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This grant is a Vocational Training Team (VVT) designed to train a Core Training Team and Certify Conference Presenters to train front-line health center nurses in the early detection of streptococcus pyogenes infections to facilitate a reduction of Rheumatic Heart Disease in Rwanda. The Health Center nurses work in poor areas without physician support. A segment of the project will also train community health workers and school teachers so they can encourage parents to seek earlier treatment for children with sore throats.
Problem Description - Rheumatic Heart Disease
Rheumatic heart disease (RHD) is an acquired autoimmune heart disease caused by prior Group A streptococcus pyogenes infection (strep throat and impetigo). RHD is a crucial public health issue worldwide. Every year the disease claims 300,000 lives of children and another 100,000 young adults (Dass & Kanmanthareddy 2021; Noubiap et al., 2019; Zuhlke & Peter et al. 2022). Despite the persistent high incidence and prevalence of RHD in low-income countries, well designed multi-pronged educational activities for healthcare providers and communities are lacking.
RHD is endemic in Rwanda with an estimated 40,000 children suffering from the disease. Rwanda is among the highest prevalence of RHD in the world (Mucumbitsi et al., 2017) and over 200 cases of severely symptomatic RHD diagnosed in Stage C/D Class IV heart failure per month. More effective strategies are needed for the prevention and control of this preventable disease that results in significant disabilities due to heart failure and premature death. Rwanda currently does not have access to Rapid Strep Test kits or ASO titer capabilities. Therefore, a clinical diagnosis of Strep Throat and impetigo with evidenced-based assessment, diagnosis, and treatment followed by education and skills for Acute Rheumatic Fever and Rheumatic Heart Disease is critical to reduce RHD incidence.
The training in this project will address culture, knowledge, skills, treatment, referral, and patient follow-up of RHD in the communities surrounding the five, level-two training hospitals selected by the Rwandan Government to receive cardiac education in 2024 though this project.
Epidemiology
RHD is the result of an autoimmune response from untreated and undertreated streptococcus pyogenes infection of either Strep Throat or Impetigo. In Rwanda (and in all sub-Sahara Africa) 40% of all sore throats are caused by Streptococcus pyogenes. Impetigo is also endemic. Unfortunately, the social determinants and epigenetics favor the autoimmune response on the M-proteins creating the cascade effect of connective tissue with acute inflammation impacting the brain, joints, renal arteries, and heart. Subsequent chronic inflammation of the mitral and/or aortic valves results in chronic heart failure, poor quality of life and early death. Acute Rheumatic Fever (ARF) can occur in 40% of the untreated and undertreated repeated Streptococcus pyogenes infections. 60% of ARF cases result in RHD. Autoimmune inflammation of the mitral valve and chordae tendinea causes significant scarring and shortening of the chordae tendineae causing significant regurgitation with left-sided heart failure. Mitral stenosis then develops.
Needs Description
Two past projects provide a foundation for this grant. 1) Specialized Cardiac Nurse (SCN) training conducted by Team Heart and the University of Rwanda in 2022-2023 and 2) Pilot Project by the Lander Rotary Club in Rwandan Nurses Saving Lives conducted in February 2023. Both projects showed a significant knowledge and skills gap of nurses that included a clear demonstration of the lack of skills in taking medical histories and an inability to conduct physical exams. These gaps presented in front-line Health Center nurses, district hospital nurses and nurses at graduate levels in nursing school. Further information is in the Community Needs Assessment.
Who Will Be Trained
The model followed in this training module was originally presented and later revised by Stuart Dreyfus in a paper in the Bulletin of Science, Technology, and Society. The model essentially discusses how an individual begins in the novice stage and, as new skills and knowledge are gained, progresses through a number of stages to end in the expert realm. The five stages of proficiency in the novice to expert model are: novice, advanced beginner, competent, proficient, and expert (Benner, 1982). When referenced in this project, the goal is to take one group from a competent level to expert and another group from advanced beginner to competent.
The VTT will train:
1. Group 1: CORE TRAINING TEAM = Five nurses and one physician. These healthcare providers already have a competent to proficient level of cardiac knowledge. They will be trained to become the country's content experts on the curriculum. As such, they will be the trainers of the Certified Rheumatic Heart Disease Conference Presenters (group 2) and presenters for the Rwandan Nurses Saving Lives conferences (group 4).
2. Group 2: CERTIFIED RHEUMATIC HEART DISEASE CONFERENCE PRESENTERS Two Non-Communicable Disease (NCD) nurses from each District Hospital Level II training center will be selected by each Hospital Director General to be the hospital's certified RHD presenter. These nurses have an advanced beginner to competent knowledge of cardiology and will be trained in the curriculum so they can assist in Rwandan Nurses Saving Lives Conference implementation. These NCD nurses will also be able to conduct conferences for their hospital staff and will assist in the evaluation.
3. Group 3 SCHOOL OF NURSING FACULTY. One nurse faculty from the School of Nursing associated with each of the District Hospital Level II training centers will be trained. This is a courtesy training with the intent to build relationships and introduce educational materials which might be considered for School of Nursing curriculum.
a. As an additional courtesy training, hospital directors will be able to invite nurses and physicians at the hospital to the training in an observer role. Again, the intent is to build relationships with leaders in the healthcare system and introduce educational materials.
