Community and Public Health Advisory Committees Meeting. Wednesday 13 September am

Transcription

1 Community and Public Health Advisory Committees Meeting Wednesday 13 September am Venue Waitemata District Health Board Boardroom Level 1, 15 Shea Tce Takapuna 1

2 Karakia E te Kaihanga e te Wahingaro E mihi ana mo te ha o to koutou oranga Kia kotahi ai o matou whakaaro i roto i te tu waatea. Kia U ai matou ki te pono me te tika I runga i to ingoa tapu Kia haumie kia huie Taiki eee. Creator and Spirit of life To the ancient realms of the Creator Thank you for the life we each breathe to help us be of one mind As we seek to be of service to those in need. Give us the courage to do what is right and help us to always be aware Of the need to be fair and transparent in all we do. We ask this in the name of Creation and the Living Earth. Well Being to All. 2

3 1 AUCKLAND AND WAITEMATA DISTRICT HEALTH BOARDS COMMUNITY & PUBLIC HEALTH ADVISORY COMMITTEES (CPHAC) MEETING 13 September 2017 Venue: Waitemata DHB Boardroom, Level 1, 15 Shea Terrace, Takapuna Time: 10.00am COMMITTEE MEMBERS Sharon Shea Committee Chair (ADHB Board member) Max Abbott - WDHB Board member Judith Bassett ADHB Board member Edward Benson Cooper - WDHB Board member Zoe Brownlie - ADHB Board member Sandra Coney - WDHB Board member Warren Flaunty - Committee Deputy Chair (WDHB Board member) Matire Harwood - WDHB Board member Lee Mathias - ADHB Board member Robyn Northey - ADHB Board member Allison Roe - WDHB Board member MANAGEMENT Dale Bramley - WDHB, Chief Executive Ailsa Claire - ADHB, Chief Executive Debbie Holdsworth - ADHB and WDHB, Director Funding Karen Bartholomew - ADHB and WDHB, Acting Director Health Outcomes Peta Molloy - WDHB, Board Secretary Apologies: AGENDA KARAKIA DISCLOSURE OF INTERESTS Does any member have an interest they have not previously disclosed? Does any member have an interest that might give rise to a conflict of interest with a matter on the agenda? Items to be considered in public meeting 1. AGENDA ORDER AND TIMING 2. CONFIRMATION OF MINUTES 10.00am 2.1 Confirmation of Minutes of the meeting held on 21/06/2017 Actions Arising from previous meetings 3. DECISION PAPERS 10.00am 3.1 Preschool Oral Health Action Plan for Metropolitan Auckland Region 4. INFORMATION PAPERS 10.10am 10.20am 4.1 Health Mums and Babies; Health Kids New Better Public Service Targets 4.2 Metro Auckland DHB Health Weight Action Plan for Children 5. STANDARD REPORTS 10.30am 5.1 Planning, Funding and Outcomes Update 6. GENERAL BUSINESS Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 3

4 1.1 Auckland and Waitemata District Health Boards Community and Public Health Committees Member Attendance Schedule 2017 NAME MAR JUNE SEP DEC Sharon Shea Max Abbott Judith Bassett Edward Benson Cooper Zoe Brownlie Sandra Coney Warren Flaunty Matire Harwood Lee Mathias Robyn Northey Allison Roe attended absent * attended part of the meeting only ^ leave of absence # absent on Board business + ex-officio member Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 4

5 Community and Public Health Advisory Committee (CPHAC) REGISTER OF INTERESTS Committee Member Max Abbott Judith Bassett Edward Benson- Cooper Zoe Brownlie Sandra Coney Warren Flaunty Dr Matire Harwood Involvements with other organisations Pro Vice-Chancellor (North Shore) and Dean Faculty of Health and Environmental Sciences, Auckland University of Technology Patron Raeburn House Advisor Health Workforce New Zealand Board Member, AUT Millennium Ownership Trust Chair Social Services Online Trust Board member Rotary National Science and Technology Forum Trust Last Updated 19/03/14 Trustee A+ Charitable Trust 17/05/17 Shareholder - Fisher and Paykel Healthcare Shareholder - Westpac Banking Corporation Husband Fletcher Building Husband - shareholder of Westpac Banking Corporation Granddaughter - shareholder of Westpac Corporation Daughter Human Resources Manager at Auckland DHB Chiropractor Milford, Auckland (with private practice commitments) 07/12/16 Community Health Worker Auckland DHB Member PSA Union Board member - RockEnrol Partner Youth Connections, Auckland Council Partner Aro Arataki Children s Centre Committee Son Aro Arataki Childcare Centre Member Waitakere Ranges Local Board, Auckland Council Patron Women s Health Action Trust Member Portage Licensing Trust Member West Auckland Trusts Services Member Henderson Massey Local Board Auckland Council Trustee (Vice President) - Waitakere Licensing Trust Shareholder - EBOS Group Shareholder Green Cross Health Director Life Pharmacy Northwest Director Westgate Pharmacy Ltd Chair Three Harbours Health Foundation Director - Trusts Community Foundation Ltd Senior Lecturer Auckland University Board Director Health Research Council Director Ngarongoa Limited, which is contractor providing services to National Hauora Coalition. GP at Papakura Marae Health Clinic Advisory Committee Member State Foundation NZ (Maori Health) Member Te Ora, Maori Medical Practitioners 09/06/17 15/12/16 06/12/16 09/12/16 Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 5

6 Committee Member Lee Mathias Robyn Northey Sharon Shea Allison Roe Involvements with other organisations Chair - Health Promotion Agency Chair - Unitec Chair - Health Innovation Hub Director - Health Alliance Limited (ex officio Auckland DHB) Director/shareholder - Pictor Limited Director - Lee Mathias Limited Director - John Seabrook Holdings Limited Trustee - Lee Mathias Family Trust Trustee - Awamoana Family Trust Trustee - Mathias Martin Family Trust Member New Zealand National Party Shareholder of Fisher & Paykel Healthcare Shareholder of Oceania Member New Zealand Labour Party Husband - member Waitemata Local Board Husband shareholder of Fisher & Paykel Healthcare Husband shareholder of Fletcher Building Husband Chair, Problem Gambling Foundation Husband Chair, Community Housing Foundation Principal - Shea Pita Associates Ltd Provider - Maori Integrated contracts for Auckland and Waitemata DHBs Provider Plunket outcomes implementation framework Project member Auckland and Waitemata DHB Maori Workforce Development project Provider - multiple management consulting projects for Te Putahitanga o Te Waipounamu Whanau Ora Commissioning Agency Iwi Affiliations: Ngati Ranginui, Ngati Hine, Ngati Hako and Ngati Haua Husband - Part owner Turuki Pharmacy Ltd, Auckland Husband - Board member - Waitemata DHB Husband Director Healthcare Applications Ltd Chairperson Matakana Coast Trail Trust Member - Rodney Local Board, Auckland Council Last Updated 20/06/17 05/07/17 09/08/17 02/11/16 Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 6

7 Auckland DHB and Waitemata DHB Community and Public Health Advisory Committee Meeting 21 June 2017 Recommendation: That the draft minutes of the Community and Public Health Advisory Committee meeting held on 21 June 2017 be approved. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 7

8 2.1 Minutes of the meeting of the Auckland DHB and Waitemata DHB Community and Public Health Advisory Committees Wednesday 21 June 2017 held at Waitemata DHB Boardroom, Level 1, 15 Shea Terrace, Takapuna, commencing at 10.01am Part I - Items considered in Public Meeting COMMITTEE MEMBERS: Sharon Shea (Committee Chair - ADHB Board member) Edward Benson-Cooper (WDHB Board member) Sandra Coney (WDHB Board member) (from 10.05am, item 3.1) Warren Flaunty (Committee Deputy Chair - WDHB Board member) Matire Harwood (WDHB Board member) Lee Mathias (ADHB Board member) Robyn Northey (ADHB Board member) Allison Roe (WDHB Board member) ALSO PRESENT: Dale Bramley (WDHB Chief Executive Officer) Debbie Holdsworth (ADHB and WDHB, Director Funding) Karen Bartholomew (ADHB and WDHB, Acting Director Health Outcomes) Tim Wood (Deputy Director, Funding) Andrew Old (Chief of Strategy, Participation and Improvement, ADHB) Scott Abbott (Business Support Manager, Planning, funding and Outcomes Unit, WDHB) Peta Molloy (WDHB, Board Secretary) (Staff members who attended for a particular item are named at the start of the minute for that item) PUBLIC AND MEDIA REPRESENTATIVES: WELCOME: KARAKIA: APOLOGIES: Tracy McIntyre (Waitakere Health Link) The Committee Chair welcomed those in attendance at the meeting. The Committee Chair provided an opening Karakia for the meeting. Apologies were received and accepted from Max Abbott, Judith Bassett, Zoe Brownlie, Ailsa Claire and from Sandra Coney for late arrival. DISCLOSURE OF INTERESTS Robyn Northey advised that she was no longer a Trustee of the A+ Charitable Trust. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 8

9 2.1 Lee Mathias advised that she was now the Chair of the Health Innovation Hub. There were no declarations of interests relating to the agenda. 1. AGENDA ORDER AND TIMING Items were taken in the same order as listed on the agenda. 2. COMMITTEE MINUTES 2.1 Confirmation of Minutes of the Auckland and Waitemata DHBs Community and Public Health Advisory Committees Meeting held on 29/3/17 (agenda pages 7 to 13) Resolution (Moved Warren Flaunty/Seconded Lee Mathias) That the Minutes of the Auckland and Waitemata District Health Boards Community and Public Health Advisory Committees Meeting held on 29th March 2017 (including the public excluded minutes) be approved. Carried Matters Arising (agenda pages 14) That with regard to a reference made to a five year review of the Green Prescription programme, Debbie Holdsworth noted that a review is due to be undertaken soon by Sport New Zealand. 3 INFORMATION ITEMS 3.1 Regional Status of Green Prescription, Active Families and Pre-School Active Families (agenda pages 15 to 18) Leanne Catchpole (Programme Manager, Primary Care Team) and Tim Wood (Deputy Director Funding) presented this item. Leanne Catchpole summarised the report. Edward Benson-Cooper queried whether data collection was important to retain funding and/or whether funding is impacted if results are not recorded. Leanne Catchpole advised that data is not recorded at an individual patient level and that contact for those participating in the Green Prescription programme is often by telephone with measurements taken at the beginning and the end of the programme. The Programme is referral based with motivational intervention. Leanne also noted that a national survey previously undertaken every two years will now take place annually and encompasses all of the healthy lifestyle programmes; survey questions such as whether lifestyle changes have been made, level of satisfaction with the programme, better knowledge of nutrition, physical activity has increased and the like will be asked. Survey results will be made available nationally. Leanne Catchpole advised that DHB and PHO representatives along with Green Prescription Providers across the region meet quarterly. Edward Benson-Cooper expressed an interest in attending one of these meetings if appropriate. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 9

10 2.1 Warren Flaunty commented on the appointment of Harbour Sport to deliver the services (Active Families, Green Prescription and Pre-school Active Families) in the Waitemata district and noted his concern in ensuring that the West Auckland population is adequately provided for and included in programmes such as these. In response, Leanne Catchpole advised that the procurement process assessed Harbour Sport to be the best provider across the district. Harbour Sport also have extensive experience in working with and providing services for the Māori and Pacific populations; Harbour Sport also has existing relationships in the West Auckland area. Tim Wood said that there had been extensive input from the evaluation panel members with an interest in Māori and Pacific populations. In response to a question from Allison Roe on how well the programme is working and potential improvements, Leanne Catchpole said that the programme works particularly well and that there had been changes made to provide face-to-face consultations. It is anticipated that the new service will provide a more supportive environment rather than gym classes only. With regard to programme accessibility, Leanne advised that to be referred to a programme GP sign off is required; discussions have been held with doctors and practices to determine what would be required to increase the number of referrals. It was also noted that other health professionals such as hospitals or physiotherapists can refer people to one of the programmes. Matire Harwood queried whether pre-school aged children would be assessed during the Before School Checks programme, which Leanne confirmed. Leanne advised, in response to a question from Lee Mathias, that Sport Trust receives funding from Spark for other child physical activity sports programmes; they have teams of staff who work with schools through Kiwi Sport and other programmes such as Harbour Sport, Mud Rush and the Shore to Shore walk. The Committee Chair asked that an update be provided at a future meeting on the effectiveness of the service delivery. The paper was received 5. STANDARD REPORTS 5.1 Planning, Funding and Outcomes Update (agenda pages 19 to 46) Debbie Holdsworth (Director, Funding) introduced this report and provided an overview of the highlights reported. With regard to the scorecard results (page 21 of the agenda), the following was noted: That the number of targets reported showing not achieved/off track, reflects areas of focus, particularly in meeting equity needs. There has been a shift from enrolments to utilisation in the oral health area, with a concentrated effort underway with the provider to improve productivity; a key element will be the preschool oral health strategy. Promising gains were being made with cervical screening, however, the decrease in trend is noted with an impact being the system level measures framework, which does not have the same focus. The matter will be discussed with the Auckland Waitemata PHO Alliance Leadership Team and primary care to progress. It is anticipated that the recently commenced HPV sampling programme will improve rates. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 10

11 2.1 Diabetes management is a primary focus for the Auckland Waitemata PHO Alliance Leadership Team and it is expected to continue to make good progress. Later in the meeting, Sandra Coney requested further information on the declining trend for cervical screening rates and how the HPV self-sampling programme would impact rates. In response Karen Bartholomew advised that there are longer term trends that can be provided to the Committee; with regard to HPV there have been two research projects running with a feasibility study recently commencing, women in the research study will count as being screened. Internationally it is shown that self-sampling has improved coverage. Ruth Bijl further advised that there had been some changes in the denominator, creating an anomaly with the data; however, strategies to continue improving coverage at a GP level are underway. Sandra Coney requested further information in the change of data around the denominator. In response to a question from Lee Mathias and whether the research includes a focus on different ethnicities, Karen Bartholomew noted that there is substantial evidence on research within different ethnicities including a range of work in high needs communities in both rural and urban settings. Primary Care Tim Wood (Funding and Development Manager Primary Care) summarised this section of the report, providing the following updates: Disposals of Unwanted Medicines Properly (DUMP) campaign The following was noted in response to questions from the Committee on the disposals campaign: That the contract for disposals is with Interwaste and that a component of disposal is an existing agreement, with the Council and Interwaste providing funding support for the DUMP campaign in the community. That each individual pharmacy advises Interwaste when they have a container for pick up. Toxic waste is collected separately to sharps. That the disposal of unwanted medicines is undertaken within the current environmental and waste management legislation; different medicines have different legislation for disposal, with some waste shipped to Australia and put into high temperature incinerators. The Committee will be provided further information on how each product is disposed of. Risk Based Audit Framework The programme will be rolled out nationally as a consequence of the achievements made during the pilot. Tim Wood also advised that from a safety and quality perspective, the audit framework is a very good initiative. Warren Flaunty suggested that when the pilot has been completed that spot audits are undertaken, but not in one area at the same time. Health Targets Reaching the Better Help for Smokers to Quit target remains a challenge for PHOs, but it is anticipated that the target will be met. In response to a question about the results of this health target not being available by ethnicity, Tim Wood advised that the Ministry of Health had made a decision that ethnicity data did not need to be reported; the DHB is requesting that this be changed. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 11

12 2.1 Diabetes Management Work is underway on the diabetes management target, with a number of solutions in place to obtain consistent data collection. In response to a question, Tim Wood noted that feedback to a General Practice is a PHO activity, it is anticipated that feedback will be provided more frequently and that generally monthly or quarterly feedback is most likely. Children, Youth and Women Ruth Bijl (Funding and Development Manager, Child, Youth and Women s Health) presented this section of the report, providing the following updates: Raising Healthy Kids All ethnicity groups have now reached the target of 100%, which is a significant achievement for both DHBs. Immunisation Health Target It is anticipated that the quarter 4 target will be reached at Auckland DHB. There is a specific focus on Māori children, with a review group established to identify children who have missed their five month immunisations at six months (approximately 30 children have been identified). Child Health It was noted that there is now a focus on utilisation measures; tooth decay identified in children at five years of age demonstrates the need to see children much earlier to provide oral health care. The proposed oral health preschool strategy will be presented to the Committee for comment. In response to a question from Robyn Northey on the scorecard not showing a trend line for Oral Healthy by 2 years, Ruth advised that this is a result of the new utilisation measure in place. In response to question from Edward Benson-Cooper about whether the target of 80% for Raising Healthy Kids is low, Ruth advised that the Ministry of Health had set the target at 95% by 2017 year end. Both DHBs have achieved and are ahead of the target rate. Health of Older People Kate Sladden (Funding and Development Manager Health of Older People) presented this section of the report, providing the following updates: Pay Equity Settlement Agreement A decision on whether contracts are in scope for the settlement or not is yet to be received, however, it was noted that workers will be paid the new rates from 1 July Kate advised that payment mechanisms have changed and that aged residential care will receive three months advance payment to manage cash flow issues that may be experienced. In response to a question from Lee Mathias about the stability of the financial situation for some providers, it was noted that an area of concern is the smaller aged residential care providers as they are paid on a bed day rate and on averages, leading to some overs and unders in that process. Kate also advised that data is being collected on the workforce of the smaller providers and a recovery mechanism will commence once the advance payment is out. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 12

13 2.1 The impact of implementing the agreement is not yet known as the DHB does not have a full understanding of the workforce in these areas, the pay rate on level of service and the level of qualification. There will be a continued discussion with the workforce. Lee Mathias suggested that this matter be placed on the risk registers of both the Auckland DHB and Waitemata DHB. In response to a question about whether there are contingency plans in place should a facility close, Kate advised that there is a facility currently closing in Auckland and that the DHBs are well versed in this process and work with NASC (Needs Assessment and Service Coordination) and families during the transition of people. It was also noted that there is a sufficient bed supply for the DHBs populations in this area. Warren Flaunty asked about the aged residential care audits and whether it was possible for spot audits in the facilities with a similar number of criteria as for pharmacies. Kate advised that there are unannounced certification audits undertaken and during that period a surveillance audit will occur. Audits have been undertaken since approximately It was also noted that issue based audits may also be carried out. In reference to the data supplied in the report (page 32) on the aged residential care audits, the Committee Chair queried the increase in the rate of corrective actions relating to health and safety, in response Kate advised that there is a small number and that a review of the standards and criteria was undertaken approximately one year ago. She also noted that the increase is not a pattern, however, it will be monitored. Mental Health Debbie Holdsworth noted the mental health teams apologies. She noted that with regard to the SACAT (Substance Addiction Compulsory Assessment Treatment) legislation update and that to support the northern region model of care, an early indication of funding had been received from the Ministry of Health, but formal notification was not yet received. Māori Health Gain Aroha Haggie (Manager, Māori Health Gain) presented this section of the report. She noted the progress of the 2017/18 Māori Health Plan. The Plans have been presented to the Auckland Waitemata PHO Alliance Leadership Team. The team endorsed the plan and agreed that two areas of focus are smoking cessation and workforce development for 2017/18. In addition Aroha noted the Whānau House Health Needs Assessment report, which is a collaboration of the Waitemata DHB, Te Whānau o Waipareira and East Tamaki Health Care PHO. The report has demonstrated that activities and services provided through Whānau House are reaching a high proportion of Māori in West Auckland. Aroha also advised that there are also areas of focus including working with Te Whānau o Waipareira and primary care on improving data collection in some spaces, giving consideration to evaluating diabetes as well as the potential for additional clinics. Pacific Health Gain The Committee noted the report. Robyn Northey said that the report was comprehensive and is to be commended. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 13

14 2.1 Asian, Migrant and Refugee Health Gain Raj Singh (Project Manager, Asian Migrant Team) was present for this section of the report. He noted the key highlight reported being the roll out of the Healthcare where should I go? which is directed at Asian migrants and students in the Auckland DHB district. The campaign will be evaluated to determine whether it has had a positive impact on PHO enrolments. Raj also noted a correction to section 9.3 of the report, advising that the data reported is quarter two and three (not four). Auckland Regional Public Health Service Jane McEntee (General Manager, Auckland Regional Public Health Services) presented this section of the report, providing the following updates: Typhoid outbreak It was noted that the outbreak would be closed by the end of June To-date there has been 24 confirmed cases, 20 of which are symptomatic and four are asymptomatic. It was also noted that the review of the management of the outbreak has been released. The review summarises that the outbreak was managed well and brought under control quickly, it also notes areas of shortfall around communication and engagement and these areas are being worked through. Mumps outbreak The Auckland Regional Public Health Service (ARPHS) has been managing an outbreak of mumps that started in January The main age group affected is 10 to 19 years of age. It was noted that despite public health measures the proportion of partially-vaccinated and non-vaccinated means cases of mumps continues to be high. The outbreak is challenging and a process is in place to manage its strategy with a number of resources being developed to assist. Response to questions included: That the review of the management of the typhoid outbreak is available on the ARPHS website. ARPHS will present a report on how the recommendations are being progressed. It was also noted that the report was well received by staff. That ARPHS is a regional service across metro-auckland. The ARPHS contract is held by the Ministry of Health, it is a non-devolved service of the Ministry. The host DHB for ARPHS is Auckland DHB and the reporting line to the DHBs is via Simon Bowen (Director Health Outcomes). The ARPHS General Manager and the Clinical Director regularly provide updates to the three metro-auckland DHBs. That it is thought the typhoid outbreak was originated from overseas and through an investigation to identify a point of source, it is strongly believed this was via food. That the high rate of those non-vaccinated against mumps (62%) includes a large number of people from overseas. This matter has been raised with the Ministry of Health, so that it can be discussed overseas. That ARPHS undertook a broad promotion during the previous school holidays to advocate vaccination for mumps. Discussion is also underway on ensuring people are aware that the vaccination does not provide a lifetime immunity. Noting that extensive work has been undertaken at Massey High School (who have had 18 cases of mumps) and that the school is working closely with ARPHS. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 14

15 2.1 That approximately three people out of 100 who receive full MMR vaccination will go on to develop mumps or measles, this can be related to the timing and age of when vaccinations are received. It is not known if there are areas of the Auckland DHB district that are at risk of a mumps outbreak. The Committee Chair requested that the Committee be provided with an update on the actions being undertaken to manage the mumps outbreak and the outcome of these actions. The Committee received the report The meeting closed at 11.48am. SIGNED AS A CORRECT RECORD OF A MEETING OF THE AUCKLAND AND WAITEMATA DISTRICT HEALTH BOARDS COMMUNITY AND PUBLIC HEALTH ADVISORY COMMITTEES HELD ON 21 JUNE 2017 CHAIR Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 15

16 2.2 Actions Arising and Carried Forward from Meetings of the Community and Public Health Advisory Committees as at 7 September 2017 Meeting Agenda Ref Topic 21/06/ Regional status of Green Prescription, Active Families and Pre-School Active Families Update on the effectiveness of the service delivery. 21/06/ Planning, Funding and Outcomes Update Cervical Screening Provide further information on the trend and changes in the denominator and impact on trend over time. 21/06/ Planning, Funding and Outcomes Update DUMP campaign The committee requested further information on unwanted medicines and how each product is disposed of. 21/06/ Planning, Funding and Outcomes Update ARPHS Update (mumps outbreak) The Committee requested an update on the actions being undertaken to manage the mumps outbreak and the outcome of these actions. Person Responsible Leanne Catchpole Dr Karen Bartholomew Expected Report Comment Back 06/12/17 An update will be provided at the December 2017 meeting To be ed directly to Sandra Coney - 11/09/17 Tim Wood 13/09/17 See agenda item /09/17 See agenda item 5.1 Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 16

17 3.1 Preschool Oral Health Action Plan for Metropolitan Auckland Region 3.1 Recommendation: That the Committee recommends to the Auckland and Waitemata District Health Boards: That the Board: a) Note a Preschool Oral Health Action Plan has been developed for the Metropolitan Auckland region to address marked ethnic and other inequities in preschool oral health. b) Endorse the Preschool Oral Health Action Plan for Auckland and Waitemata District Health Boards. c) Note the Plan will be presented to the Counties Manukau District Health Board Community and Public Health Committee for endorsement. Prepared by: Stacey Strang (Programme Manager) and Corina Grey (Public Health Physician) Endorsed by: Ruth Bijl (Funding and Development Manager, Child, Women and Youth), Dr Debbie Holdsworth (Director, Funding), Stephanie Doe (General Manager Child, Women and Family) and Dr Meia Schmidt-Uili (Division Head Child, Women and Family) Glossary ARDS BPS dmft The Plan WCTO - Auckland Regional Dental Service - Better Public Services - number of decayed, missing or filled teeth - Preschool Oral Health Action Plan for Metropolitan Auckland Region - Well Child Tamariki Oral 1. Executive Summary There are marked ethnic inequalities in preschool oral health in the Auckland region. Maori and Pacific preschool children have lower enrolment and examination rates than non-maori non Pacific children. Only a third of Maori and half of Pacific pre-schoolers in the Auckland region were seen by the Auckland Regional Dental Services (ARDS) in Of these, more than half of Maori and two thirds of Pacific had dental decay, this compares with 20% of European. The Preschool Oral Health Action Plan (the Plan) for the Metropolitan Auckland Region was developed to address these inequities and improve the oral health of preschool children (0-5 year olds) in the region. The Plan aims to: 1. Improve the oral health of pre-schoolers across metropolitan Auckland 2. Eliminate ethnic and other inequities in oral health outcomes, particularly for Pacific, Maori and other high risk children. The Plan includes specific actions within ARDS, maternity, Well Child Tamariki Ora (WCTO) and primary and secondary care services to: 1. Promote good oral health 2. Facilitate prevention and early detection of dental decay 3. Ensure prompt treatment of oral health problems in young children. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 17

