Promoting Health in Aotearoa NZ

Louise Signal, Mihi Ratima, Louise Signal, Mihi Ratima

• Publisher: Otago University Press
• Year: 2016
• Print ISBN: 9781877578823
• eBook ISBN: 9781927322680
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

The health of the planet – and all of us who live on it – is under dire threat from factors such as climate change, obesity and new infectious diseases. Progressive health promotion is an approach that can counterbalance these threats with practice, policy and advocacy for health,well-being and equity. Promoting Health in Aotearoa New Zealand provides a rich scan of the health promotion landscape in New Zealand. It explores ways in which M?ori, and other, perspectives have been melded with Western ideas to produce distinctly New Zealand approaches. In doing so it addresses the need for locally written material for use in teaching and practice, and provides direction for all those wanting to solve complex public health problems.

Chapter 1

Introduction

LOUISE SIGNAL & MIHI RATIMA

Health promotion is an internationally accepted public health approach both within the health sector and across other sectors of society. Texts on health promotion in Aotearoa New Zealand are very limited, so overseas texts are frequently used in teaching and supporting public health practice. Often they are not appropriate to Māori, other New Zealanders, and the New Zealand context. This issue has been of concern to health promotion academics and practitioners for a number of years. This book aims to make a significant contribution to addressing this lack of relevant material. In particular, it provides an opportunity for key areas of health promotion competence to be explored and promoted to the public health workforce and those engaged in health promotion initiatives across all sectors. In doing so, it supports the Health Promotion Competencies (Health Promotion Forum of New Zealand 2012), the Generic Public Health Competencies (Public Health Association of New Zealand 2007) and the Public Health Workforce Development Plan (Ministry of Health 2007).

This book is written for everyone interested in promoting health, including students, practitioners and policy-makers in health and other sectors. It will be of interest to those promoting health across the health sector, in Māori and other NGOs (e.g. Tipu Ora, the Cancer Society, the Heart Foundation, and the AIDS Foundation) and to government agencies such as Accident Compensation Corporation (in accident prevention) and the New Zealand Transport Agency (in road safety). This book will also have wider relevance to an international audience with an interest in health promotion, for example to those concerned with promoting the health of indigenous peoples.

It is anticipated that the book will contribute to the improved quality of health promotion and public health process and outcomes, including reducing inequities, by:

• more clearly defining and articulating health promotion in the New Zealand context, including Māori health promotion

• enhancing the quality of health promotion knowledge, theory and practice

• informing Treaty of Waitangi-based practice

• promoting health equity

• contributing to enhancing community readiness to lead and/or benefit from health promotion initiatives, and

• supporting a better prepared and more effective workforce.

The book focuses on key aspects of health promotion thinking and practice, and not on specific health issues, risk factors or health determinants. This has been a deliberate strategy. We have concentrated on identifying the basic tenets of health promotion in New Zealand no matter what the issue being addressed. Issue-specific content is woven throughout the book as the various contributors illustrate their particular stories.

The book was conceptualised as a text that equally integrates Māori and Pākehā analysis, consistent with an approach that emphasises the Treaty partnership and indigenous rights. We have endeavoured to achieve this by the structure of the book, by the key themes that run through it, and by collaboration between Māori and Pākehā as editors, advisors and contributors. It is signalled by the use of the phrase ‘Aotearoa New Zealand’ in the title and in each chapter.

The contributors come from a wide range of backgrounds and experience, both in health promotion and in their lives, as can be seen from their biographies. This means that topics have been written about from different perspectives using a range of theories and approaches. While this diversity provides richness to the text, in some instances it has resulted in the same issue being discussed in different ways. We see this as a strength of the book as it illustrates the diversity that is health promotion, emphasises that health promotion is a living concept that continues to evolve, and provides further points for debate.

What is health promotion?

In 1986 the World Health Organization (WHO) joined with the Canadian Federal Government and the Canadian Public Health Association to hold the first international health promotion conference in Ottawa. The main output of the meeting was the Ottawa Charter (World Health Organization, Health and Welfare Canada, & Canadian Public Health Association 1986), a brief document that has come to define health promotion internationally. It is this document that we use to define generic health promotion in this book.

The Ottawa Charter defines health promotion as ‘the process of enabling people to increase control over, and to improve, their health’ (World Health Organization et al. 1986, 2). It is defined as a method to enable or facilitate people and therefore aspires to be empowering rather than dictatorial, patronising or disabling. Whether it always succeeds in this ideal is another matter, and one we explore in this book.

