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Improving the health of Pacific peoples

Pacific peoples are more exposed to adverse health determinants than the overall New Zealand population.

The health-care system’s lack of responsiveness has a significant impact on health outcomes for Pacific people. “In contrast to other population groups, Pacific peoples have benefited the least” from health services (Tiatia, 2008). For example, Tobias and Yeh’s research (2009) suggests that the number of avoidable deaths among Pacific peoples could be reduced by improving access to, and the quality of, health services for Pacific peoples.

‘Ala Mou’i, Pathways to Pacific Health and Wellbeing 2010 – 2014 (Minister of Health and Minister of Pacific Island Affairs, 2010) identified the need to build on community connections to increase Pacific peoples’ participation at all levels of the health sector. It also identified a need to strengthen the evidence base, increase health knowledge and understanding among Pacific families and communities, and encourage community ownership and action. ‘Ala Mou’i, Pathways to Pacific Health and Wellbeing 2010 – 2014 also identified enhancing service responsiveness through development of cultural competencies across the health workforce as a priority.

The following sections describe approaches that could be used to improve the health outcomes of Pacific peoples in New Zealand. Interventions that have been used locally are discussed in conjunction with international experience and recommendations. The interventions discussed include those that work at a population level. These do not necessarily have a Pacific-specific focus. In view of Pacific peoples’ greater exposure to health risk factors and lower socio-economic resources, it is expected that a universal population health approach would have a relatively greater impact on this group.

Initiatives to protect and promote Pacific peoples’ health

The New Zealand Government’s plan for improving Pacific health is set out in ‘Ala Mo’ui: Pacific Health and Wellbeing 2010 – 2014 (Minister of Health and Minister of Pacific Island Affairs, 2010). This plan recognises the need to provide better services close to home, to support effective Pacific providers and models of care, and to better enable Pacific peoples and communities to be healthy. Social and economic issues, such as access to early childhood education, achievement at school, and warmer housing, must also be addressed to improve health outcomes.

Pacific peoples, including the young, are significantly more affected than other ethnic groups by poor nutrition, obesity, and smoking. Pacific peoples are also more likely to develop obesity and smoking-related diseases (such as type 2 diabetes and cardiovascular disease). The health outcomes for Pacific patients with these diseases are worse than those for the rest of the New Zealand population. Pacific peoples are also more likely to experience more severe forms of diabetes and cardiovascular disease than the overall New Zealand population (Ministry of Health 2008b). Pacific young people also appear to be more vulnerable to developing harmful drinking patterns.

A multi-faceted approach to reducing the levels of risk factors present in society needs to be taken in order to address the health issues faced by Pacific peoples in New Zealand. Government plays a crucial role in achieving lasting change in public health. As well as government input, community ‘ownership’ of initiatives is essential if these initiatives are to effect real change. The value of using a broad-based approach to promoting healthy behaviours has been demonstrated internationally.

The Australian government acknowledges the need for a preventive health approach, accepting many recommendations of Australia’s National Preventative Health Taskforce, including the establishment of the Australian National Preventive Health Agency. Australian Minister of Health Nicola Roxon emphasised that “preventative health is now here to stay at the heart of our health reform agenda” (Australian Government, 2010). Australia’s National Preventative Health strategy outlines a comprehensive approach to addressing smoking, alcohol consumption, and obesity. It recommends that all levels of government, businesses, the non-government sector, and communities need to be involved in preventive health initiatives and policy. Improving public health and promoting healthy behaviours is a continual process and people need to be engaged across the various facets of their lives to inform, enable, and support them to make healthy choices. Food, alcohol, and tobacco markets can be influenced through taxation, regulation, and coherent policies. All groups in society should have equal access to health-care services and primary healthcare should be refocused towards prevention of disease (National Preventative Health Taskforce, 2009).

Similarly, the World Health Organization’s Global Strategy on Diet, Physical Activity and Health (2004) recommends taking a multi-faceted approach to preventive health interventions and policies. The strategy provides a framework for policy development, implementation, and assessment. It acknowledges the importance of food marketing and food labelling and suggests that the delivery of information to the public should focus on improving public awareness and improving health literacy levels. The strategy recommends that central and local government promote physical activity and design transport polices that ensure the accessibility of walking and cycling. Physical activity should be encouraged both in the workplace and for recreation. School policies should also support the adoption of healthy diets and physical activity.

