [Accessed: December 6, 2022]

[21] Australian Indigenous HealthinfoNet. Approval for QAAMS services to use the HbA1c test to diagnose diabetes [Internet]. 2016. Available from: https:// healthinfonet.ecu.edu.au/healthinfonet/ getContent.php?linkid=320557&title=A pproval+for+QAAMS+services+to+use+ the+HbA1c+test+to+diagnose+diabetes [Accessed: December 6, 2022]

[22] Shephard M. Clinical and cultural effectiveness of the 'QAAMS' pointof-care testing model for diabetes management in Australian Aboriginal medical services. Clinical Biochemist Reviews. 2006;**27**:161-170

[23] Spaeth BA, Shephard MDS, Schatz S. Point-of-care testing for haemoglobin A1c in remote Australian Indigenous communities improves timeliness of diabetes care. Rural and Remote Health. 2014;**14**:2849. Available from: http:// www.rrh.org.au/articles/printviewnew. asp?ArticleID=2849

[24] Price C, John AS, Christenson R, Scharnhorst V, Oellerich M, Jones P, et al. Leveraging the real value of laboratory

medicine with the value proposition. Clinica Chimica Acta. 2016;**462**:183-186. DOI: 10.1016/j.cca.2016.09.006

[25] Shephard M, O'Brien C, Burgoyne A, Croft J, Garlett T, Barancek K, et al. A review of the cultural safety of a national Indigenous point-of-care testing program for diabetes management. Australian Journal of Primary Health. 2016;**22**:368- 374. DOI: 10.1071/PY15050

[26] Fekadu G, Bekele F, Tolossa T, Fetensa G, Turi E, Getachew M, et al. Impact of COVID-19 pandemic on chronic diseases care follow-up and current perspectives in low resource settings: A narrative review. International Journal of Physiology and Pathophysiological Pharmacology. 2021;**13**(3):86-93

[27] Parkinson A, Matenge S, Desborough J, Hall Dykgraaf S, Ball L, Wright M, et al. The impact of COVID-19 on chronic disease management in primary care: Lessons for Australia from the international experience. Medical Journal of Australia. 2022;**216**(9):445- 448. DOI: 10.5694/mja2.51497

[28] Australian Government Department of Health and Aged Care. Australian Statistical Geography Standard— Remoteness Area [Internet]. 2021. Available from: https://www.health. gov.au/topics/rural-health-workforce/ classifications/asgs-ra [Accessed: December 6, 2022]

[29] Spaeth B, Shephard M. Clinical and operational benefits of INR POCT in Indigenous communities in the remote Northern Territory of Australia. Point-of-Care: Journal of Near-Patient Testing and Technology. 2016;**15**:30-34. DOI: 10.1097/ POC.0000000000000082

[30] Matthews S, Spaeth B, Duckworth L, Richards J, Prisk E, Auld M, et al.

Sustained quality and service delivery in an expanding point-of-care testing network in remote Australian primary care. Archives of Pathology and Laboratory Medicine. 2020;**144**(11):1381- 1391. DOI: 10.5858/arpa.2020-0105-RA

[31] Remote Primary Health Care Manuals. Manuals [Internet]. 2022. Available from: https:// remotephcmanuals.com.au/ [Accessed: December 6, 2022]

[32] Shephard M, Spaeth B, Mazzachi B, Auld M, Schatz S, Loudon J, et al. Design, implementation and initial assessment of the Northern Territory point-ofcare testing program. Australian Journal of Rural Health. 2012;**20**:16-21. DOI: 10.1111/j.1440-1584.2011.01243.x

[33] Shephard M, Spaeth B, Motta L, Shephard A. Chapter 48. Point-of-care testing in Australia: Practical advantages and benefits of community resiliency for improving outcomes. In: Kost G, Curtis C, editors. Global Point-of-Care— Strategies for Disasters, Complex Emergencies, and Public Health Resilience. Washington DC: AACC (American Association of Clinical Chemistry) Press; 2015. pp. 527-535

[34] Spaeth BA, Shephard MDS, Omond R. Clinical application of pointof-care testing in the remote primary health care setting. Quality in Primary Care. 2017;**25**:164-175

[35] Spaeth BA, Kaambwa B, Shephard MDS, Omond R. Economic evaluation of point-of-care testing in the remote primary health care setting of Australia's Northern Territory. ClinicoEconomics and Outcomes Research. 2018;**10**:269-277. DOI: 10.2147/ CEOR.S160291

[36] Spaeth B, Shephard M, McCormack B, Sinclair G. Evaluation of HemoCue white

*Pathology Testing at the Point of Patient Care: Transformational Change for Rural Communities DOI: http://dx.doi.org/10.5772/intechopen.109769*

blood cell differential counter at a remote health Centre in Australia's Northern Territory. Pathology. 2015;**47**:91-95. DOI: 10.1097/PAT.0000000000000202

[37] Spaeth B, Shephard M, Kockcinar R, Duckworth L, Ormond R. Impact of point-of-care testing for white blood cell count on triage of patients with infection in the remote Northern Territory of Australia. Pathology. 2019;**51**(5):512-517. DOI: 10.1016/j.pathol.2019.04.003

[38] Equity Economics. Blueprint for the Future: Evaluation of NACCHO's Role under the Enhanced Syphilis Response. A Report prepared for the National Aboriginal Community Controlled Health Organisation (NACCHO). 2021. pp. 2-5

[39] Causer LM, Kaldor JM, Fairley CK, Donovan B, Karapanagiotidis T, Leslie DE, et al. A laboratory-based evaluation of four rapid point-of-care tests for syphilis. PLoS One. 2014;**9**:3. DOI: 10.1371/journal.pone.0091504

