Chronic disease in New Zealand

New Zealand is similar to other economically developed countries where chronic diseases contribute significantly to the nation’s mortality and morbidity. Cardiovascular disease is the leading cause of death and accounted for 41% of all deaths in 1999 (Ministry of Health, 2003a). Coronary artery disease is the major cause of these deaths, followed by stroke, which is also the greatest cause of disability in older people. Cancer ranks second as a cause of death, accounting for more than a quarter of all deaths in the late 1990s (Ministry of Health, 2002a). For the period 1991–2001, deaths from ischaemic heart disease and cancer exhibited a slow decline. Conversely, cancer registrations in the same period increased (Ministry of Health, 2005), partially influenced by the aging population. An epidemic of type 2 diabetes is occurring. By 2011, it is predicted that more than 2000 people a year may die from diabetes, double the figure for the early part of this century. Approximately 145 000 will suffer the human cost of living with the potentially disabling condition (Ministry of Health, 2002b). New Zealand faces further challenges with health inequalities present for Maori, Pacific Islanders and those from socio-economically disadvantaged circumstances (Ministry of Health, 2006a). For the MidCentral district, which includes Tararua, circulatory system diseases are the major cause of illness and the most important cause of mortality. Ischaemic heart disease is the most common cause of hospitalization in this category, representing 41% of all admissions (MidCentral District Health Board, 2005). Stroke and diabetes hospitalization is increasing yearly (MidCentral District Health Board, 2005). Digestive and respiratory cancers are the two most common cancer groupings causing cancer deaths. Maori have a higher than expected number of deaths from these causes (MidCentral District Health Board, 2005). Hospitalization in the Tararua district increased 17.8% from 1999 to 2001 and for the MidCentral district overall mortality was 10% higher than the national average for the same period (MidCentral District Health Board, 2005).

Service prioritization at a national level has emphasized the following health objectives: reduce smoking, improve nutrition, reduce obesity, increase the level of physical activity, reduce the incidence and impact of cancer, reduce the incidence and impact of cardiovascular disease, and reduce the incidence and impact of diabetes (Ministry of Health, 2000). Sedentary lifestyles, poor nutrition and obesity are recognized as significant risk factors contributing to the increase in non-communicable disease. They are major and increasing causes of preventable disease, disability and death nationally (Ministry of Health, 1999). Regionally the MidCentral district demonstrates a population that still has a large proportion of sedentary and inactive residents with 30% participating in less than 150 min of exercise in a seven-day period (MidCentral District Health Board, 2005). Fifty per cent of the same population consume less than the recommended five servings of fruit and vegetables daily with 56% of people considered obese or overweight (MidCentral District Health Board, 2005). Of the communities that make up the MidCentral District Health Board’s geographic area, Tararua has the second-highest proportion of current smokers at 24%, with Maori significantly over-represented (MidCentral District Health Board, 2005).

Primary health organizations and primary health care services

A strong primary care system is recognized as a necessity for improving the health status of the population generally and for reducing health inequalities (WHO, 1998). The government released the Primary Health Care Strategy in 2001 to provide direction for this sector. Subsequent development included changes in the way that services were organized as well as the method and level of subsidy of these services (Ashton, Reference Ashton2005). PHOs have been established and are the local structures for co-ordinating and delivering primary health care services in the community. They bring together a range of health professionals such as doctors, nurses, midwives, allied health professionals and Maori health providers, who are reflective of the local communities. This structure is expected to encourage integration of health care between providers, allow for multi-disciplinary teams and bring greater diversity than earlier primary care and public health structures have achieved. The PHOs are non-profit organizations and contract to district health boards to provide a comprehensive set of preventative and treatment services. Since their inception in 2002, PHO numbers have grown with 81 now operating throughout the country (Ministry of Health, 2007).

There is an expectation that PHO practice will implement both individual and population approaches (Ministry of Health, 2003b). To date, the population health role of PHOs is open to interpretation, how this relates to service delivery and other providers (Public Health Advisory Committee, 2006). Additionally, with the diversity in PHO size, demography, kaupapa, style of governance and public health capacity there is no typical PHO unit. Currently, there is significant variance in the interpretation of service delivery and how primary care and health promotion services are accommodated within the primary health care model.