18 3.1 The Plan is aligned with the Metro Auckland DHB Healthy Weight Action Plan for Children. The Plan is divided into two main streams: 1. Oral Health Promotion 2. Prevention, Early Detection and Treatment. Implementation of the Prevention, Early Detection and Treatment stream will be primarily lead by the Auckland Regional Dental Services (ARDS), which is provided by Waitemata DHB to provide dental care for children from birth to school Year 8 in the Auckland region. The Oral Health Promotion stream will require a multi-agency approach and will include working with the early childhood education sector and community and primary care providers. Key activities will include aligning oral health and obesity messages, ensuring oral health resources are culturally appropriate and incorporating oral health messages into existing community-based programmes. Implementation of the Plan has already begun and will continue over the next three years. Implementation of the Plan will be measured using key oral health indicators including proportion of five years olds without dental decay, the mean number of decayed, missing or filled teeth (mean dmft), Dental ambulatory sensitive hospitalisation rates, enrolment with ARDS, and utilisation of services. Indicators will be reviewed annually and focused on improving equity. The Committee is asked to endorse the Plan. 2. Strategic Alignment Community, whānau and patient centred model of care Emphasis and investment on both treatment and keeping people healthy Service integration and/or consolidation Intelligence and insight Evidence informed decision making and practice Outward focus and flexible, service orientation Operational and financial sustainability The Plan is designed to improve access to care and oral health knowledge. It will also support whanau and the community to develop healthy eating policies in early childhood education centres and other community settings, such as Pacific churches and Marae. The Plan was informed by community focus groups. There are marked ethnic inequities in the oral health status of pre-schoolers. The purpose of the Plan is to reduce and eliminate these inequities, improve the oral health status of pre-schoolers and improve access to dental care. Improvement of oral health in pre-schoolers requires many aspects of the healthcare system to work together including: ARDS, primary care, Well Child/ Tamariki Ora and health promotion practitioners. Evaluation and evidence will continue to be used in the implementation and monitoring of this Plan. A literature review, data analysis, focus groups and other evidence were used to inform the development of this Plan. Implementation of the Plan will take into account unique needs of individual communities and will be flexible and adaptable to meet these needs. The implementation of the majority of the plan will be undertaken within current budget. Some activities such as a service for pregnant women will require additional Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 18

19 funding to be able to be implemented. Actions which require additional funding will be implemented over the longer term and separate business cases developed Introduction/Background The Preschool Oral Health Action Plan for Metropolitan Auckland Region (the Plan) was developed due to growing concern about the marked ethnic inequalities in preschool oral health in the Auckland region. The standard measures of oral health, which include the proportion of five year olds without dental decay (caries-free rates) and the mean number of decayed, missing or filled teeth (dmft rates) have shown little to no improvement over the last two decades. Pacific and Māori children experience worse oral health outcomes than children of other ethnic groups. In 2016, 79% of European/Other, 57% of Asian, 45% of Māori and 33% of Pacific children examined at age five had no evidence of dental decay. Among Pacific groups, dental decay is more prevalent in Tongan and Samoan children (28% and 32% caries-free rates) and more severe (mean dmft 4.2 and 3.6 respectively, compared to 0.6 for European children). Among Asian children, dental decay is more prevalent in South East Asian and Chinese children (52-55% caries-free) compared to Indian children (66% caries-free). The Auckland Regional Dental Service (ARDS) provides dental care for children from birth to school year 8 living in Auckland, Counties Manukau and Waitemata District Health Boards. Within the three DHBs there are differences in the ethnic and socioeconomic composition of the preschool populations therefore some activities within the Plan will need to be tailored to the specific needs of local populations. The plan has been developed using an evidence-based approach with input from ARDS, Planning, Funding and Outcomes, Counties Manukau Planning and Funding, Regional Oral Health Service Paediatric Specialist. Focus groups were held with Maori and Pacific communities to identify barriers to service and oral health community knowledge. The Plan provides a comprehensive approach to improving preschool oral health and reducing inequities. The Plan is divided into two key workstreams: 1. Oral Health Promotion 2. Prevention, Early Detection and Treatment. The following diagram shows the key project areas under the two workstreams. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 19

20 3.1 Oral Health Promotion Work-stream Actions under the oral health promotion workstream form the foundation of the Plan and aim to reduce children s exposure to the risk factors for dental decay, namely bacteria and dietary sugar. An important way of ensuring that these activities are targeted and delivered systematically to the highest need populations is through oral health promotion work with Well Child Tamariki Ora (WCTO) and in early childhood education centres (ECEs) and other settings. This will include supporting ECEs, Pacific churches and Marae could also be supported to develop water-only and healthy eating policies. Other important health promotion activities include aligning oral health and obesity messages, ensuring oral health resources are culturally appropriate, incorporating oral health messages into existing community-based programmes, extending the current ECE-based daily tooth brushing programme in Counties Manukau to other areas in the region, and including stage-appropriate oral health messaging in antenatal education. Many of these activities align with the Metro Auckland Healthy Weight Action Plan for Children Pregnant and first-time mothers are recognised as an important target group for oral health promotion, and previous pilots of targeted, free maternal oral health services in Waitemata and Counties Manukau have been shown to positively impact on the oral health knowledge and behaviours of pregnant women. The implementation of such services would require significant additional funding, and may be something to consider in the future. Therefore activities in this area will initially focus on utilising current services to provide health promotion messages e.g. antenatal education, Lead Maternity Carers and Well Child Tamariki Ora providers. Prevention, Early Detection and Treatment Work-stream The second broad category of activities is focused on the prevention, early detection and treatment of caries. ARDS has primary responsibility, and is funded, for many of these actions. To support ARDS programme of work an associated Improvement Plan has been developed. This is currently being Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 20

21 implemented. Actions include simplifying and improving the enrolment process, raising the profile of the service in the community and amongst other health professionals, reducing access barriers to care, ensuring recall periods more closely reflect need and the recruitment and retention of staff in South Auckland. A detailed plan is also being developed to implement a systematic programme of topical fluoride application among children at high-risk of caries, including all Pacific and Māori children. 3.1 However, ARDS is not the only service that can influence preschool oral health outcomes. Other child health professionals, for example Plunket/Well Child Tamariki Ora (WCTO) nurses and General Practitioners (GPs) and Practice Nurses, also have a role in reinforcing oral health promotion messages, screening children for signs of dental decay, and referring them to ARDS for further assessment and treatment. Plunket/WCTO providers currently provide health promotion information and conduct screening Lift the Lip assessments at all core checks from nine months. Ensuring that all providers are confident in carrying out these assessments is important, as is upskilling other child professionals, such as GPs and practice nurses, who are likely to see children more frequently than dental professionals. The implementation of this plan will also contribute to the national targets: Better Public Services (BPS) Result 3 Keeping Kids Healthy, which measures avoidable hospitalisations for children 0-12 years. System Level Measure (SLM) Ambulatory Sensitive Hospitalisation rates for 0-4 years. 4. Risks/Issues There is no new funding for the implementation of this plan. The majority of activities can be undertaken within current funds. But there are some activities that will not be able to be undertaken without new funding. Health promotion resources may need to be developed and printed and a new maternity oral health service would require funding. Cases will be developed in support of these actions. 5. Progress/Achievements/Activity Implementation of the Plan will be monitored by the regional governance group that has representatives from Northland and Auckland, Waitemata and Counties Manukau Planning and Funding teams, Auckland DHB Oral Health Clinical Director, Public Health Physician, Community Paediatrician, ARDS leadership team, and Maori and Pacific representatives. The group has linkages with the Regional Child Health Network. Progress will be monitored using the following measures for children aged five years and under: Dental ambulatory sensitive hospitalisation rates the proportion of five year olds without dental decay (% caries-free) the mean number of decayed, missing or filled teeth (mean dmft) ARDS enrolments ARDS utilisation ARDS did not attend (DNA) rates ARDS arrears (proportion of enrolled children overdue for examination) ARDS treatment completion rates Proportion of children in each scoring category for Lift the Lip performed at B4SC Well child oral health and oral health promotion measures to be developed Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 21

22 All measures will be reported by age, ethnicity and DHB. A formal evaluation of implementation of actions will also be planned for Conclusion Improving the oral health of pre-schoolers in the Auckland metropolitan region is an important public health initiative. There are marked inequities in oral health with Pacific and Maori children experiencing worse oral health than children of other ethnicities. The Pre-school Oral Health Action Plan for Metropolitan Auckland Region has been developed using international evidence and local consultation, the aim of this plan is to eliminate inequity and improve oral health outcomes. The Plan will be implemented over the next three years and will be monitored using key oral health measures. The majority of the Plan can be implemented using existing resources and will include redeploying current services to reach high needs communities. As there is no new funding available there are risks that components of the plan will not be able to be implemented for example a maternal oral health service and new health promotion resources. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 22

23 3.1 PRESCHOOL ORAL HEALTH ACTION PLAN FOR METROPOLITAN AUCKLAND REGION August

24 3.1 Executive Summary This Action Plan was developed to address growing concerns about marked ethnic and other inequities in preschool oral health in the Auckland region. Standard measures of oral health, which include the proportion of five year olds without dental decay (caries-free rates) and the mean number of decayed, missing or filled teeth (dmft rates) have shown little to no improvement over the last two decades. Pacific and Māori children experience worse oral health outcomes than children of other ethnic groups: in 2016, 79% of European/Other, 57% of Asian, 45% of Māori and 33% of Pacific children examined at age five had no evidence of dental decay. Among Pacific groups, dental decay is more prevalent in Tongan and Samoan children (28% and 32% caries-free rates) and more severe (mean dmft 4.2 and 3.6 respectively, compared to 0.6 for European children). Among Asian children, dental decay is more prevalent in South East Asian and Chinese children (52-55% caries-free) compared to Indian children (66% caries-free). The Auckland Regional Dental Service (ARDS) provides dental care for children from birth to school year 8 living in Auckland, Counties Manukau and Waitemata District Health Boards. Because of this common community oral health service, this Plan is intended for the entire metropolitan Auckland region. However, there are differences in the ethnic and socioeconomic composition of the preschool populations in these three DHBs that will mean that certain activities will need to be tailored to the specific needs of local populations, and so the implementation of the Plan may differ by DHB. This Action Plan outlines a comprehensive approach to improve preschool oral health outcomes and reduce inequities. It involves multiple agencies and a range of different strategies under the headings of: oral health promotion prevention, early detection and treatment of caries. Oral health promotion activities form the foundation of the Plan and aim to reduce children s exposure to the risk factors for dental decay, namely oral bacteria and dietary sugar. An important way of ensuring that these activities are targeted and delivered systematically to the highest need populations is through the creation of oral health promoter roles to work in early childhood education centres (ECEs) and other settings. Through these roles, ECEs, Pacific churches and Marae could also be supported to develop water-only and healthy eating policies. Other important health promotion activities include aligning oral health and obesity messages, ensuring oral health resources are culturally appropriate, incorporating oral health messages into existing community-based programmes, extending the current Counties Manukau ECE daily tooth brushing programme, and including stage-appropriate oral health messaging in antenatal group education. Pregnant and first-time mothers are recognised as an important target group for oral health promotion, and previous pilots of targeted, free maternal oral health services in Waitemata and Counties Manukau have been shown to positively impact on the oral health knowledge and behaviours of pregnant women. The implementation of such services would require additional funding, and may be something to consider in the future. 2 24

25 3.1 Earlier this year, the Ministry of Health, in conjunction with the Health Promotion Agency, ran a brief social and mass media campaign about the importance of caring for baby teeth. The video and other resources from this campaign could potentially be used in the Auckland region for example, as videos played in waiting rooms in primary and secondary care services. It is important that different forms of media are considered for oral health promotion and increasing awareness of the free dental services for pre-schoolers. Research indicates that a lack of knowledge around oral health care, a belief that issues in baby teeth will disappear with the onset of adult teeth, and a lack of support from other family members are important barriers to engaging in effective protective oral health behaviours in parents, particularly for Pacific and Māori. Other activities outlined in this Plan are focused on the prevention, early detection and treatment of caries, and ARDS has primary responsibility for many of these actions. Early engagement of dental services with families will allow more opportunities for oral health promotion messages to be delivered, good oral health care habits to be established, and early signs of decay to be detected and attended to. Decay in children can be reversed at very early stages. ARDS underwent a service review in late 2016, and work has already begun to improve its engagement with families. The actions for ARDS outlined in this Plan include simplifying and improving the enrolment process, raising the profile of ARDS in the community and amongst other health professionals, reducing access barriers to care, ensuring recall periods more closely reflect caries risk, and improving quality of care and Pacific and Māori staff recruitment and retention. A plan is also being developed to implement a systematic programme of topical fluoride application among children at high-risk of caries, including all Pacific and Māori children. A concerted effort to increase ARDS enrolments in all three DHBs has resulted in consistently increasing enrolments over recent years. In Waitemata and Auckland DHBs, this has been further enhanced by the implementation of the multi-enrolment system at birth, which is also planned in Counties Manukau DHB in the near future. Work has recently been done to map out the entire ARDS enrolment process, and barriers, such as the need for parents to prove eligibility, have been removed. It is important that robust processes are also put in place to ensure that contact details for families are kept up-to-date, as many vulnerable families are transient. A comprehensive strategy to raise the profile of ARDS in the community and among health professionals must also be developed. Other strategies to improve access include extending clinic opening hours to include evenings and Saturdays, increasing use of mobile dental vans in community settings and important events, and extending the supportive treatment pathway and using outreach services to ensure high-risk children are able to complete treatment. ARDS is not the only organisation that can influence preschool oral health outcomes, however. Other child health professionals, for example Plunket/Well Child Tamariki Ora (WCTO) nurses and General Practitioners (GPs) also have a role in reinforcing oral health promotion messages, screening children for signs of dental decay, and referring them to ARDs for further assessment and treatment. Plunket/WCTO providers currently conduct screening Lift the Lip assessments at all core checks from nine months. Ensuring that all providers are confident in carrying out these assessments is important, as is upskilling other child professionals, such as GPs and practice nurses, who are likely to see children more frequently than dental professionals. 3 25

26 3.1 We would like to acknowledge our Pacific and Māori communities, particularly the parents and grandparents who participated in our focus groups. Their insights and opinions were valuable in the development of this Action Plan. 4 26

27 Contents 3.1 Abbreviations... 6 Early Childhood Caries Oral Health Status of Preschool Children in Auckland ACTIONS 1.1 HEALTH PROMOTION IN EARLY CHILDHOOD EDUCATION SETTINGS Oral Health Promoters Development of Water only and Healthy Eating Policies Toothbrushing and oral health promotion programmes through ECEs ORAL HEALTH PROMOTION IN OTHER COMMUNITY SETTINGS ORAL HEALTH PROMOTION AT A POPULATION LEVEL Oral Health Messages ORAL HEALTH PROMOTION AT AN INDIVIDUAL LEVEL MATERNAL ORAL HEALTH CARE COMMUNITY WATER FLUORIDATION AUCKLAND REGIONAL DENTAL SERVICE Enrolments Awareness of the ARDS service Access and Examinations Caries Risk Assessment and Recall Topical Fluoride Application Quality of Care and Patient Experience Staff Recruitment and Retention b. OTHER CHILD HEALTH PROFESSIONALS MONITORING OF PROGRESS AND EVALUATION References APPENDIX 1: SUMMARY OF ACTIONS AND TIMEFRAMES

28 Abbreviations 3.1 ARDS ARPHS ASH BPS dmft DHB DNA ECEs GPs HPA MoH PFO WCTO Auckland Regional Dental Service Auckland Regional Public Health Services Ambulatory Sensitive Hospitalisations Better Public Services decayed, missing or filled teeth (primary teeth) a measure of the severity of dental disease in the preschool population District Health Board Did Not Attend (an appointment) Early Childhood Education Centres General Practitioners Health Promotion Agency Ministry of Health Planning, Funding and Outcomes Well Child Tamariki Ora Providers / Plunket 6 28

29 Chart 1: Overview of Actions to improve preschool oral health in this Action Plan 3.1 Oral Health Promotion Prevention, Early Detection, Treatment Healthy food/water only policies Oral health education and promotion Auckland Regional Dental Service (ARDS) Other child health providers Topical fluoride application ECEs and other community settings At national, community and individual levels Increase enrolments and raise awareness of the service Improve access and examinations Improve caries assessment and recall Improve quality of care and patient experience Optimise staff recruitment and retention WCTO, primary, secondary and community providers Via ECEs, ARDS or primary care 7 29

30 Oral health promotion 3.1 SUMMARY OF ACTIONS A list of actions, with lead agency and timeframes, is listed in Appendix 1 at the end of this document, according to priority of action. Area General Early childhood education settings Community settings Individual level Population level Action Identify all health promotion activities for obesity and ensure that there is an oral health component incorporated. Align oral health and obesity messages. Develop specific oral health promoter roles to help implement dental-friendly policies and deliver oral health promotion messages in early childhood settings. Work with and support all ECEs to institute milk and water-only policies. Identify priority ECEs (Pacific language nests, Kohanga Reo, ECEs in areas of high deprivation) and work with them to establish dental-friendly healthy eating policies. Extend the ECE-based daily tooth brushing and oral health promotion programme (currently only in 150 Counties Manukau ECEs) to other high needs ECEs areas across metropolitan Auckland. Work to establish water-only policies in Pacific churches and Marae. Consider a targeted programme for distributing free toothbrushes and toothpaste to all members of families identified to be at high risk of caries. Include an oral health promotion component in existing community-based programmes (for example, Healthy Babies/Healthy Families), social media platforms and pregnancy/parenting apps aimed at parents. Include stage-appropriate oral health messaging and anticipatory guidance as a component of antenatal group education and for LMCs to deliver to expectant mothers on a 1:1 basis. Refresh stage-appropriate oral health messaging and anticipatory guidance as a component of WCTO delivery to parents/ caregivers at 5-7 month and 9 month core contact Implement a free/low-cost maternal oral health service for high-needs expectant/new mothers. Ensure messages link with those used in the HPA national oral health promotion programme and use relevant resources that have been developed to promote the importance of baby teeth. Work closely with dental and health literacy experts to develop new resources with a specific focus on Pacific and Māori pre-schoolers. Promote the HPA Baby Teeth Matter and other oral health promotion videos in waiting rooms in ARDS, primary care, outpatient clinics and Emergency Departments. Make take home resources available in relevant languages e.g. stickers for Preschoolers, fridge magnets for home Continue to support ARPHS in its advocacy efforts regarding community water fluoridation. 8 30

31 Prevention, early detection & treatment of caries 3.1 Area Action ARDS Enrolment Fully implement the multi-enrolment system across all three metropolitan Auckland DHBs and send enrolment acknowledgement e.g. text message and/or letter of what to expect. Simplify ARDS enrolment process for all children. Develop robust processes for ensuring that contact details of families are kept up-to-date. Profile of ARDS Develop a comprehensive strategy to increase awareness of free dental services, how these can be accessed, and what services are offered in the community and among primary and secondary health professionals. Access & Extend Saturday clinics and weekday opening hours to high priority locations. examinations Institute family-friendly examination policies. Extend the supportive treatment pathway for vulnerable families to access services and complete dental treatments. Enlist the help of Māori and Pacific community health outreach and WCTO services to help families who have repeatedly been unable to attend appointments. Increase access for first clinical examination for priority populations from 12 months of age Caries risk assessment & recall Quality of care Staff recruitment/ retention Other child health professionals Topical fluoride application Increase the use of mobile dental vans in community settings and events for opportunistic assessment and treatment. Include Māori and Pacific ethnicity as a component of the caries risk assessment score. Continue work on individualised caries risk assessment and better understanding recall periods. Institute regular consumer feedback process. Cultural competency training for all staff. Allocate time for Māori and Pacific dental therapists to engage with their respective communities for oral health promotion and education. Work with AUT to advocate for an increased number of Māori and Pacific students training in dental therapy. Provide 6 monthly topical fluoride varnish application for all high-risk preschool children (particularly Māori and Pacific children) from the age of 12 months. Ensure all Plunket/WCTO providers can conduct Lift the Lip assessments at all core checks from 9 months; refresh training and resources Consider WCTO Well Child Nurses applying topical fluoride varnish to 12 month old infants at home visits or in WCTO clinics Expand tooth brushing program in ECEs which includes 6 monthly oral health education and Lift-the-Lip to include fluoride varnish applications to arrest caries progress until appointment at dental clinic. Upskill primary and secondary care practitioners in oral health promotion, Lift the Lip assessments and ensure that they know when and how to appropriately refer children for dental care. 9 31

32 Introduction and Background 3.1 The oral health of preschool children is an area of growing concern in New Zealand. Standard measures of oral health prevalence and severity of disease at age five the proportion of children without any decayed teeth (i.e. caries-free) and the mean number of decayed, missing or filled teeth (dmft) have shown little to no improvement over the past two decades. 1 In addition, long-standing ethnic inequities in oral health outcomes remain stark. 2 Compared to other children, Pacific and Māori children experience much higher rates of dental decay and tooth extractions, and there is no evidence that these inequities have narrowed over the last two decades. 3-7 Across metropolitan Auckland, the Counties Manukau, Auckland and Waitemata District Health Boards (DHBs) are committed to eliminating inequities and improving the oral health status of all pre-schoolers. These three DHBs share a common Community Oral Health Service, known as the Auckland Regional Dental Service (ARDS), so it makes sense that there is a shared, regional approach to improving preschool oral health. However, good oral health involves more than just dental services, and there are differences in the socioeconomic and ethnic make-up of the preschool populations in these three DHBs that will mean some strategies within a regional approach will need to be modified to best fit the needs of local populations. This document outlines an Action Plan to: (1) improve the oral health of pre-schoolers across metropolitan Auckland, and (2) eliminate ethnic and other inequities in oral health outcomes, particularly for Pacific, Māori and other high-risk children. This bold and audacious goal will only be achieved through a comprehensive approach using a range of different strategies encompassing both prevention and treatment. This Plan includes specific actions within ARDS, maternity, Plunket/Well Child Tamariki Ora (WCTO), and primary and secondary care services to: (1) promote good oral health (2) facilitate prevention and early detection of dental decay (3) ensure prompt treatment of oral health problems in young children. Early Childhood Caries Good oral health practices in the first five years of a child s life are critical for lifelong oral health. 8 By contrast, poor oral health and dental decay at an early age can significantly affect physical, psychological and social development, 9 leaving children susceptible to poor oral and general health throughout their lives. 10 Early Childhood Caries is the term used to describe dental decay that affects the teeth of infants and young children. Formally, it is defined as the presence of one or more decayed, missing (due to caries) or filled teeth in a child younger than 72 months

33 3.1 Dental caries is a preventable disease that can be stopped and even potentially reversed during its early stages. 1 It is the gradual destruction of a tooth that develops in the presence of sugars and bacteria. 12 As outlined in Figure 1, there are three factors necessary for caries to develop: a tooth surface, bacteria (usually streptococcus mutans) and dietary sugars. Figure 1: The triad of factors necessary for the development of dental caries (Source: Risk factors for early childhood caries include frequent exposure to dietary sugars, inappropriate bottle feeding, high levels of colonisation by cariogenic bacteria, lack of access to dental care, low community water fluoride levels, inadequate tooth brushing or use of fluoridecontaining toothpastes, and a lack of parental knowledge regarding oral health. 13 These risk factors can be modified through appropriate interventions by health promotion, dental, and other healthcare services. Dental conditions are the leading cause of potentially avoidable hospitalisations in children aged 0-14 years. 1 This is recognised by the New Zealand government in the Better Public Services (BPS) Target number 3: Keeping Kids Healthy and in the System Level Measure aimed at reducing Ambulatory Sensitive Hospitalisations (ASH) in 0-4 year olds. The BPS target aims to achieve a 25% reduction in hospital admission rates for a selected group of avoidable conditions (including dental conditions) in children aged 0-12 years, with an interim target of 15% by Oral Health Status of Preschool Children in Auckland Free dental care for preschool and school-aged children, up to and including year 8 students, is available through ARDS for residents of metropolitan Auckland. ARDS services the populations of three DHBs: Counties Manukau, Auckland and Waitemata. Counties Manukau DHB has the highest number of pre-schoolers (41,750), followed by Waitemata (39,030) and Auckland (29,700). Counties Manukau has the most ethnically diverse young person (0-14 years) population (see Table 1), and children living there tend to experience higher levels of deprivation than those living in other DHBs. Approximately half of children living in Counties Manukau live in neighbourhoods considered to be most deprived (NZDep score 9-10), compared to 25% of children in Auckland DHB and 5% of children in Waitemata. Table 1: Ethnic composition of DHB population aged 0-14 years (Source: 2013 Census) Ethnicity Auckland DHB Counties Manukau DHB Waitemata DHB Māori 13% 24% 17% Pacific 18% 29% 11% Asian 25% 19% 17% European 41% 26% 52% Other* 3% 2% 3% *Comprised mainly of children identifying as Middle Eastern, Latin American or African (MELAA) 11 33