[40] Australian Government Department of Health Therapeutics Goods Administration. Chlamydia, gonorrhoea and syphilis IVD self-tests: clinical performance requirements and risk mitigation strategies—Version 1.0 [Internet]. 2021. Available from: https:// www.tga.gov.au/sites/default/files/ chlamydia-gonorrhoea-and-syphilis-ivdself-tests.pdf [Accessed: December 6, 2022]

[41] Centres for Medicare & Medicaid Services. Individualized Quality Control Plan (IQCP) [Internet]. 2021. Available from: https://www.cms.gov/Regulationsand-Guidance/Legislation/CLIA/ Individualized\_Quality\_Control\_Plan\_ IQCP [Accessed: December 6, 2022]

[42] Milat AJ, Newson R, King L. Evidence and Evaluation Guidance Series, Population and Public Health Division. Increasing the Scale of Population Health

Interventions: A Guide. Sydney: Ministry of Health; 2014

[43] Milat AJ, Newson R, King L, Rissel C, Wolfenden L, Bauman A, et al. A guide to scaling up population health interventions. Public Health Research and Practice. 2016;**26**:1. DOI: 10.17061/ phrp2611604

[44] Laferty L, Smith K, Causer L, Andrewartha K, Whiley D, Badman S, et al. Scaling up sexually transmissible infections point-of-care testing in remote Aboriginal and Torres Strait Islander communities: Healthcare workers' perceptions of the barriers and facilitators. Implementation Science Communications. 2021;**2**:127. DOI: 10.1186/s43058-021-00232-8

### **Chapter 8**

## The Rural Way: Rural Nurses' Contribution to New Models of Health Care, Reducing Health Disparities – Stories from Practice

*Jean Ross, Josie Crawley and Rachel Parmee*

### **Abstract**

This chapter reports on a research project that set out to capture the unique stories from rural nurses from Aotearoa, New Zealand. During the past three decades changing socio-political and economic contexts have affected the delivery of health care while rural nurses have responded with new models of practice which has resulted in an emerging rural nurse discourse related and specific to rural New Zealand. Rural nurses have maintained and, in some cases, improved the health care of these rural communities. A total of 26 rural nurse participants shared their stories providing data to explore the structured phenomenon of rural nursing in New Zealand. Personal and human dimensions are illuminated, as the in-depth meaning of the experience is described by each individual storyteller. Interviews were conducted to collect retrospective stories uncovering the participants' rural nurse journey. Revealed are a sense of place and people, involving what nurses' express, as the rural way. A nursing discourse is developed which complements and extends international theories. The rural nurse of New Zealand is imbued with pioneering spirit; entrepreneurial practice shaped by their rural communities highlighting what we suggest is the rural way. Further expansion of the rural way was uncovered with follow up interviews exploring their practice during the COVID-19 pandemic.

**Keywords:** rural, rural nurse, models of care, reducing health disparities, narrative, COVID-19

### **1. Introduction**

The professional identity of the rural nurse from Aotearoa New Zealand came of age between the 1990s and the early 2000s. This time period is associated with significant changes to the governance, funding and delivery of health care in rural contexts as a result of the global financial crisis of the late 1980s. Changing health care ideologies moved away from a top-down approach to a bottom-up approach reflected in the major health care reforms revealing the adoption of neo-liberal ideology [1]. The National government of the day acknowledged continuing inequalities in health, for

Māori (indigenous population of Aotearoa New Zealand) and Pacific populations was continuing to decline with extensive statistical differences between Māori and non-Māori and equally between urban and rural regions [2]. Changes where needed to address these disparities [2]. The government's aim was to increase efficiency and address these needs while providing healthcare in the most economically and practical ways [3]. The government authorised major health reforms, resulting in changes for the provision of healthcare [1] delivery, funding, governance structures [2, 3] and models of healthcare [4–7].

The establishment of Rural Community Trusts (RCTs) was one outcome of the country's major health-care reforms [8]. RCTs designed and managed their own individual local health services, this model was regarded by the government as innovative and came with associated cost savings. As well as encouraging community involvement in health-care decision-making [8] the RCTs assisted in the development of "by Māori for Māori" iwi providers [9]. The benefits of RCTs became the funding structure that improved and supported community participation, collaboration, and teamwork. Further this ideology was extended and underpinned in the early 2000s by the 'Primary Health Care Strategy' [10] and further laid the foundation in which to position nurses at the foreground of the delivery of Primary Health Care (PHC) and improve nurses' contribution to the delivery of health care. This shift in focus has been beneficial for the advancement of PHC nurses and in particular rural nurses' practice development and contribution to the delivery of sustainable health care.

This original qualitative research aimed to explore rural nurse practice in Aotearoa New Zealand following decades of change leading to the development of new rural health delivery models. The rural nurse participants shared their stories exploring the past, the present and the future experiences leading to a unique rural nursing discourse which complements and extends the international literature from America [11] Canada [12] and Australia [13] in alignment with health beliefs of rural populations and the nuances associated with geographical locations. Traditional discourses aligned with rural nursing practice include personal and professional connections with the rural community; being known in the community; dual relationships; and always being on call; broad scope of practice; jack of all trades, master of none; and a sense of belonging to the geographical location. These discourses are well entrenched within national and international nursing organisations; rural communities; policy development; education, workforce planning and research informing practice.