Tararua PHO has an enrolled population of 15 241 (Ministry of Health, 2007) and as such is one of a number of smaller PHOs. The ethnic makeup of the Tararua community is predominantly European at 80% and Maori 18%. Both figures are proportionately larger than the national average, with the community exhibiting less ethnic diversity than nationally (Ministry of Social Development, 2006). The nature of the community with the population spread over many towns and settlements presents resource challenges. The community has some clear strengths. The people of Tararua actively contribute to community activities and respond to community needs with pragmatism and resourcefulness (Ministry of Social Development, 2006).

The purpose of establishing new structures for service delivery is to bring closer integration of primary care and public health. Public health has much to offer primary care, able to provide direction in promoting health, preventing disease and prolonging life. There is a substantial history of activity in the sector, working towards enabling people to increase control over and to improve their health. Amongst primary care providers, there is strong support for the integration of population perspectives and health-promoting practice but a degree of uncertainty about how this translates into service provision. With funding for health care from the Ministry of Health now devolved to district health boards (Ashton, Reference Ashton2005) there is significant potential for localized understanding of health and planned co-activity.

There is an expectation that PHOs will engage with their communities. In part, this has been achieved with community members involved in governance and opportunities for public participation in forums. The degree to which community expressed needs are prioritized depends on the facilitators’ health assessment, whether this matches the community view and the value placed on partnership. This variance in participation expressed as ‘community organization for participation’ is well described by Tones and Tilford (Reference Tones and Tilford2001). To date, service provision remains predominantly top-down but does emphasize the importance of enlisting community support and community networks. The inclusion of community development and empowerment approaches in programme planning is being encouraged from the public health sector. The approach has the ability to raise awareness of chronic disease and its determinants and engage the community to take action and ownership.

With service delivery expected to combine primary care, public health and community involvement into one integrated primary health care structure, there is a need to share information on practice, establish a knowledge base and emerge over a time with an evidence base of best practice for the sector.

Description of the Heartbeat Tararua service

Funding support for Heartbeat Tararua was made available through MidCentral District Health Board in recognition of the need for action on preventing and managing chronic disease in the Tararua District and to support the development of integrated primary health care services. It demonstrates the monies available through the devolution of funding that can now be supplied to providers at a local level.

Implemented in late 2004, Heartbeat Tararua is a lifestyle change programme designed to provide the opportunity for all people within the Tararua communities to make positive and informed choices towards a healthier lifestyle. It is a community-based programme focusing on the issues of obesity, nutrition, physical activity and smoking. It demonstrates an integrated format combining both primary care (clinical treatment for those at risk) and public health (population-based prevention services). The programme is additionally supported by a diabetes and cardiovascular screening service designed to improve access to primary care for those whose clinical condition, history and lifestyle factors indicate need (Ministry of Social Development, 2006).

The individual approach places an emphasis on high-risk groups; specified as those already suffering from ischaemic heart disease, obesity, type 2 diabetes and those at high risk of developing these conditions. Clients identified as ‘high risk’ are enrolled in the Heartbeat Primary Care Service, which provides specialist dietary, physical activity and smoking cessation advisors that plan and support a tailored lifestyle change process. Although no theoretical basis has been stated, the focus on the enhancement of personal skills through education and social support to promote individual behaviour change fits attitude, social influence and self-efficacy models. Enrolment in the service is most commonly by referral from a health professional, typically a general practitioner but other practitioner referral and self-referral is possible.

There is recognition that those at risk may not be accessing services. The population approach seeks to reach greater numbers of the community. It was implemented by accessing local community events through both small group meetings and gatherings as well as larger more formalized events. Prior planning in consultation with target groups resulted in tailored ‘awareness raising’ ventures which promoted the importance of healthy lifestyle choices. The approach was predominantly one of education, where a change in knowledge is expected to lead to changes in behaviour. Early implementation had a further objective of raising community awareness of PHOs and their extended service capabilities, including the individual Heartbeat Tararua service. The community responded promptly with high interest with both community groups seeking access for event planning and individuals wishing to enrol in the supported lifestyle change service. As is not uncommon with a primary care orientation, this programme has been initiated by health providers. In this instance it was well received and regarded as relevant to the community. The existing strong community networks and links with the programme manager were a significant factor in the rapid community acceptance and uptake.

The burgeoning popularity of the programme and interest in the individual service highlighted an approach that was high in demand on time and staff numbers and could only address a small number of the overall community. There was recognition of the need to ensure a service that sort to include those not currently enrolled with a service provider or accessing health care and catered for those who by limitation of numbers could not access the individually assisted service. Staff expressed the need to capture the community’s enthusiasm and respond with a more structured population strategy that was inclusive allowing all interested to participate beyond the event level. The situation represented a good platform to establish primary health care in the community with trust already established and the community demonstrating a willingness to be involved.

