Health Promotion in a New Zealand Setting: Working with

Health Promotion in a New Zealand Setting: Working with Families with

Children 0-5 Years

Trinie Moore, Angela Baldwin, Janet Gafford

5th National Rural Health Conference

Adelaide, South Australia, 14-17th March 1999

Proceedings

Trinie Moore

5 th NATIONAL RURAL HEALTH CONFERENCE

Health Promotion in a New Zealand Setting: Working with Families with Children 0-5 Years

Trinie Moore, Angela Baldwin, Janet Gafford

INTRODUCTION

The Royal New Zealand Plunket Society is the major provider of well childservices in New Zealand for families with children age 0-5 years. It is contractedby the New Zealand government to provide parenting education, clinicalassessment, and family/whanau care and support for all families in its caresupervision. As a national organisation, Plunket works with families in all areasof New Zealand, from the urban to the most remote isolated communities.

The Plunket Society’s vision is to ensure that “New Zealand children are amongthe healthiest in the world." The service visits approximately 91% of all newbabies, around 52,000 new babies every year.

The service delivery team comprises a complementary mix of staff with differentskills and training who employ a team approach to meet the health needs ofindividual families. These include: Plunket Nurse - a registered nurse with post-registration education in child and maternal health; Community Karitane andKaiawhina - workers who have received training in a wide range of parenting andfamily health issues so they can work alongside families by offering practicalsupport and education. Kaiawhina are Maori health workers who work in theirown community to support families. Plunket Kaiawhina work in partnership withlocal Iwi (tribal group), Maori health providers or other community agencies;Volunteers - provide additional support which includes facilitation ofneighbourhood support groups, management of car seat rental schemes andpromotion of safety initiatives in the community.

HEALTH PROMOTION FRAMEWORK

The Plunket Society uses a health promotion framework basing care delivery onthe Ottawa1 and Jakarta Charters2 and on the Treaty of Waitangi (the foundingdocument of New Zealand). The Ottawa Charter (1986) defined healthpromotion as "the process of enabling people to increase control over and toimprove their health."

In New Zealand the concept of health promotion needs to be examined in termsof the Treaty of Waitangi. When acting as Minister of Health, Prime MinisterShipley3 stated that:

1. World Health Organisation. The Ottawa Charter, Geneva: WHO, 1986.2. World Health Organisation. The Jakarta Declaration, Geneva: WHO, 1996.

196


“…the government affirms that Maori as tangata whenua hold a unique place in our country and that the Treaty of Waitangi is the nation’s founding document. To secure the Treaty’s place within the health sector is fundamental to the improvement of Maori health.”

The Treaty of Waitangi was signed on 6 February 1840 between 540 Maorichiefs and the representative of Queen Victoria, Governor Hobson. Thedocument forms the basis for bicultural relationships and understandings in NewZealand. The Treaty of Waitangi has three articles related to consultation,absolute sovereignty of Maori over their lands and treasures, and partnershipand equality.

The Treaty has particular relevance to rural health in areas where there is a highMaori population. This is especially significant because of the disparity in healthbetween Maori and non-Maori. Maori are at high risk of poor health outcomesfrom a number of child related causes of morbidity and mortality, for exampleSudden Infant Death Syndrome (SIDS), glue ear, asthma, and unintentionalinjuries.4

Implicit within the concept of health promotion is the idea of empowerment. Adefinition that the Plunket team understand and utilise in everyday interactionswith clients is “enabling a parent to develop personal capacity and authority totake charge of everyday family life."5 In a rural environment the families oftenhave developed many strengths from living in isolated areas and thereforehaving to be self reliant.

Another inferred concept in health promotion is the socio-ecological perspective.This perspective advocates that health providers work with people in theirnatural setting within the context in which they live. In a rural location, it views therural remoteness as a positive attribute and sees the potential that the family hasas a result of living in a rural environment.