The occupational title of the 'rural nurse' from Aotearoa New Zealand has been questioned by Ross [14] as to whether this title is an adequate portrayal of their practice and contribution to the delivery of health care? In short, her findings suggest this title does not do justice to their practice and further research into this goal is required. This research seeks to investigate further rural nurses' practice and contribution to health care revealing that rural nurses throughout the latter part of the twentieth century and early part of the twenty-first century were pivotal in pioneering new models of practice; expanding the scope of nursing services available to their rural communities; reducing inequities while maintaining and in some cases improving health. More recently COVID-19 has created new challenges for those rural nurses and rural communities [15]. Follow up interviews in 2020 heightened further demands on rural nurses' practice, further revealing pioneering practice adding to the unique rural nursing discourse.

*The Rural Way: Rural Nurses' Contribution to New Models of Health Care, Reducing Health… DOI: http://dx.doi.org/10.5772/intechopen.109768*

### **2. Narrative research: diving into the story**

A narrative inquiry approach was the methodology chosen for this research, providing "… a way of understanding and inquiring into experience" [16]. This qualitative research celebrates the power that story has, to explore meaning, make connections, entertain, and build empathy and share experience with others [16, 17]. Haven [18] recognises the power the story has to explore meaning and make connections between the storyteller and the recipients. Stories have provided the data to explore the structured phenomenon of rural nursing in New Zealand—as lived and told by experienced rural nurses.

### **2.1 Rural nurse participants**

Rural Nurses from Aotearoa New Zealand were invited to share their stories. The snowball effect was engaged with revealing a total of 58 expressions of interest, of which 40 rural nurses met the research criteria (rural practice in New Zealand for more than 15 years) and 26 rural nurses were able to commit to the project

requirements and timeframes. These rural nurses' ages ranged from 40 to 70 years while their demography included nurses of Māori (indigenous population of Aotearoa New Zealand) and European descent, male and female, recently retired and currently employment, representatives from all regions of habited Islands from the far North of the North Island to the far South of the South Island. Island groups (North and South Islands, Great Barrier, Chatham, Pitt and Stewart Island) refer to the Aotearoa New Zealand map in **Figure 1**. Participants for this part of the research project were not identified.

### **2.2 Data collection**

The original research was conducted in 2017/2018 we engaged with semi-structured interviews to collect retrospective stories covering the participants rural nurse stories either face-to-face, SKYPE (video) or telephone. Interviews ranged from 45 to 90 min in length. Interviews were, framed around Clandinin and Connelly's [19] three-dimensional space narrative structure which is a model that examines personal and social interactions across the continuity of time and context, as well as personal and social features experienced by both the researcher, and participant. The framework was shared with all participants before the agreed interviews, however during the interviews began with an open question from the interviewer—*"Tell me about your rural nurse journey".* Each nurse was a primary source, sharing their unique nursing story. Each interview was recorded, transcribed, and sent back to the interviewee (rural nurse) to check validity, or to add key forgotten moments. Each transcript was then returned to the researchers. Each nurse was a primary source, sharing their unique nursing story.

There were 16 rural nurses from the original research project) who agreed to have their stories published in *Stories of nursing in rural Aotearoa: A landscape of care* [20]. These rural nurses in 2020 were contacted by email inviting them to contribute with follow up interviews exploring their practice during the COVID-19 pandemic. Nine of the 16 rural nurses agreed to participate and were interviewed by the first author. This follow up interview enquired whether the COVID-19 pandemic had affected the rural nurses' practice and if so, seek what were the outcome?

The interviews were digitally recorded via zoom meetings, edited to remove identifying features of individuals mentioned and then developed into podcasts and broadcasted on Otago Access Radio (https://oar.org.nz/) before been thematically analysed. Podcasts consist of positive conversations with people from around the world related to COVID-19 is a further expansion of the rural way related to rural nurses from Aotearoa New Zealand uncovered

### **2.3 Data analysis**

Each transcript was read at least twice by the researchers with key repeated concepts identified by commonality across interviews: the umbrella concepts of past, present and future, situation and place. Data from each interview was then coded into themes and subthemes until saturation occurred and no new themes emerged [21]. Researchers could not guarantee absolute confidentiality to participants, as pioneering innovation can be traced back to place and sometimes person. Participants knew personal and community names would be protected, but that emergent themes and specific detail might identify location. We placed safeguards to protect participants by asking all participants to check transcripts, with highlighted areas we thought

### *The Rural Way: Rural Nurses' Contribution to New Models of Health Care, Reducing Health… DOI: http://dx.doi.org/10.5772/intechopen.109768*

potentially might be recognisable. Once corrected transcripts were returned, we coded each transcript, removing the participants name, individual participants were identified by code only (by number). A phenomenon of interconnected narratives emerged, showed how stories of the past shape the present and influence discourse All transcripts are kept on a passworded hard drive and will be kept for seven years as per ethical requirements.

Ethical approval was obtained from Otago Polytechnic Research Ethics Committee, Otago Polytechnic, Dunedin, New Zealand in 2017 and extended in 2020 to accommodate further interviews from the original rural nurse participants who consented to have their stories published in a book. Ethical approval also included consultation and engagement from the Office of Kaitohutohu. The Kaitohutohu office at Otago Polytechnic upholds the mana (integrity) of the partnership with the local Māori (indigenous population Aotearoa New Zealand) community, and is consulted during research development, looking at the proposed research from a Māori Kaupapa point of view. Māori are under-represented in the nursing profession, *comprising* only 8% of practising nurses [22] so the inclusion of Māori as part of this research is of the utmost importance to further our understanding and future engagement [23].