The United Kingdom (UK) has produced a cross-government strategy, Healthy Weight, Healthy Lives: A Cross-Government Strategy for England (Department of Health, 2008) to address the increasing number of Britons who are overweight or obese. The strategy acknowledges the responsibility of the private and voluntary sectors, government, as well as personal responsibility.

Action is focused on five areas:

  • promoting children’s health through promotion of breastfeeding, giving better information to parents, and the promotion of healthy diet and activities in schools
  • promoting healthier food choices through a healthy food code with industry, allowing local regulation of fast food outlets, and reviewing the advertising of unhealthy food to children
  • building physical activity into people’s lives, by ensuring that walking and cycling routes are considered in urban design processes
  • creating incentives for better health by working with employers and evaluating the role of individual financial incentives
  • providing personalised advice and support through dietary and activity services.

The assessment of extensive and consistent evidence suggests that taking a broad approach, at the population level, is the most effective way to prevent cardiovascular disease. Recommended actions for reducing cardiovascular disease focused on changing legislative, regulatory, fiscal, and voluntary behaviours. The UK’s Healthy Weight, Healthy Lives: A Cross-Government Strategy for England (Department of Health, 2008) recommends improving information about nutritional content and food labelling, restricting the marketing of foods to children, considering how agricultural policy may affect health, controlling food outlets, and making environmental changes to incentivise physical activity (National Institute for Health and Clinical Excellence, 2010).

The Healthy Eating – Healthy Action Oranga Kai – Oranga Pumau programme aims to improve physical activity and nutrition, and promote environments that support healthy lifestyles. It encourages government and non-government agencies to work together, as well as working with the food and advertising industries (Ministry of Health, 2008e). Areas of activity include schools, the workplace, and the primary health-care system. The Healthy Eating – Healthy Action Oranga Kai – Oranga Pumau programme was promoted through a social marketing campaign. Promoting breastfeeding, especially to Māori and Pacific women, was a key focus of this campaign.

Consistent with the strategy, New Zealand’s 2008/09 health targets included nutritional targets (Ministry of Health, 2008d). However, these targets were not included in subsequent years (Ministry of Health, 2009b). Funding for healthy-eating interventions and education has been reduced, with a greater emphasis on improving levels of physical activity and individual responsibility (Capital and Coast District Health Board, 2009). The requirement to serve only healthy food in school canteens has been removed (Minister of Education, 2009).

Pacific peoples’ health outcomes can be improved by providing better information, adjusting the cost of foods to encourage healthy food choices, empowering communities, and encouraging inter-agency cooperation. These mechanisms, along with workforce development, service responsiveness, and research into Pacific people’s specific health needs are discussed in further detail below.

Better information

Evidence suggests that in many areas of health, Pacific peoples do not have good information (Ministry of Health, 2008b). This means that they cannot make fully informed decisions about their health or that of family members. Generic information targeting the wider New Zealand population does not seem to be working as well for Pacific peoples. To increase understanding and knowledge, and to build health literacy within Pacific communities, public health information needs to be tailored to the needs of specific community groups.

Pacific young people are more likely to be non-drinkers, but if they do drink, they often do so at harmful levels. There is a lot of peer pressure to drink, and alcohol is accessed through friends and not consumed at home. There is little support for young people who do not drink and parents are not aware of their children’s drinking. The Alcohol Advisory Council’s (ALAC) Pacific Action Plan (2009) acknowledges the need to address these issues using a Pacific perspective. Education messages are more effective when presented in culturally appropriate ways and environments. ALAC aims to educate parents and communities, and to promote non-drinking as ‘cool’ (Alcohol Advisory Council of New Zealand, nd).

Alcohol marketing to young people encourages them to start drinking earlier and increases the amount consumed by those who already drink. Alcohol is a particular risk factor for Pacific youth. Regulating promotions that encourage increased consumption of alcohol (for example, supermarket discounting of beer) and the future control of advertising and sponsorship, as recommended in the Law Commission’s review of the sale and supply of alcohol, would reduce the alcohol-related problems experienced by Pacific peoples (Alcohol Advisory Council of New Zealand, 2010).