Support for integrated primary health care

The high-risk approach has significant potential for motivated individuals (Rose, Reference Rose2001). Research indicates that lifestyle education given to clients diagnosed with non-communicable disease is effective in creating positive lifestyle change. Study results have produced either a moderate effect (Gaede et al., Reference Gaede, Beck, Vedel and Perderson2001) or a more substantial effect (Steptoe et al., Reference Steptoe, Doherty and Rink1999; Clark and Hampson, Reference Clark and Hampson2001; Clark et al., Reference Clark, Hampson, Avery and Simpson2004). Those most effective in establishing and maintaining behavioural changes have intervened using counselling directed at behavioural and attitudinal change tailored specifically to the individual’s readiness to change (Steptoe et al., Reference Steptoe, Doherty and Rink1999; Clark and Hampson, Reference Clark and Hampson2001). In addition, French and Rosenberg (2005) demonstrated a relationship between cigarette smoking and other health behaviours. Smokers are also more likely to demonstrate poorer nutrition and sedentary lifestyles. This indicates that individually tailored programmes aimed to create behavioural change across the spectrum of nutrition, physical activity, obesity and smoking would be most beneficial to those at high risk rather than programmes targeted at single issues. It is well accepted that intervention efforts cannot be expected to change behaviour directly but need to address the mediators of behaviour change, as these need to be influenced to create changes in behaviour.

There is substantial recommendation for the inclusion of a population-based approach. Both Rose (Reference Rose1992) and Mittlemark (Reference Mittlemark1999) have demonstrated that there is often no obvious and clinically meaningful risk factor threshold that differentiates those at risk from those not at risk and focusing on those at the extreme end of clinical indicators is less efficient than improving the risk profile of the entire population. Furthermore, a population approach is beneficial as it encourages determination and action on a common cause (Rose, Reference Rose2001).

Both high-risk and community-based approaches are considered desirable for the challenges of preventing chronic disease (Harris and Zinman, Reference Harris and Zinman2000; Huot et al., Reference Huot, Paradis and Ledoux2003). There is encouragement for a more health-promoting-type practice. There is increasing support for community development (Rance and Manahi, 2006) with government working to establish and disseminate an evidence base to practitioners (Ministry of Health, 2006b). The Healthy Eating – Healthy Action Strategy (Ministry of Health, 2004) calls for an integrated and comprehensive approach to addressing nutrition, physical activity and obesity, highlighting the importance of both individual behaviour and the environment. The shift in emphasis from individually focused explanations of health has been driven by the recognition of the influences that social, environmental and political factors have on health. The Ottawa Charter, although still encouraging the development of personal skills, created a major thrust for creating environmental, social change and political activity (Tones and Tilford, Reference Tones and Tilford2001).

Public health for creating improved population health

The primary care sector is expected to incorporate public health activity with the emphasis on being responsible for a community population. Public health has an extensive history in the prevention of chronic disease particularly in the prevention of cardiovascular disease. Early programmes such as the North Karelia and the Stanford Three-Community Project used comprehensive community interventions drawing on social learning theory (Bandura, Reference Bandura1986) and the theory of planned behaviour (Ajzen and Fishbein, Reference Ajzen and Fishbein1980). Using the tools of education linked with enhanced social environments, behaviour change was sought at an individual level, with the expectation of creating change across a community. Second-generation programmes, the Stanford Five City Project, the Minnesota Heart Health Program and the Pawtucket Heart Health Program sought to increase behaviour change across the community using the previous foundation plus new theories of community organization (MacLean, Reference MacLean1994). Finally, third-generation programmes expanded existing foundations further; additionally, they targeted hard to reach populations, adapted intervention strategies to local realities and included empowerment approaches (Shea et al., Reference Shea, Basch and Lantigua1992; Paradis et al., Reference Paradis, O’Loughlin and Elliot1995; Macauley et al., Reference Macauley, Paradis and Potvin1997). To date, results exhibit modest success with programmes still lacking the desired depth of community change sought (Goodman and Yoo, 2005).

No single factor is likely to be the sole determinant of success or failure. Reasons for poor performance include limitations to the interventions and theories used as well as poor connection between programme design and implemented activities. To gain insight into design these components have been examined separately to elicit the particular combination of participatory involvement and intervention strategies that will provide the recommended framework for the population approach for Tararua Heartbeat.