We were aware the research was likely to involve Māori as there is a higher number of registered nurses identifying as Māori in the rural practice setting (N = 59; 11.6%) of 6.5% of the overall workforce [24]. Statistics show that 14% of the New Zealand population identify as Māori, with over three quarters of this population living outside the Auckland region, making up a significant part of the rural communities [25] *"Rural nursing is also clearly a valued setting for Māori registered nurses' employment…"* themes from the rural nurses' stories could *"… include reference to tikanga Māori (a Māori concept valuing Māori knowledge into practice), within the context of describing their work"* [23] p. 68.

### **3. Findings and discussion**

Engaging with a thematic analysis has revealed a unique discourse of rural nursing in Aotearoa New Zealand. Rural nurses revealed their innovative practice exposing their contemporary identity of the nurse practising in the rural context. This rural nurse discourse identifies the rural nurse as a pioneer supplying the backbone of health care to the community; an entrepreneurial practitioner expanding the limits of scope of practice to meet community needs. The creative development of tenacious nurses and local communities' embracing responsive solutions and new models of healthcare to accommodate the challenging landscapes and changing socio-political tides, accommodating indigenous provision of health care highlight what we suggest is the rural way, as supported by the following data and discussion.

### **3.1 The rural way**

A description of the rural way incorporates values, attitudes or characteristics that are common in rural indigenous and non-indigenous rural people [23]. These features of rural people or communities were often seen as being different to urban environments, a product of geographic context and isolation from others, encompassing a way of being and a Māori way of being in the rural. Being in the rural revolves around embracing the rural, rural culture, values, beliefs and performing in the rural. For example, resourcefulness (mention is made to #8 fencing wire (**Figure 2**)

a well-known depiction of New Zealanders ability to mend, fix or create solutions to problems by using #8 wire) is made necessary due to being at a distance from many health resources as discussed by the following participants:

*People are very different in a rural area, I think, than they are in the city. They are very different people; in that they are more community orientated. I think in the city, a lot of people don't even know their neighbours. And in rural areas, they are '#8 wire' people; they manage to fix things that you think 'wow, look at you, look what you managed to do!'. They're quite resourceful. (Storyteller 12)*

*They've [rural people] got a 'can do' attitude. They care about their neighbours. They're "greenies" in their own right, so they love the environment they live in, and they look after it (believe it or not). They're known for their number 8 wire approach and their ability to diversify when the need arises. (Storyteller 11)*

*It's about 2 ½ hours. Ambulance, it can be up to 3. And if you've got – obviously road works, or flooding, we're actually chopped off. We can't get there, and it's only by helicopter. But then, if the weather's no good, the helicopter can't fly anyway. So, we do need to have some sort of independence, and be able to intubate and keep somebody alive until help can come. (Storyteller 16)*

Many (but not all) of the rural nurse participants had been born and bought up in rural communities. The specific rural settings the nurses lived and worked in were often spoken about as part of their own connection with the rural, leading to a sense of place and a sense of belonging (rural knowing) (**Figure 3**). Knowing is associated

*The Rural Way: Rural Nurses' Contribution to New Models of Health Care, Reducing Health… DOI: http://dx.doi.org/10.5772/intechopen.109768*

### **Figure 3.**

*The hay barn is full on a fine day in Paradise. Source: Martin London Photography (published with permission).*

with understanding the rural context, community and the local unique rural community rhythm, which connects the rural nurse to identify with that rural community as revealed by the following storytellers:

*I live it, dream it. That's massive for me. Space – so, a paddock with some sheep and a hill and a tree and a mountain in the background, for me, is prayer. Literally. Because I love – I love – the rural setting. I love the fact that you're this tiny little town surrounded by this magnificent beauty. (Storyteller 10)*

*I think this is paradise myself, that's why I wanted to come back, I love the hills, I love the seasons yeah, it's perfect being here I will always stay here. (Storyteller 9)*

*Living in the rural area, I understand the nature of their farming lifestyle, both dairy and mixed farming, logging, freezing works, the seasonal work like shearing, lambing, tailing, haymaking cropping and all that entails, you know the dangers of tractors quad bikes. I supported the local rugby teams often knowing the players. The families that have been here for a long time, I know them well. (Storyteller 1)*

Despite a love of rural environments, almost all interviewees discussed challenges that they pose. The most cited challenge was isolation due to long distances from other healthcare centres, and weather (and typically a combination of the two). Geographic factors affect healthcare delivery in rural settings but are also cited as a reason why rural nurses require a resilience – they need to be able to provide care and the necessities of life in areas with limited resources, we consider these nurses both pioneers and entrepreneurial practitioners.

### **3.2 Pioneering practice**

Where health services did not exist, nurses employed a pioneering spirit to develop a service that met the client and community needs. They forged new roles, did further training, fundraised for resources, and met challenges with courageous strategies. Changing governance structures meant that nurses were able to shape the direction and delivery of healthcare during the major health care reforms. Rural nurses initiated many practices, whose origins have now been absorbed into contemporary health practice. Like all new practices, changes were scaffolded to make innovation possible. In this case, nurses becoming intravenous-certificated was an important first step to providing local access to chemotherapy. The alternative model required residents to travel 3–5 h, in each direction, to an urban health-care facility (ese rural nurses set out to avoid residents having to travel long distances to acquire treatment in urban contexts) as they progressed with new and never been offered health care services firstly by nurses and secondly in rural regions in the 1990s. This innovative practice was later recognised by the establishment of Nurse Specialists. These approaches to the delivery of healthcare were designed to meet the localised health needs of the community as depicted in the following excerpts:

*[w]e needed to adapt, which as rural nurses we do very well. So we changed it [the delivery of chemotherapy] to more of a medical day unit and took on doing other transfusions…(Storyteller 16)*

*So, I pioneered additional services that the nurses could provide for the community, for example cervical smears, which at that time was not the norm for nurses to be offering. (Storyteller 1)*

The rural nurses acknowledge the community role and are encouraged to pioneer and deliver health services in local regions that accommodates the particular nuances related to that community for example, Māori nurses embrace their own identity and have a responsibility to meet the needs of their families or whanau which involves caring for the whole family and not just the individual patient because whanau play a role in a patient's recovery [26].

