Filling health gaps in the Wairarapa: primary health care nurses are finding innovative ways of working together to meet the needs of the Masterton and Wairarapa communities.

NURSES WORKING in Masterton and other Wairarapa communities are united in one thing: they want to provide affordable, accessible care that will create healthy families and communities.

Choice Health in downtown Masterton is home to the Wairarapa District Health Board's (DHB) public health service. The nursing staff consists of two asthma and diabetes nurse educators, two public health nurses, an adolescent public health and sexual health nurse, and an immunisation co-ordinator. They work alongside a number of other services within the facility, including the school dental service, audiology and a small team of health promoters. The nursing services are free, with people seen either at a Choice Health clinic or out in the community--at schools, marae, community houses or church halls.

"The pakeha, middle class has no problem accessing health in this region," said asthma and diabetes nurse educator Mollie Kainuku, who has nursed in the district for the past 30 years. "The people we see at outreach clinics struggle to feel good about themselves, are usually brown skinned, and often can't afford doctors' or chemists' fees. Some haven't seen a doctor for years.

"Many have no transport or phone, so most of us spend a lot of time home visiting, often to remote rural areas, ensuring people have the medication they need and are using it correctly. Going into people's homes is a privilege. It also enables us to check up on the health of the whole family."

Every Monday afternoon, Kainuku runs a nurse-led clinic at Cameron Community House in Masterton East. Here she and the other asthma and diabetes nurse, Jenny Skeet, the hospital cardiac outreach nurse, Maureen Barnes, and nurses from the local Maori health provider Whaiora Whanui will see up to 30 people, most of them "the poorest of the poor and sickest of the sick". Often Kainuki will arrange for a hospital specialist to attend for an hour, with five minute appointments for each person needing specialist treatment. Otherwise she will drive people to the hospital to see the specialist there.

Barnes has been running a cardiac outreach service, working at the interface between primary and secondary services, for the past five years. The service, she says, is making a real difference to hospital readmission rates among cardiac patients. Five years ago, these rates were the second highest in the country. "Working in the community, along with other primary health care nurses, enables us to identify the service gaps and to fill them appropriately," said Barnes. "At these combined clinics, we can monitor people's health in a supportive and co-operative way."

At Cameron House, the nurses teach people how to manage their own illnesses, primarily respiratory, diabetes and cardiac disease. They work hard to encourage people to stop smoking and to adopt healthy eating habits. "It's all about empowering people to improve their own health," said Kainuku.

A pre-school for Cook Island children is held at Cameron House on Monday mornings. Kainuku has formed a relationship with the mothers in this group, taking their blood pressures and testing them for diabetes. Over the last couple of years, she has noticed a real improvement in the children's health. Sine would like to see other Pacific groups using the house at other times during the week and is looking for ward to the DHB taking on a Samoan worker in the near future. Occasionally Pacific health promoters are available from the Hutt Valley DHB to assist the nurses communicate the health message, eg the importance of regular cervical smears, to the mothers.

Kainuku has initiated nursing outreach services at Greytown's Papawai Marae and Pirinoa Marne near the southern coast. Often the hospital dietitian will accompany her, as well as Barnes and the Whaiora Whanui disease state management (DSM) nurse Gael Binns. Immunisation coordinator Paula Minto will also attend, especially during 'flu injection time. Kainuku's aim at the marae based clinics is to help people stay out of hospital by maintaining their own health, and to encourage them to keep a watchful eye on each other. Sine also visits a weekly asthma support breathing group at a Masterton church hall, demonstrating new medications and answering any concerns people may have.

Public health nurses Wendy- Ann Havard and Rangi Waikari cover the 30 primary and intermediate schools in the district, focusing most of their efforts on the lower decile schools. However, with Waikari resigning from the position last month, Havard is now having to cope on her own until a replacement is found.

As well as visiting children at school, Havard will visit children whose health she is monitoring in their homes. There, she often picks up on a range of other family health issues. "Recently I visited a child at his home to check on his impetigo. I discovered his mother was eight months pregnant. Because of her lack of English, she had not accessed any lead maternity carer. I was able to provide knowledge and support to enable her to access maternity services. Now we have formed a special relationship, even though we still have language difficulties. The children, who used to be very wary of me, now come up to me at school and take me by the hand if they have anything they are concerned about and need to show me. To have gained their trust is very special to me."

Last year, Havard had a number of referrals from teachers concerned with children who were soiling. This year she and the hospital continence nurse Jenny Rowley have started an encopresis and enuresis clinic at the hospital. Along with a paediatrician, they work together providing treatment, education and ongoing support for children and their families. Often Havard will assist a school apply for some high needs funding in order to fund a teacher aide to work with children with these difficulties. "A smelly child soon becomes a very isolated child. Sometimes the teachers are just too busy to help these children individually. A teacher aide can remind children to go to the toilet and supervise with a shower if required. Many teachers are unaware of encopresis and appreciate gaining an understanding of the condition."