With regard to promoting informed choice, research suggests that there is a need to provide 'at a glance' information regarding the nutritional content of foods (Food Standards Agency nd, a), and that a ‘traffic light’ system is particularly well understood by the general public (Food Standards Agency nd, b). The current food labelling method in New Zealand is frequently misunderstood, particularly by Māori, Pacific, and low-income people. A ‘traffic light’ system for food labelling is better understood by shoppers, particularly Māori and Pacific peoples (Gorton, Ni Mhurchu, Chen, & Dixon, 2009). A voluntary ‘traffic light’ scheme was implemented in the UK and was supported by some in the food industry. A mandatory scheme was also proposed. This was supported by health organisations (Faculty of Public Health, 2008) but not adopted (British Broadcasting Corporation, 30 Jan 2008). ‘Front-of-pack’ food labelling is currently being considered by the Australia and New Zealand Food Regulation Ministerial Council. Submissions showed that food manufacturers are against a ‘traffic light’ system and in favour of a ‘nutrition labelling’ approach, with health organisation submissions supporting the opposite position. The New Zealand Government submission did not express a view on the merits of either option (White, Thomson, & Signal, 2010).

The 2007 Survey of Public Opinions about Advertising Food to Children showed that most parents and grandparents of children aged up to 13 years are very concerned about children being obese or overweight. They were also concerned about the contribution that the advertising of food and drink products to children makes to this problem. Over 80 percent are in favour of stopping advertising of unhealthy food and drinks to children (Phoenix Research, 2007).

A modelling study showed that control of television advertising is an effective and cost effective means of reducing childhood obesity and future disability (Haby et al, 2006). Advertising is self-regulated in New Zealand. Since 2008, a food-rating system has been applied to determine products that can be advertised to children. Some countries have laws which specify what can be advertised to children (Shaw, 2009).

Media campaigns which encourage people to give up smoking and controls on the promotion of tobacco products are more beneficial when used in conjunction with other measures (Ministry of Health, 2004a). Some New Zealand campaigns have been considered well targeted for their specific audiences, but international experience suggests that they could be made more effective. Media messages could be linked to messages on health warning labels on tobacco products and combined with tobacco tax increases. Campaigns to “denormalise” the tobacco industry could be used (Wilson, Thomson & Edwards, 2008). The graphic health warnings on tobacco products were heightened in 2008 (Ministry of Health, nd, g). The Government has recently further controlled the display of tobacco products in retail outlets (Ministry of Health, nd, d). Other options include extending non-smoking areas to mirror those in other countries, such as the United States and Australia. This would help reduce role modelling of smoking to children and add to the denormalisation of smoking within wider society (Wilson, Thomson, & Edwards, 2008).

Influencing cost

Influencing the cost of products and services can influence people’s consumption. Price changes can limit consumption of potentially harmful products and increase consumption of more healthy products. Pacific peoples are more exposed to adverse influences on health, such as smoking, poor nutrition, and being overweight, so measures that influence cost will benefit this group.

Increasing the price of cigarettes reduces the number of people who take up smoking as well as reducing the proportion of young people who smoke, and how much they smoke. Similarly, people with fewer financial resources are more sensitive to price increases (Ministry of Health, 2004a). In 2010, the Government increased the excise duty on tobacco products. The retail price of cigarettes increased by an estimated 8 percent. Further increases are planned over the next two years (Ministry of Health, nd, h) The consumption of alcohol is also price-sensitive, and price increases influence consumption by young people and heavier drinkers. Price increases reduce the prevalence of harmful drinking (New Zealand Law Commission, 2010).

Taxation of unhealthy food also has the potential to improve diet, which would reduce obesity and cardiovascular disease (Brownell & Frieden, 2009). For example, increasing the price of sweetened beverages, considered one of the drivers of the obesity epidemic, reduces their consumption. A tax can account for the societal costs of products not captured in the price the consumer pays (Brownell & Frieden, 2009; McColl, 2009). Revenue generated from taxes could be used to fund programmes to prevent obesity. Although there are shortcomings of the available evidence, it indicates that introducing food taxes and subsidies can improve health outcomes and these should be part of a comprehensive strategy to prevent obesity (Thow, Jan, Leeder, & Swinburn, 2010). The regressive nature of the taxes would mean poorer people would be more affected, but would also potentially derive greater benefits. Accordingly, this consideration has led to calls for taxation to be combined with subsidies for healthier food options (Brownell & Frieden, 2009).

A New Zealand-based randomised controlled trial comparing 12. 5 percent price discounts and tailored nutrition education showed significant and sustained benefits of discounts on healthier food purchases. One-third of the participants were Māori, one-third Pacific, and one-third non-Māori, non-Pacific peoples (Ni Mhurchu, Blakely, Jiang, Eyles, & Rodgers, 2010).