*[In establishing operating mobile ear health clinics in rural isolated regions with a high Māori population] We were taking away all the barriers to access, for example, unwarranted cars, unregistered cars, unregistered drivers, petrol in the tank. We were just trying to drop all those barriers so the children could get what they needed without adults putting up the problems that they had, that were getting in the way. (Storyteller 2)*

Rural nurses share on-call (after hours provision of emergency and acute health care) with general practitioners covering 24 h of healthcare at the weekends and during weeknights. One noticeable difference between rural and urban nursing practice has been the expectation that rural nurses would provide an emergency health-care service in the form of Primary Response in Medical Emergencies (PRIME). It is important to acknowledge this in the context of changing models of healthcare and funding and the provision of sustainable healthcare by rural nurses. PRIME is distinct to Aotearoa New Zealand operating only in rural locations and funded by the Ministry of Health and the Accident Compensation Corporation (ACC) and is administered by St. John Ambulance service. PRIME utilises the skills of speciality

*The Rural Way: Rural Nurses' Contribution to New Models of Health Care, Reducing Health… DOI: http://dx.doi.org/10.5772/intechopen.109768*

trained rural GPs and/or rural nurses in areas to support the ambulance service where the response time for assistance would otherwise be significant or where additional medical skills would assist with the patients' condition [27].

*… we got a defibrillator and introduced a higher level of care, making the practice more of a casualty outpost rather than just a house with a medical kit in it.* (Storyteller 3)

*[Before PRIME<sup>1</sup> ] I found myself stitching people up and putting IVs in without any training... We trained sideways, literally doing our nursing training, our extra training, I trained to Level 4 as an ambulance officer. (Storyteller 3)*

*…in the local hospital… there were no permanent medical doctors in the hospital and the nurses ran the hospital with the General Practitioners' support… I was a 'jack of all trades' and would do a bit of this and that.*

The RCTs, including nursing services, were driven by the health needs of their communities which, over time, granted rural nurses a strong community involvement while enhancing communities' social capital (as discussed in the excerpts from the rural nurses' stories above). Nurses talked of adapting their practice to accommodate community need to achieve this they needed to be responsive to the community be tentative and pioneer new approaches and models of practice. In the long run, all these trusts ensured the feasibility of community health services, having been redesigned to perform this function [8]. The trusts generally employed all local healthcare staff including the general practitioner and rural nurses. These new employment arrangements gave the RCTs significant advantage the local health professionals were in a strong position to work collaboratively, maintaining effective teamwork and sharing skill base as a result, which benefitted the community.

Many of these aspects of rural nursing show a pioneering spirit, several of these historical practices are now incorporated into community nursing as routine everyday practice. Rural nurses have very autonomous roles, with high levels of responsibility. This both expands nursing skills to the edge of scope of practice, but also sometimes restricts what intervention is possible. Nurses often spoke of "being it", "the only", very different from team nursing in an urban hospital setting as highlighted by the following rural nurses:

*It really came home to me one night that I was it. … In the rural setting, I guess, those of us who do work here realise we often have to step up to the challenge… It is a different culture, an unspoken knowing that you will work together to do the best, whatever it takes. (Storyteller 9)*

*We've had to be quite resourceful in what we do and how we work. We rely on a lot of nurses stepping up into different specialties [like Rural Nurse Specialist, Nurse Practitioners, Clinical Nurse Specialists] because it's very difficult to retain doctors in a lot of those areas… It's an exciting place for a nurse to work. You get to work truly to the top of your scope of practice. (Storyteller 11)*

*…rural nurses [need to be] recognised for the skill set that they have, because I believe it is different, it's so different. But that we can support them so that they can do it* 

<sup>1</sup> PRIME relates to Primary Response in Medical Emergencies and is unique to New Zealand rural practice. Both nurses and doctors working in a solo capacity are skilled in emergency community management.

*knowing that they're going to be backed up, knowing that they're not going to fall into working outside of scope. All those things that are very, very difficult when you are on an Island on your own… (Storyteller 10)*

Islands provide their own special geographic constraints. Islands are considered as distinct places. Islands are different from the mainland areas especially when they are situated the furthest away from adjacent mainland communities [28]. Islands are surrounded by water; connected/disconnected; isolated; habituated; uninhabited, while having similarities with others or differences and experience their own challenges [29]. Challenges may pertain to the island's own climate which have a direct bearing on island and rural culture and economy. This brings demands on the services and supply industries and can also impact on resources as dis-economy of scale is experienced living on an island because of small community populations that raises costs of living including transport, production of electricity and the moving of goods onto the island all come with a cost (**Figure 4**) [30]. And further consideration of rural peoples' resilience, independence and self-sufficiency relates to rural Island life as highlighted in the following excerpts:

*Internationally they say that there is something different – or set apart about people who choose to live remotely… There is a need for the people to be self-sufficient, independent and resilient to enjoy or, in fact, survive island life. (Storyteller 6)*

*Islands are bound by geographical constraints - distance and boundaries. An island is defined as a piece of land surrounded by water – often also by isolation – by detachment or surrounded in some way…. A good example being in poor weather you just can't get a seriously sick patient off the Island as the helicopter cannot land whereas on the mainland there may be other options. (Storyteller 6)*