Community integration is another important element to health promotion. Thisconcept acknowledges that no one programme can meet all of a family’s needs.6The provision of health services to rural areas goes beyond general practicesand hospitals and involves other primary care nurses, allied professionals andvoluntary organisations. Therefore different health, education and social welfareproviders need to recognise and acknowledge the strengths in each other’sspecialities and work together to provide for the optimal health of the client.7 Notonly do other service delivery providers need to recognise the strengths in eachother’s service but funders need to recognise this as well. Lack of incentives to

3. Shipley J., in Nursing Council of New Zealand Guidelines for Cultural Safety in Nursing and Midwifery Education Wellington: Nursing Council of New Zealand, 1996.

4. Ministry of Health. Progress on Health Outcome Targets, Wellington: Ministry of Health, 1998.5. Zerwekh, J. The practice of empowerment and coercion by expert public health nurses. IMAGE:

Journal of Nursing Scholarship, Summer 1992; 24:2: 101 -105.6. National Committee to Prevent Child Abuse Critical Elements for Effective Home Visitor Services

Chicago: NCPCA Publications, 1996.7. Moore, T. Baldwin, A. Gafford, J. Trout, F. Plunket Nursing in 1998. Primary HealthCare 1998; 1:2:

7-9.

197


collaborate has been an issue in rural health in New Zealand. Currently thegovernment is encouraging communities to consider a range of integrated carearrangements. It has been noted that integration initiatives seem to work moresuccessfully in small rural communities than in large urban ones.8 For examplerural Plunket clinics are often held in Community Centres and involve input fromother providers of health, education and social services.

An effective method of facilitating integration is by linking clients to communitynetworks, often on an informal basis. In New Zealand the Plunket Societyfrequently assists families to become involved in the local community throughinformal networking by holding education groups in small rural towns. Thispromotes clients meeting each other and arranging their own networks.

In a health promotion setting, it is important to work with people rather than forthem,9 in order to develop the client’s personal skills and enable them to makehealthy choices for their own and their family’s lives. To achieve this thecommunity health worker needs to endeavour to establish a partnership with theclient. This supportive one to one association is continuous and encouragesadult and parenting growth and change..10 The elements of a partnership withina therapeutic relationship enable community workers to use a problem solvingapproach for a variety of health priorities. This problem solving approachinvolves long term relationship building and appears to achieve results slowly. Itbuilds on family and client strengths.

Home visiting is often the most effective way to build this type of relationshipparticularly in a rural setting where appropriate facilities for other methods ofservice delivery are limited. The other advantage of home visiting is that it canreach people who otherwise would not receive the service because of a numberof barriers.11 12 This is especially relevant to the rural community where transportcosts or lack of transport means that clients and their families would be unable toreceive any well child and family services.

There are a number of factors that contribute to health outcomes and theseinclude general socio-economic, cultural and environmental conditions.13

According to the Ottawa Charter one of the principles of health promotion is toachieve equity of health outcomes. Rural families are entitled to the same levelof health status as urban families. In New Zealand this poses a challengebecause some distinguishing features of rural areas such as distance,

8. English, B. Rural Health Policy; Meeting the Needs of Rural Communities; Consultation Draft, Wellington: Ministry of Health, 1998.

9. Schulz, A. What is Health Promotion? Canadian Nurse August 1995; 31-34.10. Orr, J. Assessing individual and family health needs. In Luker, K., Orr, J, (Eds.) Health Visiting:

Towards Community Health Nursing (2nd ed.) Oxford: Blackwell Scientific Publications, 1992; p154. 11. Weiss, H. Home visits: necessary but not sufficient. Home Visiting; Future of Children 1993. 3:3: 113-

128.12. Wasik, B.H. & Roberts, R. N.) Survey of home visiting programs for abused and neglected children

and their families. Child Abuse and Neglect. 1994 18:3: 271-283.13. National Health Committee The Social, Cultural and Economic Determinants of Health in New Zealand:

Action to Improve Health Wellington: National Advisory Committee on Health and Disability, 1998.

198


population size and availability of providers and geography can combine to makeaccess to health services difficult.14 Of the health services, primary health carewith its prevention focus has the greatest ability to improve health outcomes.Successful primary health activities will reduce the risk and potential impact ofinjury and disease, prolong life, improve the quality of life and may reduce thenecessity for secondary health care services.15 However, ensuring equity ofhealth outcomes for rural populations presents difficulties for service delivery.