Heating homes is important for positive health outcomes, particularly for children, but the cost can be prohibitive. Currently, the Government is providing subsidies for insulation and the clean heating of homes. The subsidies are greater for those with Community Services Cards (CSC), and are accessible to homeowners and landlords where the tenant is a CSC holder. The majority of Pacific peoples rent their homes, but some insulation schemes have negotiated with landlords on behalf of tenants. The Energy Efficiency and Conservation Authority programme plans to insulate more than 188,500 homes over four years. However, the costs involved can still act as a barrier to participation.

Pacific peoples face financial barriers to accessing health care, and spending on health care is a lower priority for Pacific peoples. It is not surprising that access to preventive care is lower than in other groups, particularly when there is a financial cost. Cervical screening often incurs direct fees, in comparison; breast screening is fee-free. The Ministry of Health does offer some funding for free access to cervical screening for priority groups, including Pacific women. This is managed through district health Boards, while some Primary Health-Care Organisations fund their own initiatives (H Lewis, personal communication, October 2010).

Empowering communities

Working with communities is a key way to empower people and influence decision-making. The Ministry of Pacific Island Affairs (MPIA) works with Pacific communities to improve their well-being. For example, MPIA is currently working with Pacific community groups to identify ways to use community wealth in order to become community housing owners and providers of rental accommodation for Pacific peoples.

The Healthy Village Action Zones strategy is an example of government-community partnerships. The strategy was designed by the Auckland DHB to improve the health of Pacific peoples. Community groups and health providers work together – key areas of action are health promotion in communities, workforce development, and improving the responsiveness of mainstream health-care providers (Auckland District Health Board, nd). Community workers have worked within primary care services to enhance chronic disease management, to increase contact with patients, and improve understanding. Improving engagement with the health-care system for Pacific peoples is one of the objectives of the Pasifika Lotu Moui Health Programme in Counties Manukau. The programme is church-based, and other objectives include improving nutrition, increasing physical activity, and increasing smoking cessation (Counties Manukau District Health Board, 2006). The nutrition programme focused on Pacific groups and increased their nutritional knowledge, although it was acknowledged that ongoing education would be required to achieve behavioural change (Marinerway Consulting Group, 2006).

Evidence shows that community-level initiatives improve nutrition and physical activity, including among disadvantaged communities (World Health Organization, 2004). Evaluation of community programmes is required to demonstrate the local benefits, and to identify the most effective approaches. The impact of an initiative may not be seen until a number of years after it is introduced. Measures should be developed to assess the longer-term outcomes of interventions as well as shorter-term interim impacts, such as increases in levels of knowledge and attitude changes.

The Gambling Act 2003 requires territorial authorities to have a policy which states whether gaming venues are permitted in a district, and if so, whether there are restrictions on the number of machines. The objectives of the policy include preventing and minimising the harm related to gambling (Wellington City Council, 2010). The Ministry of Health helps territorial authorities develop gambling venue policies and promote awareness of, and community action on gambling (Ministry of Health, 2010e).

The density of alcohol outlets is related to overall alcohol consumption, as well as binge and underage drinking. High outlet density is more common in lower socio-economic neighbourhoods (New Zealand Law Commission, 2010). Giving local communities a greater influence over liquor licensing decisions in their areas has been proposed as part of the solution (ALAC, 2010).

To reduce smoking around Pacific children, Pacific solutions have been proposed. These suggestions include changing Pacific adults’ attitudes to smoking around children and educating adults on the benefits of avoiding exposure. Information about the harm that smoking causes, and about smoking cessation programmes, is more likely to be effective for Pacific families if it is framed as being about protection of vulnerable children and the well-being of future generations. Interventions that have a community approach, ‘for Pacific, by Pacific’ are needed (Lanumata Thomson, & Wilson, 2010).

Innovative ways of delivering services, including a community nutrition project and a patient self-management project (Counties Manukau District Health Board, 2007), have been tried as part of the Let’s Beat Diabetes Programme (Counties Manukau District Health Board, nd, a). The patient self-management project, which was part of this programme, showed demonstrable benefits (Massey University, Centre for Health Services Research and Policy, 2008).