*The Rural Way: Rural Nurses' Contribution to New Models of Health Care, Reducing Health… DOI: http://dx.doi.org/10.5772/intechopen.109768*

*…when I realised my father was having a heart attack that night, it was 10 o'clock at night, and the first thing I did was – rather than think 'well, is he going to survive' – I looked out the window to see what the weather was like. You couldn't have a plane because it was dark, so were we going to be able to get a boat to get him off the Island? (Storyteller 10)*

*We're very vulnerable to commercial decisions here because we rely on businesses that have ferries and planes, and if they change their practices, that can change things overnight for what we do here. (Storyteller 3)*

We further identified several themes that rural nurses' practice typically possesses for example innovation and adaptability while working autonomously but in collaboration with the residents and team members aligned with the rural community which we have identified as the rural nurse as entrepreneurial practitioners.

### **3.3 Entrepreneurial practitioners**

Rural healthcare professionals are usually in reciprocal relationships with the community they serve. They see the community itself as inherent to their practice, and for some nurses, to their sense of self and for Māori nurses this sense of self relates strongly with knowing their communities and whanua contributes to a sense of belonging, provides insight, and helps to establish therapeutic relationships [23]. Many of the rural nurses expressed that they were highly supported and valued by their community. This support is not only due to good will and established relationships, although that is undoubtedly a part of it. Due to matters of geographic isolation and resource scarcity, community support is often a requirement if the community is to have operating healthcare services:

*I feel supported by the community as I nurse. The proof of that is when there's an emergency. It is common that the locals will stop and assist. Someone might offer to carry my heavy packs into the bush, others will rush off to find family members of the injured. And afterwards some may phone me up saying, 'oh, I realise that you were up really late last night, can I blah blah blah for you?' (Storyteller 6)*

Sense of place is important to both the nurse, and to the patient. Relationships and empowering clients to make their own choices about location are seen as important to the rural nursing role, while recognising the increased risks isolation entails. An often-discussed aspect of rural nursing was enabling people to maintain their independence; to remain in their home or the local community whilst receiving care:

*And I think a lot of times, when people talk about encouraging people in palliative care to die or saying that people want to die at home, I think 'community' is what they mean. 'Home' doesn't necessarily always mean the house where they lived. But it means where they're comfortable, where their community is, where their support is… (Storyteller 7)*

*So, yes, I think we provide a magnificent service, I really do. An essential service. We keep people out of hospital or bring them home much earlier. (Storyteller 12)*

Rural nurses show ingenuity in the face of scarce resources, often working in isolation with high responsibility and autonomy. Despite the increased likelihood of working by oneself in a rural context, the interviewees recognise that working with other healthcare professionals is vital to ensuring the best outcomes for patients, but often collegial relationships are at distance:

*I work in partnership and collaboration with the General Practitioners, I support them, just as they support me. They trust my ability allowing me to manage their patients. There is real teamwork here. (Storyteller 1)*

Although pre-established connections cause challenges with maintaining professional boundaries it can be of benefit to patients in that these relationships can be useful in a therapeutic sense, but also in that health care practitioners feel accountable to the community:

*… sometimes when you know them [a patient who cannot be saved], you're dealing with your own grief. It's nothing like the grief of the family, obviously, but you're still dealing with your own grief. And then you think – it's the old beat up story – 'did I manage to…', 'was there anything else I could have done', or 'did I not do…'. And as I said, you've got nobody to bounce those ideas off because you're there on your own. … You're there, until somebody else turns up. (Storyteller 8)*

Understanding the community, and its needs are necessary to be able to forge creative ways to provide services that are accessible and appropriate. Nurses often have a pre-established connection with patients or can quickly form one, sometimes patients are family or friends, working in partnership over long periods of time has numerous advantages for the provision of patient-centred health care linking health requirements and needs and building a sense of connectedness and fulfilment for the nurse. These links create additional complexities, but also opportunities for additional support. Working in partnership with the patient/client is seen as vital, requiring a connectedness to the community. In rural nursing, nurses often get to see the difference they make through continuity of care. Rural nurses describe great satisfaction from seeing their skills being valued by their clients and are professionally invested in the change they help engender with clients:

*…you tell them to go to so-and-so because they will be able to fix it for you, whether that's home help or something. I'm very aware what's available in the community (Storyteller 13)*

*If I nurse somebody who comes from [community name removed]…, you know there's issues around distance, you know there is an issue around the limit of health services in their home area, what their shopping and other services are like. You actually really do understand some of the challenges for people, and that makes a big difference. (Storyteller 5)*

*… you watch people grow. Especially young mums with babies that are struggling… And then you watch them flourish and they get it all together. And you watch the children flourish and go to school, and then you see them in school. It's kind of nice. (Storyteller 8)*

*The Rural Way: Rural Nurses' Contribution to New Models of Health Care, Reducing Health… DOI: http://dx.doi.org/10.5772/intechopen.109768*

### **3.4 Entrepreneurial practice the nurse practitioner**

The rural nurses we interviewed revealed the practice models they adopted in response to funding changes. Firstly, nurses had the opportunity to purchase and govern general practices, which were traditionally owned and operated solely by GPs – those with a medical background. Nurse Practitioner training was seen by nearly all respondents as the extra training that legitimised what nurses had to do anyway in rural settings, but previously through indirect routes. However – it was generally felt that their work was not understood, appreciated, or valued by those outside of the rural setting:

*By doing my Nurse Practitioner training, I could then offer this broader, rounder service. I could finish the consult by signing the script, ordering more medication, or – more importantly than the medication – ordering an x-ray, working out which bloods were needed and why. So, investigations were bigger for me in becoming a Nurse Practitioner than prescribing was. Prescribing was the added plus.*

*(Storyteller 10)*

*Nurse Practitioner was that I felt that it was really helpful to have the ability not just to prescribe, but to actually be able to assess properly; to learn how to assess, diagnose, treat, look for problems and do as much as I can in the areas preventing people from having to come up to tertiary care. (Storyteller 7)*

### **3.5 Entrepreneurial practice responsive to change**

A common sentiment among rural nurses was that industry and demographics within rural communities have changed dramatically over time (**Figure 5**). Changes in industry are said to explain the changes in demographics, with more transient workers and immigrant workers unfamiliar with the Aotearoa New Zealand health system and language barriers. This changes the context in which rural nurses operate, as the high degree of interconnectedness in rural communities, while still existing, is somewhat diminished:

*But in the rural areas, there are now more transient populations. The dairy farm workers in the [place name removed] area alone are from 10 different nationalities. Many don't speak English. So you have a language barrier, communication barrier, expectations [that do not align with how the New Zealand health system works]. (Storyteller 1)*

*After starting this job for a couple of years, I could have driven right through my area and named every house, every child, every person. I don't even bother trying these days. (Storyteller 8)*

*It was very obvious when working in Public Health especially in the school situations as the migrant workers [from diary conversions] brought with them their own social issues previously not seen in the established communities. (Storyteller 14)*

*I would say we sometimes end up with quite a lot of transient people because they come and get a job and then there's trouble with getting accommodation and stuff, and they have to move on… (Storyteller 9)*

### **Figure 5.**

*Chatham Island industries: Hotel, fish factory and sheep penned for embarkation. Source: Martin London Photography (published with permission).*

Responsive practice has equally been demonstrated as rural nurses responded to the COVID-19 pandemic. These nurses collaborated with health professionals to ensure adequate care for patients was offered but in different innovative ways. We can acknowledge the pioneering spirit associated with rural nursing practice from Aotearoa New Zealand continued in a similar vein as to the changing health care system identified in the larger research project. This often-involved nurses, health workers and more broadly local authority Council taking on responsibilities outside their normal duties to keep communication lines open and work closely together as highlighted in this excerpt:

*… very early on in the piece realised that patients weren't going to come see us... because of their own fear around contracting COVID in the practice. So, we activated a project called COVWELL, which basically is a COVID wellness... made these phone calls to all our high risks patients. This was about a 7 or 8 minute phone making sure they were well, that they understood, if they needed to go into isolation what that meant and what it looked like, making sure they had support around them... for them to know that actually you are on the end of a telephone if I do get sick...*

*(Rural Nurse, podcast 46).*

Rural nurses enhanced their practice as community educators and effective collaborators with a variety of local colleagues and members of their rural communities, drawing attention to community resilience and the progressive rural nurses' pioneering spirit.

### **4. Conclusion**

The health care system in Aotearoa New Zealand during the 1990s was subjected to major economic and a change to delivery models, especially in rural regions influenced by neo-liberal political philosophy [3]. Rural nurses put a stake in the ground with the aim of responding to these changes and enabling equity – exploring new practice models to ensure that the best levels of healthcare were available. The

*The Rural Way: Rural Nurses' Contribution to New Models of Health Care, Reducing Health… DOI: http://dx.doi.org/10.5772/intechopen.109768*

aim of this chapter has been to report on a research project that set out to capture the unique stories from rural nurses from Aotearoa New Zealand with the aim to make visible their practice. Narrative inquiry has provided a depth of meaning to the rural nurse experience and uncovered the discourse of rural nursing in New Zealand in the twenty-first century adding to the international rural nursing discourse. Narrative inquiry methodology recognises the power that story has, to explore meaning, make connections, entertain, and build empathy and share with others. This methodology has provided a depth of meaning to the rural nurse experience; the data analysis and research findings demonstrate that rural nurses have maintained and, in some cases, improved the health care of these rural communities in Aotearoa New Zealand. This rural nursing discourse identified in this research identifies the rural nurse with pioneering spirit; as an entrepreneurial practitioner involving what nurses' express, as the 'rural way'. From their innovative practice emerged the contemporary identity of the nurse practising in the rural context which has uncovered the discourse of rural nursing in New Zealand in the twenty-first century and amplified rural nurse voices. This pioneering spirit initially identified in the 1990s has continued in a similar vein, during the COVID-19 pandemic into the 2020s. It is now timely to add to the international dialogue a specific New Zealand discussion and discourse.

### **Acknowledgements**

The authors wish to thank the rural nurses who gave up their valuable time to share their stories and agreed for them to be published in *Stories of nursing in rural Aotearoa: A landscape of care*. Sincere thanks are extended to our colleagues Raeleen Thompson and Rachel Parmee for their dedication as they also interviewed rural nurses as part of this research. Further acknowledgment is extended to Otago Polytechnic, Dunedin New Zealand for contestable funding in support of this research between 2016 and 2021.

### **Conflict of interest**

The authors declare they have no conflict of interest.