Participatory approaches

Health promotion in New Zealand has made significant progress; however, to achieve greater gain there is a need to implement sustainable programmes (Wise and Signal, Reference Wise and Signal2000). Globally, participatory approaches are increasingly finding favour. Evidence suggests that communities can be mobilized to identify, plan, channel resources and undertake effective action for health promotion and health-enhancing social change (McLeroy, 1996). The underlying principal is one of community development through capacity building where the participatory process focuses on building community health promotion capacity through the process of organizational development (Simmons et al., Reference Simmons, Voyle, Fout, Feot and Leakehet2004; Sotomayer et al., Reference Sotomayer, Dominguez and Pawlik2007). Where personal, collective and relational skill development is used to assist in capacity building, the approach becomes one of empowerment (Braun et al., Reference Braun, Ichiho, Kuhaulua, Aitaito and Tsark2003; Reference Braun, Tsark, Santos, Aitaoto and Chong2006). The empowerment approach is underpinned by social capacity theory, where a multi-level ecological framework considers both individual psychological and behavioural conceptions (sense of community, collective efficacy – or empowerment, neighbouring and citizen participation) and institutional and community network-level conceptions (Perkins et al., Reference Perkins, Hughey and Speer2002). Endorsed by Perkins et al. (Reference Perkins, Hughey and Speer2002) the creation and establishment of common goals and empowerment approaches within localities where networks are limited or non-existent allows for the development of an organizational structure.

Where the programme meets an identified need in the community a favourable outcome is more likely regardless of facilitator (Balcazar et al., Reference Balcazar, Alvarado, Alcalay, Schindeldecker and Newman2001; Braun et al., Reference Braun, Tsark, Santos, Aitaoto and Chong2006; Jenum et al., Reference Jenum, Anderson, Birkeland, Holme and Graff-Iverson2006). The degree of participatory activity is varied and can be graded low to high (Brager and Specht, Reference Brager and Specht1973). Programmes that plan jointly between host agency and community (Balcazar et al., Reference Balcazar, Alvarado, Alcalay, Schindeldecker and Newman2001; Simmons et al., Reference Simmons, Voyle, Fout, Feot and Leakehet2004; Gracey et al., Reference Gracey, Bridge, Martin, Jones and Spargo2006; Sotomayer et al., Reference Sotomayer, Dominguez and Pawlik2007), or alternatively delegate some (Ronda et al., Reference Ronda, Van Assema, Candel, Ruland and Steenbakkers2004a; Reference Ronda, Van Assema, Ruland, Steenbakkers and Brug2004b) or all control to the community (Wagner et al., Reference Wagner, Wickizer, Cheadle, Psaty and Koepsell2000; Braun et al., Reference Braun, Ichiho, Kuhaulua, Aitaito and Tsark2003; Reference Braun, Tsark, Santos, Aitaoto and Chong2006) are well received. The participatory process encouraged an increased focus on health both with the individual and in the community. Wallerstein (Reference Wallerstein2002) notes the connection between the process of participation, empowerment and the level of community capacity, where increasing mastery of the social action process can aid in increasing the levels of civic engagement. Sustainability of initiatives is thus enhanced as community members feel better equipped and able to manage projects. Rifkin (Reference Rifkin1990) also reports on the sustainability of this approach. Having identified with the project and being involved in the process of managing it creates a sense of ownership. On a precautionary note high participatory activity does not necessarily lead to more successful outcomes as much rests with the remaining intervention design (Wagner et al., Reference Wagner, Wickizer, Cheadle, Psaty and Koepsell2000; Simmons et al., Reference Simmons, Voyle, Fout, Feot and Leakehet2004; Blumenthal et al., Reference Blumenthal, Fort, Ahmed, Semenya and Schreiber2005).

In the Tararua example, the shared agenda means that the potential to work collectively is high and that success for the programme is more likely if care is taken in reconsidering the design. Tararua also has effective community networks, which are likely to aid the speed of the work. However, where networks are slim or non-existent if care is taken in the empowerment and organizational process this should not limit success in other programmes. Additional time will be required in the implementation. Where interests differ there is a need to nurture a value for health amongst the community and recognize and treat as valid issues expressed by the residents. This indicates the need for flexibility in planning. This represents a fundamental shift in programme type moving from a health system-driven approach, to one that recognizes the value of community development.