Much of Havard's work is very hands-on and demanding of her time and energy. Recently there was an outbreak of skin infections at one low decile school. As the families were having difficulties accessing health care, she arranged for the doctor to visit the school to run a free clinic once a week until the outbreak was resolved. "For some families, treating a skin infection is not a priority. I will follow up these children with daily visits and monitor the treatment until the infection is cleared. When children have impetigo or infestations of head lice, their learning is affected because they can't concentrate and are uncomfortable. It's great to see their learning improve once they get on top of their health problems."

For Havard, seeing individual children and their families gaining new health knowledge and learning to manage their health issues is all the reward she seeks. Although she would like to concentrate more on health promotion and population health, personal health in the area takes priority. One of her recent successes has been helping a boy with chronic eczema. Thanks to an application for some high needs funding, teacher aide hours were approved at the boy's school to ensure he had supervision with showers and help applying his creams. Havard applied for further funding to cover the boy's medication and for the purchase of several sets of cotton underwear, more suitable for his skin than the nylon he had been wearing. He was also referred to Kainuku for management of his asthma.

Recently the boy was able to attend a health camp in Otaki. "He was so excited about this trip," said Havard. "For him, it was as good as a trip to Disneyland. These days he is a different child, so much happier than when he used to sit in class scratching himself continually until he bled. Now he can learn and his teachers can get on and teach, no longer distracted by his behaviour."

A number of recent school mergers in the Wairarapa has seen several low decile schools absorbed into higher decile schools. The nurses have observed some real benefits arising from these mergers, as they believe a healthier societal mix is developing. "Initially there was a lot of 'white flight' when the mergers were announced," said Kainuku. "However, I think those families are the losers. The mergers are helping to raise health standards, as children from disadvantaged families observe and emulate the healthy behaviour and habits of children from more advantaged backgrounds. There is also a much richer cultural mix in these schools, which is of benefit to everyone."

Adolescent public health and sexual health nurse Karen Jamison runs a weekly sexual health clinic at Choice Health and works in secondary schools, running regular clinics and assisting teachers with the health curriculum. Both the teenage pregnancy and abortion rates in the Wairarapa are above the national average, with an upward trend in sexual diseases, reflecting national trends. "Often young people are just seeking the confidence to go to a doctor about their concerns," said Jamison. "They want to check out if what they have is really worth taking seriously, I'm a good neutral person to talk to. I work under standing orders from the hospital's sexual health clinic doctor. Otherwise I refer people to a GP for further treatment."

At Choice Health, many of her clients will come in off the street without appointments. Some come seeking help to purchase sanitary products or to manage their periods. "I know of many young women not attending school because of their periods, Some are having to use rags and wash them out. Government subsidies for these products would really assist people who are struggling financially."

Nearly two years ago, local doctor Cath Becker founded a GP clinic at Wairarapa's only total immersion Maori language school, Te Kura Kaupapa Maori O Wairarapa. The kura has a roll of over 100 and includes some secondary levels. The free clinic, funded by the DHB, is held each Wednesday for students at the school and their whanau. Like the nurses, Becker believes services need to be taken out to some communities in order to meet people's needs usefully. "Many of the people who come to this clinic are uncomfortable with or unable to access the mainstream health system. I believe a small health gain for one person in the family impacts positively on all family members and results in better health outcomes for the children at the kura. As people's 'health literacy' improves, people become more confident and assertive about obtaining medical care and are more willing to attend the mainstream medical centres for after-hours care."

Experienced practice and Plunket nurse Janine Vollebregt has recently joined Becker at the clinic. She records people's health histories, takes blood pressures, tests for diabetes and triages the patients. Both Becker and Vollebregt hope the clinic concept can be expanded to other parts of the Wairarapa this year.

As project manager for stage one of the nursing innovation Wairarapa Primary Health Care Nurses' Group, Vollebregt has been instrumental in setting up a new free health service for young people in the south Wairarapa. Based in Greytown, the service was opened in February and is aimed at a client base of 12-24 year olds, with the local Kurinui High School providing the core component. As clinic nurse, Vollebregt offers a range of services, including health assessments, pregnancy testing and education, nutritional advice, weight monitoring and referrals to other agencies.

"Research has shown that many young people in the Wairarapa cannot or do not access the health services they need," she said. "This service is the first of a number of nurse led, mobile clinics in a variety of locations. We are now advertising for some one to co-ordinate the establishment of the other mobile services."