CHALLENGES ASSOCIATED WITH RURAL SERVICE DELIVERY

One of the major challenges associated with rural service delivery is the longdistances that need to be travelled for clients to be seen. This increases thecosts in providing the service. This increase in cost to provide a high quality ruralservice is not recognised by the funders. Plunket is funded approximately $31.00per visit to provide the service to all families but in the rural environment the costof providing a visit may increase to $60.00. Within Plunket, there is recognition ofisolation and associated needs. However, as this is not recognised by thefunders, it results in a lesser service because of the inability to provide the levelof service required.

The population based funding model for rural services adds complexity to ruralservice delivery. The lower population results in greater numbers of part timestaff in isolated areas. This impacts on staff supervision and education. ThePlunket Society believes that it is important to ensure that all staff are highlyqualified so at significant cost it will pay for staff to attend staff development daysin urban locations.

Supervision is difficult over long distances. Adequate management supervisionof staff is achieved through Managers having days of travelling to visit all thestaff. Many of the rural clinics have phones and faxes so that staff are able tocommunicate with management and receive information. Also, because of thelong distances there are often few peer relationships. The Society is presentlyexamining peer supervision models to assure that staff have adequateprofessional supervision which involves reflective practice and support.

Community expectations of health workers may pose difficulties for staff workingin rural environments. Staff are unable to disappear; as part of the communitythey are contacted at all times of the day or night to assist families with anyproblems experienced. This problem is by no means limited to the Plunketservice but to all rural health providers.

CASE EXAMPLES: HEALTH SERVICE DELIVERY METHODS IN THE


15. Ministry of Health. Strengthening Public Health Action: The Strategic Direction to Improve, Promote and Protect Public Health. Wellington: Ministry of Health 1997.

199


RURAL ENVIRONMENT

The Minister of Health's Rural Health Policy states “if you have seen one ruralcommunity, you have seen one rural community."16 In other words all ruralcommunities are different. In order to achieve equity in rural health, healthworkers need to examine the strengths and weaknesses of the community andwork with the people to enhance their health. As the needs in differentcommunities vary, diverse programmes need to be established in conjunctionand consultation with the local community. Communities are central todeveloping solutions that fit local needs.17 The Plunket Society works in differentways in rural communities to achieve health gains. The following examples showthese variances.

The first area is Kaikohe which is located in Northland, the far north of NewZealand. Northland, according to the census statistics has the second highestrate of unemployment in the country and the second highest proportion of peopleof Maori ethnicity18. In Kaikohe the Plunket Management Information Systemdata show that the majority of families with children 0-5 years are Maori (82%).According to Plunket staff, much of the housing is substandard and consists ofconverted caravans and tin shacks. There is often no running water or phonesand sanitation is poor. Positives of the area are that the families are usually wellfed and warm as they obtain their food and firewood from the land.

In this area access to any health service is difficult due to a number of reasons:

• Acceptability of the service - if services do not have the right staff ethnic mix,people are unwilling to use them.

• Isolation - much of the isolation results from poverty factors as familiescannot afford to get to any services.

• No phones - means it is difficult to contact families to arrange anappointment to visit.

• Transient population - this means that knowing where families are locatedcan be difficult.

The Plunket service has overcome some of these problems by appointing Maoristaff in the area. This makes the service culturally appropriate to the clientele.These staff have made the Plunket clinic more welcoming by Maori and Englishsignage and Maori posters and carvings.

The Plunket service combats the isolation in this region by home visiting for aslong as people require it and organising for the families to drop into the Plunketclinic when they are in town to do their shopping. Isolation is also decreasedthrough different services working together to integrate and co-ordinate theircare to families. For example, if a midwife is going to see a family one week, the



18. Statistics New Zealand Census 96: Regional Summary Wellington: Statistics New Zealand, 1997.

200


Plunket worker will leave a visit until the following week. This ensures that thefamily receives the visits over a longer period of time rather than having twovisits close together.

The lack of telephones is a very difficult issue for the service to manage. Itmeans that appointments cannot be confirmed before home visiting; often thePlunket team member might go to conduct a home visit and there will be no oneat home. To make contact, the worker needs to leave a note. Often the familybelong to a wider family and the worker is able to leave a message with anothermember of the family.