Intervention strategies for the prevention of chronic disease

A systemic review on community-based intervention strategies for the primary prevention of diabetes found a predominance of behavioural type approaches (Goodman and Yoo, 2005). It is acknowledged that a change in knowledge will not necessarily bring about changes in behaviour. For many individuals a change in behaviour may offer little or no benefit and thus there is little or no motivation for change. Hence, intervention efforts have been directed towards addressing the mediators of behaviour change (Bartholomew et al., Reference Bartholomew, Parcel, Kok and Gottlieb2000; Bauman et al., Reference Bauman, Sallis, Dzewaltowski and Owen2002). Comprehensive programmes have sought the support of socio-ecological models of health with limited to modest success dependent on how each programme has operationalized the context. According to these models, health behaviours are influenced by the proximal intrapersonal and psychological factors plus the more distal social and physical environmental factors. Programmes have planned around these models in a variety of ways and can be seen to exhibit areas of action embodied by the Ottawa Charter: creating supportive environments, strengthening community activity or both. A common strategy to promote physical activity has been the formation of walking groups lead by lay health leaders or health services using existing resources (Bjaras et al., Reference Bjaras, Harberg, Sydhoff and Ostenson2001; Huot et al., Reference Huot, Paradis and Ledoux2003; Kelley et al., Reference Kelley, Baldyga, Barajas and Rodriguez-Sanchez2005). However, there is no indication of the sustainability of this approach either through something as simple as maintaining interest in inclement weather (Bjaras et al., Reference Bjaras, Harberg, Sydhoff and Ostenson2001; Kelley et al., Reference Kelley, Baldyga, Barajas and Rodriguez-Sanchez2005) or local action maintaining community interest (Huot et al., Reference Huot, Paradis and Ledoux2003). Interactive nutrition and/or physical activity sessions, educational and practical in nature have been commonly provided through existing health services and other providers (Huot et al., Reference Huot, Paradis and Ledoux2003; Ronda et al., Reference Ronda, Van Assema, Candel, Ruland and Steenbakkers2004a; Reference Ronda, Van Assema, Ruland, Steenbakkers and Brug2004b; Kelley et al., Reference Kelley, Baldyga, Barajas and Rodriguez-Sanchez2005; Staten et al., 2005; Gracey et al., Reference Gracey, Bridge, Martin, Jones and Spargo2006; McCarthy et al., Reference McCarthy, Yancey, Harrison, Lewslie and Siegal2006; Schuit et al., Reference Schuit, Wendal-Vos, Verschuren, Ronckers and Ament2006). By using group activities (that may or may not have included participatory process in intervention design) these reach larger numbers of the community. However, these still bear strong similarity to the individual approach in that they view health as predominantly an individual responsibility and have failed to achieve significant success. Raphael (Reference Raphael2003) is critical of these types of programmes as they have a propensity to focus on personal barriers to change. A comprehensive programme that identifies barriers across social, cultural, community and environmental factors has been recommended (Goodman et al., Reference Goodman, Yoo and Jack2006).

A particular challenge for the population approach is the need to provide an intervention that is suitable for diverse groups. Historically, public health has had its greatest successes when seeking change through environments and this should not be forgotten in the prevention of chronic disease. One intervention that targeted a low-income, multi-ethnic district initiated a chronic disease awareness campaign with a participatory problem-solving approach addressing low levels of physical activity in the community (Jenum et al., Reference Jenum, Anderson, Birkeland, Holme and Graff-Iverson2006). Similar to previous programmes, physical activity was encouraged by establishing walking groups. However, this programme also sought sustainable change in the physical environment making improvements to the availability and safety of the tracks. There were significant improved health effects on risk factors for type 2 diabetes and cardiovascular disease from participants (Jenum et al., Reference Jenum, Anderson, Birkeland, Holme and Graff-Iverson2006). However, the programme failed to capture young women and demonstrates the complexity and difficulty in reaching all members within a community. There is recognition of the physical environment as a resource for health in this intervention. Sloane et al. (Reference Sloane, Nascimento, Flynn, Lewis and Guinyard2006) have taken this further and argue that every community or neighbourhood is located within a ‘resource environment’ for recreation, food and other health-promoting or health-compromising goods and services and that defining, describing and measuring these resource environments will define and prioritize suitable interventions. This study developed tools for assessing nutritional and physical activity resources that were practical, user friendly and provided relevant information leading to community interventions that produced sustainable change in the environment. Conceptualization of features of neighbourhoods, influenced by factors such as income distribution and segregation, have to date mostly being ignored and should be considered more carefully in future planning.