Investigating the health status of primary school children in Tonga: Lessons learnt and reflections on field work in the Pacific Islands.

Globally, the child health focus has been on reducing under-5-year mortality, with large populations in low-resource regions prioritised. Children in older age groups, particularly in less populated regions such as the Pacific, have received limited attention. Child health research in the Pacific region has been lacking, and research approaches for the region have historically been from Western biomedical paradigms. We completed the study of primary school children's health over a period of 5 years. Firstly, we conducted a literature review, then we completed an audit of hospital admissions of primary school children, then we completed a two-round Delphi process and finally, we piloted the survey in three primary schools. Our results found there were high levels of oral health problems, ear health, obesity and exposure to violence and poverty impacting on the quality of health of primary school-age children. Identifying these indicators was made possible by the partnerships and trust established by the study team and provides specific and measurable targets for future work to improve the quality of child health outcomes. This paper describes key field work lessons learnt for research in the Pacific region. It must: (i) be on the platform of relationship, cultural safety and local ownership; (ii) include consideration of holistic Pacific paradigms of health; (iii) be adaptive to the context and environment; and (iv) be committed to long-term partnership and work.

Surviving versus thriving: The wellbeing of primary school aged children in Tonga.

AIM: To enable improvements in global child health, the focus must move beyond child survival to child wellbeing. In the Pacific Islands, the wellbeing of children has received little attention. This study aimed to investigate the wellbeing of children from three primary schools in Tonga. METHODS: A cross-sectional survey was completed in three primary schools in Nuku'alofa with children aged 5-15 years. The study participants (256 children, 143 caregivers) completed the Child Health and Illness Profile - Child Edition, CHIP-CE (Version 1.0). RESULTS: On average, >70% of children and caregivers described home and school environments as positive. From the children's reports, boys had significantly lower scores for risk avoidance than girls (3.40 vs. 3.73, P < 0.001). Children aged 5-7 versus 8-15 years had significantly lower scores for satisfaction (3.63 vs. 3.92, P = 0.002), resilience (3.34 vs. 3.56, P = 0.016) and achievement (3.25 vs. 3.62, P = 0.002). From the caregivers' report, girls had significantly lower scores for academic performance than boys (3.60 vs. 3.81, P = 0.04). Boys had significantly lower scores for individual risk association compared to girls (3.93 vs. 4.29, P = 0.01). Overall CHIP-CE scores were lower than those of comparable populations in the West, while at the same time protective factors were documented. CONCLUSIONS: Understanding child wellbeing in the Pacific is critical for strengthening protective factors known to mitigate poor child health outcomes. Continuing to base global child health success on child survival alone misses opportunities for improving the wellbeing of nations.

Evaluation of vision screening of 5-15-year-old children in three Tongan schools: comparison of The Auckland Optotypes and Lea symbols.

BACKGROUND: Comprehensive vision screening programmes for children are an important part of public health strategy, but do not exist in many countries, including Tonga. This project set out to assess: (1) the functional vision of children attending primary schools in Tonga and (2) how a new recognition acuity test (The Auckland Optotypes displayed on a tablet computer) compares to use of a standardised eye chart in this setting. METHODS: Children from three Tongan primary schools were invited to participate. Acuity testing was conducted using a standardised recognition acuity chart (Lea symbols) and the tablet test displaying two formats of The Auckland Optotypes. Measures of ocular alignment, stereo acuity and non-cycloplegic photorefraction were also taken. RESULTS: Parents of 249 children consented to participate. One child was untestable. Only 2.8 per cent of testable children achieved visual acuity worse than 0.3 logMAR in the weaker eye. Results from the Spot Photoscreener suggested that no children had myopia or hyperopia, but that some children had astigmatism. The tablet test was practical in a community setting, and showed ±0.2 logMAR limits of agreement with the Lea symbols chart. CONCLUSION: The sample of children in Tongan primary schools had good functional vision. A modified version of the tablet acuity test is a promising option for vision screening in this context.

Cancer management in the Pacific region: a report on innovation and good practice.

Pacific island countries and territories (PICTs) face the challenge of a growing cancer burden. In response to these challenges, examples of innovative practice in cancer planning, prevention, and treatment in the region are emerging, including regionalisation and coalition building in the US-affiliated Pacific nations, a point-of-care test and treat programme for cervical cancer control in Papua New Guinea, improving the management of children with cancer in the Pacific, and surgical workforce development in the region. For each innovation, key factors leading to its success have been identified that could allow the implementation of these new developments in other PICTs or regions outside of the Pacific islands. These factors include the strengthening of partnerships within and between countries, regional collaboration within the Pacific islands (eg, the US-affiliated Pacific nations) and with other regional groupings of small island nations (eg, the Caribbean islands), a local commitment to the idea of change, and the development of PICT-specific programmes.

Child morbidity as described by hospital admissions for primary school aged children in Tonga 2009-2013.

AIMS: To describe inpatient utilisation patterns for primary school aged children in Tonga. METHODS: We described admissions for children aged 5-11 years to the main hospital in Tonga from January 2009 to December 2013. Rates with 95% confidence intervals (CI) were compared using rate ratios (RR). RESULTS: There were 1,816 admissions. The average annual admission rate was 20.2/1,000 (95% CI 19.3-21.1). Hospital admission rates were higher in younger than older children (5-7 versus 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 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). CONCLUSIONS: In children 5-11 years in Tonga, 85% of admissions were for five groups of conditions. These data inform priority areas for healthcare spending and enable comparisons over time and between different Pacific countries.