The Let’s Beat Diabetes programme began in Counties Manukau in 2005, with a five-year plan. The programme aims to prevent and better manage diabetes with a ‘whole society, whole life-course, whole family/whānau’ approach. Its areas of action are wide, and include using social marketing to encourage behaviour change within communities, changing urban design, working to create a healthier food environment, working with schools to improve children’s health, and improving primary care management and integration of care services (Counties Manukau District Health Board nd, b). A 2009 overview evaluation showed progress across these areas, and enhanced community awareness and participation in healthy lifestyles (University of Auckland, Centre for Health Services Research and Policy, 2009).

Inter-agency cooperation

Initiatives to improve health outcomes by adjusting influencing factors require a multi-faceted approach with strong inter-agency cooperation and collaboration. For example, improvements in housing can contribute to improved health outcomes. In 2009, the Ministry of Health and the National Heart Foundation of New Zealand sponsored an international rheumatic fever and rheumatic heart disease control workshop. The workshop participants concluded that rheumatic fever in high-risk populations in New Zealand can be reduced to that of low-risk populations by 2020. Recommendations to achieve this were:

  • programmes that address household crowding should be continued
  • prevention activities in school- and community-based clinics in all high-risk schools should be implemented
  • a comprehensive health promotion plan for rheumatic fever should be developed
  • a web-based rheumatic fever register should be developed in order to improve the effectiveness of secondary prevention using monthly penicillin injections.

Implementing these recommendations requires input from the health sector, the public health services, and the housing sector.

Poor housing affects children more than adults, particularly children of low-income families, in larger families, rental dwellings, and more deprived neighbourhoods (Centre for Housing Research, 2010). Poor housing is associated with poorer health, educational, and social outcomes. There are a number of possible strategies to improve housing, and consequently, children’s well-being. These include improving the quality and security of the rental market through a rating system allowing comparison of dwellings, ensuring landlords have the incentive to supply healthy and affordable living conditions, and encouraging a wider range of providers into the market (Centre for Housing Research, 2010). Improving house heating has clear health benefits for asthmatic children in New Zealand (Howden-Chapman et al, 2008). Installation of house insulation has improved well-being and reduced time off work and school due to illness, for both children and adults (Howden-Chapman et al, 2007).

In addition to government subsidies for insulation and heating, the Ministry of Pacific Island Affairs has been working with other government agencies to achieve improvements in housing for Pacific families:

  • Department of Building and Housing – to promote awareness among Pacific peoples of their rights with regard to renting, and the assistance or products available that will improve the quality of their housing
  • Ministry of Social Development – to enable access to information about housing and other social benefits. Written information has been provided in Pacific languages and is also broadcast on Pacific radio stations
  • Housing New Zealand Corporation – to develop its Pacific strategy, Orama Nui - Housing Strategy for Pacific Peoples (HNZC, 2009).

Increasing the Pacific health workforce

Developing the Pacific health workforce will make a significant contribution to improving Pacific health outcomes. Pacific health and disability workers bring “connections with Pacific communities, personal understanding of Pacific issues, and Pacific cultural and language skills” (Minister of Health and Minister of Pacific Island Affairs, 2010).

Currently, the Pacific population comprises nearly 7 percent of the total New Zealand population, yet only 1.7 percent of all doctors in 2007, (Medical Council of New Zealand, 2008) and approximately 2.8 percent of all enrolled or registered nurses in 2006 (Health Information Service, cited in Minister of Health and Minister of Pacific Island Affairs, 2010 p11). Although the proportion of Pacific doctors has steadily increased from 1.1 percent in 2003, the Medical Council of New Zealand has noted that “Pacific doctors continue to be markedly under-represented compared with their proportion of the population” (Medical Council of New Zealand, 2008). The Health Workforce Advisory Committee also noted the reported shortage of Pacific health workers across all areas of the workforce, including mental health, allied and primary health, and support workers (Ministry of Health, 2006a).

The Health Workforce Advisory Committee recommended that increasing the proportion of Pacific peoples in the health workforce to more closely match the population should be a priority. The committee identified the need to attract, recruit, and retain Pacific health and disability workers, and made a number of recommendations. These included improving educational achievements of Pacific students, strengthening leadership within the health system, developing the cultural competencies and capacity of the existing workforce, and creating more supportive organisational environments. Some of the recommendations focused on priority health issues for Pacific peoples, such as developing the cervical and breast cancer screening programme workforce (Ministry of Health, 2006a)7.