The Ottawa Charter defines health broadly as ‘a state of complete physical, mental and social well-being’(World Health Organization et al. 1986, 2). This is the definition of health contained in the 1946 constitution of the WHO (World Health Organization 1946). The definition has been criticised for having no boundaries to what is encompassed by health – that is, for being so broad as to be meaningless – and for requiring health to be complete when many people live full and active lives with health problems (Rootman & Raeburn 1994). It has also been criticised for omitting spirituality as an aspect of health (Khayat nd), an issue of particular relevance in the New Zealand context due to its inclusion in Māori models of health (Durie 1998). Despite these valid concerns, this definition provides an aspirational goal for health promotion that clearly sets a broad agenda.

Next, the Charter identifies a wide range of prerequisites, or determinants, of health including peace, shelter, income, a stable ecosystem, equity and social justice. It foreshadows the wide range of potential areas of health promotion activity and highlights the emphasis health promotion places on addressing inequity. Some of the roles that health promoters can play are then identified. Included here are advocate, enabler and mediator, although there are others such as community leader, policy analyst, educator and social marketer.

A comprehensive range of health promotion strategies is also highlighted. First, at the policy level, the strategy of building healthy public policy is identified as a process that ‘puts health on the agenda of policy makers in all sectors and at all levels, directing them to be aware of the health consequences of their decisions and to accept their responsibilities for health’(World Health Organization et al. 1986, 3). Hancock (1985) clearly defines this concept and distinguishes it from health care policy. Second, is creating supportive environments. This includes the ‘protection of the natural and built environments and the conservation of natural resources’ and ‘living and working conditions that are safe, stimulating, satisfying and enjoyable’. (World Health Organization et al. 1986, 3, 4). While this is presented as an action, and is crucial to health, it is an outcome that uses actions such as healthy public policy, community action and personal skills development to achieve it. It is useful to recognise that creating supportive environments is an outcome, otherwise it can be confusing to consider how best to act in this domain. Third, is strengthening community actions through empowerment and self-determination. Fourth, is developing personal skills through ‘providing information, education for health, and enhancing life skills’ (World Health Organization et al. 1986, 4). Fifth, is reorienting health services beyond clinical and curative services towards health promotion and to a focus on the whole person. Finally, the document calls for international action to advocate for the promotion of health, a call that has been picked up to some extent by nations throughout the world.

In summary, health promotion acknowledges that health is a complex concept determined by a wide range of factors. Therefore, health promotion identifies a complex set of solutions at multiple levels: at the individual, community and societal levels and through the health sector. It is not looking for single solutions to complex problems. It is this fundamental component that we believe makes health promotion so attractive.

The Ottawa Charter integrates working at an individual lifestyle level and structural policy-based approaches. Baum (2002, 34) notes that this integration is ‘perhaps the genius of the Ottawa Charter’. Certainly, our experience has been that those with conservative agendas can use the Ottawa Charter to focus on individual responsibility for health and the promotion of healthy lifestyles. Equally, those with more radical agendas can use it to promote community development and structural change at the policy level. Stone (1988) argues that the most powerful concepts are those that are ambiguous, ones that everyone can see their face in and therefore ones that everyone can agree with. It is this ambiguity, this genius of those who wrote the Charter, which means that policy-makers and practitioners support this framework and use it to emphasise individual, community or structural approaches according to their politics.

A further level of integration that the Charter achieves is to combine ‘the distinction between health promotion as a bureaucratic entity or formal domain of study and practice, as opposed to health promotion as a process concerned with empowering people to take control of their own health’ (Pedersen, Rootman & O’Neill 2005, 255). It is our aim, in this book, to take a similarly integrated approach.

What is Māori health promotion?

The concept of Māori health promotion draws on both Māori and Western traditions and aspirations (Ratima 2001). It is grounded in Māori worldviews and realities, and therefore Māori beliefs, values and aspirations are at the core. Māori health promotion is identity-centred and seeks to improve Māori health as a foundation for the achievement of individual and collective potential. At the same time, Māori health promotion draws on the best of wider local and global health promotion knowledge and experience that is relevant to Māori contexts. Māori health promotion therefore recognises or incorporates many of the determinants, values, principles, processes and strategies outlined in the Ottawa Charter. As well, it shares a fundamental goal of enabling people to increase control over, and improve, their health – though health is more broadly defined to explicitly include spiritual and other dimensions. Māori health promotion is discussed in detail in Chapter 3.

Why undertake health promotion in New Zealand?

Health promotion in New Zealand is critical given the instrumental value of health. That is, that good health is a foundation for the achievement of potential for individuals, groups of people (including families, whānau, hapū and iwi) and society as a whole.

