Community and Health Workers Responses to Culturally Safe TB Ward at Atoifi Hospital, Solomon Islands. Rowena T. Asugeni Director of Nursing, Atoifi Adventist Hospital 12 th March, 2015

Background  Providing health service in East Kwaio is a challenge due to remote location, limited infrastructure, social and cultural issues  Historically m ajor barriers present for East Kwaio people to access services at Atoifi – particularly people from the mountains  Consequence is that although Atoifi is one of the best health care providers in the country, there are still major health issues in the nearby communities  One such health issue is Tuberculosis (TB). Although hospital here for 40 years – highest rates of TB are in Malaita  TB identified as a priority area for research and action

Background  During research capacity building in 2011 here in Atoifi, the hospital and community chose TB as a research priority.  Provincial TB Health Managers visited Atoifi in 2012 during research workshop.  A study was conducted in 2011 revealed barriers to access health service  Delays in accessing hospital services were:  Traditional medicine  Food  Loneliness  Transport/Distance  Cultural issues of TB ward being next to OB ward  As administrators, we decided to do something about this  In 2013 and 2014, TB Ward was re-designed and re-built to be culturally appropriate for Kwaio people

Aim  To explore community and health service responses to new culturally safe TB ward  This study was apart of my Master of Leadership Development course at Pacific Adventist University in 2014

Methods  Key stakeholder interviews and focus group including: a. Coast and mountains: chiefs, church leaders, teachers, women b. Health workers: registered nurses, nursing students, health administrators and TB Manager.  Voice recorded, transcribed and translated  Written responses transcribed  Data were thematically analysed using Microsoft Excel

Results 1. Reasons for relocation and re-development of new TB Ward Example 1. Culture “ Last time hospital keepim olketa (mountain people) just next to the place wea olketa women give birth lo olketa pikinini yia. Lo culture blo Kwaio, dat wan hem very! very! very! taboo something nao yia. Olketa man even olketa women never go next to a place wea hemi dirty and hem a curse. Dis kind wea OB ward hem stay next door lo place wea olketa man live, hem samting wea hem no accept lo culture”. (Female, Community participant 4, Interview). [“In the past, hospital kept them (mountain people) just next to the place where women gave birth to their babies. In Kwaio culture, such situation is a very! very! very! forbidden thing. Men even women never live next to a place that is unclean or a curse. Having obstetric ward next door to the place where men live, is something that is not culturally accepted”.]

Results 2. Culturally Safe Tuberculosis Ward: Operational Challenges Example 1. Disposal of sputum “ Sputum olketa no allowim fo flashim lo toilet, u flashim lo dea, u compensation too. But if olketa garem proper slush room fo olketa sputum an explainim lo patient why nao no can takem olketa sputum den torowe olbaot hem gud” (Male, Nurse Probationer 2, Focus Group 1). [“Sputum is not allowed to be flashed in the toilet, you flash there (toilet), you compensate too. But if they have proper slush room for sputum and explain to patient why not to carelessly discard sputum is important”.] Example 2. Gender " Wane ola e toto’o mola, tee ola ne ame lea na lauta noni ani leka mai ani aga afuia ta agea maka tobi, ngaia na gila ki ame siria (Male participant, Mountain hamlet). [" All of us just the same.. no one is higher than the other, however, ladies who are to take care of the TB patient must be free from menstrual period".]

Results 3. Culturally Safe Tuberculosis Ward: Opportunities for positive impacts Example 1. cultural awareness “…leader (mountain leader) ya nao bae hem orientatim olketa students or other RN fo u mi adjust according lo culture blo olketa lo dea. hao bae u mi treatim olketa, hao bae umi care fo olketa olsem in a way, bae hem no makem olketa feel out…” (Female, Nursing student 2, Focus Group 1). ["…leader (mountain leader) will orientate students or registered nurses so all of us will adjust to their culture. How we should treat them, how we should care for them in a way not to make them feel out"]

Results 4. Culturally Safe Tuberculosis Ward: Factors for sustainability Example 1. Appropriate leaders Olketa should advicim nao olketa gang wea stay kam lo bush yia, olketa should involve lo makem idea blo olketa fo fair wantaem blo u mi (Male, Nurse Probationer 1, Focus Group 1). ["They (health administrators) should advice those people from the bush, they should involve in sharing their ideas equal with our ideas".] Example 2. Appropriate leadership and management system. The right leaders are those with public health and community health oriented leadership experiences. Leaders who are willing to discern and work things through people and community. Leaders who do things through bottom-up approach and not top-down approach. Leaders who look at the community needs and try to build communities! rather than telling them what to do or leaders who abuse the right of the community. They can be church leaders who understands the need of the community because they are the head of the institution. Therefore, at the management level, church leaders are the ones needed to be recognised leaders for the new change.(Female, Health Administrator 1, Interview )

Discussion  The Change Management Process is under way with TB services at Atoifi – this is being directly informed by results from this study  Results from this study help to change from old TB work to new TB work  3 important factors cut across the results that help managers in the change management process: Health Culture Religion

Triangular Model A new found concept called “ Culturally Safe TB Health Triangular Model”.

Sustainable Leadership Model for CSTBW in Atoifi Hospital refers to “Connected Leadership”.

Current Situation  Although incomplete the new TB ward was used as an isolation ward for people from the mountains during recent measles outbreak  After the measles outbreak then TB patients admitted – again from mountains  Nurses attend to TB patients in new TB Ward and are gradually adjusting to a different way of delivering TB services  Patients from the mountain are now requesting that other diseases be diagnosed and treated in new culturally appropriate TB ward

Where to Next?  Further research is needed throughout the Change Management Process to evaluate the transition from old TB ward to new TB ward.  Further research with TB patients admitted to the Culturally Safe TB ward to ensure it meets the needs of people in Kwaio who require treatment for TB.  We need to investigate other hospital services to ensure they are culturally appropriate and providing services that suit all Kwaio people and use this to plan ongoing services.

Bao lea baita