34 3.1 Figure 2 and shows the percentage of the preschool population, by DHB, enrolled and examined by ARDS in Table 2 shows numbers and percentages by ethnicity. Māori and Pacific children have lower enrolment and examination rates than non-māori non-pacific children: only about a third of the Māori preschool population and a third to half of the Pacific preschool population, in Auckland were examined at an ARDS clinic in % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Figure 2: % of the preschool (0-4 y) population enrolled (blue bars) and examined (red bars) at ARDS in 2016 ADHB CMDHB WDHB % enrolled % examined by ARDS * Denominator: Estimated Resident Population 0-4 years; Numerators: Number of children enrolled in ARDS; Number of children examined by ARDS in 2016 Table 2: ARDS Enrolment and Examination numbers and percentages, by DHB and ethnic group, 2016 DHB Māori % of population Pacific % of population Other* % of population Auckland Population ,640 - Enrolled % % 17, % Examined % % 11, % Counties Manukau Population ,400-19,110 - Enrolled % % 17, % Examined % % 10, % Waitemata Population ,380 - Enrolled % % 27, % Examined % % 17, % *Other non- Māori non-pacific The ethnic and socioeconomic differences by DHB are reflected in preschool oral health outcomes, which are routinely measured in children examined at age five. The prevalence of dental decay is estimated using the proportion of children who are caries-free and the severity of dental disease is measured using mean dmft (see Figures 3a and 3b). Since 2012, Waitemata DHB has had the highest caries-free rates in five year olds (approximately two-thirds) and Counties Manukau DHB the lowest (approximately one-half). Similarly, severity of disease is worst in Counties Manukau, with five year old children having an average of 2.5 decayed, missing or filled teeth, compared to Waitemata, where the mean dmft at age five is less than 1.5. It 12 34

35 3.1 is important to note that the numbers and rates reported here reflect the oral health status of preschoolers that have been examined by ARDS; it is likely that oral health measures are worse in children who have not engaged with the service. 80% Figure 3a: % of children examined at age 5 with no dental decay 70% 60% 50% 40% 30% 20% WDHB ADHB CMDHB National 10% 0% Figure 3b: Mean number of decayed, missing or filled teeth in children examined at age WDHB ADHB CMDHB National Note: 2016 national figures are unavailable. * Figure 3a: Denominator: Children examined by ARDS in each year; Numerator: Children with dental decay. Figures 4a-4c show caries-free rates at age five by ethnic group and DHB. These graphs demonstrate the striking differences in the prevalence of dental disease by ethnicity. In 2016, 79% of European/Other, 57% of Asian, 45% of Māori and 33% of Pacific children examined at age five had no evidence of dental decay

36 3.1 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Figure 4a: % of children examined at age 5 with no dental decay - Auckland DHB European Asian Maori Pacific 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Figure 4b: % of children examined at age 5 with no dental decay - Counties Manukau DHB European Asian Maori Pacific 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Figure 4c: % of children examined at age 5 with no dental decay - Waitemata DHB European Asian Maori Pacific Progression of caries All children start caries free at birth, but by the age of one year Pacific, Māori and Asian children show signs of dental decay. Figure5 shows the proportion of children who are caries free between 14 36

37 3.1 the ages of one and four, using Counties Manukau DHB as an example. This shows that there are differences in the progression of caries by ethnicity and age of the pre-schooler. By the age of three inequities are evident: - Pacific: 61% are caries free at 3 years but this reduces to 30% caries free at 5 years - Māori: 72% are caries free at 3 years but this reduces to 38% caries free at 5 years - Asian/Other: 80% are caries free at 3 years but this reduces to 56% at 5 years - European: 93% are caries free at 3 years but this reduces to 75% at 5 years 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% Figure 5: % of children without decay, by age, Counties Manukau, % 86% 93% 80% 72% 61% 86% 69% 65% 50% 41% Preschool age (years) 38% 30% 75% 56% Asian European Maaori Other Pacific * Denominators: Children in each ethnic group examined by ARDS in 2016; Numerator: Children in each ethnic group with dental decay. This graph shows that early prevention and intervention is needed to reduce inequities in oral health outcomes. There are also differences in oral health outcomes within Asian and Pacific groups (see figures 4a- 4b). Among Pacific children, Tongans experience the poorest oral health outcomes, with the lowest caries-free and highest mean dmft rates, while Niueans experience less severe disease than other Pacific groups. Among Asian children, Chinese and South East Asians have lower caries-free and higher dmft rates than Indian children. In light of these inequities, it is essential that a strategy to improve preschool oral health in Auckland focuses on the highest-risk children and considers innovative approaches to reach Māori and Pacific communities, and in particular Tongan children

38 3.1 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Figure 5a: % of children examined by ARDS at age 5 with no dental decay NZ European Indian Chinese South East Asian Maori Niuean Cook Island Samoan Tongan Figure 5b: Mean number of decayed, missing or filled teeth in children examined by ARDS at age Tongan Samoan Cook Island South East Asian Niuean Maori Chinese Indian NZ European 16 38

39 ACTIONS 3.1 This section describes and outlines evidence for actions to improve preschool oral health. Preschool oral health is not just the responsibility of ARDS: good oral health must be viewed in the context of good overall health, and so all child health and health promotion agencies, services and practitioners have a role in looking after our children s teeth. In this section, actions are placed under two broad categories: (1) oral health promotion (which mostly focuses on actions outside of ARDS), and (2) prevention, early detection and treatment of caries (which is further divided into actions under the remit of (i) ARDS and (ii) other health services). However, there is a great deal of overlap between these categories, and the divisions should be viewed as arbitrary only. Multiple actions in many different areas from many different organisations and people will be needed to make significant progress towards the bold and audacious goal of reducing inequities in preschool oral health outcomes. ORAL HEALTH PROMOTION The prevention of dental caries, through the promotion of a healthy diet and the early establishment of good oral hygiene habits, is the single most important strategy in improving preschool oral health. Children are generally seen at dental clinics every 6-18 months, but their teeth are constantly exposed to factors that can heighten or reduce their risk of caries. Therefore the day-to-day oral health environment to which a child is exposed is the single most important factor in determining whether or not he or she will develop caries. Oral health promotion activities thus form the basic foundation of this Action Plan. Promoting oral health in young children is best achieved through a multi-pronged approach utilising oral health promotion through Well Child Tamariki Ora and other providers and in community settings where preschool children are active. This will include the development of healthy policies in preschool and other family settings, promoting oral health messages through mass and social media, oral health awareness raising in the community, and one-on-one anticipatory guidance via interactions with healthcare practitioners. The role of sugars in the development of caries cannot be overemphasised. Frequency, amount and timing of sugar consumption are the most important dietary factors increasing a child s risk of developing caries. 1 Children with early childhood caries are more likely to consume sugar between meals, especially in the form of sugar sweetened beverages (soft drinks and fruit juices), which add 15, 16 no nutritional value to a child s diet. The common risk factor approach to disease prevention is useful when considering health promotion messages for oral health. 17 Dietary sugar is a common risk factor with a role in dental caries, obesity, heart disease, stroke, cancers and diabetes, 18 and a systematic review and metaanalysis has demonstrated that there is a significant relationship between obesity and dental caries in children from industrialised countries. 19 Any intervention that reduces sugar consumption in 17 39

40 3.1 children is therefore likely to have a positive impact on the prevalence of both caries and obesity. Through the Ministry of Health s childhood obesity target, there are already specific activities in place, such as healthy conversation training, that could easily incorporate an oral health element. It is important that, as much as possible, health promotion messages and policies to improve oral health and reduce obesity in children be aligned. For example, oral health education and first feeding guidelines start with WCTO at the 5-7 months core contact visit and messages at this visit can be impactful before high sugar foods and drinks are given to the infant. ORAL HEALTH PROMOTION ACTION 1: Identify all health promotion activities for obesity and ensure that there is an oral health component incorporated. Align oral health and obesity messages. 1.1 HEALTH PROMOTION IN EARLY CHILDHOOD EDUCATION SETTINGS Oral Health Promoters One way to ensure that oral health promotion is prioritised and aligned with other health promotion activities is to have dedicated oral health promoter roles based within each of the three DHBs. These oral health promoters could facilitate links between health services (including ARDS and the Auckland Regional Public Health Service [ARPHS]) and early childhood community settings (for example, Early Childhood Education Centres [ECEs], Pacific churches and Marae) and help to champion oral health and ensure that it is incorporated into any health promotion activities focused on preschool children. Auckland DHB currently has two health promoters who work closely with high-priority ECEs (those centres with >50% Pacific or Māori enrolled or with equity ratings from the Ministry of Education of 1-3). These health promoters are actively engaged with 40 ECEs, including Pacific language nests and Kohanga Reo, to help develop sound policies around hygiene and nutrition, deliver skin infection education modules, provide health resources, and help modify ECE environments to improve the health of teachers and attendees. They have been able to successfully link ECEs with organisations such as the National Heart Foundation, which is also able to provide assistance with nutrition policy. Many of these ECEs would not have otherwise engaged with outside organisations due to technology and time barriers. The health promoters have also given lectures on child health to first and third year AUT students studying early childhood education. They are also linked with the Auckland DHB ARDS preschool coordinator, who has actively been working to increase enrolments into the ARDS service. There are no roles equivalent to the Auckland DHB ECE health promoter in Waitemata or Counties Manukau DHBs currently. Counties Manukau fund a Preschool Oral Health Education and Tooth brushing program (Mighty Mouth / Smilecare) in 150 ECEs with high Māori and Pacific rolls in high deprivation areas, however there are more ECEs where there is no preschool Oral Health promotion service

41 3.1 The ARDS preschool coordinator roles (one in each of the three DHBs) were originally focused on increasing newborn enrolments with ARDS. However with automated ARDS enrolments at birth now a reality in both Auckland and Waitemata DHBs (and planned in the near future for Counties), the roles have evolved to increase enrolments and keep details up-to-date in older preschool children. The Auckland DHB preschool coordinator recently held a successful dental community day in Glen Innes during the school holidays to raise awareness of ARDS and increase enrolments. This also included the distribution of free toothbrushes and toothpaste, with the support of the local Pak n Save. The ARDS preschool coordinator roles are well placed to work in conjunction with ECE health promoters and could be expanded to include oral health promotion. ORAL HEALTH PROMOTION ACTION 2: Develop specific oral health promoter roles to help implement dental-friendly policies and deliver oral health promotion messages in early childhood settings Development of Water only and Healthy Eating Policies Research has shown that strongly worded nutrition policies in ECEs create a culture of health promotion, where teachers and parents are encouraged to reassess unhealthy preferences and follow best practice to promote good health and nutrition for children in their care. 20 Evidence also suggests that teacher role-modelling can positively influence pre-school eating (and drinking) behaviours. 21 In 2016 the Ministry of Education wrote to all school principals and Boards of Trustees, encouraging them to adopt water/milk-only policies. This should be extended to all ECEs, with a particular focus on Pacific language nests, Kohanga Reo and ECEs in areas of high deprivation (these can be identified using the Ministry of Education s equity rating scores). These ECEs should also be supported to establish healthy eating policies, with an emphasis on reducing sugar. This could be done via existing ECE networks (for example, there are Pacific ECE networks in West and South Auckland) and in conjunction with the Auckland DHB ECE Health Promoters and the National Heart Foundation. There is an opportunity to link with Healthy Auckland Together and work with other agencies already working in this area, such as the National Heart Foundation and Healthy Families South Auckland and Waitakere. ORAL HEALTH PROMOTION ACTION 3: Work with and support all ECEs to institute water-only policies. Identify priority ECEs (Pacific language nests, Kohanga Reo, ECEs in areas of high deprivation) and work with them to establish dental-friendly healthy eating policies. ORAL HEALTH PROMOTION ACTION 4: Work to establish water-only policies in other childhood settings, such Pacific churches and Marae, and home childcare services

42 Tooth brushing and oral health promotion programmes through ECEs 3.1 In many regions of New Zealand oral health promotion for pre-schoolers and their parents is directed through ECEs, including Kohanga Reo and Pacific ECEs. Initiatives within ECEs have included: brushing programmes, Lift the Lip checks, delivery of health promotion messages and establishing sugar-free drink and healthy eating policies. 22, 23 These programmes have been based on the successful ChildSmile Nursery programme, itself part of a multi-pronged approach to child oral health that has resulted in significant improvements in child oral health in in Scotland. 24 In Counties Manukau DHB, the Mighty Mouth programme has been running an oral health education and daily tooth brushing programme in 150 preschools with high needs / high Māori and Pacific rolls since 2012, and there are plans to potentially fund an additional 80 preschools. A comparison of preschool children participating in the Mighty Mouth Tooth brushing programme with preschool children not in the programme, undertaken by Litmus evaluation, showed that the programme had a significantly positive impact on pre-schoolers : frequency of tooth brushing, knowledge of reasons for visiting a dental clinic, and knowledge about healthy food and drink choices. 25 According to oral health stakeholders interviewed as part of the development of the Ministry of Health s national oral health promotion initiative, supervised brushing programmes are an effective way to educate children about brushing, contribute to the development of positive oral health habits, and ensure that high needs pre-schoolers in ECEs are brushing at least once per day. 22 However, logistical considerations (student/teacher ratios, the need for brushing to be supervised and obtaining consent for children to participate) mean that brushing programmes can be a challenge to establish and sustain. If these challenges can be overcome, oral health programmes in ECEs can be a good avenue for health promotion. It should be noted that ECE programmes will fail to reach those children not enrolled in ECE, many of whom may be the most vulnerable to poor oral health. Pacific children, for example, have the lowest rates of ECE attendance in New Zealand (91% of five-year-olds have attended ECE, compared to 94% of Māori and 98% of other groups), and so reaching out to these children in other settings is important. 26 ORAL HEALTH PROMOTION ACTION 5: Extend the ECE-based daily tooth brushing and oral health promotion programme (currently only in Counties Manu) to other high needs ECEs areas across metropolitan Auckland. 1.2 ORAL HEALTH PROMOTION IN OTHER COMMUNITY SETTINGS DHBs run a number of programmes for Māori, Pacific and Asian populations where oral health promotion for pre-schoolers could potentially be included. For example, all three DHBs run Pacific church health promotion programmes, and Auckland and Waitemata also run parenting courses for Pacific families. There are also other breastfeeding and parent support groups, as well as 20 42

43 3.1 programmes such as Healthy Babies/Healthy Futures in the community which for high needs Māori, Pacific and Asian populations. All three DHBs also run integrated care (Whanau Ora and Fanau Ola) services in primary care, where nurses visit the homes of high-needs Māori and Pacific families to conduct comprehensive health and wellbeing checks. It is important that oral health is included as a core component of these checks for families with pre-schoolers. ORAL HEALTH PROMOTION ACTION 6: Identify and include an oral health promotion component in existing community-based programmes (for example, Healthy Babies/Healthy Futures), social media platforms and pregnancy/parenting apps aimed at parents. 1.3 ORAL HEALTH PROMOTION AT A POPULATION LEVEL The Ministry of Health has been working with the Health Promotion Agency (HPA) for the last two years to develop a new national initiative to promote and improve oral health preventive behaviours and practices, particularly tooth brushing, among preschool children. The key messages of the campaign are: Baby teeth are important and necessary for the health of permanent teeth Under five year olds need to have their teeth brushed by an adult Brush baby teeth twice a day with fluoride toothpaste Everyone should be using fluoride toothpaste A national social media, radio and television campaign targeting Māori and Pacific parents began at the end of 2016 and concluded in April The advertisement featured a tooth fairy reminding a father to brush his pre-schooler s teeth twice a day with fluoride toothpaste. According to the HPA, 77% of the combined target audience saw the tooth fairy advert on TV at least once and 59% saw it at least five times. The social media component had 850,000 Facebook views and the advert was viewed 380,000 times in online advertising. Traffic to the Ministry of Health website, increased by 170% from the same period last year. There were also low-cost resources (posters, banners for websites, e-newsletters, signatures and Facebook pages) associated with the campaign. The messages espoused by the campaign were important, as previous work has shown that there is a lot of confusion among parents about the correct toothpaste to use (many parents believe that children should be using child-specific lowerfluoride paste, a perspective created and perpetuated by toothpaste companies) and the importance of baby teeth. An HPA proposal is currently with the Ministry of Health for future potential phases of the campaign. While that campaign had specifically been designed to promote tooth brushing behaviour, there are other resources on the importance of reducing sugar intake, available through the HPA, which have 21 43

44 3.1 been highly recommended by those working in childhood obesity, and which are also helpful for oral health promotion. ORAL HEALTH PROMOTION ACTION 7: Ensure messages link with those used in the HPA national oral health promotion programme and use relevant resources that have been developed to promote the importance of baby teeth, and utilise translated resources where appropriate for priority population groups Alongside the current national oral health campaign, the Ministry of Health have plans (but with no specific time-frame yet) for targeted distribution of free toothbrushes and fluoride toothpaste for pre-schoolers at high risk of caries. 22 In Scotland, free toothpaste/toothbrush packs are distributed to every child on at least six occasions during their first five years as part of the ChildSmile Core programme. 24 In addition, every 3- and 4-year old attending an ECE is offered free daily tooth brushing. In New Zealand all infants are supplied with a free toothbrush and toothpaste through Plunket and WCTO at their 5-7 months core contact (health check) to coincide with first foods and healthy foods promotion. In 2017 free toothbrush and toothpaste has been extended for the B4 School Check, however many families cannot afford to replace the toothbrushes and toothpaste. In addition Counties Manukau DHB supplement oral health promotion with supply of toothbrushes and toothpaste for Pre-schoolers in high deprivation areas distributed through WCTO and ARDS clinics however this is not feasible as a regular three monthly activity (recommended toothbrush replacement). While the distribution of free toothbrush/toothpaste packs may not be feasible at a population level here in Auckland, it may be effective at a sub-population level. Anecdotal reports from healthcare workers indicate that there are many struggling families (many of whom are Māori and Pacific) where one toothbrush is shared amongst all family members. Giving these families toothbrushes for all family members (both children and adults), alongside messages of the importance of tooth brushing and not sharing toothbrushes, would not only improve oral health behaviours, but also reduce transmission of other infectious diseases. There may be opportunities to partner with local businesses or toothbrush companies to help with the funding of such a strategy. The Auckland DHB Preschool Coordinator, for example, has previously been able to secure free toothbrushes for preschoolers in the Glen Innes area through the local Pak n Save. ORAL HEALTH PROMOTION ACTION 8: Consider a targeted programme for distributing free toothbrushes and toothpaste to all members of families identified to be at high risk of caries. To maximise effectiveness, this programme would distribute toothbrushes at regular intervals over a specified time period, not just be a one-off

45 Oral Health Messages 3.1 Careful consideration should be given to the content of oral health promotion messages, particularly for Māori and Pacific families. Previous research has shown that Māori and Pacific parents do agree that oral health care is important and are motivated to ensure that their children maintain good oral health because of physical appearance, personal hygiene and preventing dental complications. However, there are a number of barriers that can stand in the way of parents engaging in effective protective oral health behaviour. These barriers include a lack of knowledge around oral health care, with many Māori and Pacific mothers having not developed a strong oral health care foundation during their own childhoods A second chance discourse, where parents believe that dental issues in baby teeth (such as yellow staining and cavities) disappear with the onset of adult teeth is also common. 27, 28 A lack of prioritisation of oral health care in struggling and busy households, and a lack of support for parental efforts to reduce dietary sugar from other family members (particularly grandparents, and especially in the spirit of fun and reward) can also make it difficult to maintain good preschool oral health. In focus groups held across the country, Māori and Pacific parents also reported a belief (not reported by parents identifying with other ethnic groups) that oral health care was not necessary when a child was still breastfeeding, as the antibodies contained in breast milk provided a sufficient level of protection from dental problems. 27 It is these sorts of barriers that need to be addressed in oral health promotion efforts. Research has also shown that there are certain prevalent behaviours associated with poor oral health in Pacific children that are open to modification through good oral health counselling and promotion. In the Pacific Island Families Study, only half of four year olds brushed their teeth more than once a day, 60% had snacks before bed and many used a sipper bottle with something other than water. Tongan children in this study were more likely to engage in these behaviours and to have experienced dental extractions by the age of four. 30 This finding is consistent with ARDS data. Educating parents about the importance of oral health care is vitally important, particularly mothers. Multiple studies in highly deprived areas have shown that Māori and Pacific mothers often have poor oral health, and oral health knowledge, themselves Between 2012 and 2015 Counties Manukau and Waitemata DHBs ran a successful trial providing free oral health care services (including treatment, education and preventive care) to high risk and high needs pregnant women at low cost using existing community oral health facilities. 25 While oral health outcomes of offspring were not evaluated, participants reported a greater awareness of oral health and a greater focus on self-care behaviours and whanau oral health. In addition, some of the women who migrated to New Zealand as adults reported that they learnt new information about how to care for their children s oral health. 29 ORAL HEALTH PROMOTION ACTION 9: Work closely with dental and health literacy experts to develop new resources with a specific focus on Pacific and Māori pre-schoolers. Ensure oral health promotion messages are evidence based and are informed by feedback received via focus groups and interviews that have examined Māori and Pacific attitudes and knowledge towards preschool oral health

46 3.1 ORAL HEALTH PROMOTION ACTION 10: Promote the Health Promotion Agency s Baby Teeth Matter and other oral health promotion videos in waiting rooms in ARDS, primary care, outpatient clinics and Emergency Departments. Consider collaborating with other teams working in other areas of child health, so that the video includes information on other important child health issues, such as SUDI and rheumatic fever. Make take home resources available in relevant languages e.g. stickers for Pre-schoolers, fridge magnets for home message reminders. There are also pregnancy and parenting apps targeted at Māori, Pacific and Asian families that could be used to promote oral health. For example, Tapuaki is a Pacific pregnancy and parenting education website and app that currently has very limited information on oral health promotion and the ARDS service. Oral health messages should also be an important component for other innovative social media programmes aimed at new parents: for example, TxtMATCH is a text messaging service for new parents currently being evaluated by the University of Auckland. 1.4 ORAL HEALTH PROMOTION AT AN INDIVIDUAL LEVEL Anticipatory guidance refers to information that is given to families and children to promote health, prevent disease and increase awareness about what to expect as the child enters the next developmental phase. 12 Child healthcare providers, particularly Lead Maternity Carers (LMCs), Plunket/WCTO providers, GPs and practice nurses, are in an ideal position to provide oral health care and hygiene counselling, as they are the health professionals that see infants and pre-schoolers most often. In particular, LMCs and WCTO providers have scheduled and structured visits with mothers and children, and can establish a good relationship with families, making them a trusted source of oral health information. Oral health guidance and education and a Lift the Lip screen are already components of WCTO visits (oral health counselling at each contact from 5-7 months and Lift the Lip from 9-12 months). 31 However, some infants, especially Māori and Pacific, begin teething as early as three months, 22 and good oral health behaviours start as soon as a child is born. Therefore leaving anticipatory guidance on oral health care until a child s teeth have erupted may mean that certain behavioural patterns are difficult to stop. In addition, studies have shown that pregnancy (particularly for first-time mothers) is a time when women may be more receptive to oral health messages in the long-term. 32, 33 This finding has led to many professionals in the sector recommending that key oral health messages start being delivered before a baby is born. This would allow time for families to become orally fit before their children start teething