Vollebregt believes this is a really exciting time for primary health care nurses. "Although getting the GPs on board with the new nursing model was difficult initially, they have now recognised the strength of us all working together to improve services in this region. The launch of the Wairarapa Community Primary Health Organisation at the beginning of the year should be another wonderful opportunity for all health professionals to work together to fill the service gaps."

Whaiora Whanui is one of three Maori health provider groups in the Wairarapa. Set up in 2001 by the whanau and hapu of Ngati Kahungunu, it now employs three registered and two enrolled nurses who work alongside a committed team of community health workers. Whaiora Whanui is a kaupapa Maori service that recognises and practises the traditional Maori standards that contribute to well-being Their main focus is those with identified health needs who have difficulty accessing medical services. This focus involves the pro motion of key health messages such as: giving up smoking, whanau wellness, being active, well children, regular wellness checks, eating well and a safe whanau.

Patients self-refer or are referred to the service from the hospital (eg district nurses, ward staff and midwives), from Choice Health or local GPs. The nurses believe winning people's trust and confidence is the key to their effectiveness, but this takes time to build. "We will follow up those patients who have missed out on their immunisations or cervical smears," said DSM nurse Gad Binns. "Our immunisation outreach programme enables us to immunise children in their own homes. The parents and their children need this service as many do not have transport and have difficulty accessing this service at their GPs."

Whaiora Whanui has recently signed a memorandum of understanding with the two other Maori providers in the region, Te Hauora Rununga O Wairarapa and Rangitaane O Wairarapa, This is another milestone in being able to work cohesively in the community, ensuring quality accessible health services are delivered.

Enrolled nurse Jean Kawana sees much of her role as an advocate for people needing help with a variety of issues. "At Whaiora Whanui, we look at health in a holistic sense. People's material and spiritual needs have to be met before we can deal with their physical needs. It's no good giving nutritional advice to someone whose cupboards are empty. A lot of our people, especially our older people, are quite shy and don't know what they are entitled to. It's great that they feel they can phone up this service to get advice and assistance.

"We have a good liaison with other community services and are happy to accompany people to these services to give them the confidence to seek the information they require in order to make good choices. Some people don't understand what the doctor is saying or can't hear what is being said. Others don't like to watch their babies being immunised."

Like other primary health care nurses, Binns is determined to see people get in formation that enables them to make positive health choices. Like the rest of the team, she believes the work being done by the Maori providers is the key to encouraging wellness in the next generation. "If young people have a better understanding about what causes diseases like diabetes and asthma, then I am confident they will make good health choices. It may take another few years but I am sure the health statistics in the Wairarapa can be improved."

PROFILING WAIRARAPA'S HEALTH NEEDS

AN ASSESSMENT of health needs in the Wairarapa, prepared for the district health board by the Wellington School of Medicine and Health Sciences three years ago, clearly showed the Wairarapa had greater disadvantage in a whole range of socioeconomic and health measures relative to the New Zealand average. (1)

The population of the region is 38,000, 16 percent of whom are Maori and two percent Pacific peoples. However, the percentage of Pacific peoples is growing, Just under half the population live outside the main towns, with a larger percentage of older people compared with New Zealand overall. Two main groups are identified as having high health needs in the district: those of low socio-economic status and Maori. Hospitalisation rates for injuries are high, including injuries resulting from motor vehicle crashes, for falls in the over 65 age group, and for children suffering unintentional injuries, burns and poisonings. There are high numbers of pregnancy related complications in the 15 to 24 age group, a high postnatal mortality rate for Maori babies and a low cervical screening rate. Immunisation rates also appear low.

Rural populations appear to have high health needs and are relatively under-serviced, with low numbers per capita of GPs, nurses, dentists and pharmacists. The three Maori health providers are also stretched to provide services.

The lower socio-economic status of some intense pockets of deprivation in Masterton and South Wairarapa means fewer people have cars and phones in an area where public transport is poor or nonexistent. This further compounds people's access to health and other services. Maori incomes are lower than Maori incomes nationally and are around 53 percent of non-Maori incomes. Maori unemployment is on average three to four times the non-Maori rate. Masterton's unemployment rate is the highest in the district.

Smoking rates among people over 15 are higher in the Wairarapa than nationally. Highest rates are found among Maori and young women. There are also higher cancer death rates than the New Zealand average, and higher rates of hospitalisation for diabetes and asthma for both Maori and non-Maori. Respiratory infections are the commonest cause of avoidable hospitalisation for Maori.

REFERENCE

(1) Wellington School of Medicine and Health Sciences (2001) An Assessment of Health Needs in the Wairarapa: Te Tirohanga Hauora O Wairarapa. The Wairarapa District Health Board.