*Rural Health – Investment, Research and Implications*

### **Author details**

Jean Ross\*, Josie Crawley and Rachel Parmee College of Health, Otago Polytechnic, Dunedin, New Zealand

\*Address all correspondence to: jean.ross@op.ac.nz

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*The Rural Way: Rural Nurses' Contribution to New Models of Health Care, Reducing Health… DOI: http://dx.doi.org/10.5772/intechopen.109768*

### **References**

[1] Barnett JR, Barnett P. Primary health care in New Zealand: Problems and policy approaches. Social Policy Journal of New Zealand Te Pura Whakaaro. 2004;**21**:49-66

[2] Matherson D, Neuwelt P. New Zealand's journey towards peoplecentred care. The International Journal of Person-Centred Medicine. 2013;**2**(1):73-79

[3] Barnett JR, Barnett P. Reinventing primary health care: The New Zealand case compared. In: Crooks VA, Andrews GA, editors. Primary Health Care: People, Practice, Place. Farnham, England: Ashgate; 2009. pp. 149-165

[4] Prince R, Kearns R, Craig D. Governmentality, discourse and space in the New Zealand health care system 1991-2003. Health & Place. 2006;**12**:253-266

[5] National Health Committee. Rural Health: Challenges of Distance Opportunities for Innovation. Wellington, New Zealand: National Health Committee; 2010

[6] Dalziel P, Saunders C. Wellbeing Economics: Future Directions for New Zealand. Wellington, New Zealand: Bridget Williams Books Publishing Trust with the G & N Trust; 2014

[7] Carryer J, Halcomb E, Davidson PM. Nursing the answer to primary health care. Collegion. 2015;**22**(2):151-152

[8] Eyre R, Gauld R. Community participation in a rural community health trust: The case of Lawrence, New Zealand. Health Promotion International. 2003;**18**(3):189-197

[9] Gauld R. Revolving Doors: New Zealand's Health Reforms. Wellington, New Zealand: Institute of Policy Studies Victoria University; 2001

[10] Ministry of Health. Primary Health Care Strategy. Wellington, New Zealand: Ministry of Health; 2001

[11] Bushy A. Orientation to Nursing in the Rural Community. Thousand Oaks, California: Sage Publications; 2000

[12] Macleod M, Browne AJ, Leipert B. International Perspective: Issues for nurses in rural and remote Canada. 2008;**6**(2):72-78

[13] Hegney D, Francis K, Mills J. Rural health. In: Frances K, Chapman Y, Davies C, editors. Rural Nursing: The Australian Context. Australia: Cambridge University Press; 2014. pp. 18-33

[14] Ross J. Place Matters to Rural Nurses. Department of Geography: University of Otago, Dunedin, New Zealand; 2016

[15] Ross J, Mann S, Leonard G. Rural nursing during the COVID-19 pandemic: A snapshot of nurses' experiences from Aotearoa New Zealand. Journal of Nursing Practice. 2020;**3**(1):186-192

[16] Clandinin J. Engaging in Narrative Inquiry. New York: Routledge; 2013

[17] Crawley JM. "Once upon a time": A discussion of children's picture books as a narrative education tool for nursing students. The Journal of Nursing Education. 2009;**46**(1):36-39

[18] Haven KF. Storyproof: The Science Behind the Startling Power of the Story. Libraries Unlimited: Westport, Connecticut; 2007

[19] Clandidin J, Connelly M. Narrative Inquiry: Experience and Story in Qualitative Research. San Francisco, CA: Jossey-Boss; 1998

[20] Ross J, Crawley J, editors. Stories of Nursing in Rural Aotearoa: A Landscape of Care. Dunedin, New Zealand: Rural Health Opportunities; 2018

[21] Birks M, Mills J. Grounded Theory: A Practical Guide. 2nd ed. London: Sage; 2015

[22] Nursing Council of New Zealand. The New Zealand Nursing Workforce: A Profile of Nurse Practitioners, Registered Nurses and Enrolled Nurses 2018-2019. Wellington: Te Kaunihera Tapuhi o Aotearoa/Nursing Council of New Zealand; 2019. Available from: https:// www.nursingcouncil.org.nz/NCNZ/ News

[23] Brooke L, Hogarth K. Māori rural nurses' stories and their connections to communities: A thematic analysis. Scope: Kaupapa Kāi Tahu. 2021;**6**:62-71

[24] Nursing Council of New Zealand. Nursing Council of New Zealand Annual Report 2015. Wellington, New Zealand: Nursing Council of New Zealand. Available from: https://www. parliament.nz/en/pb/papers-presented/ current-papers/document/51DBHOH\_ PAP67663\_1/nursing-council-of-newzealand-annual-report-2015-e18

[25] Statistics New Zealand (2015) New Zealand in Profile: 2015. Wellington: Statistics New Zealand. Available from: http://www.stats.govt.nz/browse\_for\_ stats/snapshots-of-nz/nz-in-profile-2015. aspx [Accessed: March 10, 2015]

[26] Hunter K, Cook C. Cultural and clinical practice realities of Māori nurses in Aotearoa New Zealand: The emotional labour of Indigenous nurses. Nursing

Praxis in New Zealand. 2020;**36**(3):7-23. DOI: 10.36951/27034542.2020.011

[27] Ross J, Kemp T, London M, Jones S. Growing Rural Health: Tipu Haere Tuawhenus Hauora: 30 Years of Advocacy and Support in Aotearoa. Dunedin, New Zealand: Hauora Taiwhenua Rural Health Network; 2022

[28] Baum T. The fascination of islands: A tourist perspective. In: Lockhart DG, Drakakis-Smith D, editors. Island Tourism: Trends and Prospects. London: Pinter; 1997. pp. 21-36

[29] Ross J. Editorial. Scope: Health & Wellbeing. 2021;**6**:7-8

[30] Dillon D. Rural contexts-Islands. In: Ross J, editor. Rural Nursing: Aspects of Practice. Dunedin: Rural Health Opportunities; 2008. pp. 19-30

### Section 3