47 3.1 ORAL HEALTH PROMOTION ACTION 11: Include stage-appropriate oral health messaging and anticipatory guidance as a component of antenatal group education and for LMCs to deliver to expectant mothers on a 1:1 basis. Refresh stage-appropriate oral health messaging and anticipatory guidance as a component of WCTO delivery to parents/ caregivers at 5-7 month and 9 month core contact. 1.5 MATERNAL ORAL HEALTH CARE In 2008, the Ministry of Health released a report on Maternal and Child Oral Health. This report recommended that all pregnant women should be targeted for oral health promotion, with additional resources to develop programmes for socially disadvantaged women and those from high risk populations. 34 In 2012 the MOH invited submissions for a Request for Proposals (RFP) to pilot pregnancy-related oral health care services that could be delivered in community oral health facilities where unused capacity existed. Waitemata DHB was successful in its submission and in 2013 commenced a two year pilot study to provide free oral health care to a minimum of 400 pregnant women who were eligible for a Community Services card and between 12 weeks gestation and 9-months post-partum. The pilot ran from January 2013 to November 2014, but due to the high volume demand and positive interim outcomes, an extension to funding was granted with an end date of 31 December Counties Manukau DHB was also successful in their submission and a similar trial for free oral health care for pregnant women with Diabetes in Pregnancy ran in Counties Manukau DHB area from December 2012 to December 2015 with dental services provided during pregnancy and postnatally to completion of dental treatment. The aim was to get the women dentally fit and included full dental services and dentures where that was the best outcome. Both Trials were evaluated by Litmus Research and assessed as offering value for money in providing much-needed oral health treatments to participating women (92% of all women had caries with an average of 8.42 teeth per person affected by decay), increasing the use of community oral health facilities, increasing oral health literacy among expectant and new mothers, increasing whānau enrolment in community oral health facilities and engaging referral agencies in oral health care. 25 The evaluation concluded that it was unlikely that the post-trial sustained oral health outcomes achieved could have been attained at a substantially lower cost through other service delivery mechanisms. Given the success of the trials, a free/low-cost maternal oral health service for low-income/highneeds expectant and new mothers would be an important component of any strategy to improve preschool oral health. If such a service were to be implemented, it is essential that it would have a strong preventive (as well as treatment) focus. The use of oral health therapists to diagnose, examine and implement phases of prevention and refer women on to dentists for restorative work where required would ensure that a focus on prevention was central to each visit and to maximise value for money. A recall period for maintenance of oral health and implementation of other preventive activities (such as smoking cessation support and fluoride application) would be 25 47

48 3.1 important, not just for the mother, but also to ensure enrolment, examination and health support for the child/children has also occurred. ORAL HEALTH PROMOTION ACTION 12: Implement a free/low-cost maternal oral health service for high-needs or medically compromised expectant/new mothers. 1.6 COMMUNITY WATER FLUORIDATION Community water fluoridation remains one of the most effective and cost-effective population means of reducing dental decay. 35, 36 While most areas in Auckland are fluoridated, there are certain pockets (for example, Onehunga, Waiheke and more rural areas not on reticulated water supply) where children are not exposed to fluoridated water. ARPHS is currently the lead agency for the advocacy of water fluoridation. ARDS and other organisations will continue to support ARPHS water fluoridation advocacy efforts. ORAL HEALTH PROMOTION ACTION 13: Continue to support ARPHS in its advocacy efforts regarding community water fluoridation

49 Prevention, Regular Assessment and Early Detection of Caries 3.1 Early identification of high-risk children and detection of early carious lesions is important to prevent, stop, and potentially reverse, the development of caries. 1 Caries risk assessment is the determination of the likelihood of the incidence of caries during a certain time period. 37 Research has shown that caregivers of young children routinely perceive their children s oral health to be better than it actually is; the difference between parental assessment and actual clinical treatment needs is greatest for children under the age of two. 38 Regular assessment and screening of the oral health status of young children is therefore essential. In particular, the Ministry of Health recommends identifying children at greatest risk early and targeting finite resources to children at highest need. 2 ARDS, as a dental service for children, is best placed to detect and treat carious lesions in young children. However, all child healthcare professionals should be able to screen infants to determine caries risk, provide anticipatory guidance, and refer children to dental professionals in a timely fashion. 37 The actions under this heading are therefore divided into two: those under the remit of (1) ARDS and (2) other child health professionals. Actions under the remit of ARDS include strategies along the entire oral healthcare pathway, from enrolment and examination to treatment completion and follow-up AUCKLAND REGIONAL DENTAL SERVICE ARDS provides free dental care to all children in the Auckland region from birth up to school Year 8. Service provision extends from Wellsford to the Bombay Hills through a combination of fixed clinics (42), diagnostic vans (18), transportable dental units (21) and one fully mobile clinic. 39 A service review of ARDS was completed in October This review examined all aspects of the service (both for preschool and school-aged children) and included a number of recommendations. Where relevant, these recommendations have been incorporated into this Preschool Strategy. ARDS enrols children from birth and aims to see all children for their first dental examination by the age of 1. It operates an individualised model of dental care: at examination, a child s risk of caries is determined, based mainly on their oral health status. The child s risk assessment then determines the intervals at which they will be recalled for further examination (6-, 12-, or 18-monthly). If treatment is required, a signed consent form and/or attendance of a parent or guardian is necessary. Completion of treatment is an important performance indicator: in 2015, the percentage of children who had not completed treatment ranged from 31% in Waitemata DHB to 48% in Counties Manukau DHB. ARDS currently runs a supportive treatment pathway in parts of West and South Auckland to ensure treatments are complete for very high-risk children (for example, those under Oranga Tamariki care)

50 3.1 ARDS uses an information technology (IT) system known as Titanium to collect and record patient data. This system is not able to link to other health IT systems such as the NHI system and esam. Enrolments Early enrolment of children into the community dental service enables engagement of families and potentially detection of caries at a young age. Maximising enrolments is also essential because many key performance indicators use enrolments, rather than eligible population, as a denominator. Children who are not enrolled are therefore likely to represent unmet need. In 2015, approximately 60% of children in Auckland and Counties Manukau DHBs and 75% of children in Waitemata DHB aged 0-2 years were enrolled in the ARDS service. By 2016 these numbers had increased to 85% of children in Auckland and 93% of children in Waitemata DHB. Enrolment into ARDS has been facilitated by WCTO providers, who provide enrolment papers to families at scheduled Well Child visits. Preschool coordinators have also been employed in each DHB area to increase enrolments and enhance links with existing preschool networks in the community. Waitemata and Auckland DHBs also implemented enrolment processes in maternity units, and Counties Manukau undertook a mail out campaign to families in 2015, leading to increases in enrolments. Auckland, Northland and Waitemata DHBs are currently working hard to establish the N-CHIP multienrolment system from birth, which will include enrolment onto the national immunisation register, ARDS and WCTO. Once this is in place, enrolments will increase substantially, and efforts should be concentrated on those children who somehow miss out on the multi-enrolment process. For parents whose children were not born in New Zealand, the process of ARDS enrolment could also be simplified by allowing online or phone enrolments. Enduring consent for assessment and treatment could then be obtained at the child s first appointment. There is evidence refugee and new migrant children have poorer oral health outcomes than other children. SERVICE ACTION 1: Fully implement the multi-enrolment system across all three metropolitan Auckland DHBs and send enrolment acknowledgement to parent/ caregiver e.g. text message and/or letter of what to expect. SERVICE ACTION 2: Simplify process of ARDS enrolment for all children. SERVICE ACTION 3: Develop robust processes for ensuring that contact details of families are kept up-to-date. This would include developing a process where families can update their contact details easily online, via text, the 0800 phone number or by post

51 Awareness of the ARDS service 3.1 A consistent finding in previous surveys, 40 the ARDS review, DHB focus groups with Māori mothers and Tongan and Niuean grandparents and from feedback from various community organisations held by the DHB. It is also apparent that, even in parents whose children are enrolled with ARDS, community awareness of the free child dental health service, how it can be accessed, and what services it can offer, are low. Cost of dental care was cited as a barrier to good preschool oral health, so it is imperative that families are made aware that the free service can be accessed at any stage (i.e. that parents do not have to wait for an appointment for their child to access services). Increasing awareness of the ARDS service should be done via multiple channels: antenatally through LMCs, postnatally via WCTO providers, ARDS preschool coordinators, primary care and community health workers. Consideration could be given to developing fridge magnets and other resources to promote awareness of the ARDS service. ARDS should also utilise existing community networks (for example, Pacific churches in all three DHBs and preschool networks) to promote oral health and the ARDS service. Parents have previously noted that regular ARDS updates (about the service and when, where and how to access it) via school newsletters are also very helpful. 40 ARDS could also increase community awareness of the service, engage in oral health promotion and potentially use mobile units for opportunistic dental assessment and treatment at specific community events (for example, Pasifika, Toddler Day Out). Awareness of the ARDS service, and when to refer children, should also be improved in community, primary and secondary care. It is unclear how well known the ARDS service is to other healthcare professionals in contact with children and their families, such as General Practitioners (GPs), practice nurses, paediatricians, paediatric nurses, and cultural support workers. These healthcare professionals need to know where to refer children at high risk of, or with active, dental issues. The referral process needs to be simple and seamless. Māori, Pacific and Asian support workers in contact with children and their families in secondary care and also in community settings must also be made aware of the ARDS service. SERVICE ACTION 4: Develop a comprehensive strategy to increase community awareness of free dental services, how these can be accessed, and what services are offered. Efforts to increase awareness must start in communities at highest need. SERVICE ACTION 5: Develop a strategy to increase awareness of, and ease of referral of children into, its services for healthcare workers in community, primary and secondary care. However, enrolment in and of itself will not improve preschool oral health. Once enrolled, the challenge is to ensure that children receive regular, appropriate and timely assessments of their oral health

52 Access and Examinations 3.1 It is well established that location, hours of operation and cost are significant barriers to care, particularly for Māori and Pacific people. 41, 42 Until recently, most ARDS clinics operated during the week. These days may not suit working parents and those who do not have transport during the week. Results from previous surveys have shown that parents would prefer the option of early evening and Saturday appointments. 40 In response to this, Counties Manukau DHB has recently piloted a Saturday clinic in Manukau from (8am-5pm). This clinic runs two dental chairs: one for booked appointments and the other available on a drop-in basis. These Saturday clinics have been very popular, with an average chair utilisation for dental assessments of children. (Children in need of dental treatment are re-booked for procedures during the week). There are plans to not only continue this clinic but also extend Saturday clinics to other locations in the Auckland region. Bookings are also a potential barrier and source of confusion. ARDS makes appointments for children based on their recall period (when the child is due for an appointment, a letter is sent to parents notifying them of the location, date and time). Patient-focused bookings (where families are able to choose times most convenient for them) are not currently an option, and although some clinics have been trying to book all children in the same family together, family-based bookings are not currently routinely done. Ideally ARDS would have some flexibility in their appointments through the day that all siblings could be examined at the same visit, even if they have not been booked together. Appointment Did Not Attend (DNA) rates provide an indication of service access and uptake. ARDS DNA rates generally range from 17-35%, and the highest rates are in Counties Manukau DHB. Waitemata and Auckland DHBs have a DNA strategy with specific actions that ARDS could consider implementing. Patient-focused bookings have been shown to be highly effective in reducing DNA rates and increasing access; if this is not possible, then at a minimum ARDS should consider implementing processes to make it much easier for parents to change appointment times. Currently, parents are sent a reminder text 1 week and 2 days before a child s appointment. If they want to change the appointment time, they have to phone a 0800 number, where they are often met with an answerphone message. An option to text back may help facilitate this process, as would some form of online feedback (for example, a smartphone app). Ensuring that all children complete treatments is also a challenge. ARDS have a supportive treatment pathway to support vulnerable families to attend appointments and ensure completion of treatments in West Rodney: this programme should be extended to include children in other areas with high DNA rates. ARDS could also enlist the help of Māori, Pacific and other outreach services to help engage with families who have been hard to reach. This has previously been successfully done for immunisations. The location of ARDS clinics may also be a barrier to care for those without transport. The ARDS review noted that the move to centralised clinics has led to low engagement in communities where transport and/or availability of parents are limited. 39 Specific examples of communities not well served by the current Hub and Spoke model of care are: Wellsford, Point England, Otara, Mangere and Clendon. Many children in these communities will be from families with multiple risk factors for poor oral health. As recommended in the ARDS review, a strategy to improve access for these 30 52

53 3.1 communities includes adapting diagnostic vans for treatment purposes and making them more available at a wider range of community events and sites. Infrastructure (for example, power outlets) will also be needed to enable the use of mobile facilities in community settings. Community settings could include Pacific churches (DHBs have existing networks through the Lotu Mou i, Enua Ola and HVAZ programmes), marae, and community squares or centres in areas of high deprivation. ARDS could use a similar model to that used by mobile cervical screening buses. Large scale community events, such as Pasifika, also represent good opportunities to conduct opportunistic dental assessments of pre-schoolers and deliver oral health promotion. SERVICE ACTION 6: Extend Saturday clinics and weekday opening hours to high priority locations. SERVICE ACTION 7: Institute a policy whereby all eligible children within the same family are seen at the same visit, even if only one child was booked for an appointment. SERVICE ACTION 8: Extend the supportive treatment pathway to more areas to support vulnerable families to attend appointments and ensure completion of treatments. SERVICE ACTION 9: Enlist the help of Māori and Pacific outreach services to help find families who have persistently not attended appointments and/or not completed treatment. SERVICE ACTION 10: Continue and increase the use of mobile vans in community settings (e.g. Pacific churches, Marae, community centres) and at major community health focused events likely to attract a large number of young families Caries Risk Assessment and Recall ARDS operates an individualised dental care model. This means that dental therapists assess each individual child s risk of caries based on a scoring system to estimate their risk of caries ( low, medium or high ) and determine the period at which they should be recalled for dental assessments (6, 12 or 18 months). The current scoring system takes into account factors relating to the child s medical history, previous attendance, bottle feeding and dietary habits, exposure to fluoride and clinical findings. If a child is overdue by more than 30 days for their scheduled dental examination (based on this recall period), he or she is said to be in arrears. Approximately 31% of pre-schoolers enrolled in ARDS were in arrears in 2016, and Māori and Pacific children were more likely than other children to be overdue for their scheduled examination

54 3.1 Staff feedback during the ARDS review in 2016 was that recall times needed to be reviewed as there was a possibility that too many children were being recalled at 6 months, leaving limited capacity to make appointments for other children. Since then, work has been done to better understand recall periods in the three DHBs. Across the Auckland region, 16% of children are on 6-month, 76% on 12- month, and 8% on 18-month recall periods. It appears that the highest risk children are on high-risk recall periods, but many low-risk children are on 12-month recall periods. ARDS is currently working with three clinics in areas identified to have low-risk children, to further examine how low-risk children could be safely transitioned into 18-month recall periods. This in turn will free up ARDS resources to focus on the children at highest risk of caries. Given that the majority of Māori and Pacific children have caries by age 5, it seems sensible to include some kind of weighting for ethnicity when considering caries risk. Some may argue that this is stigmatising; however, there are other DHBs and other areas in medicine (for example, cardiovascular risk assessment) where consideration of ethnicity in the assessment of risk is done routinely and with positive effect. For example, in Nelson Marlborough DHB all Māori and Pacific children are considered high risk and are on a 6-month recall period: once a year they are assessed by a dental therapist and given topical fluoride, and in the intervening six months they are assessed by a dental assistant, who also applies topical fluoride. This combination of dental therapist/dental assistant work could be considered by ARDS. SERVICE ACTION 11: Consider including Māori and Pacific ethnicity as a component of the current caries risk assessment score and putting all Māori and Pacific children on a 6-month recall period. Continue work on individualised caries risk assessment and better understanding recall periods. Topical Fluoride Application One of the recommendations of the ARDS Review was that a preschool workforce be established to apply fluoride varnish treatments to Māori, Pacific and at-risk preschool children in community locations from 12 months of age. Systematic reviews have found that regular fluoride varnish applications are an effective, safe and practical way to increase fluoride exposure in the oral biofilm 13, 43 of at-risk preschool children, thereby reducing their risk of caries. Counties Manukau DHB is already planning to start delivering this service through their existing Mighty Mouth programme through Early Childhood Education Centres. Auckland and Waitemata DHBs do not currently have a similar programme for their preschool populations, and it is unclear whether fluoride application is best delivered through this model in these two DHBs. In Northland DHB, topical fluoride application has been delivered to pre-schoolers via primary care, and anecdotally it has been very effective. A cost-effectiveness study is currently underway there. At Nelson Marlborough DHB, all high risk preschool children (including all Māori and Pacific children) receive topical fluoride 6-monthly through the community oral health service. This is also practice in Waikato particularly in areas of non-fluoridated community water for preschool children 32 54

55 3.1 on a 7 month recall. In Otago, all preschool children (regardless of caries risk status) receive topical fluoride on a 3-monthly basis. Whatever model is chosen for delivering topical fluoride to high-risk children, careful consideration will need to be given to the timing of fluoride application, record-keeping and documentation (to ensure that children who are due for fluoride receive it regularly). Overseas studies recommend that topical fluoride be applied by dental personnel, but there is evidence that a well-trained nondental workforce can also be used. SERVICE ACTION 12: Provide 6 monthly topical fluoride varnish application for all high-risk preschool children (particularly Māori and Pacific children) from the age of 12 months. Quality of Care and Patient Experience ARDS does not currently have any regular or formal mechanism to collect consumer feedback. One of the recommendations of the ARDS review was to institute such a process. 39 Focus groups with Māori mothers found that some parents disliked the facilities at mobile clinics (not enough room to sit or bring prams), and some were dissatisfied with set-up of appointments (for example, not booking siblings together) and with waiting times for appointments. However, parents did not have issues with ARDS staff, who were described as friendly. Previous surveys have noted that approximately 10% of respondents were dissatisfied with communication of appointment times, brushing techniques and good oral habits. ARDS received 48 complaints in 2015 and most of these also related to poor communication and/or information. 39 It is imperative that all frontline ARDS staff are able to communicate easily with families from a variety of different backgrounds, particularly Māori, Pacific and Asian patients. A number of ARDS staff members have undergone cultural competency training: this should be extended to all staff who come into contact with preschoolers and their families. SERVICE ACTION 13: Institute a process enabling regular consumer feedback. SERVICE ACTION 14: All staff delivering dental care and/or oral health promotion undergo cultural competency and clinical safety training to ensure they are able to communicate easily with all families and safely deliver a fluoride varnish application program

56 Staff Recruitment and Retention 3.1 To reduce inequities in oral health outcomes, it is important to ensure that oral health staff reflect the population they serve. The number of Māori and Pacific dental therapists within the ARDS service has been increasing over the years, but remains small, given the proportion of families accessing the service who are Māori and Pacific. There are Māori (Te Mangai Hau) and Pacific (Pacifica Nifo) dental therapy groups within ARDS, which provide support and advice to Māori and Pacific ARDS staff and leadership within their communities. They also assist with cultural competency training. Dental professionals are respected sources of oral health promotion and education within communities. ARDS could allocate specific time for Māori and Pacific dental therapists to engage in community oral health promotion and attend events to encourage Māori and Pacific high school students to consider a career in dental therapy. ARDS provides clinical training placements for all dental therapy students from AUT and a smaller number of students from Otago University. These institutions do not currently have a robust strategy in place to train more Māori and Pacific therapists. ARDS could therefore provide a leadership role in advocating for a number of training positions specifically for Māori and Pacific students, as well as enhanced pastoral support. SERVICE ACTION 15: Allocate time for Māori and Pacific dental therapists to engage with their respective communities for oral health promotion, education and encouraging high school students into a career in dental therapy. Advocate for an increased number of Māori and Pacific students training in dental therapy. 2b. OTHER CHILD HEALTH PROFESSIONALS Other child health professionals (for example, Plunket/WCTO providers, GPs, practice nurses, paediatricians, and paediatric nurses) also play an important role in the early detection of caries and prompt referral of pre-schoolers to the ARDS service. Plunket/WCTO providers conduct Lift the Lip assessments at all core checks from the age of 9 months. Oral health is also an important part of the B4 School Check. It is important that all Plunket/WCTO providers undergo Lift the Lip training and refreshers if necessary. These providers must also ensure that all oral health assessments and advice are documented. Similarly, those working in child health in primary and secondary care are uniquely placed to undergo opportunistic assessments of oral health status in pre-schoolers. An examination of the throat, for example, is frequently carried out when GPs assess an unwell child. Through training, these medical professionals can be made aware of the importance of oral health screening and they too could conduct Lift the Lip assessments and refer pre-schoolers to the ARDS service. This could 34 56

57 3.1 be done as part of a Continuous Medical Education (CME) process, for which healthcare practitioners could earn CME points. There are also other community-based health programmes for children and families run by the DHBs where a Lift the Lip could easily be incorporated, for example, Fanau Ola family assessments in primary care. SERVICE ACTION 16: Ensure that all Plunket/WCTO providers are competent in undertaking a Lift the Lip Assessment, undergo regular refresher courses and conduct assessments at all core checks from 9-12 months. SERVICE ACTION 17: Upskill primary care practitioners (GPs and practice nurses) in oral health promotion, Lift the Lip assessments and ensure that they know when and how to appropriately refer children urgently (and non-urgently) for oral health care. Publicise Oral Health e-referral pathways to GPs, private Dentists, and WCTO for appropriate Oral Health care referrals. SERVICE ACTION 18: Upskill secondary care child health workers (paediatricians, paediatric registrars and nurses) in oral health promotion, Lift the Lip assessments and ensure that they know when and how to appropriately refer children urgently (and non-urgently) for oral health care. Publicise Oral Health e-referral pathways to Secondary and Tertiary care for appropriate Oral Health care referrals. MONITORING OF PROGRESS AND EVALUATION Progress will continue to be monitored using the following measures for children aged five and under: Dental ambulatory sensitive hospitalisation (ASH) rates Caries-free rates dmft ARDS enrolments ARDS utilisation ARDS did not attend (DNA) rates ARDS arrears (proportion of enrolled children overdue for examination) ARDS treatment completion rates 35 57

58 3.1 Proportion of children in each scoring category for Lift the Lip performed at B4SC Well child oral health and oral health promotion measures to be developed All measures will be reported by age, ethnicity and DHB. A formal evaluation of implementation of actions will also be undertaken. References 1. Bach K, Manton DJ. Early childhood caries: a New Zealand perspective. Journal of Primary Health Care 2014;62(2): Ministry of Health. Early Childhood Oral Health. A toolkit for District Health Boards, primary health care and public health providers and for oral health services relating to infant and preschool oral health. In. Wellingtonq: Ministry of Health; Hunter PBV, Kirk R, de Liefde B. The Study of Oral Health Outcomes: The New Zealand section of the WHO Second International Collaborative Study. In. Wellington: Department of Health; Thomson WM. Ethnicity and child dental health status in the Manawatu-Wanganui Area Health Board. New Zealand Dental Journal 1993;89: Lee M, Dennison PJ. Water fluoridation and dental caries in five- and 12-year-old children from Canterbury and Wellington. New Zealand Dental Journal 2004;100: Kilpatrick NM, Gussy MG, Mahoney E, Wellington:. Maternal and Child Oral Health: Systematic review and analysis: A report for the New Zealand Ministry of Health. In. Wellington: Murdoch Children s Research Institute and Ministry of Health; Association NZD. New Zealand Dental Association Position Statement on Child Oral Health Department of Health, British Association for the Study of Community Dentistry. Delivering better oral health: an evidence-based toolkit for prevention. In. London: Department of Health; Sheiham A. Oral health, general health and quality of life. Bulletin of the World Health Organization 2005;83: Kawashita Y, Kitamura M, Saito T. Early childhood caries. International Journal of Dentistry 2011;Article ID American Academy of Paediatric Dentistry. Policy on early childhood caries (ECC): classifications, consequences, and preventive strategies.. In. Oral health policies reference manual. Chicago: Council on Clinical Affairs; New Zealand Dental Association. Healthy Smile, Healthy Child: Oral Health Guide for Well Child Providers. In. Auckland: New Zealand Dental Association; Chou R, Cantor A, Zakher B, Mitchell JP, Pappas M. Preventing dental caries in children <5 years: systematic review updating USPSTF recommendation. Pediatrics 2013;132: State Services Commission. Better Public Services: A Good Start to Life Hallett K, O'Rourke P. Social and behavioural determinants of early childhood caries. Australian Dental Journal 2003;48(1): Gussy MG, Waters EG, Walsh O, Kilpatrick NM. Early childhood caries: current evidence for aetiology and prevention. Journal of Paediatrics and Child Health 2006;42:

59 Sheiham A, Alexander D, Cohen L, Marinho V, Moyses S, Petersen PE. Global oral health inequalities: task group implementation and delivery of oral health strategies.. Advances in Dental Research 2011;23(2): Borutta A, Wagner M, Kneist S. Early childhood caries: a multifactorial disease. OHDMBSC 2010;IX(1): Hayden C, Bowler JO, Chambers S, Freeman R, Humphris G, Richards D, Cecil JE. Obesity and dental caries in children: a systematic review and meta-analysis. Community Dentistry and Oral Epidemiology 2013;41(4): Hawkes C, Smith TG, Jewell J, et al. Smart food policies for obesity prevention. Lancet 2015;385(9985): Ward S, Belanger M, Donovan D, et al. Systematic review of the relationship between childcare educators' practices and preschoolers' physical activity and eating behaviours. Obesity Reviews 2015;16(12): Allen and Clarke Policy and Regulatory Specialists Limited. Child Oral Health Promotion Initiative: Stakeholder Engagement and Resource Stocktake Report. In. Wellington: Health Promotion Agency; Gawith L. Evaluation report of the Oranga Niho: Oranga Kata Healthy Teeth: Healthy Smile PHO-based oral health promotion project for children under 5 years. In. Christchurch: Canterbury District Health Board; Macpherson LMD, Ball GE, Brewster L, Duane B, Hodges C-L, Wright W, Gnich W, Rodgers J, McCall DR, Turner S, Conway DI. Childsmile: the national child oral health improvement programme in Scotland. Part 1: establishment and development. British Dental Journal 2010;209(2): Gregg L, Thompson A, Smith L. Evaluation of the low-cost oral health trials. Final report. In. Wellington:: Litmus Limited; Ministry of Education. Participation in Early Childhood Education. In. Wellington: Ministry of Education; Kaitiaki Research and Evaluation. Oral Health in Preschoolers. In. Wellington: Health Promotion Agency; Broughton JR, Person M, Mipi JT, Cooper-Te KR, Smith-Wilkinson A, Tiakiwai S, Kilgour J, Berryman K, Morgaine KC, Jamieson LM, Lawrence HP, Thomson WM. Ukaipo niho: the place of nurturing for oral health. New Zealand Dental Journal 2014;110(1): Litmus Limited. Low Cost Oral Health Trial. Service Experience Qualitative Research Report. In. Wellington: Litmus Limited; Schluter PJ DC, Cartwright S, Paterson J. Maternal self-report of oral health in 4-year-old Pacific children from South Auckland, New Zealand: Findings from the Pacific Islands Families Study. Journal of Public Health Dentistry 2007;67(2): Ministry of Health. Well Child / Tamariki Oral Programme Practitioner Handbook: Supporting families and whanau to promote their child's health and development. Revised In. Wellington: Ministry of Health; Phelan C. The Blue Book oral health program: a collaborative partnership with state wide implications. Health Promotion Journal 2006;17: Plutzer K, Spencer AJ. Efficacy of an oral health promotion intervention in the prevention of early childhood caries. Community Dentistry and Oral Epidemiology 2008;36( ). 34. Murdoch Childrens Research Institute. Maternal and Child Oral Health systematic Review and Analysis. A report for the New Zealand Ministry of Health. In; September Ran T, Chattopadhyay SK, Force CPST. Economic Evaluation of Community Water Fluoridation: A Community Guide Systematic Review. American Journal of Preventive Medicine 2016;50(6):

60 Iheozor-Ejiofor Z, Worthington HV, Walsh T, O'Malley L, Clarkson JE, Macey R, Alam R, Tugwell P, Welch V, Glenny AM. Water fluoridation for the prevention of dental caries. Cochrane Database of Systematic Reviews 2015;DOI: / CD pub Kagihara LE, Niederhauser VP, Stark M. Assessment, management, and prevention of early childhood caries. Journal of the American Academy of Nurse Practitioners 2009;21: Divaris K, Vann WF, Baker AD, Lee JY. Examining the accuracy of caregivers' assessments of young children's oral health status. Journal of the American Dental Association 2012;143(11): Harun L. Auckland Regional Dental Service Review Report. In. Auckland: Waitemata District Health Board; Dawe M, Parsonage P. Report on the Auckland Regional Dental Service Stakeholder Surveys for the Waitemata District Cluster Areas. In. Auckland: Health & Safety Developments Management Research & Consultancy; Southwick M, Kenealy T, Ryan D. Primary care for Pacific people: a Pacific and health systems approach. Report to the Health Research Council and the Ministry of Health. In: Pacific Perspectives, ed. Wellington; Jansen P, Bacal K, Crengle S. He Ritenga Whakaaro: Māori experiences of health services. In. Auckland: Mauri Ora Associates; Marinho VC, Worthington HV, Walsh T, Clarkson JE. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2013:p. CD

61 APPENDIX 1: SUMMARY OF ACTIONS AND TIMEFRAMES 3.1 Start: Immediately/Short-term Area Action Description and Issues to consider Lead Agency Time frame Oral health promotion October 2017 Prevention Prevention, early detection, and treatment: ARDS Early childhood settings Messaging Enrolment Examinations and Treatment 1. Develop specific oral health promoter roles to help implement dental-friendly policies and deliver oral health promotion messages in early childhood settings 2. Align oral health and obesity prevention and health promotion messaging 3. Continue to support ARPHS advocacy work around community water fluoridation in the Auckland region 4. Increase awareness of the free ARDS service amongst the community and health professionals 5. Fully implement the multi-enrolment system across all three Auckland DHBs 6. Simplify the ARDS enrolment process and the way in which services can be accessed 7. Develop robust processes for keeping contact details of families up-to-date There needs to be a stocktake of the current health promotion workforce in ECEs for each DHB. This should include feedback from ECEs about how these roles are working. Options to consider include: consolidating the roles into one health promoter role or ensuring that the messages that oral health and other health promoters are aligned. New resources need to focus on Māori and Pacific children (health literacy considerations). Messages must be evidence based and informed by feedback from Māori and Pacific. Resources to counter the anti-fluoride arguments to successfully implement fluoride varnish application for pre-schoolers Develop a comprehensive strategy to increase community awareness of free dental services, how these can be accessed, and what services are offered. Focus on areas with highest need. Enrolment in the ARDS service will be part of the National Child Health Information Platform (NCHIP) programme for all children born in the Auckland region. ARDS has mapped out the enrolment process in detail to identify potential barriers and areas where the process can be simplified. Families should be able update their contact details easily online, via text, 0800 number or by post and at every contact with ARDS. Communication between different providers of care (for example, Plunket/WCTO and primary care) may also be necessary for families that move frequently. Potential collaboration with NIR Urgent in Counties Manukau to reduce barriers to access and DNAs PFO to lead a stocktake of health promotion workforce and activities for ECEs PFO All ARDS PFO, ARDS ARDS ARDS October 2017 Ongoing December 2017 Ongoing Ongoing 8. Extend Saturday clinics and weekday ARDS Ongoing opening hours to high priority locations 9. Implement family-friendly examination All eligible children in the same family should be seen at the same ARDS September 39 61

62 3.1 Wider early childhood health workforce Risk Assessment Prevention Quality of care Community outreach Coordination between providers policies 10. Extend the supportive treatment pathway to support more vulnerable families to attend appointments and ensure completion of treatments 11. Consider including high-risk ethnic groups as a component of the current individual caries risk assessment score and more systematically assign recall intervals to more appropriately affect the level of caries risk 12. Systematic programme of topical fluoride application 13. Institute a regular consumer feedback process for ARDS 14. Cultural competency and healthy conversations training for all ARDS staff delivering dental care 15. Use mobile vans in community settings and at major community health focused events 16. Improve and facilitate bi-directional communication between ARDS and other providers, particularly Plunket/WCTO and primary care 17. Upskill Plunket/WCTO providers in oral health assessment and promotion. visit, regardless of how many were booked for an appointment. Children with siblings known to have caries or a history of caries should also be considered high-risk and be placed on 6-month recall periods. Work with Māori and Pacific providers and Plunket to help find families who have persistently not attended appointments and/or not completed treatment. An evaluation of the current Supportive Treatment programme at Ranui is currently underway. ARDS has conducted a detailed analysis of current recall intervals and found that 75% of children are on a 12-month recall period and that most clinics seem to be using 12 months as a default recall interval, even for children at low risk of caries. Work is ongoing in this area. To be started in children at highest risk of caries, particularly Pacific and Māori children from 12 months of age. Model of delivery is likely to be through dental assistants, but other aspects may differ between DHBs. Review delivery through WCTO or Preschool Tooth brushing programs An important component of assessing quality of care and patient experience. All staff delivering dental care or dental assistants / patient care assistants To examine children due for assessment and promote oral health and free oral health services. E.g. Pacific churches, Marae; E.g. Pasifika, Toddler Day Out Plunket/WCTO and other providers want to know the outcome of any referrals to ARDS, and can help families who may experience barriers to ARDS care with processes from enrolment through to examination and treatment completion. Dental DNA follow-up process for WCTO / Plunket to action Ensure that all WCTO providers are competent in undertaking a Lift the Lip Assessment, undergo regular refresher courses and conduct assessments at all core checks from 9-12 months ARDS June 2018 ARDS ARDS and PFO June 2018 ARDS November 2017 ARDS Ongoing ARDS Ongoing ARDS ARDS/PFO Ongoing 40 62

63 Start: Medium term 3.1 Area Action Description and Issues to consider Responsibility Time frame Oral health promotion PFO Ongoing Workforce Early childhood settings Community Maternity Recruitment and retention of Māori and Pacific staff 18. Promote water-only and healthy eating policies in ECEs and other early childhood settings 19. Targeted programme to distribute free toothbrushes and toothpaste to high needs families, including advice on how often to replace toothbrushes, the importance of not sharing them, and information about fluoride toothpaste 20. Include an oral health promotion component in existing community-based programmes and social media platforms 21. Implement a free/low-cost maternal oral health service for high-needs expectant/new mothers 22. Increase the number of Māori and Pacific dental therapists via scholarships to AUT 23. Engagement with communities and high school students; promotion of oral therapy as a career Link with obesity work being done within the DHB and by other organisations (ARPHS ECE team; National Heart Foundation ECE healthy eating awards; Healthy Families Waitakere Pacific ECE network) To maximise effectiveness, the programme would distribute toothbrushes at regular intervals over a specified time period. There are co-benefits for other infectious diseases, e.g. rheumatic fever. Depending on the model of delivery chosen, toothbrush distribution could be incorporated into the topical fluoride application programme. Strengthen oral health messages delivered through existing programmes and resources reaching Māori, Pacific and Asian mothers and parents, e.g. Health Babies Healthy Futures. Mothers have a central role in helping children develop good oral health care habits early on and research has indicated that mothers with dental decay may play a role in the early colonisation of bacteria in their children. The children of teenage mothers are particularly at risk of poor oral health, so targeting these mothers through teen pregnancy units will be important. Funding issue Northland DHB has a scholarship programme for a Māori dental therapy student to attend AUT and then guarantees them a job at the Public Health Unit on graduation. AUT collaboration Funding issue Allocate time for Māori and Pacific dental therapists to engage with their respective communities for oral health promotion, education and encouraging high school students into a career in dental therapy PFO and ARDS to explore partnership with commercial sector PFO PFO PFO, in conjunction with the provider arms ARDS December 2018 December 2018 Dependent on funding Ongoing Ongoing 41 63

64 Start: Longer term 3.1 Area Action Description and Issues to consider Responsibility Time frame Oral health promotion Primary and secondary 24. Oral health promotion video to be played in waiting rooms ARDS, PFO, Provider arm Dependent on funding Workforce health setting Early childhood settings Primary and secondary care Maternity 25. Extend the ECE-based daily tooth brushing and oral health promotion programme in high needs ECEs across metropolitan Auckland. 26. Upskill primary and secondary care child health workers in oral health 27. Upskill LMCs to provide oral health advice to pregnant women in the last trimester of pregnancy. Funding issue Train GPs, practice nurses, paediatricians, paediatric registrars and nurses in oral health promotion, Lift the Lip and ensure they know when and how to appropriately refer children urgently (and non-urgently) for oral health care. Publicise e-referral pathways for appropriate care Funding issue to refer pregnant women for low cost dental care Individual DHB PFOs ARDS, PFO ARDS, PFO Dependent on funding 42 64

65 4.1 Healthy Mums and Babies; Healthy Kids - New Better Public Service Targets 4.1 Recommendation: That the Committee note the two new Better Public Service Targets and associated programme of work: a) Healthy Mums and Babies b) Healthy Kids Prepared by: Ruth Bijl (Funding Manager, Child, Youth and Women s Health) Endorsed by: Dr Debbie Holdsworth (Director of Funding) and Dr Karen Bartholomew (Acting Director Health Outcomes) Glossary ASH BPS KRA LMC NW SLM - Ambulatory Sensitive Hospitalisation - Better Public Service - Key Result Area - Lead Maternity Carer (a self-employed midwife or obstetrician funded under Section 88) - National Women s - System Level Measures 1. Executive Summary This paper provides information on the new Better Public Service (BPS) Key Result Areas (KRA) current performance and planned activity. The Committee is asked to note these priority areas will be a focus for activity from 2017/18 and are included in the Annual Plan. 2. Background Since 2012 there have been a set of ten BPS whole-of-government KRA targets, organised into five domains: Reducing long term welfare dependence Supporting vulnerable children Boosting skills and employment Reducing crime Improving interaction with the government. Health is the lead agency for the previous Result 3: Increase infant immunisation rates and reduce the incidence of rheumatic fever. DHBs also have an interest in several of the other result areas in terms of vulnerable children and social investment. The BPS KRAs are in addition to (though may overlap with) the Health Targets (Increased Immunisation and Raising Healthy Kids) which are set by the Ministry of Health. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 65

66 A refreshed set of ten BPS targets were announced on 4 May There are two new BPS targets led by Health: Result 2: Healthy Mums and Babies: By 2021, 90% of pregnant women are registered with a Lead Maternity Carer (LMC) in the first trimester, with an interim target of 80% by 2019, with equitable rates for all population groups Result 3: Keeping Kids Healthy: By 2021, a 25% reduction in the rate of hospitalisations for avoidable conditions in children aged 0-12 years, with an interim target of 15% by Both Result areas align with current DHB work programmes; some activity is metro Auckland or regional and some related to the national direction. Examples of alignment include the System Level Measures (SLM) quality improvement work programme, the Sudden Unexplained Death of an Infant (SUDI) prevention work programme and a focus on pregnancy and the First 1,000 Days of Life. 3. Result 2: Healthy Mums and Babies The target for pregnant women registered with an LMC in the first trimester is 80% by 2019; 90% by The latest data available is 2015 with data available about 18 months after the close of the period. All metro Auckland DHBs have seen improved rates of first trimester registration with an LMC since Waitemata DHB is at 70% and has consistently been higher than the national rate. Auckland DHB on the other hand is near the bottom of the country at 56%. Auckland is not expected to be able to achieve the target due to the configuration of the workforce. In 2015, 48% of women who gave birth at National Women s (NW) were under the care of a self-employed midwife, 27% a private obstetrician (a combined total for LMCs of 75%), 18% were under the NW community clinic and 6% under the NW specialist medical and diabetes team (NW Annual Clinical Report 2015). The Ministry of Health s Report on Maternity 2015, notes 79.3% of women were registered with an LMC in Auckland DHB. Of women registered with a DHB primary maternity service nationally only 29% did so in the first trimester (MoH 2015). Importantly, there is a significant difference by ethnicity and by deprivation. Table 1 shows the percentage of women enrolled with an LMC within the first trimester for Māori, Pacific and Other women. Table 1. Proportion of women registering with an LMC within the first trimester, 2015 (latest available data) by ethnicity DHB of Domicile Māori Pacific Other Total Auckland 38% 30% 64% 56% Waitemata 55% 44% 77% 70% Result 2 is already an indicator under the National Maternity Monitoring Group. There has been an improvement work programme for this indicator including workforce development (new graduate midwife support), the development of a regional Health Pathway, and a focus on communication improvements for providers, women and whānau. This has been supported by the Maternity Quality and Safety Programme (MQSP) funded by the MoH. The indicator measures early (first trimester) registration with a LMC. From previous work on this indicator, it is known that approximately 70% of women see primary care first, before registering with an LMC. The current indicator definition does not include primary care contact; only registration with an independent LMC. From 2015 the MoH began collecting and reporting data for registration with DHB midwifery services. It is expected that women register later with DHB midwifery services as DHB community midwifery services are generally caring for women who require secondary care, who Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 66

67 are vulnerable, who have specific language requirements or who have been unable to find an independent LMC. In 2015 the proportion of women registering with a DHB community midwifery team in the first trimester was 41% for Waitemata DHB, 30% for Auckland DHB and 23% for Counties Manukau. 4.1 The importance of early engagement with health services is endorsed by maternity and child health leaders. Ideally, women would engage prior to conception in order that they receive best advice regarding such issues as nutritional supplementation (e.g. Folic acid) and other lifestyle advice (particularly smoking and alcohol cessation, and activity). However, we know from local research (Growing Up in New Zealand) that approximately 50% of pregnancies are planned. Increased use of Long Acting Reversible Contraception (LARC) may change this over time. The first trimester of pregnancy is also an important time to receive advice and for an informed discussion and antenatal screening to be undertaken. While BPS2 focuses on LMC registration partly as a measure of receipt of this package of information, advice and assessment, primary care can also provide this care (and GPs who claim first trimester care under section 88 are required to in the specification). Given the benefits of early engagement with a health professional, the DHB will have a clear programme of work designed to achieve the intent of the target. In 2017/18 we plan to: Improve information sharing regarding pregnant women and newborn infants between GPs, LMCs, DHB and Well Child Tamariki Ora providers under the leadership of the Pregnancy and First Year of Life Service Alliance, including through development of agreed expectations regarding what health information needs to be shared and when Continue to support new graduate midwives to enter the self-employed LMC workforce In partnership with Primary Care (and utilising the first trimester health pathway), promote early engagement with LMCs, supported by the development of resources in a range of Pacific and other languages as required to increase health literacy Develop and trial an incentive scheme to engage young pregnant women with an LMC earlier in their pregnancies. 4. Result 3: Healthy Kids The conditions included in Result 3, avoidable hospitalisations for children aged 0-12 years, with a target of 25% reduction by 2021 have now been confirmed by the MoH. The high level groups of conditions included are: Respiratory conditions (including pneumonia, bronchitis, bronchiolitis and bronchiectasis, asthma, wheezing and lower respiratory tract infection) Dental conditions (including dental caries, diseases of pulp/periapical tissues) Dermatological conditions (including skin infections, dermatitis and eczema) Head injuries, including neonatal events (age =< 28 days) (including traumatic brain injuries (TBI) and non-tbi head injuries). From Table 2 below it can be seen that there are approximately 3-4,000 hospitalisations for BPS3 avoidable hospitalisation conditions annually. Between 65-70% of hospitalisations are in children under four years old. Waitemata DHB has the lowest age-standardised rates, and Auckland DHB the highest in metro Auckland. Although Waitemata and Auckland DHBs have similar numbers of hospitalisations, there are fewer children in the Auckland DHB population (72,707) compared to Waitemata DHB (101,424) which means there are higher rates in Auckland DHB. There are substantial differences in rates by ethnicity as outlined in Table 3, with Māori rates approximately double, and Pacific rates three to four times higher, than other ethnicities. There is also a clear Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 67

68 gradient by deprivation with children in the most deprived areas (age-standardised rate of 51.6 per 1,000 Waitemata DHB and 78.5 Auckland DHB) having rates two to three times higher than those in the least deprived (age-standardised rate of 22.5 per 1,000 Waitemata DHB and 27.7 in Auckland DHB). Respiratory conditions are the commonest conditions resulting in avoidable hospitalisations. 4.1 Table 2. Number of hospital admissions and rate for avoidable hospitalisations in metro Auckland ( ) DHB of Domicile Number of hospitalisations Age-standardised rate (per 1, year olds) 12 months to June months to June months to June months to June months to June months to June 2016 Waitemata 2,992 3,175 3, Auckland 3,106 3,577 3, Counties Manukau 4,268 4,871 4, National 28,585 31,469 30, Table 3. Number of hospital admissions and rate for avoidable hospitalisations ( ) in metro Auckland by ethnicity DHB of Domicile Ethnicity Number of hospitalisations Age-standardised rate (per 1, year olds) 12 months to June months to June months to June months to June months to June months to June 2016 Waitemata Māori Pacific Other 1,609 1,803 1, Auckland Māori Pacific 1,094 1,253 1, Other 1,571 1,765 1, Counties Manukau Māori 1,199 1,397 1, Pacific 2,040 2,370 2, Other 1,029 1,104 1, Table 4. Number of hospital admissions ( ) by high level condition type Waitemata DHB and Auckland DHB Condition group DHB of Domicile Number of hospitalisations 12 months to June months to June months to June 2016 Age-standardised rate (per 1, year olds) 12 months to June months to June months to June 2016 Respiratory Auckland 1,775 2,331 2, Waitemata 1,588 1,857 1, Dental Auckland Waitemata Skin Auckland Waitemata Head injury Auckland Waitemata Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 68

69 There is an overlap with these conditions and Ambulatory Sensitive Hospitalisations (ASH). ASH are hospitalisations considered potentially preventable through high quality and timely primary care. The Government s new Keeping Kids Healthy BPS target potentially avoidable hospitalisations per capita, is a measure of the number of hospitalisations among children aged 0 to 12 for selected health conditions. The measure includes selected conditions that are considered ambulatory sensitive, such as dental, respiratory and skin conditions, as well as selected head injuries and traumatic brain injuries. These conditions were chosen because they can potentially be reduced by government agencies working together to keep kids healthy and, when necessary, intervening early to stop issues escalating to the point where hospitalisation is needed. The ASH indicator has been controversial as audits and the Waitemata DHB and Auckland DHB survey of Māori Pathways ASH published in 2016 indicate that approximately 70% of children are seen by primary care before admission. In addition the social determinants of health, for example housing, household crowding and socioeconomic status are strong drivers of preventable hospitalisations in children. 4.1 The current ASH indicator is defined for children 0-4 years old. ASH for 0-4 years has been a longstanding indicator in the Māori Health Plan and is an SLM domain. There is also an existing indicator of ASH rates for 0-14 years reported in the DHB Health Needs Assessments and the Child Youth Epidemiology Service annual reports; it is noted in these reports that most hospitalisations in children occur in children ages 0-4 years. There is no current indicator for the age range 0-12 years for ASH. Some of the acute conditions and potential interventions where children are hospitalised are different for pre-school compared with school aged children, for example asthma is more relevant for school age children. There is a metro Auckland work programme on ASH for 0-4 year olds as one of the SLM indicators. The target for this SLM is a 5% reduction in ASH 0-4 year olds by June This is considered an ambitious target as ASH has been relatively static over the last decade despite free primary care visits for under six year olds. The key activities in the SLM plan, and aligned in the Annual Plan, which are likely to be relevant to the new Result 3 are the implementation of the maternal smoking incentives programme (with a focus on Māori women and whānau), promotion and improvement in rates of immunisation in pregnancy, improvement in vaccination of children hospitalised with respiratory infections and rheumatic fever activities. In 2017/18 we plan to: Implement an incentive programme to help pregnant women quit smoking, particularly targeting Māori Implement the National SUDI Prevention Programme comprehensively in Auckland and Waitemata DHBs building on the strong foundations of the Northern Regional SUDI Action Plan Increase access to pregnancy immunisations (Boostrix and influenza), including through secondary maternity clinics Improve information sharing between hospitals and general practices to support identification of children aged less than 5 years eligible for influenza vaccination and support Primary Care to recall and vaccinate soon after discharge from hospital Complete audit of asthma action plan use in primary care and secondary care by December 2017 Achieve equity for Maori children fully immunised by 8 months of age Implement activities to reduce skin infections such as delivering an education package for skin infections Implement the pre-school oral health strategy. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 69

70 5. Next steps A range of working groups are undertaking these activities. They are reporting through to the Auckland DHB and Waitemata DHB Pregnancy and First Year of Life Service Alliance co-chaired by Ailsa Claire (Chief Executive, Auckland DHB) and Barbara Stevens (Chief Executive Officer, Auckland PHO). This group may be renamed to align with BPS2. Consideration is also being given to extending this group to cover BPS3. Information and metrics are also shared with the regional child health network Conclusion The two new health led Better Public Service targets are aligned to areas of focus and work programmes in the DHB, to System Level Measure work in primary care, and also to the opportunities for Māori health advancement and the renewed child health focus for Pacific health gain. The targets will be very challenging to meet, however a range of concrete activities have been identified to progress. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 70

71 4.2 Metro Auckland DHB Healthy Weight Action Plan for Children Recommendation: 4.2 That the Community and Public Health Advisory Committee: a) Receive the plan and provide feedback b) Note final plan will be considered by the Auckland and Waitemata DHB Boards for endorsement. Prepared by: Rebecca McCarroll (Public Health Dietitian) and Dr Philippa Anderson (Public Health Physician Counties Manukau Health) Endorsed by: Dr Debbie Holdsworth (Director, Funding), Dr Karen Bartholomew (Acting Director, Health Outcomes) and Ruth Bijl (Funding Manager, Child, Youth and Women s Health) Glossary ARPHS - Auckland Regional Public Health Service BMI - Body Mass Index CPHAC - Community and Public Health Advisory Committee HAT - Healthy Auckland Together NGO - Non-Government Organisation PHO - Primary Healthcare Organisation WHO - World Health Organisation 1. Executive Summary The metro Auckland DHB Healthy Weight Action Plan for Children has been developed to contribute to our vision that All Tamariki in the Auckland Region of New Zealand are of a healthy weight. The plan has been developed collaboratively across the region and intends to align our activities and clarify the role of the three metro Auckland DHBs and Healthy Auckland Together (HAT) in preventing and reducing the rates of unhealthy weight through to 30 June The plan takes a life-course approach with identified actions for key target populations, including women prior to and during pregnancy, pre-school and school aged children and adolescents. We also place particular importance on ensuring the actions meet the needs of our Māori and Pacific populations who are disproportionately affected by this issue. This plan is being presented to CPHAC to provide an opportunity for members to provide feedback on the final draft and to recommended endorsement to the respective Boards. 2. Strategic Alignment Community, whānau and patient centred model of care This plan is designed to support tamariki to maintain a healthy weight throughout childhood. In order to do this we must support whanau and communities to address the environments and behaviours that impact on their ability to make healthy food choices and keep active. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 71