Health promotion campaigns may be conducted in conjunction with otherproviders in the area - not necessarily health care providers. One example ofthis, which resulted in a positive impact, was a campaign to organise a drivingcourse for clients. The Plunket Nurse had discovered that many people weredriving in their cars with no driver’s licence. When they were pulled over by thepolice for a routine check of their vehicle and licence it was found that they weredriving illegally. This created problems for the clients as they were then issuedwith a fine and were warned not to drive else more severe penalties would beenforced. The Plunket nurse discussed this problem with the police andorganised a driving course so that the clients could obtain their licence. Of thecourse participants 100 per cent obtained their driver’s licence. This healthpromotion activity had a significant effect on the community as it enhancedsafety on the roads for this area. It also had financial implications as the clientsno longer had to pay large fines for driving illegally.

While these strategies for rural Maori have proven effective, the services areprovided at greater cost because of the intensity of the service. The cost of thesedifferent strategies for Maori are not recognised by the funders, increasing thedifficulty of providing the service within given resourcing.

The second area is called Wanaka and is located in Central Otago. This areahas a high predominance of New Zealand European (85-90%) and a lowproportion of New Zealand Maori (5-7%).19 Isolation is a major problem in thisarea due to the vast geographic area and conditions. To drive from one end ofthe region to the other would take up to a day. It is a portion of the country that isvery vulnerable to the weather. In the winter there will be many icy and snowydays which increases isolation of these families as they are unable to drivewithout endangering their and their family’s lives. Many of the roads areunsealed and therefore driving around the region is slow. The township ofWanaka has a population of approximately 3000 people which increases up to20,000 in peak holiday seasons. It has a mixed income population with someprofessional high earning income people along with low-income people who livein the area in order to obtain seasonal work on the ski fields. Other times of theyear they are on the unemployment benefit. In other parts of the area there aremany farming families living on high country sheep stations (personalcommunication-Helen Umbers December 1998).

19. Statistics New Zealand Census 96: Regional Summary Wellington: Statistics New Zealand, 1997.

201


Wanaka has few services available to families - primarily the Plunket service,two General Practices and Presbyterian Support Services. Presbyterian SupportServices assist families with budgeting, obtaining food parcels and relationshipcounselling. The nearest hospital is 1½ hours drive away from Wanaka andprovides limited medical and surgical services. The nearest fully servicedhospital is 3½ hours drive away.

The Plunket team uses several strategies to try and overcome the isolation fromservices for these families. They home visit all families with a new baby for atleast the first three months. However, because of the lack of funding these visitsmay only occur monthly. This is very different to the city where a mother maycome into a Family Centre or have a weekly visit. Whenever possible, thePlunket team try to maintain contact via the telephone. Some of the funding forextra services does not come from the health budget. In Wanaka the RuralEducation Adult Programme helps to fund the Plunket team to provide parentingcourses to the community. This extra funding assists with community networkingas the parents are able to meet with each other and discuss parenting concerns.

To ensure that the families get the full use of the services in the region Plunkettries to integrate its services with the other providers. The Plunket staff have agood relationship with the General Practices and concerns regarding familiesare shared and referred to each other. The other way that Plunket supportsfamilies is through working in a collaborative way with Presbyterian SupportServices. Often the Plunket team will organise special information sessions withother health providers in the region. An example of this is an immunisationinformation evening. The Plunket Nurse obtained the services of a Paediatricianfrom the base hospital three hours away to come and discuss immunisationswith the local community. This was well supported by the other local healthproviders and it is hoped it will result in an increase in the uptake ofimmunisations.

CONCLUSION

The Plunket staff uses a health promotion framework in rural communitysettings. The challenge with working with families in the rural environment is toensure that the service assures equity of health outcomes. This is difficult giventhe population funding model. There is no simple way to achieve equity ofoutcomes given the major challenges of the isolation of these families. Perhapsit is time for New Zealand to look at other funding options. Within availableresources, Plunket is trying to work innovatively with rural communities andfamilies to develop strategies to address the issues they face because of theirlocation. These strategies reflect the different features of the community and theenvironment.

202


Arts in Health Trade Booth

203

Documents

Health Promotion in a New Zealand Setting: Working with