There is seemingly much to celebrate about health in New Zealand. Life expectancy continues to increase and is well above the Organisation for Economic Co-operation and Development (OECD) average, and we have one of the highest OECD rates of adults reporting to be in good health (89 per cent) (OECD 2013). However, these averages obscure important health issues and inequities in health that demand attention. Paramount among these is that Māori life expectancy at birth is at least eight years less than that for non-Māori (Blakely, Tobias, Atkinson, Yeh & Huang 2007). Further, findings from the 2011/12 Health Survey show that ‘Māori and Pacific adults generally experience disadvantage across all indicators of health status and access to health service … [and] many health conditions are more common in people living in more socioeconomically deprived areas’ (Ministry of Health 2012, ix).

While the daily smoking rate continues to fall, with less than one in five adults now smoking (17%), there are substantial inequities with two in five Māori (41%) current smokers. Our obesity rate continues to climb from 19% for adults in 1997 to 30% in 2013/14, and is much higher in Māori and Pacific adults (46% and 67% respectively) and for people living in more deprived areas. Obesity is a major risk factor for heart disease, type 2 diabetes and some types of cancer. The rate of diabetes is higher among Māori (7%) and Pacific (9%) adults than the national average (6%) (Ministry of Health 2014), and there are much wider disparities in terms of complications which are likely due to differential access to, and quality of, diabetes care (Harwood & Tipene-Leach 2007). Further, more adults have been diagnosed with a mood and/or anxiety disorder at some time in their life (13% in 2006/07 compared to 18% in 2013/14). Overall, 6% of adults had experienced high or very high levels of psychological distress in the last four weeks, and there are wide ethnic inequities with Pacific and Māori adults more likely to have experienced psychological distress (13% and 9% respectively). There has been a decrease in the percentage of adults who are hazardous alcohol drinkers from 18% in 2006/07 to 16% in 2013/14, but Māori rates are higher at 30% (Ministry of Health 2014).

We have unusually high rates of infectious diseases such as acute rheumatic fever (largely only a problem among Māori communities), meningitis and skin infections, and there are substantial ethnic and socioeconomic inequities in infectious disease incidence that are increasing (Baker et al. 2012). Further, New Zealand has one of the highest rates of melanoma in the world (Erdmann et al. 2013).

While New Zealand is often regarded as a ‘great place to bring up children’, New Zealand’s child health outcomes compare poorly internationally. In a 2009 OECD report, ‘Doing Better for Children’, New Zealand ranked 29th out of 30 countries for child health and safety (OECD 2009). In fact, some of New Zealand’s disease patterns among children are closer to those of developing countries (Public Health Advisory Committee 2010, vii).

There are important health issues and inequities in child health. For example, 10% of New Zealand children are obese. Obesity rates are higher among Māori (15%) and Pacific (25%) children, and children living in the most deprived areas (18%). Asthma is common in childhood with 15% of children taking asthma medication; the rate is higher in Māori children (21%) (Ministry of Health 2014). Māori children report more frequent and severe symptoms and have higher rates of hospitalisation for asthma. Poor access to preventative care and differences in asthma treatment by ethnicity contribute to inequities (TMG Associates 2009).

Comparatively, total life expectancy in New Zealand is above the OECD average but lower than a number of countries such as Spain, Italy and Australia. While we are one of the OECD leaders in reducing smoking for the total population, this is not true for Māori, as noted above, and we have one of the highest OECD obesity rates. New Zealand also has above the OECD average rates of mortality from heart disease, all cancer mortality and infant mortality. While we are below the OECD average for stroke, traffic accidents and suicide, this total population figure again masks considerable inequities. Further, we fare worse than Australia in many arenas, including heart disease, all cancer mortality, diabetes, suicide and infant mortality (OECD 2013).

There is much that health promotion has contributed to improving health in New Zealand. However, there is still much to do to impact on preventable health issues, address the determinants of health and eliminate inequities in health.

Challenges faced in writing this book

One of the challenges in writing this book is the difficulty in isolating the impact of health promotion initiatives on health outcomes given the complex array of influences that prevail. However, a...

Table of contents

• Front Cover
• Title Page
• Copyright
• Contents
• Dedication
• Mihi
• 1. Introduction
• 2. The origins of health promotion
• 3. Māori health promotion
• 4. Pacific health promotion
• 5. Health promotion and immigrant communities: Lessons from a case study of Indian immigrant women in New Zealand
• 6. Health promotion evaluation and intervention design
• 7. Ethics and health promotion
• 8. Promoting health equity
• 9. The politics of health promotion
• 10. Hauora, health and wellbeing: The right of every child and young person
• 11. Promoting health through the health care sector: Insights from primary care
• 12. Settings-based health promotion
• 13. The health promotion workforce: Challenges and opportunities
• 14. Critical reflections and future challenges
• Contributors
• Acknowledgements
• Index
• Back Cover