72 Emphasis and investment on both treatment and keeping people healthy Service integration and/or consolidation Intelligence and insight Evidence informed decision making and practice Outward focus and flexible, service orientation Operational and financial sustainability 3. Background The plan has been developed with the aim of protecting tamariki from developing an unhealthy weight. 1 Assisting them to maintain a healthy weight is an important part of how we can ensure they have the best start to life. This is the first child healthy weight action plan to be developed by the Auckland DHBs. The three metro Auckland DHBs have worked together to consolidate activities and collaborate with partners to develop this plan. Whilst recognising there are differences between the DHBs, due to the characteristics of the different populations and current service provision, it was determined that having a regional plan supported collaboration across the metro Auckland area, as well as consistency where appropriate. We believe that the actions outlined within this plan will contribute towards the cross-sectoral response required to address childhood weight management. Stakeholders from across the Auckland region have provided feedback on the draft plan. A literature review of current evidence was undertaken to inform the plan - there is a compelling logic from the literature that action to prevent and treat unhealthy weight in childhood will benefit children and the future adults they will become. A stocktake of DHB, NGO and community physical activity and nutrition activities for children and their families was also conducted. The plan has been designed with the specific goal of supporting tamariki to maintain a healthy weight throughout childhood. The plan is intended to be a living document that will be reviewed and developed over time. Implementation of the majority of the plan will be undertaken within the current budget, where this is not the case the resources have been highlighted or phased. The ability to undertake some actions is dependent on the continuation of currently funded contracts. 4.2 Globally childhood obesity is recognised as a growing and important issue because of the impacts on a child s immediate health, educational attainment and quality of life, as well as being associated with a wide range of adult health conditions and increased risk of premature onset of illness. This has implications both for the health and wellbeing of individuals and also for the sustainability of the health system and the economic and social future of communities more broadly. In New Zealand addressing obesity has been identified as a key priority in two key government strategic documents. The first is the recently refreshed New Zealand Health Strategy: Future direction which outlines the high-level direction for New Zealand s health system over the 10 years from 2016 to It is accompanied by a Roadmap of Actions which specifically requires (Action 8) 1 Throughout the Metro-Auckland DHB Healthy Weight Action Plan for Children the preference is to use the description of unhealthy weight however overweight and obesity are clinical descriptions of Body Mass Index (BMI) cut off values and it is often correct to be using these terms rather than our preferred language of unhealthy weight. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 72

73 a focus on increasing efforts on prevention, early intervention, rehabilitation and wellbeing for people with long term conditions, such as diabetes and cardiovascular disease, by addressing common risk behaviours such as high BMI and intervening at key points across the life course. 4.2 The second key government strategic document is the New Zealand Ministry of Health s 2015 Childhood Obesity Plan which is based on elements of the World Health Organisation (WHO) Commission s advice, particularly the importance of a life-course approach to obesity, focusing on maternal, infant and child nutrition and physical activity, and the broader food environment. In this context the metro Auckland DHB Healthy Weight Action Plan for Children has been developed and focuses on the activities that will be undertaken to contribute to our vision that All Tamariki in the Auckland Region of New Zealand are of a healthy weight This plan takes a life-course approach, with identified key target populations including: women prior to and during pregnancy (in order to optimise the peri-conception factors which influence weight gain), pre-school and school aged children and adolescents. Taking a life-course approach, and collaborating with our external partners to improve the nutrition and physical activity environments of our populations, is critical to enable a meaningful impact on childhood weight management. We place particular importance on ensuring the actions of this plan meet the needs of our Māori and Pacific populations who are disproportionately affected by this issue. The plan also intends to clarify the role of the three metro Auckland DHBs and HAT in preventing and reducing the rates of unhealthy weight by outlining our focus areas and actions planned through to 30 June While it is recognised that a range of activities across a range of sectors will be needed to impact on unhealthy weight, this plan is primarily focused on describing the contribution the health sector can make to larger societal efforts. As DHBs we have two important roles: To collaborate with other partners across systems and communities to address the pervasive environmental influences that make it difficult to make healthy choices. Environmental influences include the built, transport and physical activity environments, the constitution, the supply and marketing of food and the wider political and socio-cultural context. This work is being lead out of Auckland Regional Public Health Service (ARPHS) through HAT. An especial role and responsibility in working to promote individual and population health. Through primary care, community and secondary services we encounter many opportunities to provide health information and create supportive environments to enable staff and the communities we serve to be healthier. This can include where services are directly provided, and where we fund and work with others to provide health care services. 4. Development of the Plan In parallel to recommendations from the WHO Commission on Ending Childhood Obesity and subsequent release of the New Zealand MoH Childhood Obesity Plan, the metro Auckland DHBs committed to the development and implementation of this joint Healthy Weight Action Plan for Children. The plan outlines a suite of health-led actions for preventing and managing high BMI, and integrates these alongside activities from the MoH Childhood Obesity Plan. Initially, Waitemata and Auckland DHBs and Counties Manukau Health developed two separate draft plans, which were then amalgamated into one. While this metro Auckland DHB Healthy Weight Action Plan for Children articulates our joined-up focus on healthy weight in childhood, each DHB Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 73

74 operates within a distinct strategic framework, which has influenced the development of the DHBspecific actions within the plan. 4.2 Included in the plan is a comprehensive stocktake of existing relevant child community nutrition and physical activity services within the region. A literature review has also been undertaken and key information is presented in the plan. Both of these pieces of work are time sensitive and will need to be updated over time. During the development of the draft plan a Stakeholder Engagement Plan was developed to ensure early engagement with key partners (both internal and external). Initial discussions were carried out with key groups including: Māori and Pacific representatives, HAT, the metro Auckland Clinical Governance Forum and members of the Northern Region Child Health Network. The draft plan was then circulated to a wider group of stakeholders and feedback invited by . Stakeholders from across the Auckland region who provided feedback were: ARPHS, the MoH, Primary Healthcare Organisations (PHOs), Non-Government Organisations (NGOs), Māori and Pacific partners (including MoU partner Te Whanau o Waipareira Trust), Regional Sports Trusts, Healthy Families Waitakere, the University of Auckland and DHB representatives. If you would like to provide additional feedback on the plan please engagement@waitematadhb.govt.nz by Wednesday 27 September. 5. Ability to affect change Addressing unhealthy weight is complex. It is recognised that government commitment and leadership, as well as a whole-of-society approach, will be required to make the significant changes needed to reverse the rates of unhealthy weight. In this context the actions to address unhealthy weight by health-led services (primary and secondary care) may be predicted to have small impact if considered in isolation. However, this activity could potentially be an important part of a bigger societal shift around the perception of healthy weight. DHB collaboration and advocacy for system level and environmental change, and support of our Partners working in this space (HAT, Healthy Families NZ), is critical to strengthen the collective voice and leadership across a range of sectors. 6. Alignment The metro Auckland DHB Healthy Weight Action Plan for Children aligns with the HAT Plan and Preschool Oral Health Action Plan for metro Auckland Region. Key activities include aligning oral health and obesity messages, and ensuring all resources are culturally appropriate. The plan also aligns with the System Level Measures and the Māori and Pacific health plans child health and longer term focus. The plan supports the ongoing high achievement of the Raising Healthy Kids health target. 7. Future Development This plan is a living document that will continue to be developed in the coming months and years. There is an expectation that as the plan matures there will be greater harmonisation across the region. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 74

75 8. Conclusion The metro Auckland DHB Healthy Weight Plan for Children has been presented to CPHAC to provide an opportunity for members to provide feedback on the final draft. The plan takes a life-course approach and has a clear action plan detailing planned activity. The plan has been developed collaboratively across the region with input from multiple stakeholders. Accountability for the plan will sit with the Northern Region Healthy Weight group which reports through to the Northern Region Child Health Network. There will be regular updates to Boards and Committee on progress of activities outlined in the plan. 4.2 Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 75

76 4.2 Metro-Auckland DHB Healthy Weight Action Plan for Children

77 Mihi 4.2 To be provided 2 77

78 Foreword 4.2 The three Auckland metro DHBs Auckland, Waitemata and Counties Manukau - have worked together to develop this Healthy Weight Action Plan for Children. While it is recognised that a range of activity across a range of sectors will be needed to impact on unhealthy weight this plan is primarily focused on describing the contribution the health sector can make to larger societal efforts. We believe that the actions outlined within this Action Plan will contribute towards the crosssectoral response required to address childhood weight management. Taking a life-course approach, and collaborating with our external partners to improve the nutrition and physical activity environments of our populations, is critical to enable a meaningful impact on childhood weight management. We place particular importance on ensuring the actions of this plan meet the needs of our Māori and Pacific populations who are disproportionately affected by this issue. We acknowledge and thank all our external partners who have collaborated with us to develop this plan. 3 78

79 4.2 Vision All Tamariki in the Auckland Region of New Zealand are of a healthy weight 4 79

80 Acknowledgements

81 Contents 4.2 Mihi... 2 Foreword... 3 Vision... 4 Acknowledgements... 5 Glossary... 7 Executive summary... 8 Introduction Taking Action on Unhealthy Weight - a way forward for the metro-auckland region The Role of Health Services Culturally appropriate, tailored and targeted delivery Working with our partners Appendix 1: Evidence for Actions Appendix 2: Stocktake Appendix 3: Population demography and Obesity data Appendix 4: Health Equity Campaign Appendix 5: Monitoring and Evaluation

82 Glossary 4.2 ARDS - Auckland Regional Dental Service ARHP Auckland Regional Health Pathways ARPHS - Auckland Regional Public Health Service Auckland DHB - Auckland District Health Board B4SC BFHI BMI CM Health B4 School Check Baby Friendly Hospital Initiative Body Mass Index Counties Manukau Health (Counties Manukau DHB) ECE - Early Childhood Education Enua Ola - Enua Ola project aims to increase levels of physical activity and improve nutrition amongst Pacific adults using a community action approach GP GDM - - General Practitioner Gestational Diabetes Mellitus HFW - Healthy Families NZ Waitakere Healthy Families - Healthy Families NZ Manukau, Manurewa-Papakura MMP HIC - High income countries HVAZ - Healthy Village Action Zones HBHF HPS - - Healthy Babies Healthy Futures programme Health Promoting Schools LC - Lactation Consultant LMCs - Lead Maternity Carers LMIC - Low and middle income countries Lotu Mo ui - Partnership between CM Health and Pacific churches and communities in Counties Manukau to work together to improve health outcomes for Pacific people. MoH - Ministry of Health - NGO - Non-Government Organisation PHO - Primary Health Organisation Waitemata DHB - Waitemata District Health Board WCTO - Well Child Tamariki Ora provider Whānau ora WHO - - An approach that places families/whānau at the center of service delivery World Health Organisation 7 82

83 Executive summary Supporting children to maintain a healthy weight throughout childhood is an important part of giving them the best start to life. In order to achieve this we must work with families and communities to address the environments and behaviours that can make it difficult for both children and adults to eat healthily and keep active across their lifetime. This includes encouraging mothers prior to and during their pregnancy to achieve a healthy weight, encouraging breastfeeding and healthy infant feeding, and identifying and working with children and families who are struggling to maintain a healthy weight in childhood and adolescence. 4.2 As District Health Boards 1 (which includes community, primary care and secondary services), we have two important roles: Firstly to collaborate with other partners across systems and communities to address the pervasive environmental influences that make it harder to make healthy choices. A number of factors including the built, transport and physical activity environments, the constitution, supply and marketing of food and the wider political and socio-cultural context, can encourage behaviours and choices that may not be in the best interests of a child s health. It is essential that we collaborate and advocate for policies and processes that work towards making the healthy choice the easy choice for individuals. This work is being led out of the Auckland Regional Public Health Service through Healthy Auckland Together. Secondly we have a specific role and responsibility to promote individual and population health. Through primary care, community and secondary services we encounter many opportunities to provide health information and create supportive environments to enable staff and the communities we serve to be healthier. This can include where services are directly provided, and where we fund and work with others to provide health care services. This Action Plan is focused on the activities that will be undertaken to contribute to our vision that All Tamariki in the Auckland Region of New Zealand are of a healthy weight. The Northern Regional Child Health Network will co-ordinate, support and monitor the implementation of the plan with ultimate accountability sitting with District Health Boards. 1 A brief summary of the health status and health needs of our populations, across the three metro- Auckland DHBs, will be available in a separate document (metro-auckland DHB Healthy Weight Strategic Plan). 8 83

84 Summary of Actions 4.2 This Action Plan is a living document that will continue to be developed in the coming months and years. There is an expectation that as the plan matures there will be greater harmonisation across the region. 1. Women of Childbearing Age Scientific research confirms that the influences that alter risk of obesity in childhood begin prior to conception and persist throughout growth and development into adulthood. As many pregnancies are unplanned it is important that the total population is of a healthy weight. Women of Childbearing Age Adult Obesity and Co-morbidities Actions Timeframe Responsibility Measures DHB Additional resource required Survey Pacific women and men who have maintained weight loss from the Aiga challenge for three years regarding enablers to weight loss maintenance by December 2016 and utilise survey findings in a review of the Aiga challenge. Investigate access barriers to bariatric surgery for Māori and Pacific women of child bearing age Scope what an Adult Obesity Service (intensive lifestyle intervention Tier2-3 service) might look like as part of the bariatric pathway Dec 2017 Jun 2018 Dec 2017 Pacific Health Portfolio Manager Clinical Director Health Gain Team Clinical Director Health Gain Team # who have maintained weight loss in past three years; enablers to weight loss/maintenance Bariatric surgeries in 2017/18: ADHB = # Māori ADHB = # Pacific WDHB = # Māori WDHB = # Pacific WDHB/ ADHB ADHB/ WDHB ADHB/ WDHB N N N 9 84

85 Actions Timeframe Responsibility Measures DHB Additional resource required Promote Green Prescription to primary care and identify and address barriers to primary care referrals Healthy Food Environments Implement the National Healthy Food and Drink Policy in DHB-owned sites Complete baseline audit Complete follow-up audits Work with ARPHS and Healthy Families NZ through Healthy Auckland Together (HAT) to implement the National Healthy Food and Drink Policy for Organisations in the community. Dec 2017 Jun 2018 Jun 2017 Jun 2018, 2019, 2020 Dec 2018 Public Health Registrar (WDHB/ADHB); Primary Care Portfolio Manager (CM Health) Public Health Dietitian and Food Service Manager (WDHB/ ADHB); Food Service Manager & Clinical Director Population Health (CM Health) Public Health Dietitian (ARPHS); Clinical Director Population Health (CM Health) # of adults enrolled in Green Prescription by ethnicity 50% compliance 100% compliance # of community organisations who have implemented the Policy All All All N N N 4.2 Work with DHB contracted providers to support implementation of aligned healthy food and drink policies As above # of providers who have implemented the Policy All N 10 85

86 2. Pregnant Women and Infants We know that the risk of obesity can be passed from parents to children. Babies whose mothers begin pregnancy already obese or suffering from diabetes, or whom develop Gestational Diabetes (GDM) pre-dispose the child to develop increased fat deposits which are associated with future metabolic disease and obesity. The way that children are fed early in life will further influence their risk of developing obesity and the balance of evidence suggests breastfeeding confers some protection against this. 4.2 Pregnant Women and Infants Pregnancy Actions Timeframe Responsibility Measures DHB Additional Resource Required Ensure culturally appropriate antenatal education available to promote and support breastfeeding WDHB/ADHB Continue to support the implementation of the Healthy Babies Healthy Futures (HBHF) programme: Providing women and their families with key breastfeeding messages through textmatch messaging, community promotion, and teaching practical skills for better nutrition and increased physical activity Working with partners to engage with specific vulnerable community groups (Māori, Pacific, Asian, and South Asian) On-going On-going Jun 2018 Child, Youth and Women Team Leader (WDHB/ADHB); Maternity Integration Manager (CM Health) HBHF Programme Manager HBHF Programme Manager Deliver contracted volumes of pregnancy and parenting programmes with 80% of services delivered to the priority populations (1 st time mothers, Maori and Pacific) % of target (1000) and # of people receiving textmatch service % of target (1000) and # of mothers engaged in healthy conversations All WDHB/ ADHB WDHB/ ADHB N N N 11 86

87 Actions Timeframe Responsibility Measures DHB Additional Resource Required Further strengthen HBHF connections with maternity services, Kohanga reo, Churches and ECEs to increase access to the HBHF programme Promoting HBHF to pregnant mothers at the earliest possible stage when engaging with DHB services Dec 2017 Dec 2017 HBHF Programme Manager HBHF Programme Manager # of Community Learning Programme (CLP) groups held within community settings % of target (2000) and # of mothers given the opportunity to engage with a HBHF provider WDHB/ ADHB WDHB/ ADHB N N 4.2 CM Health Continue the development of Te Rito Ora service and B4 baby services which engage with women in antenatal period to support breastfeeding Child Health Service Development Manager 70% women accessing the service will be fully/exclusive breastfeeding at 6 weeks CM Health N Work with Lead Maternity Carers (LMCs) to ensure height and weight are recorded on booking form. Education to ensure this is measured rather than selfreported. On-going Women s Health Senior Programme Manager (ADHB/ WDHB); Maternity Quality and Safety Coordinator (CM Health) 100% of booked women have height and weight recorded in clinical records All N 12 87

88 Actions Timeframe Responsibility Measures DHB Additional Resource Required Collaborate with primary care, Green Prescription providers, LMCs, DHB maternity services and HBHF; to enhance referrals to Green Prescription and ensure tailored advice for pregnant women on optimal weight gain: Promote and facilitate the adoption of MoH Guidelines for Healthy Weight Gain in Pregnancy (e.g. weight gain charts) Dec 2018 Programme Manager Primary Care; Women s Health Senior Programme Manager (WDHB/ ADHB); Manager/ Maternity Quality and Safety Co-ordinator (CM Health) All N N 4.2 Incorporate referrals to Green Prescription and healthy weight gain in pregnancy conversations into existing Auckland Regional Health Pathways Establish a baseline(1) and increase(2) referrals of pregnant women into Green Prescription for healthy weight management Optimise management of diabetes in pregnancy and ensure national guidelines are adhered to; assess compliance with HbA1c and that the appropriate referral pathway is followed Promote the Auckland Regional Health Pathway to GPs, LMCs and other appropriate health professionals Oct 2017 Oct 2018 Dec 2017 Women s Health Senior Programme Manager (ADHB/ WDHB); Maternity Quality and Safety coordinator (CM Health) Health Pathways updated to include referral options for pregnant women, e.g. Green Prescription # pregnant women enrolled in Green Prescription >90% of Māori, Pacific, Asian and Other women have an HbA1C included in first antenatal bloods 90% of booked women with elevated HbA1c follow appropriate pathway All N N N N 13 88

89 Actions Timeframe Responsibility Measures DHB Additional Resource Required (See previous page) 100% of women with HbA1c >50 at booking referred and seen in diabetes in Pregnancy in Clinic within 2 weeks All N Develop Pathway for management of pregnant women with high BMI Dec 2018 Maternity Quality and Safety co-ordinator (CM Health) Pathway developed and implemented CM Health N 4.2 Undertake quality research TARGET *-Recruit women for multisite study Gestational Diabetes Mellitus Study of diagnostic thresholds (GEMS)*- Recruit women for multisite study Healthy Mums and Babies Study (HUMBA)**- Undertake the study in partnership with UoA, Recruit women into the HUMBA study, Implement findings into practice Principle investigator CM Health/Principle investigator ADHB/WDHB Feedback from study Principle Investigator of the progress of the 2 studies: Target to complete recruitment by October 2017 GEMS: to have 50% recruitment by December 2018 All N * TARGET is a study to investigate how gestational diabetes Mellitus (GDM) should be treated. It is a a multisite study currently underway through the Liggins Institute. **GEMS is a multisite study currently underway through the Liggins Institute. CM Health is a contributing site. The study aims to determine the appropriate thresholds for diagnosing gestational diabetes in pregnancy. **HUMBA is a research study underway to trial a nutritional intervention during pregnancy to study whether it can impact on outcomes for both mother and baby 14 89

90 Infancy 4.2 Actions Timeframe Responsibility Measures DHB Additional resource required Ensure culturally appropriate postnatal and community support available to promote and support All breastfeeding through: Enhance the pregnancy and parenting education smartphone app and website to encourage all women, particularly Māori, Pacific and Asian, to breastfeed for at least the first 6 months of their baby s life Postnatal support through Titifaitama and Whakura Wananga including peer support and breastfeeding support groups Jun 2018 Women s Health Senior Programme Manager Women s Health Senior Programme Manager Increased Māori, Pacific, and Asian partially breastfeeding rates at 6 months # Māori and Pacific women who breastfeed # who attend support groups ADHB/ WDHB WDHB Y N Intensive post-natal support through Te Rito Ora service including peers support, drop in clinics Evaluate effectiveness of Auckland DHB breastfeeding community clinic and home visiting approach and integrate learnings into future efforts. Mar 2018 Service Development Manager Child Health Women s Health Senior Programme Manager Kaitipu Ora Workers will engage with clients a minimum of 3x in Week 1 postnatally, and then weekly until Week 12. Build findings from evaluation into contract for the 17/18 financial year CM Health ADHB N N 15 90

91 Actions Timeframe Responsibility Measures DHB Additional resource required Community cooking courses to support pregnant woman and parents and whānau of 0-2 year olds to make healthy, affordable and culturally appropriate meals which meet the nutrition needs of pregnant women and infants and toddlers Ongoing Service Development Manager Child Health 100 participants will complete the course CM Health N 4.2 Evaluate the community peer/mentor support breastfeeding programme pilot to ascertain its success with Māori, Pacific and low-ses women. In collaboration with Plunket co-design and develop healthy breastfeeding and first foods guidance (both regarding timing and food type) for parents with focus on Pacific, Māori and Asian Families Dec 2017 Jun 2018 Women s Health Senior Programme Manager Child Health Senior Programme Manager Evaluation outcome report ADHB/ WDHB Consumer resource produced ADHB/ WDHB N N 16 91

92 Actions Timeframe Responsibility Measures DHB Additional resource required 4.2 Training and Education Enhance the training plan for GPs, nurses and other relevant health professionals to increase their confidence in having culturally appropriate conversations about child weight and healthy lifestyles with families and work with families to identify solutions that work for them Opportunities to do this include; Providing CME /CNE sessions Promote the use of the Weight Management for Children Health Pathway included in the Auckland Regional Health Pathways Webinar and podcasts developed with the Goodfellow unit Regular primary care e-updates Ongoing Child Health Senior Programme Manager (WDHB/ADHB); Service Development Manager Child Health (CM Health) # of training sessions delivered to GP/Primary care % of participants who identified an increase in knowledge or confidence with having conversations about healthy weight following the sessions All N N 17 92

93 3. Children and Adolescents The prevention and treatment of childhood obesity requires influence regarding healthy diets and healthy movement alongside individual level approaches to enable behaviour change for children, young people, caregivers and families. 4.2 Children and Adolescents Schools and ECEs Actions Timeframe Responsibility Measures DHB Additional resource required Strengthen support for schools to implement healthy food and beverage policies In collaboration with HAT and Healthy Families NZ Waitakere, engage intersectorally to support a gap analysis of healthy food environments in and around Kohanga reo, Pacific Language nests and ECEs to determine areas for future DHB support Utilise INFORMAS survey results, along with information from the Heart Foundation, ARPHS, Healthy Families NZ sites and the Diabetes Projects Trust to engage with high-priority ECEs and schools to support development and implementation of food policies and healthy food environments. Dec 2018 June 2018 Dec 2018 Public Health Dietitian (WDHB/ADHB); Project Manager Mana Kidz (CM Health) Public Health Dietitian Public Health Dietitian (WDHB/ADHB); Mana Kidz project office (CM Health) WDHB/ADHB: 80% of contracted schools have a healthy food and drink policy. CM Health: 80% of Mana Kidz schools have a healthy food and drink policy Gap analysis complete # of Kohanga reo, Pacific Language nests, ECEs requiring support # of ECEs and schools with healthy food policies All WDHB/ ADHB All N N N 18 93

