Effective strategies to treat acute rheumatic fever needed

Northland Māori need effective strategies to treat acute rheumatic fever

Research by the University of Auckland has found a lack of throat swabbing and inappropriate prescription of antibiotics in primary care is preventing the diagnoses and treatment of acute rheumatic fever and group A streptococcus bacteria in Northland Māori.

The study, Whānau perceptions and experiences of acute rheumatic fever diagnosis for Māori in Northland, New Zealand, by Dr Anneka Anderson, Dr Clair Mills and Dr Kyle Eggleton, has recently been published in the New Zealand Medical Journal.

The study also found access to primary care, having health professionals follow sore throat guidelines, and trust in health professionals also slowed down the diagnosis.

Lead author Dr Anderson says they are calling for the development of an effective quality improvement strategy for sore throat management, promoting free rapid-response throat swabbing for high-risk populations, and exploring options of self-swabbing to improve acute rheumatic fever (ARF) services.

ARF is a preventable inflammatory disease that can develop after pharyngitis caused by group A streptococcus (GAS) bacteria. It can result in rheumatic heart disease (RHD) which can lead to cardiac surgery and valve replacement. Prevention of ARF requires early effective treatment of GAS with an appropriate antibiotic. Both ARF and RHD remain significant causes of morbidity and mortality in New Zealand.

“In New Zealand, acute rheumatic fever remains a significant health problem with persistent ethnic inequities. Māori children 5–15 years of age in Northland have some of the highest rates nationally,” Dr Anderson says.

In 2011, Northland District Health Board (NDHB) reported that 95 percent of ARF cases within the DHB were Māori children. Rates of ARF among Māori children in Northland, calculated from 2002–2011, were some of the highest in the country with rates of 78/100,000 per year in Māori children between 5–15 years of age compared to 4.6/100,000 per year in non-Māori.

The study included 36 people, 18 adults over 25-years, 14 children aged under 15, and four youth aged 16-24 years.

The study found not all whānau were able to access medical care for their children when needed. Barriers to access included not being able to get appointments with general practice clinics, direct economic costs and indirect costs such as not being able to get time off work, not having access to transport, not being able to afford petrol for vehicles and geographic distance.

Some whānau reported having negative experiences within primary care services that created mistrust of GPs. Participants described feeling as though they were inferior and were discriminated against. Whānau felt their doctors judged them by where they lived and how they looked, did not listen to them, and were dismissive of their experiences and questions.

Whānau commonly cited concerns about lack of throat swabbing and under prescription of antibiotics as barriers to trusting GPs. Participants were aware that sore throats could lead to rheumatic fever and should be swabbed by health professionals. However, many participants described situations when they had presented with sore throats, asked for throat swabs and had not been given them. Whānau claimed that unless they had “pushed” they would not have had a throat swab taken.

The study also looked at delays in diagnosis of ARF. Diagnosis of ARF (from time first taken to a GP) for participants varied between an immediate diagnosis at primary care to a four-month delay and eventual diagnosis in hospital. Two RHD participants explained that their past ARF went undiagnosed until they presented with RHD symptoms. Another two children were only diagnosed with ARF when they presented at hospital with other illnesses. Delays in diagnosis occurred even when whānau suspected their children had ARF and voiced their concerns to GPs. One parent had ARF as a child and her eldest son had also been diagnosed with ARF. When her youngest son began exhibiting rheumatic fever symptoms she took him to her GP several times, but he was misdiagnosed on each occasion.

The study applied a qualitative kaupapa Māori approach, which has been described as a critical framework that gives meaning to the life of Māori and analyses unequal relations of power that influence Māori wellbeing. It is a methodology that is controlled by Māori to benefit Māori.

“This approach highlighted how systemic structural failures of New Zealand’s health system perpetuate inequitable outcomes in ARF experiences for Māori,” Dr Anderson says.

Barriers whānau faced accessing primary health services in Northland included geographic distance, unavailability of appointments, lack of access to transport and childcare, direct and indirect costs of services, and lack of trust in health professionals due to poor management and whakawhanaungatanga (relationship building) by GPs.

“These barriers are consistent with health literature in New Zealand, indicating these are persistent issues not yet addressed through health policy or systematic change.”

ends

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