4. Group 4: Up to 146 HEALTH CENTER NURSES . This group is the target audience for the Rwandan Nurses Saving Lives Conferences. The are front-line nurses, serving in remote areas without physician support. They are the first medical people to assess, diagnose, treat and possibly refer strep throat/rheumatic heart disease cases.
5. Group 5: Up to 160 COMMUNITY HEALTH WORKERS AND SCHOOL TEACHERS will be trained by the Certified Rheumatic Heart Disease Presenters (NCD nurses) the day before the Rwandan Nurses Saving Lives conference. The intent is to increase community awareness that strep throat can cause a fatal heart disease and that the health center nurses can assess, diagnose and treat the children. This training was recommended by nurses in the needs assessment.
Who Will Be Beneficiaries
• Communities. The 1.2 million Rwandans who live in the catchment area and who seek medical treatment (5 District hospitals designated by the government), which is potentially about 10% of the country's population.
• Group 1(Core Training Team)- They will increase their knowledge and skills on RHD, mentorship, conference implementation, and advocacy to stakeholders.
• Group 2 (District hospital NCD nurse) who become Certified Rheumatic Heart Disease Conference Presenters will upgrade their skills, knowledge, and mentoring techniques. This will benefit them, the patients they assess and treat, and the other healthcare professionals they train and mentor.
• Group 3 (School of Nursing Faculty)- They will gain understanding of the curriculum and receive course materials to provide education to the nursing students. They have the opportunity to observe and upgrade the quality of the nursing instruction in their nursing school. As well, nurses and doctors invited by the director generals of the hospitals will benefit by increased knowledge and skills.
• Group 4: Health Center nurses and the patients they assess and treat. Since nearly 80% of the health care provided in the country begins at this level, the patients they assess and treat are the primary beneficiaries.
o First, their patients are beneficiaries. Children with Streptococcus infections are the primary focus. In addition, this conference also discusses heart failure, which affects all ages. Therefore, all patients are truly the beneficiaries of the new knowledge and skills the nurses will obtain.
o Second, The nurses themselves are also beneficiaries. They will learn to take their first full history and physical, with the use of a stethoscope. This increase in knowledge and skills directly impacts professional identity and increases trust within the community. The nurses new critical thinking skills directly impact the children with potential Streptococcus pyogenes infections through better health care.
• Group 5: The Teachers and Community Health Workers
o Teachers will gain insight into the disease process, and signs and symptoms a teacher may see. This will enable teachers to discuss recommended treatment options with students and parents.
o Students are the beneficiaries because they have the potential for earlier and more competent health care and treatment.
o Community Health Workers (CHW) are often seen as wise people and parents listen to the CHW for decisions concerning using traditional medication versus seeing the Health Center Nurse. All Group 5 members will impact the community's health awareness.
Main Goals
1. Increase the frontline Health Center nurses' knowledge of the disease progression from Streptococcus pyogenes infection to RHD.
2. Increase the nurses' skills on assessments, diagnosis, and treatment plans concerning Strep infections, ARF, RHD, and HF.
3. Build a core group of content experts who will train, mentor, and advocate for sustainability and a national rollout of this education.
4. Build a sustainable process where the Core Team (Group1) trains Group 2 and together train Groups 3 and 4.
Future Insight
The overall vision is to train the front-line Health Center nurses as 80% of the healthcare in Rwanda begins at this level. These nurses are a critical component of the healthcare system and they work without physician support with limited knowledge and skills.
To achieve this vision, a series of events must take place beginning with developing a Core Training Team of Curriculum/Content specialists and constructing a group of Certified Rheumatic Heart Disease Conference Presenters who will train front-line Health Center nurses. This VTT is will develop a Rwandan expert Core Training Team who then Certify Rheumatic Heart Disease presenters and these two groups will then work together to present the the Rwandan Nurses Saving Lives conference to Health Center Nurses. Once the Core Training Team and Certified Rheumatic Heart Disease presenters are delivering correct and consistent education, mentorship, and support of nurses is in place, then Rwanda will be ready for a national rollout.
The Rwandan Nurses Saving Lives Conferences that train the front-line, Health Center nurses will increase the knowledge, skills, and confidence of those nurses and improve their abilities in recognizing, treating, and refer patients with signs and symptoms of Streptococcus pyogenes infections, Acute Rheumatic Heart Fever, Rheumatic Heart Disease, and Heart Failure. In addition to training the Health Center nurses, we believe a natural outcome of the trainings will be the strengthening of the relationships and networks between the Health Center nurses and District hospital nurses as this is the first program to bring a hospital's designated Health Center's nurses and the NCD nurse together in an educational setting that reinforces the importance of effective communication and team work to ensure smooth referrals and follow up. In addition, this training will naturally expand community awareness about the need to seek treatment for sore throats by training community health workers and schoolteachers.
All these steps will increase capacity among Rwandans to implement conferences in the future. The Core Training Team will have curriculum expertise. The Certified Rheumatic Heart Disease Conference Presenters will be able to participate in the trainings for Health Center nurses. Therefore, this VTT begins a process to transfer conference content and leadership to Rwandans.
Most importantly, for the future, the Rwandan government wants a future national roll-out and it is in their national strategy. Team Heart, a cooperating partner to this grant, is committed to looking for sources to support this program in an ongoing way with the Rwandan local Team Heart in the lead, and with the individuals trained in this grant as trainers. The results from this grant will help obtain sources of support.
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