In our own backyard: Investigating the health status of primary school children in Tonga

Abstract

Background Over the last two decades, much of the global child health focus has been on the reduction of the under-five mortality rate. Concurrently, children in low-resource regions with the largest populations have received most of the global attention. While this is justified, the plight of children in the primary school age group in smaller, low-resource regions such as the Pacific have been largely ignored. The aim of this thesis is to investigate the health needs of primary school children in Tonga using a culturally appropriate survey methodology. Methods This thesis includes two reviews of the literature, one retrospective and two prospective studies, and reflections on community engagement, cultural competence, and fieldwork in Tonga. a) Literature reviews: Studies of (i) primary school children’s health in low and lower middle-income countries; and then (ii) of children’s health in Tonga were identified and reviewed. b) (Study 1) Child morbidity in Tonga as described by hospital admissions for primary school aged children 2009-2013: Admissions for children aged 5-11 years to the main hospital in Tonga from Jan-2009 to Dec-2013 were described. c) (Study 2) Developing a survey for primary school children in Tonga: Using a Delphi technique and Pacific methodologies, 33 panel members reviewed two rounds of online questionnaires to determine what to include in a survey to describe the health of primary school aged children living in Tonga. d) (Study 3) Exploratory study investigating the health needs of primary school children in Tonga: From the results of Study 1 and Study 2, a survey approach was developed that included measurements of anthropometry, vision, ear health, and oral health, and questionnaires (translated into Tongan). This survey was administered to 256 children, 143 caregivers, and 20 teachers in three primary schools in Tonga. e) Community engagement and cultural competence: Pacific theory and methodologies underpin the entire process of this thesis from conception to completion, including the Fonofale model, Talanoa approach, and Kakala framework. In order to ensure this project was community led and owned, a philosophy of community engagement was followed that had service at its centre and the end goal of solidarity. The principles of humility, respect, empathy, and trust were the foundational pillars to achieve this outcome. Results Reviews: Forty studies from lower and lower middle-income countries of primary school aged children were identified and reviewed. The majority of the studies were from the African and South East Asian World Health Organization regions, with none from the Pacific. Only three studies covered the general health of children, with the remainder focussed on discrete diseases or health issues. None included non-physical aspects of health such as wellbeing, or social determinants of disease. Thirty-one published studies of child health in Tonga were identified. These studies covered single health issues including: immunisation, nutrition, rheumatic heart disease, respiratory disease and oral health. Study 1 - Child morbidity in Tonga as described by hospital admissions for primary school aged children 2009-2013: There were 1,816 admissions. The average annual admission rate was 20.2/1000 (95% CI 19.3-21.1). Hospital admission rates were higher in younger than older children (5-7 vs. 8-11 years, RR=1.28, 95% CI 1.18-1.41) and in boys than girls (RR=1.52, 95% CI 1.38-1.68). Injury and poisoning (28%), non-respiratory infectious diseases (19%), respiratory conditions (16%), abdominal/surgical conditions (13%) and dental (9%) were the most frequent admission reasons. A larger proportion of younger versus older children were hospitalised for dental (16% vs. 1%, P<0.001) or respiratory conditions (18% vs. 14%, P=0.02). A larger proportion of older versus younger children were hospitalised for abdominal/surgical conditions (15% vs. 11%, P=0.008), other infectious diseases (21% vs. 17%, P=0.04), other conditions (10% vs. 6%, P<0.001) and cardiac conditions (2% vs. 1%, P<0.001). Study 2 - Developing a survey for primary school children in Tonga: Panel consensus was met on a range of domains to be included in the survey method. The domains were: general demographics (80%), environment (80%), resilience and risk (88%), household economics (80%), psychological functioning (92%), social functioning (92%), physical functioning (88%), cognitive functioning (92%) and individual health conditions (84%). Of the subtopics within these domains particular importance was placed on including questions that described exposure of children to violence and abuse (93%), and on ensuring responses from the children were included. Study 3 - Exploratory study investigating the health needs of primary school children in Tonga: Four percent of the children failed vision testing, 36% failed audiology testing and 63% failed oral health screening. The prevalence of overweight was 19%. Caregivers reported respiratory symptoms (n=86, 65%), injury (n=59, 41%), pain (n=53, 40%), stomachache (n=48, 36%) and ear infection (n=39, 30%) as the most common ailments in their child. Mean health related quality of life scores were measured using the Child Health and Illness Profile-Child Edition. From the children’s reports boys had significantly lower scores for risk avoidance than girls (p = 0.0005). Children aged 5-7 versus 8-15 years had significantly lower scores for satisfaction (p = 0.0005), resilience (p = 0.016) and achievement (p = 0.002). From the caregivers’ report girls had significantly lower scores for academic performance than boys (p = 0.04). Boys had significantly lower scores for individual risk association compared to girls (p = 0.01). The children in Tonga experienced lower health related quality of life in comparison to children in the United States of America and Spain. Over 60% of caregiverss and teachers that responded felt that children are exposed to violence in Tonga and over 70% felt that neglect and abuse of children is a problem in Tonga. Five of 49 (10%) caregivers said that their child had been physically hurt by an adult in the last 12 months. Seventy-seven percent of caregiverss had smacked their child at least once in the last four weeks. Five main themes emerged regarding child maltreatment in Tonga: types of violence, parenting and discipline, causation and influences, effects and denial. Community engagement, cultural competence and reflections on field work: Within the process of engagement and field work, challenges were identified and countered. These included: participation fatigue, environmental constraints, resource constraints, health system limitations, translation of western paradigms, cultural barriers, language barriers, and experience. Successes were celebrated such as the use of technology, interdisciplinary and multidisciplinary approaches, community uptake, and cultural competence. Conclusion Tonga is a small nation in the Pacific. The health needs of its primary school aged children have not previously been an area of specific focus. The findings from this thesis outline a careful process developed to investigate the health of primary school aged children in Tonga. This thesis highlights the issues of overweight, ear/hearing health, oral health, health related quality of life and exposure to violence as important factors affecting the health and wellbeing of these children. In the Sustainable Development Goals era, there is a need to move away from just whether children survive, to how children survive. The focus on under-five mortality has been and continues to be essential. At the same time, the primary school age group is a critical time period for the development of behaviours that may put children at risk of morbidity throughout their life. It is also an accessible population due to their attendance of school and the ability to access them there. Measuring and defining health requires consideration of more than just the lack or existence of physical illness. Survival on its own is not a worthy aspiration if not partnered with a goal of thriving and being enabled to fulfil ones potential.