Improved immunization practices reduce childhood hepatitis B infection in Tonga.

BACKGROUND: Hepatitis B infection is hyper-endemic in Tonga and 19% of pregnant women test positive for hepatitis B surface antigen (HBsAg). Routine childhood immunization against hepatitis B was introduced in 1989 and the target for elimination was set at <1% HBsAg prevalence in children. A study conducted in 1998, a decade after the introduction of hepatitis B immunization, found the HBsAg prevalence to be 3.8% in pre-school children. The finding resulted in the strengthening of the delivery of hepatitis B vaccine with emphasis on providing the first dose within 24h after birth. The aim of this study was to measure the impact of improved immunization practices on the prevalence of hepatitis B infection in pre-school children, and to assess the progress towards hepatitis B elimination in Tonga. MEASURED OUTCOME: Prevalence of HBsAg antigen. TYPE OF STUDY: Cross-sectional study. METHODS: Children aged 6-59 months who were admitted to Vaiola Hospital, Nuku'alofa, Tonga, and had blood collected for clinical investigation, were tested for HBsAg with a rapid serological test (Abbott Determine). A total of 449 children were recruited and interviewed and 375 (84%) were tested for HBsAg. Convenience testing was chosen, as it was likely to be a relatively unbiased method in this situation where all children on the island have good and equitable access to hospital services. Immunization status was checked against the children's immunization cards and cross-checked against the records kept by the public health nurses. Information about socio-economic status, parent education, blood transfusion, breast-feeding, mode of delivery, and place of birth was collected through interviews with mothers using a standardized questionnaire. RESULTS: Three children tested positive for HBsAg resulting in a prevalence of 0.8% (CI 0.2-2.5%). Hepatitis B 1 (Hep B 1) immunization coverage was found to be high, 99.1% (CI97.7-99.7) and 91.9% (CI 88.9-94.2) of children received the first dose of hepatitis B vaccine within 24h after birth. Coverage for the third dose of hepatitis B vaccine was 97.6% (CI 95.5-98.7) and of the children with complete immunization 84.7% (CI 80.9-87.9) had received all three doses by 6 months of age. CONCLUSIONS: The results show that the instituted changes in the delivery of hepatitis B vaccine have been effective in reducing the transmission of hepatitis B to children and indicate that Tonga appears to have achieved the elimination target of less than 1% HBsAg prevalence in children. This convenience survey used a simple, cost effective and reproducible study design. Convenience testing can be recommended for surveillance of the effectiveness of immunization programmes in settings where the population has good access to health services.

Evaluation of a screening protocol using auscultation and portable echocardiography to detect asymptomatic rheumatic heart disease in Tongan schoolchildren.

BACKGROUND: Rheumatic heart disease (RHD) is an important problem in developing countries; however, many cases are detected only when the disease has progressed to cardiac failure. Screening can detect cases earlier, but there are no screening guidelines. METHODS: We performed a cross-sectional screening study in Tonga among 5,053 primary school children, in whom auscultation followed by echocardiography of those with heart murmurs were used to identify RHD. We also analyzed whether a three-stage screening protocol of auscultation performed by a medical student to detect any heart murmur, second-stage auscultation performed by a local pediatrician to differentiate pathological from innocent murmurs and echocardiography of those with pathological murmurs altered outcomes. RESULTS: The prevalence of definite RHD was 33.2 per 1,000. The prevalence of RHD increased significantly with age, peaking at 42.6 per 1,000 in children aged 10-12 years. Most valve lesions (91 [54%] of 169) were mild. Auscultation to detect pathological murmurs was poorly sensitive (46.4%), and the finding of any murmur on auscultation did not affect the likelihood of detecting pathology on echocardiography. The finding of a pathological murmur did significantly increase the likelihood of detecting pathology on echocardiography, but still missed 54% of those with pathology (mainly RHD) detected on echocardiography. CONCLUSIONS: Screening is a useful method for detecting asymptomatic RHD in regions of high prevalence and we report a high echocardiographically confirmed prevalence. The most appropriate screening strategy remains to be confirmed, however, and implementation will depend on the availability of echocardiography and trained staff.

Health research in the Pacific.

The Pacific Island countries are geographically scattered, with contrasting environmental, social, and political systems, and in varying stages of economic development, but all are going through a rapid epidemiological transition. Processes that took place over thousands of years in Western countries have been very much compacted in time in the Pacific. These processes have produced major changes in environment and lifestyle, which have produced epidemics of non-communicable disease. While it is important to consider non-communicable diseases as a group, it is also important to conduct research into their specific causes. There has been a great deal of research into cardiovascular disease and diabetes in the Pacific, but it is only recently that the importance of cancer as a major source of mortality and morbidity in the Pacific has been recognised, even though it appears to carry a similar burden of morbidity and mortality. It is therefore important that research into the causes and control of cancer in the Pacific is conducted. However, it is also crucially important that this research both learns from the successes and avoids the mistakes of the past. In particular, it is crucial that cancer research in the Pacific is not another opportunity for "research colonialism," but instead provides opportunities for Pacific-training of Pacific health researchers and the conduct of Pacific-led research.