A number of projects have been initiated to strengthen the Pacific health workforce, such as the Auckland DHB Parish Community Nursing Pilot established in 2004/05. The Pasifika Medical Association’s ‘Healthcare Heroes’ programme encourages high school students to pursue health science careers. The association also runs the ‘Students are our Future’ mentoring programme for health science students (Pasifika Medical Association, nd).

Healthcare heroes

The Pasifika Medical Association’s Healthcare Heroes programme takes an innovative approach to increasing the participation of Pacific professionals in the healthcare workforce.

The association is working with 21 schools with a low decile ranking and high numbers of Pacific students. Association members work with science teachers and career advisors to develop a clear pathway for science students through the school years, promote science as part of future career options, and to encourage schools to share best practices with each other. Mentoring of year 13 students, career workshops, and a student conference are proving successful in making students and their teachers aware of the variety of careers and the benefits of a future health-science career.

Otahuhu College is one of three colleges that have furthered this approach by establishing a Health-science Academy. From year 11, students are given the opportunity to focus on science. Additional resources are provided to enhance science teaching and students undertake healthcare-related workforce placements.

The programme is continually evaluated and what influence it has had will be assessed in late 2011. 

The number of Pacific health workers in mainstream services is improving and the Pacific health provider sector has grown significantly. There are three Pacific-governed-and -owned PHOs and three Pacific-governed-and -owned health providers that are part of general PHOs. This is widely recognised as a major achievement towards improving health outcomes for Pacific peoples. There are many Pacific providers offering a wide range of services, and work is underway to develop the workforce capacity, building on the increases that have already occurred.

The Pacific Provider Development Fund (PPDF) was introduced in 1998 and provides targeted funding to help increase the accessibility and effectiveness of health services for Pacific peoples. The PPDF supports the development of a qualified Pacific health workforce by assisting individual Pacific peoples to gain health qualifications as well as further skills and experience, and to develop the range and quality of services delivered by Pacific providers. The PPDF also funds the development of credible models of Pacific health (for both Pacific and non-Pacific providers) to increase the capability of health professionals to effectively interact with Pacific peoples. An evaluation of the fund found that PPDF investment had strengthened providers in the primary health-care sector (CBG Health Research Ltd, 2007). The scheme could be enhanced by improved planning, monitoring, and evaluation of projects and greater engagement with and support of providers (Ernst & Young, 2009).The Ministry of Health continues to support the development of Pacific providers and of a skilled workforce through the Serau – Pacific Provider and Workforce Development Fund Programme of Action 2009/10–2011/12 (Ministry of Health, nd, e). A major challenge for developing a strong Pacific health workforce is the generally lower levels of education success experienced by Pacific students, particularly the lower achievement in science (Ministry of Health, nd, e). There are some signs that the education system is performing better for Pacific students. In 2009, 27.8 percent of Pacific school-leavers were able to go straight into degree-level tertiary education. This number has more than doubled since 2002 (Ministry of Education, 2010).

Improving the responsiveness of services

While many of the issues Pacific peoples face when experiencing a medical problem, such as cost, are shared with other groups in the New Zealand population, there are issues that are specific to Pacific peoples. Differences in health outcomes show that there are issues for specific groups within the Pacific population. Systems and initiatives designed for the general population do not effectively engage Pacific peoples in health care and ensure effective treatment and follow-up services. For example, cultural attitudes and understandings about mental illness play a role in the low rate of Pacific peoples seeking help from GPs. The low rate of referral for mental health services and the high level of mental health issues, especially in Pacific young people, indicate a need to identify how best to engage Pacific peoples with appropriate professional services.

Research into lower levels of educational support for Pacific students shows that some teachers need to face their own expectations and understandings about Pacific students, including biases, cultural generalisations, and tokenism, before they can adopt new ways of working with Pacific students and their families (Alton-Lee 2003; Timperley & Robinson, 2001). Similarly, mental health professionals need to consider the underlying reasons for lower levels of follow-up or specialist support for mental illness provided for Pacific peoples. Methods to improve the effectiveness of mental health services should be developed.

The New Zealand Tobacco Use Survey 2008 (Ministry of Health, 2009a) indicates that while Pacific smokers are as likely to attempt to quit as the total population, they are least likely to quit for the good of their own health and most likely to quit because of the cost. While the cost of nicotine replacement therapies is subsidised, there are other indirect costs to accessing cessation treatments. It has been shown that proactive cold-calling, retail displays of smoking cessation treatments at shopping centres, and the use of quit contests can overcome some of the barriers to treatment that Pacific peoples face (Glover & Cowie, 2010).