94 Actions Timeframe Responsibility Measures DHB Additional resource required Obesity Intervention Contract a provider to deliver a comprehensive, multicomponent whānau-focused physical activity, nutrition and parenting programme for pre-school children identified as being 98 th centile, including a psychological component and development of specific approaches for Māori and Pacific populations Contract a provider to deliver a comprehensive, multicomponent whānau-focused physical activity and nutrition programme for overweight/obese school aged children and adolescents, including specific approaches for Māori and Pacific communities WDHB/ADHB Mar 2018 CM Health Mar 2017 Dec 2017 Ensure Raising Healthy Kids health target is met through a suite of initiatives: Undertake communication activities to promote and familiarise primary care / WCTO partners with target On-going Ensure referral process for referrals from B4 school provider to primary care for children with BMI>98th centile is in place and all obese children are referred to primary care and that referral is acknowledged (electronic referral process in CM Health, paper based in ADHB/WDHB). On-going Programme Manager Primary Care (WDHB/ ADHB); Service Development Manager Child Health (CM Health) Programme Manager Primary Care (WDHB/ ADHB); Service Development Manager Child Health (CM Health) Child Health Senior Programme Manager (WDHB/ ADHB) Service Development Manager Child Health (CM Health) # of children enrolled; # of Māori and Pacific children enrolled (baseline) # of children enrolled; # of Māori and Pacific children enrolled By December 2017, 95% of obese children identified in the B4SC programme will be referred to a health professional for clinical assessment and family based nutrition, activity and lifestyle interventions All All All N N N N

95 Actions Timeframe Responsibility Measures DHB Additional resource required Provide community, primary and secondary care training by dietitian on use of Be Smarter brief intervention and goal setting healthy lifestyles tool and other resources so health professionals are confident to initiate conversations with families and talk about healthy weight to enable families to be as healthy as they can be Define and implement an evaluation of families and health professional engagement with Raising Healthy Kids referral pathway. Jul 2018 Jun 2017 (See previous page) (See previous page) # of health professionals trained Evaluation plan complete with recommendations All N N 4.2 Support the implementation of the regional growth chart solution for use in secondary care in metro Auckland DHBs Work with ARDS and the Northern Region DHBs to develop consistent health promotion messages using the common risk factor approach for obesity and oral health Investigate translation into priority languages Scope the feasibility for a pilot to assess measuring weight and height at the year eight dental check. The aim is to facilitate collection of data for population level monitoring of trends and to feedback to parents information on their child s weight and growth. This pilot could potentially assess: Consenting of children. Dec 2018 Jan 2018 Dec 2018 Regional Healthy Weight Working Group Child Health Senior Programme Manager & Public Health Physician (oral health) Regional Healthy Weight Working Group and Public Health Physician (oral health) An electronic growth chart is implemented in the metro Auckland DHBs Message alignment complete with 5 key messages agreed upon. Priority languages identified and translation services costed. Pilot complete All All CM Health Y N Y 20 95

96 Actions Timeframe Responsibility Measures DHB Additional resource required Impacts on clinic flow and staffing. Resource requirements. Scalability. Data collection requirements and utility. Communication of outcomes to parents. Staff and consumer perspectives. Identification of any adverse or unexpected outcomes. 4.2 This would inform the assessment of whether this could be implemented across the region and the trade-off of costs compared to the potential impact of the information gained for children, their families and the sector as a whole

97 Introduction 4.2 There is a strong social and political consensus that our New Zealand tamariki should be protected and nurtured to enable them to live happy and healthy lives. Protecting them from developing an unhealthy weight 2 and assisting them to maintain a healthy weight is an important part of how we can ensure they have the best start to life. Rates of obesity have been rising globally in the last two to three decades in all ages, genders and ethnic groups. New Zealand has the third highest rate of obesity among Organisation for Economic Co-operation and Development (OECD) countries.(1) In children obesity has been associated with a number of short and medium term health problems including delayed motor development,(2) asthma,(3) childhood hypertension,(4) dyslipidaemia,(5) and shares aetiological features with the development of obstructive sleep apnoea, reproductive health abnormalities and type 2 diabetes.(6-8) Unhealthy weight is associated with poorer educational attainment, psychosocial difficulties and disorders for children though it is unclear whether unhealthy weight contributes to the development of these disorders or is a comorbidity or sequelae of the disorder itself.(9) In the long-term we know that a child in the obese weight range is more likely to be obese in adulthood.(10-12) Helping children attain a healthy weight in childhood is likely to moderate their risk of ill health in adulthood by reducing the prevalence of obesity and associated noncommunicable disease. Obesity in childhood is strongly associated with the future development of cardiovascular disease and diabetes.(13, 14) Adverse health consequences can present in adulthood despite a normal weight being attained which suggests that there is residual risk from being an obese child independent of adult Body Mass Index (BMI).(15) High BMI in adulthood has serious health impacts and contributes to the development of noncommunicable diseases including some cancers, diabetes and cardiovascular disease. This has implications for the sustainability of the health system and the economic and social future of communities more broadly. Overweight and obesity is predicted to displace tobacco as the leading risk factor for health loss in 2016.(16) Pacific and Māori children and those living in quintile 4 and 5 (most deprived) are more likely to be at an unhealthy weight. These differences are consistent with international evidence(17) and may represent inequities in access to the socioeconomic determinants of health, varying food and physical activity environments, as well as access to care and the quality of care received; all of which influence risk of unhealthy weight, and the effectiveness of interventions.(18) It is vital that we continue to be focused on reducing these inequities. Some research has suggested that compared to other ethnic groups Asian young people may have higher rates of body fat for a given BMI and may be more prone to central obesity. Further research and monitoring is however needed to confirm this and understand implications for intervening. 2 Throughout this document the preference is to use the description of unhealthy weight however overweight and obesity are clinical descriptions of BMI cut off values and it is often correct to be using these terms rather than our preferred language of unhealthy weight

98 High BMI can be considered a normal response to the obesogenic environment that children and adults live in.(19) It results from a complex interplay of factors including but not limited to biology, the food system, the physical activity environment, individual factors, and consequently, requires multifaceted and intersectoral solutions. 4.2 Addressing unhealthy weight is complex. It is recognised that government commitment and leadership as well as a whole-of-society approach will be required to make the significant changes needed to reverse the rates of unhealthy weight. There is a compelling logic from the literature that action to prevent and treat unhealthy weight in childhood will benefit children and the future adults they will become. Change is needed to ensure that our tamariki live in environments where fresh healthy food choices are more visible, affordable and available than unhealthy food and where environments enable and promote physical activity. While current evidence suggests the impact of healthcare interventions on unhealthy weight in childhood are likely to be small, early intervention has the potential to benefit both the individual, with sustained improvement in health, and society as a whole through healthier and more productive citizens and reductions in the burden of non-communicable disease and preventable mortality (Appendix 1). The development of the metro-auckland DHB Healthy Weight Action Plan for Children has been informed by a comprehensive stocktake of existing relevant child community nutrition and physical activity services within the region (Appendix 2). The plan outlines a suite of health-led actions for preventing and managing high BMI. This metro-auckland DHB Healthy Weight Action Plan takes a life-course approach to childhood unhealthy weight with identified key target populations including: women prior to and during pregnancy (in order to optimise the peri-conception factors which influence weight gain), pre-school and school aged children and adolescents. While the metro-auckland DHBs are committed to working collaboratively across the sector to improve healthy weight management, each DHB acknowledges the differences within their unique populations with differences in the numbers of Māori and Pacific children in each DHB, numbers living in the most deprived areas as well as the number of children with an unhealthy weight (Appendix 3). Strategic Context Globally action on high BMI in childhood has been recognised as imperative and the World Health Organisation (WHO) has formed a The Commission on Ending Childhood Obesity to lead this response, chaired by New Zealander Sir Peter Gluckman.(9) The Commission developed a framework as well as a number of recommendations for governments aimed at reducing obesity in children under five years. In addition the McKinsey Institute has developed a comprehensive discussion paper Overcoming obesity: An initial economic analysis which makes a strong economic argument for addressing unhealthy weight and contends that a comprehensive, systematic programme of multiple interventions is needed.(8) The recently refreshed New Zealand Health Strategy: Future direction outlines the high-level direction for New Zealand s health system over the 10 years from 2016 to It is 23 98

99 accompanied by a Roadmap of Actions which specifically requires (Action 8) a focus on increasing efforts on prevention, early intervention, rehabilitation and wellbeing for people with long-term conditions, such as diabetes and cardiovascular disease, by addressing common risk behaviours such as high BMI and intervening at key points across the life course. Specifically: implement and monitor a package of initiatives to prevent and manage obesity in children and young people up to 18 years of age. The package should take a life-course and progression of condition approach, and ensure parents have good information and that those with greater need receive greater support. Action will be taken across a range of settings where children learn, live and play, such as schools.(14) 4.2 The Ministry of Health s (MoH) 2015 Childhood Obesity Plan is based on elements of the WHO Commission s advice, particularly the importance of a life-course approach to obesity, focusing on maternal, infant and child nutrition and physical activity, and the broader food environment.(3) The MoH Childhood Obesity Plan provides a package of initiatives to prevent and manage weight in children and young people up to 18 years of age. Included in this plan is a new health target for any obese four-year old children identified in the B4 School Check to be referred to an appropriate health professional for follow up and management. The Childhood Obesity Plan has three focus areas and 22 initiatives, which are either new or an expansion of existing initiatives: (see Figure 1): 1. Targeted interventions for children who are identified as being obese ( 98 th percentile of BMI-for-age) 2. Increased support for those children at risk of becoming obese 3. Broad approaches to make healthier choices easier for all New Zealanders

100 Figure 1. Summary of the Ministry of Health s Childhood Obesity Plan 4.2 The plan requires leadership and action across government agencies, the private sector and community sectors and settings. Nine of the 22 initiatives (initiatives 1, 2, 4-7, 20-22) are to be led by the broader Health sector and will require activity at the DHB level to develop and implement strategies to support these activities. In addition activities led by other sectors will require collaboration from the DHBs; these include the Health Promoting Schools (HPS) initiative (initiative 19) and the dissemination of information and resources to be developed by the MoH and the Health Promotion Agency (initiative 11). While this Metro-Auckland DHB Healthy Weight Action Plan for Children articulates our joined-up focus on healthy weight in childhood, each DHB operates within a distinct strategic framework which has informed the development of the DHB specific actions within this Plan. Auckland and Waitemata DHB Strategic Themes Auckland DHB and Waitemata DHBs seven strategic themes below provide an overarching framework for the way services are planned, developed and delivered. These themes are linked to both Boards joint priorities of better outcomes and improved patient experience

101 Community, whānau and patient-centric model of care Evidence informed decision making and practice 4.2 Emphasis and investment on treatment and keeping people healthy Outward focus and flexible, service orientation Service integration and/or consolidation Operational and financial sustainability Intelligence and insight Counties Manukau Health - Healthy Together Strategic Plan The Healthy Together is based around the following three strategic objectives: 1. Healthy people, whānau and families - together we will involve people, whānau and families as an active part of their health team 2. Healthy services together we will provide excellent services that are well-supported to treat those who need us safely, with compassion and in a timely manner 3. Healthy communities - together we will help make healthy options easy options for everyone Together means collaboration and partnership with people, whānau, families, communities, health and other providers, aiming to: Provide high quality and high performing modern specialist and hospital based services; Strengthen primary and community based services to reduce the burden of disease and prevent ill health; and Achieve health improvement for all with targeted support for our most vulnerable people and communities. Achieving a healthy weight for tamariki has been identified as one of the key health indicators on which Counties Manukau Health (CM Health) will measure success of the Healthy Together Strategy. In addition Ko Awatea is currently leading a piece of work Mana Taurite: Equity in Health Campaign with three key work streams, one of which has a focus on reducing childhood obesity. A number of projects are currently underway and they listed in Appendix 4. In thinking of how to move forward in this context the DHBs must sustain parallel streams of activity, firstly in collaboration and advocacy for system level and environmental changes, and

102 secondly in shaping and affecting change in how health-led services are provided to reduce the impact of obesity across the life-course (Figure 2). 4.2 Taking Action on Unhealthy Weight - a way forward for the metro- Auckland region Progress to reduce the impact of high BMI for our current generation of children and their whānau, as well as for future generations, requires both support for individuals with their specific health needs (related to obesity and its associated diseases), as well as to improve the environments that children and their families live in, to increase access to healthy food, expand opportunities for sport, play and other physical activity. In addition we need to ensure that we work collectively, across the society as a whole, to facilitate people to make healthy choices. Healthy Auckland Together (HAT) is a key regional coalition coordinated by the Auckland Regional Public Health Service (ARPHS) that aims to promote environmental change to increase physical activity, improve nutrition and reduce obesity. HAT partner agencies include: Auckland Council, Auckland Transport, the Health Promotion Agency, Aktive Auckland Sport and Recreation, the Heart Foundation, metro Auckland DHBs, Healthy Families New Zealand, the MoH, Primary Healthcare Organisations (PHOs), Mana Whenua and Non-Government Organisations (NGOs). The backbone function of this work is undertaken by ARPHS and funded by the three metro- Auckland region DHBs. HAT has developed a five year plan that focuses on those aged two years and older. The plan includes actions specifically relating to schools and Early Childhood Education (ECE) settings. HAT partners are planning a range of strategic and operational activities to foster improvements in the food environment, including undertaking a gap analysis of healthy food environments in and around Kohanga reo, Pacific Language Nests and ECEs. These include supporting school decision-makers in developing healthy food environments, working with the Heart Foundation to support and expand its programme to improve the food environment in decile 1-4 schools, strengthening the focus on healthy eating and physical activity polices as part of the ARPHS pre-licencing ECE assessments and supporting active transport to and from school within our region. Through collaborations and partnerships the broader health sector can influence and impact parts of the community from which it may have had difficulty reaching, or where by acting alone it would not have the capacity or expertise to effect change. Through the HAT partners, and the Healthy Families NZ initiative (refer Working with our Partners section), clear pathways for sustaining and expanding these collaborative activities exist

103 Figure 2 Diagrammatic representation of DHB roles in childhood obesity 4.2 The Role of Health Services Recommendations for a health sector response to childhood obesity have been developed by the United Kingdom s National Institute for Clinical Evidence which identify the following strategies as essential: Ensuring family-based, multicomponent lifestyle weight management services for children and young people are available as part of a community-wide, multi-agency approach to promoting a healthy weight. They should be provided as part of a locally agreed weight management pathway; Dedicating long-term resources to support the development, implementation, delivery, promotion, monitoring and evaluation of these services; Raising awareness of local lifestyle weight management programmes; and Ensuring lifestyle weight management health professional staff are trained and have the necessary knowledge and skills.(20) In New Zealand we can, through the health system, work to reduce child unhealthy weight by: Ensuring women are supported to maintain a healthy weight prior to and during pregnancy and are monitored for Gestational Diabetes Mellitus (GDM). Ensuring breastfeeding is supported and healthy infant feeding is sustained. Supporting children and their families with appropriate monitoring of weight in primary care, Well Child Tamariki Ora (WCTO) services, at the Before School Check (B4SC) and at the adolescent HEEADSSS assessment. (It is important that the BMI of all children: Māori, Pacific, Asian, European and other ethnic minority groups,

104 including migrants and refugees, is monitored to ensure any child identified as overweight is referred for appropriate support). Ensuring that health care practitioners are supported with the right tools and training so they are confident to talk to families about their child s weight in an appropriate and strength based way. Promote the use of the locally adapted Health Pathways; and Providing programmes that use the best evidence to support children who are in the unhealthy weight range. 4.2 The different parts of the DHB health services (primary, secondary and tertiary care), have a clear opportunity to support and drive these health-led activities. This plan is about articulating those actions so the role of the three metro-auckland DHBs is clear, along with the work the DHBs do alongside the wider health sector (predominantly HAT) in reducing the rates of unhealthy weight. The Northern Regional Child Health Network The Northern Regional Child Health Network (constituted by the four Northern Region DHBs (Northland, Waitemata, Auckland and Counties Manukau) has an annual planning process which has identified achieving a healthy weight for tamariki as a priority area. A healthy weight working group has been established, with a work plan 3, to support the achievement of the network s plan. This work has been mainly focused on localising the Auckland Regional health pathway for weight management in children, improving communication across the Northern region and implementing an electronic growth charts in metro Auckland hospitals. The Northern Regional Child Health Network will co-ordinate, support and monitor the implementation of the plan with ultimate accountability sitting with the District Health Boards. 3 This regional network work plan will be reviewed in light of the development of this plan

105 The Role of Primary Care Primary Care has a particular contribution to make in supporting children, young people (and their whānau) to achieve a healthy weight. This includes traditional primary care as well as school-based health services in primary, intermediate and secondary schools. 4.2 There has been debate about the ethics of identifying overweight and obese children when the evidence for effective interventions is limited. Some are concerned about the possibility of causing harm in the form of stigmatising children and parents feeling blamed. An alternative view is that health professionals have a responsibility to identify overweight and obesity because it poses risk to children s health now and in the future. Growth is a dynamic and fundamental marker of health in children, and growth surveillance is a core aspect of child health. Growth surveillance assists parents and health professionals to identify concerns in growth trajectory and trigger lifestyle changes that will help the child grow into a health weight. Primary care are well-placed to do this. Raising the issue of childhood obesity with parents and caregivers can be difficult and the conversations around weight need to be managed sensitively and with skill. There is detail in the action plan regarding training for, and resources to support, Primary Care. A specific goal of this plan is to work with primary care to identify strategies for embedding growth monitoring in primary care pathways and supporting them with technological solutions and ensuring that ongoing practice is driven by analysis and understanding of what practice level data tells them. Culturally appropriate, tailored and targeted delivery Metro-Auckland DHBs recognise that attitudes and beliefs regarding food and healthy weight differ between cultural groups, and that interventions and programmes need to be tailored to ensure they address the specific issues and needs of particular settings or groups. Differing contexts, including the settings in which communities and groups can be reached, provide unique challenges and opportunities which will influence the way in which interventions can be delivered. Understanding the sociocultural perspectives of priority populations, including Māori, Pacific and Asian, and the delivery of culturally appropriate, tailored, high quality and accessible interventions is essential for eliminating inequities. This can best be achieved by positioning priority populations as decision makers at the forefront of planning and evaluation processes. Also essential is working together with whānau. The Whānau ora approach commits to planning and delivering care based around the strengths and needs of whānau to support whānau, increasing their capacity to undertake functions necessary to promoting whānau health and wellbeing. While this approach has been developed from Māori kaupapa, using a family-centred approach is likely to resonate with other priority populations such as Pacific communities. Metro-Auckland DHBs will hold the following determinants at centre of the continuous evaluation cycles built into this plan: (1) relationships and social connectedness; (2) holistic health including spiritual beliefs and cultural practices (Indigenous worldview); (3) historical trauma and the impacts of colonisation

106 Working with our partners 4.2 Across metro-auckland multiple collaborative initiatives are already in place or planned to support the prevention and management of childhood overweight. It is imperative that we work together to ensure regionally consistent messages and resources are available to support healthy eating, lifestyles and activity. Initiatives that the DHBs are involved with are summarised below. These and further activities are described in Appendix 2 Stocktake of existing initiatives. Healthy Families NZ is a large-scale initiative funded by the Ministry of Health that brings community leadership together in a united effort for better health. The initiative is being implemented in 10 locations around the country. Healthy Families NZ locations are led by a range of locally based organisations including Councils, Iwi and Regional Sports Trusts. There are two Healthy Families NZ locations in the Auckland region: Healthy Families Waitakere and Healthy Families Manukau, Manurewa-Papakura. The Lead Provider for Healthy Families Waitakere is Sport Waitakere and Auckland Council is the Lead Provider for Healthy Families NZ Manukau, Manurewa-Papakura. Auckland Council have established the Tamaki Healthy Families Alliance, which is a partnership between Council, Nga Mana Whenua o Tamaki Makaurau and Alliance Health Plus. The Alliance Communities Initiatives Trust (ACIT) is part of Alliance Health Plus and employs the majority of the Healthy Families Manukau, Manurewa-Papakura workforce. Taking a whole-of-community approach to prevention of chronic disease, Healthy Families NZ activates local leadership at all levels to create health change in schools, early childhood education, workplaces, sports clubs, marae, places of worship and community spaces. The initiative aims to create healthier environments for people to live healthy active lives by making good food choices, being physically active, sustaining a healthy weight, being smokefree and moderating alcohol consumption. Each Healthy Families NZ site has a local strategic leaders group with individual and collective spheres of influence across a multitude of sectors and settings who are supporting, driving and influencing healthy change in their communities. Waitemata DHB participates in the Healthy Families Waitakere strategic leaders group. Counties Manukau Health currently engages operationally with Healthy Families Manukau, Manurewa-Papakura but does not participate in their Prevention Partners Leadership Group. Healthy Babies Healthy Futures (HBHF) is a community-based obesity prevention and reduction programme aimed at improving maternal and infant nutrition and physical activity for Māori, Pacific and Asian pregnant women, young mums and their families in Waitemata DHB and Auckland DHB. The programme utilises a community development approach, and involves an innovative text-based health information component. The programme is currently being evaluated. Te Rito Ora is a free community based service that provides breastfeeding and baby feeding support for mothers and babies who live in Counties Manukau. The service provides:

107 Antenatal in-home breastfeeding education (from 31 weeks) Intensive in-home postnatal breastfeeding support Community based Lactation Consultant (LC) Service for mothers with more difficult or complex breastfeeding issues Breastfeeding support groups and peer supporter programme The programme is currently being evaluated. 4.2 The B4 School Check (B4SC) is a health and social assessment programme for four year olds, which is undertaken in a variety of settings including the home environment and clinics. The B4SC includes a growth assessment using height, weight and BMI. Children with a BMI equal to or over the 98th percentile are given advice on healthy eating and an active lifestyle, and referred to their General Practitioner (GP) and, where available, to a community physical activity and nutrition programme. In ADHB/WDHB, Green Prescription Active Families is the main physical activity and nutrition programme available to the community, but as it is contracted to provide for five to 18 year olds, the programme currently only allows four year olds to attend as family members of an older sibling that is referred. In CM Health, a pre-school Active Families programme, Active Futures, is available in the community. There is now also a B4SC community worker home visiting service available in the metro Auckland area to provide additional visits to families where a child is identified as being of an unhealthy weight at the B4SC. This service provides culturally appropriate advice and information, and support to families to make, and sustain, a range of healthy lifestyle choices with the goal that the child will grow into a healthy weight. Well Child Tamariki Ora work more broadly also provides breastfeeding support, nutritional advice and regular growth monitoring. Increasingly it is being recognised that growth needs to be discussed at each WCTO contact, with appropriate advice about nutrition, healthy weight gain and weaning foods. Green Prescription is a health professional s written advice to an adult (18+) patient to be physically active, as part of the patient s health management. It is a MoH funded programme that aims to increase physical activity levels in line with the NZ Eating and Activity Guidelines for Adults. Health professionals (usually GPs) can refer anyone who would benefit from increased physical activity to Green Prescription for support with improving strength, stability, fitness, nutrition or weight loss. It is a three month programme that includes face-to-face and phone support. ADHB/WDHB now includes pregnant women and women of childbearing age as priority groups. Green Prescription Active Families is a Ministry funded nutrition and physical activity programme for families. It has been provided in Waitemata DHB and CM Health for several years, and more recently in Auckland DHB. The programme is available via self-referral, or referral from any health professional (usually a GP or Paediatrician). The programme runs for up to 12 months, and is available to children and youth aged five to 18 years, and their families, with priority given to children aged five to 12 years. The most recent national monitoring report for the programme year 2015 showed that 85% of families surveyed noticed positive changes in their child s health and/or fitness, and 6% did not. Of those that noticed changes, 44 % said that their child had lost weight. Measured changes in weight or BMI were not assessed.(21) CM health/wdhb/adhb have recently made contractual changes including identifying Māori and Pacific families as priority