The Ministry of Health is responsible for leading tobacco control in New Zealand. Its strategy Clearing the Smoke: A five-year plan for tobacco control in New Zealand (2004-2009) aims to significantly reduce the levels of tobacco consumption and smoking prevalence and improve the inequality of health outcomes among different ethnic and socio-economic groups. The objectives of the strategy are: to prevent people from taking up smoking, promote smoking cessation, and prevent harm to non-smokers from second-hand smoke (Ministry of Health, 2004a).

A more systematic approach to cessation interventions, called the ABC approach, has been promoted. Key steps in this approach are for health practitioners to ask about smoking status, offer brief advice, and offer evidenced-based cessation interventions – ABC. With respect to Pacific peoples it is noted that:

Pacific cultural competencies are crucial to better health outcomes for Pacific peoples, and in the context of ABC, remind us that health is more than simply the provision of health services, it recognises, healthy cultures, health environments, healthy lifestyles and healthy participation in the wider society.
(Ministry of Health, 2009c). 

As the majority of Pacific peoples access mainstream services, integrating cultural competence and accountability into mainstream services, particularly primary care (Ministry of Health, 2008f), will be key to improving responsiveness to the needs of Pacific peoples. The public health system needs to better meet the needs of Pacific peoples. Cultural competence is broadly described as “the capacity of a health system to improve health and well-being by integrating cultural practices and concepts into health service delivery” (Tiatia, 2008). Doctors’ lack of rapport with Pacific patients may limit their ability to provide effective health care to this group. Improving health professionals’ confidence in working with Pacific peoples may help to address this lack of rapport that many doctors feel (Davis et al, 2005). Effective means need to be found to roll-out the enhancement of cultural competence in the primary and secondary health sectors. The Cornerstone programme of the Royal New Zealand College of General Practitioners includes the requirement to maintain cultural competence of all staff (Royal New Zealand College of General Practitioners 2008).

To be effective, health-care providers need to engage Pacific peoples in meaningful discussions about health issues and treatment options. These discussions can be enhanced by knowledge about a person’s cultural background, and an understanding of their perspectives and knowledge.

Improving the evidence on Pacific people’s health needs

To be fully effective for Pacific peoples, policy decisions and health service delivery must be based on evidence about what Pacific peoples require and what works best.

There is now more specific information available about Pacific health outcomes. For example, until Te Rau Hinengaro: The New Zealand Mental Health Survey was carried out in 2002–03 very little was known about the prevalence of mental disorders in Pacific populations. Previous epidemiological (the study of the incidence and distribution of disease) studies did not have sufficient samples of Pacific peoples for meaningful analysis, and earlier measures of admission to mental health facilities typically under-counted Pacific peoples because of inadequate coding of ethnicity (Oakley Brown et al, 2006). The Pacific Health Chart Book 2004 (Ministry of Health, 2004b) provides a comprehensive health profile comprising health outcomes, service use, exposure to health risk factors, determinants of health, and indicators to allow Pacific peoples’ progress to be monitored. Information on immunisation uptake, oral health, antenatal care experience, and the economic impact of traditional gift giving has been provided by the Pacific Islands Families Study (Paterson et al, 2008). The study tracks the experiences of a cohort of children born in 2000 and their parents or caregivers. The Pacific Health Dialog journal provides a medium for the dissemination of research with a Pacific focus. Awareness of Pacific health research is promoted through Pacific Health Review.

The Alcohol Advisory Council of New Zealand (ALAC) considers that improved research and evaluation are required to better understand how to intervene to reduce the adverse consumption of alcohol in Pacific young people (ALAC, nd). Evidence about Pacific health issues and uptake of services is scarce. There are several reasons for this:

  • research/data collections often have insufficient sample size to allow sub-group analysis, or the groups are combined or prioritised (eg Māori and Pacific)
  • Pacific peoples have a high non-participation rate in surveys and research
  • methodology and analysis of data can fail to include issues that may be relevant to Pacific communities.

Research is required to determine how the steps in the clinical pathway, from onset of symptoms to passage through primary and subsequent care, interact and how this interaction influences health outcomes.

Many research limitations can be overcome by better research design and by engaging with Pacific peoples in a more proactive and tailored way. Strategies such as over-sampling of Pacific peoples should be automatic in any research design.

 

7. It is difficult to find data relating to the non-registered health and disability workforce.

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