108 groups, including parenting skills into the programme content and BMI recording as part of outcome measures. 4.2 Healthy Village Action Zones (Auckland DHB), Enua Ola (Waitemata DHB) and LotuMoui (CM Health) are Pacific community church-based programme that support Pacific communities to create and lead healthy lifestyles. The programmes in Auckland DHB and Waitemata DHB include the eight week adult Aiga weight loss challenge to encourage community engagement and support healthy choices in order to improve health, and reduce overweight and obesity rates within Pacific communities. Health Promoting Schools (HPS) is a national approach funded by Ministry of Health. It is an education settings approach and is a community-led development initiative which focuses on the health and wellbeing of the school communities. The purpose of HPS is to support schools identify and address barriers to learning and enable improving student achievement. Schools include health and wellbeing in their planning, review processes, teaching strategies, curriculum and assessment activities. Health Promoting Schools facilitators work with school leaders to create and implement an action plan to address their identified health and wellbeing priorities. HPS service provides school communities with links to appropriate health and social services. HPS prioritises decile 1-4 (year 1-8) schools and schools with high Māori/Pacific population (year 1-8). In 2016/2017 CM Health had 107 target schools. Out of 107 schools, 81 are engaged with HPS (have completed the rubric) initiative. There are 50 decile 1-4 schools across Waitemata DHB and 60 across Auckland DHB). Auckland Regional Dental Service (ARDS) provides a range of oral health services that contribute to an improvement in the oral health status of the DHB s population. The service is available for children until the end of school year eight. The service provided includes: preventative care, oral health promotion and education, diagnostic services, treatment of oral disease and restoration of tooth tissue. There are similarities in health promotion messaging for oral health and childhood unhealthy weight, and therefore collaborative opportunities for ARDS and the northern region DHBs to develop consistent health promotion messages. Dental care for adolescents is provided by contracted dental providers. We need to work with ARDS and the northern region DHBs to develop consistent health promotion messages for obesity and oral health. The University of Auckland is a partner in the HAT coalition and is working collaboratively with and the metro-auckland DHBs to collect data on the food environment in and around ECEs / Kohanga reo, schools and the DHBs. The majority of this research stems from the International Network for Food and Obesity/NCDs Research, Monitoring and Action Support (INFORMAS), which is coordinated by the School of Population Health. The University also runs a Dietetic Training Programme, designed to provide the postgraduate training required to enable graduates to practise as Dietitians in New Zealand. As part of the training programme the University offers a teaching clinic where the whānau of children identified as obese at their B4SC can receive free advice on nutrition and physical activity. Research opportunities are also available for University of Auckland students within Waitemata, Counties and Auckland DHBs

109 Treaty Partners: Auckland DHB has a Memorandum of Understanding (MoU) with Te Rūnanga o Ngāti Whātua. Te Rūnanga o Ngāti Whātua has strong links with Māori communities across Auckland City and represents the aspirations of these communities. Te Rūnanga o Ngāti Whātua has contributed to the content of the Auckland District Māori Health Plan and will be key to partnering with the DHB to engage key stakeholders for increased Māori health gain. Waitemata DHB has Memorandum of Understanding (MoU) with partners, Te Rūnanga o Ngāti Whātua and Te Whānau o Waipareira Trust. Both partners have strong links with Māori communities. Te Whānau o Waipereira Trust has strong links with whānau in West Auckland and Te Rūnanga o Ngāti Whātua has strong links across Waitemata DHB, particularly in the South Kaipara area. Te Rūnanga o Ngāti Whātua and Te Whānau o Waipareira Trust have contributed to the content of the Waitemata District Māori Health Plan and will be key to partnering with the DHB to engage key stakeholders for increased Māori health gain. CM Health is committed to reducing health inequalities, accelerating Māori health gain and progressing the principles of the Treaty of Waitangi. The opportunity and challenge of Māori health outcome improvement is one shared with Treaty partner, Manawhenua I Tamaki Makaurau. This is an important partnership relationship for CM Health and integral to moving forward in-step with the local hapu, iwi and Māori communities. 4.2 This plan supports the relationship interests of the metro-auckland DHBs and Treaty partners, who are focused on addressing health inequalities and accelerating the health interests of Māori in this District

110 Figure 4: Child healthy weight programme logic: we are committed to addressing unhealthy weight by taking a life-course approach with a focus on achieving equality in health outcomes For whom Activities Outcomes Women of Childbearing age Promote Healthy food environments Strengthen primary care s ability to identify women of an unhealthy weight and offer advice and referral to Green Prescription Short term Medium term Long Term Increased awareness of the importance of weight management to the future health of a baby Better understanding of a healthy diet Healthy food environments in households with pregnant women and/or young children More women entering pregnancy at a healthy weight Normalisation of Healthy weight Normalisation of Healthy food environments 4.2 Pregnant women and infants Research is undertaken to build the evidence base for appropriate nutritional advice during pregnancy Pregnant women are weighed at the beginning of pregnancy and are aware of the appropriate weight gain during pregnancy Health professionals are confident to provide appropriate weight management advice Evidence based nutrition advice is provided to pregnant women Woman gain a clinically appropriate weight during pregnancy Reduction of GDM Increase in babies being born having been exposed to healthy in utero environment Communities understand and support women of childbearing age to maintain a healthy weight Reduction in the prevalence of obesity in infants Pregnant women are screened for GDM and are offered appropriate nutrition and clinical services Good clinical outcome achieved for mother s with GDM and their babies Women have access to culturally appropriate, relevant nutrition advice during pregnancy Woman choose to breastfeed after the birth of their babies Infants benefit from protective effects of breastfeeding Sound advice re breastfeeding is provided during the antenatal visit and advice and support is available throughout the postnatal period Children are offered appropriate first foods in appropriate portion sizes Children and adolescents Health professionals provide consistent advice re the appropriate weaning foods and timing of introduction of complimentary feeding Health professionals measure and weigh children and are confident to provide appropriate weight management advice in a strengths based way Services that provide practical nutritional and cooking skills are available in the community to parents of infants Increased knowledge and capability to provide children with appropriate food Increased child, adolescent and parental awareness about healthy food options and the importance of maintaining a healthy weight Infants/children develop a preference for healthy foods Children & adolescents exposed to healthy food environments Reduction in the prevalence in obesity More physically active communities Physical activity and nutrition programmes are available to children (Active futures/active families) which incorporate parenting principles Parents more confident parents not using food as a reward Four year olds >/=98% centile are referred to physical activity/nutrition programme ECEs and Schools support healthy nutrition through health food policies as well as physical activity Health target met Children & Adolescents are more physically active Adolescents in an unhealthy weight range and their families supported to change behaviours

111 Appendix 1: Evidence for Actions Women of childbearing age Issue and Rationale for action Scientific research confirms that the influences that alter risk of high BMI in childhood begin even prior to conception and persist throughout growth and development into adulthood. Biological risk factors that can occur prior to conception include whether the mother to be experiences over or under-nutrition, is obese, or experiences stress before and during pregnancy. As many pregnancies are unplanned it is important that the population as a whole is of a healthy weight. This will offer an individual personal health benefits as well as protect future children. Emerging evidence suggests that paternal weight may also influence future obesity risk.(17) Contextual and wider societal factors such as the obesogenic environment with promotion of energy-dense and nutrient poor food, limitations on safe and accessible physical activity, reduced task based mobility and active transport can make opportunities to eat healthily and exercise more difficult for individuals and society as a whole. Individuals behavioural responses in the context of a challenging environment alongside biological influences will determine their weight trajectory over their life course.(17, 19) Actions must address both the environment and support the individual. Current Situation Primary care practitioners and the DHBs are both involved in efforts to support overweight and obese adults to lose weight and maintain their weight loss. These efforts include: The Aiga Weight Loss Challenge Referrals to Green Prescription providers from primary care DHB-based chronic conditions management services. There are currently several approaches influencing the community and environments people live in that the DHB is actively involved with, including the Pacific community church-based programme Healthy Village Action Zones (HVAZ; Auckland DHB), Enua Ola (Waitemata DHB) and LotuMoui (CM Health), the community development initiative Healthy Families NZ and the regional Healthy Auckland Together (HAT) coalition to promote environmental change that increases physical activity, improves nutrition and reduces unhealthy weight. In addition the Ministry of Health (MoH) funds a range of health promotion services in Auckland that promote healthy eating and physical activity with the goals of promoting and supporting healthy lifestyles and wellbeing, and through this, reducing childhood obesity. The DHBs, together with the Auckland Regional Public Health Service (ARPHS), the Ministry of Health (MoH) and other organisations have developed and are implementing a National

112 Healthy Food and Drink Policy. This policy will be strengthened in collaboration with the National Food and Drink Environments Network. 4.2 What do we know about what works? Evidence statement Improving built environment Environmental interventions that support healthy nutrition and activity choices are needed to support healthy weight within populations.(19) Food policies Food policies work through enabling healthy preference learning, removing barriers to healthy preference choice, supporting reassessment of unhealthy preferences and stimulating a positive food-systems response.(22) Community-led approaches Community engagement and mobilisation to effect policy and systems changes are important in supporting healthy environments and addressing high BMI at a population level.(23) Workplace health Adults spend approximately one third of their lives in the workplace; poor employee health can cost organisations through absenteeism, poor productivity and lower retention.(24) Pre-conception health Children of women with prenatal obesity are two-four times more likely to be overweight in later childhood.(25) Relevance to the plan Support HAT in addressing the built environment. DHB Food and Drink Policy implementation; support HAT in advocacy; support MoH-funded NGOs which encourage and support policy change and implementation in settings such as schools, ECEs, churches and other community settings; support in policy submissions relating to the food system and nutrition. Support Healthy Families NZ and look at ways to promote and promulgate successful strategies. Support HAT; Support Healthy Families NZ; and DHB workplace wellness initiatives. Promote national guidelines and support DHB adult weight management pathway; promote Green Prescription referrals

113 MoH Childhood Obesity Plan activities Health-led initiatives within the MoH Childhood Obesity Plan, which incorporate the preconception period for youth and women of childbearing age and require DHB action include: 4.2 Supporting the Healthy Families NZ initiative Implementing the National DHB Healthy Food and Drink Policy Aligning public health and clinical advice with the updated MoH Eating and Activity Guidelines. 2. Pregnant women and infants Issue and Rationale for action We know that the risk of obesity can be passed from parents to children. This transference of risk is assumed to be both due to the biological influences we inherit from our parents and the way family life shapes behaviours that children adopt as they grow into adulthood. Parents can shape future behaviours through the eating and physical activity behaviours they adopt for their families and these can persist across generations due to socioeconomic conditions and cultural traditions and behaviours. Biological factors can alter risk through two proposed developmental pathways. The first of these, more common in developing countries, results from malnutrition or fetal growth restriction in the antenatal period and early child development due to poor maternal nutrition amongst other factors. Susceptibility is influenced by epigenetic processes, where environmental influences, in this case malnutrition, alter the way genes function. These epigenetic effects do not necessarily change objective measures such as birth weight. Babies who have experienced under nutrition and were born with low birth weight, or who are short-for-age, are at far greater risk of developing overweight and obesity later in life when faced with the obesogenic environment that is the norm for our society.(17, 26) The second well described developmental pathway is characterised by mothers who begin pregnancy already obese or suffering from diabetes, or whom develop gestational diabetes mellitus (GDM). These maternal conditions predispose the child to develop increased fat deposits which are associated with future metabolic disease and obesity. It is hypothesised that epigenetic effects further modulate this risk.(17) The way that children are fed early in life will further influence their risk of developing obesity and the balance of evidence suggests breastfeeding confers some protection against obesity and that there is a dose-response effect.(25, 27-31) The World Health Organisation (WHO) Commission on Ending Childhood Obesity reinforces that Breastfeeding is core to optimizing infant development, growth and nutrition and may also be beneficial for postnatal weight management in women. Summaries of the evidence suggest a number of ways that the diet of a mother and the type of feeding and complementary foods given to an infant can influence the child s preferences:(17)

114 The flavours of foods that mothers eat can be passed on both in-utero and when breastfeeding and these can influence a child s future taste preferences. Children who are formula fed have more difficulty initially accepting flavours of fruits and vegetables and some children to bitter tastes. Infants tend to be more accepting of the flavours of the foods eaten by their mother during pregnancy and lactation when they are first exposed to foods. It has been identified that in general infants prefer sweet and salt tastes and dislike bitter tastes. Repeated exposures (tasting of food) for fruits, vegetables and other healthy foods influences infants to prefer these, by experience of a variety of such foods and then parental and social modelling; and those fed a variety of fruits or vegetables were more accepting when novel ones were introduced. Children are more likely to eat new foods if they are eating the same thing as their parent. 4.2 Maternal diet is important for the on-going health of the mother, their risk of obesity and/or unhealthy pregnancy weight gain and can influence a child s future taste preferences. Data from New Zealand has shown that poorer dietary patterns are associated with mothers-to-be being born in New Zealand, of Pacific or Māori ethnicity, younger maternal age and lower educational levels and are associated with other unhealthy behaviours including smoking and alcohol consumption in pregnancy and not taking appropriate folic acid supplementation. This suggests a clear need for additional support for these populations and the coordination of dietary advice alongside antenatal care more broadly.(32) It is apparent from this evidence that interventions before and early on in conception and in infant feeding, may offer opportunities to modulate risk. Other influences on risk of obesity will also be important. The WHO Commission point to a recent meta-analysis which demonstrated that maternal smoking during pregnancy was associated with higher odds or chance of a child developing obesity (OR 1.6; 95% CI: ). This reinforces the importance of maintaining current efforts across women and children s health to improve obesity and other health indicators.(17) Current Situation The MoH Guidance for Healthy Weight Gain in Pregnancy was released in 2014, and is being adopted and used across primary care providers, including General Practitioners (GP)s, Lead Maternity Carers (LMC)s and within Healthy Babies Healthy Futures (HBHF). It is not known if adoption is consistent across all providers. GDM guidelines have also been implemented across the metro Auckland DHBs. General Practitioners and LMCs can currently refer pregnant women to Green Prescription, however, Green Prescription providers may need further upskilling on supporting pregnant women at risk of GDM as this is perceived to currently not be a common referral.cm Health has not managed to get traction with Green Prescription to deliver a programme specifically for pregnant women but this is described in the action plan

115 The HBHF programme has been in place since 2014 in Auckland DHB /Waitemata DHB. This community-based obesity prevention and reduction programme is aimed at improving maternal and infant nutrition and physical activity for Māori, Pacific and Asian pregnant women and their families. The programme has been well received by women, and has received MoH funding for a further year, from It utilises a community development approach, and involves an innovative text-based health information component. HBHF is being evaluated by an external evaluator to determine reach and impact. 4.2 Te Rito Ora, a free community based service that provides breastfeeding and baby feeding support for mothers and babies who live in Counties Manukau, has been in place since mid Te Rito Ora has received MoH funding for a further year, from The programme is being evaluated by an external evaluator to determine reach and impact. All DHBs are part of the Baby Friendly Hospital Initiative (BFHI). Breastfeeding rates differ by ethnicity, but are high on discharge from hospital (above the BFHI target of 75%), and then drop significantly by six weeks postnatal and again even further at three months. For women who experience complex breastfeeding problems Lactation Consultant (LC) support is available while they are in hospital. Waitemata DHB also provides outpatient LC support four days a week across Waitakere and North Shore sites. Auckland DHB implemented community LC support in 2016, consisting of clinics co-located with midwifery and Well Child providers, and a home visiting service. Te Rito Ora provides community based LC support for women in Counties Manukau and there is also lactation Consultant support available through Turuki Heath Care B4Baby programme. Whilst LC support is acknowledged as being critical for women experiencing complex breastfeeding problems all women have access to services for breastfeeding support, through their LMC and the Well Child Nurse service. The uptake of this advice amongst new mothers is however unclear and the quality and consistency of such advice may differ. Consistent training and advice is needed across community, primary and secondary care settings regarding breastfeeding and first foods, and increased breastfeeding advice and support for women in pregnancy and postnatal is required across the region. What do we know about what works? Evidence statement Gestational Diabetes Mellitus (GDM) Antenatal and pregnancy nutrition and lifestyle interventions in obese and normal weight pregnant women, particularly dietary interventions, reduce weight gain in pregnancy, prevent excessive weight gain in pregnancy, and may reduce the prevalence of GDM.(33-35) Studies have primarily looked at maternal health and birth outcomes and it is noted that most studies have not had as a specified outcome of interest childhood obesity. The WHO Commission notes that observational data suggests that interventions targeting weight gain in pregnancy and glycaemic control are likely to be effective and note that interventions prior to conception will add additional benefit.(17) Physical activity in pregnancy Relevance to the plan Promote Healthy Weight Gain guidelines; implement GDM pathway; support HBHF

116 Evidence statement Physical activity during pregnancy and the postpartum period is beneficial for maternal and fetal health, is not associated with risks for the new-born and may lead to improvements in lifestyle that confer long-term benefit.(36) Breastfeeding Data from observational studies indicates that breastfeeding anytime in the first year of life provides moderate protection for childhood obesity, and may reduce the odds of childhood overweight by %.(25) In a large interventional study of breastfed infants, follow-up at 11.5 years found no significant difference in Body Mass Index (BMI) between breastfed infants in study sites compared to control sites though the intervention had clearly increased breastfeeding duration, exclusive breastfeeding, and overall prevalence during the first year of life.(37) This suggests that this intervention alone would not likely prevent childhood obesity but should be undertaken in concert with other activities. Baby friendly Hospital Initiatives (BFHI) have the highest impact on promoting any breastfeeding (RR % CI ) and are effective in initiating breastfeeding but other interventions are required to promote exclusive breastfeeding to 6 months of age and continued breastfeeding past 6 months of age. Breastfeeding interventions are most effective at supporting exclusive breastfeeding, and continued breastfeeding when provided concurrently in a combination of settings including health, home, family and community settings.(38) Pooled results from trials across low and middle income countries (LMIC) and high income countries (HIC) show that group counselling in the community (RR 1.65, 95% CI ), BFHI support (RR 1.20, 95% CI ), and counselling or education by health staff delivered in multiple settings had the largest effects on breastfeeding initiation in the first hour.(38) Pooled results from trials across LMIC and HIC interventions delivered in the health system or home and family environment have comparatively greater impact on maintaining exclusive breastfeeding 4 than those delivered solely in the community but interventions improve significantly by 79% (RR % CI ) when interventions are delivered concurrently in any combination of settings (across healthcare, home and community settings). Education or counselling has the greatest impact on promoting exclusive breastfeeding. Where this is undertaken in the health system and community this is likely to be the most powerful. However some studies in developed (HIC) countries have not demonstrated a statistically significant effect of breastfeeding education and interventions in general demonstrate Relevance to the plan Promote Healthy Weight Gain guidelines; promote Green Prescription referrals for pregnant women; support HBHF. Suite of DHB initiatives to promote breastfeeding Defined as feeding with breast milk up to 6 months of age and no other liquids or solids other than vitamin/mineral supplements or medications

117 Evidence statement lesser impact in HIC which could be due to better baseline levels of knowledge and understanding about breastfeeding.(38-40) Interventions in HIC show a greater effect on promoting continued breastfeeding 5 than pooled results. Counselling or education when given concurrently in any setting (across healthcare, home and community settings) significantly promoted continued breastfeeding (RR % CI ).(38) There is mixed evidence on the utility of peer support programmes. Universal peer support programmes have not been found to improve breastfeeding but targeted programmes (for example for low income or specific ethnic groups) may be effective to reduce breastfeeding noninitiation (RR % CI ).(41) There is significant heterogeneity in study results and some studies have not been able to demonstrate a statistically significant effect in high income countries which suggest context and specific peer support programme design may significantly impact success.(41, 42) Introduction of solids Late introduction of first foods, provides moderate protection for childhood obesity.(25) Relevance to the plan Support HBHF and Te Rito Ora. 4.2 MoH Childhood Obesity Plan activities Health-led initiatives within the MoH Childhood Obesity Plan specifically for maternity and the first year of life that require DHB action include: Implementing the GDM guidelines Utilising the MoH Guidance for Healthy Weight Gain in Pregnancy resource Referring pregnant women with or at risk of GDM to Green Prescription 5 Where breastfeeding persists greater than six and less than 23 months of age

118 3. Children and Adolescents Issue and Rationale for action The prevention and treatment of childhood obesity requires that (1) supportive policies and health promoting environments are created and maintained across the different levels and sectors that influence healthy diets and healthy movement and (2) that individual level approaches work in concert with this to enable behaviour change for children, caregivers and families. 4.2 Interventions that focus on individual behaviour change can consequently focus on different groups such as pre-school or school aged children, adolescents or parents and caregivers and can be implemented in different settings, including childcare and schools, health care and the broader community. In considering potential interventions it is important to balance the evidence for different strategies with local knowledge that the community holds. In childhood obesity, where Māori and Pacific children bear an unequal burden of disease, it is essential that interventions be tailored to meet the needs of these communities and that there is opportunity to adapt in response to the communities perspectives. The WHO report into Population-based Approaches to Childhood Obesity Prevention (2012)- confirmed that childcare services (such as Early Childhood Education Centres (ECEs) and Kohanga reo that provide educational and developmental activities for children prior to formal compulsory schooling) are an important setting for public health action to reduce the risk of overweight and obesity in childhood.(12) These settings, alongside schools, provide an opportunity to access large numbers of children for prolonged periods of time and because of this are influential in children s development and behaviours. They are also a conduit to parents and caregivers and the home environment.(12) More recently, the WHO Report of the Commission on Ending Childhood Obesity (2016) made specific recommendations for child-care and school environments ((9): Child-care environments: 1.8 Require settings such as schools, child-care settings, children s sports facilities and events to create healthy food environments. 4.9 Ensure only healthy foods, beverages and snacks are served in formal child care settings or institutions 4.10 Ensure food education and understanding are incorporated into the curriculum in formal child-care settings or institutions 4.11 Ensure physical activity is incorporated into the daily routine and curriculum in formal child care settings or institutions. School environments: 2.2 Ensure that adequate facilities are available on school premises and in public spaces for physical activity during recreational time for all children (including those with disabilities), with the provision of gender-friendly spaces where appropriate

119 5.1 Establish standards for meals provided in schools, or foods and beverages sold in schools, that meet healthy nutrition guidelines Eliminate the provision or sale of unhealthy foods, such as sugar-sweetened beverages and energy-dense, nutrient-poor foods, in the school environment. 5.3 Ensure access to potable water in schools and sports facilities. 5.4 Require inclusion of nutrition and health education within the core curriculum of schools. 5.5 Improve the nutrition literacy and skills of parents and caregivers. 5.6 Make food preparation classes available to children, their parents and caregivers. 5.7 Include Quality Physical Education in the school curriculum and provide adequate and appropriate staffing and facilities to support this. Assessment of weight outcomes vary between studies and potential measures of body weight reported can include BMI, BMI Z-score 6, BMI percentile and weight. It is important to note that due to children s normal growth, BMI and weight may increase even as children s growth trajectory shifts as indicated by change in BMI z-score. It is unlikely that a single intervention at any time point in a child s life would be sufficient to sustain a healthy weight. While environmental drivers towards overweight and obesity persist, and are heavily weighted to promote excess energy consumption and inadequate physical activity, children may need to be exposed to a coherent sequence of age-appropriate interventions in order to achieve and maintain a healthy weight.(17) Current Situation All DHBs provide the Green Prescription Active Families family-based nutrition and physical activity programme for children aged 5-18 years. Green Prescription Active Families is delivered in Auckland, on the North Shore and in Waitakere. In Counties Manukau, Active Families has been predominately delivered in Otara historically. However with the development of new Active Futures programme, both programmes will be providing services in Otara, Mangere as well as further south in Maurewa-Papakura. Currently the Green Prescription Active Families family-based nutrition and physical activity programme does not include four year olds in Auckland and Waitemata. With the initiation of the new MoH raising healthy kids target this has been identified as an area of need. 6 "A BMI z score or standard deviation score indicates how many units (of the standard deviation) a child's BMI is above or below the average BMI value for their age group and sex. For instance, a z score of 1.5 indicates that a child' is 1.5 standard deviations above the average value, and a z score of -1.5 indicates a child is 1.5 standard deviations below the average value". National 68. Obesity Observatory on behalf of the Public Health Observatories in England A simple guide to classifying body mass index in children

120 Children identified in the B4SC may benefit from such programmes and health care practitioners will require appropriate referral pathways to be identified. As part of the MoH target the MoH is providing funding for the expansion of community physical activity and nutrition programmes to pre-schoolers in ADHB/WDHB from July Four year old children are assessed for unhealthy weight at the B4SC. Children identified as obese are referred to an appropriate health care practitioner typically their family GP. The Clinical Guidance for Weight Management in New Zealand Children and Young People provides GPs with some information on subsequent management. A localised childhood healthy weight pathway has been development to support Well Child Tamariki Ora (WCTO), B4SC and GP providers to ensure children identified as being overweight or obese receive appropriate evidence-based care. The assessment and management of children with high BMI will be further supported through appropriate resources for brief intervention. A goal setting tool (Be Smarter) has been identified as the best available resource for community and primary care providers to enable them to provide evidence-based and consistent advice to families, and consistent reinforcement of this advice across different settings and services. As of June 2017 there are 1430 ECEs (49 are Te Kōhanga Reo and 562 schools in the broader Auckland region.(43, 44)) Children may be physically active in ECEs and school, through activities such as sport or active play, or through everyday tasks such as getting to and from school. In the Auckland region approximately 45% of children aged 2 14 years usually use active transport to get to and from school.(45) Although children are considered by educators and parents to be naturally active and energetic, children have been found to be sedentary the majority of the time while in ECE care. Contributing factors include lack of space, the large majority of ECEs not having a written physical activity policy and many not offering structured physical activity.(46) For secondary students, of those surveyed (n=8,500) only 10% (14% males and 6% females) met the current New Zealand physical activity recommendation of 60 minutes per day.(47) Nutrition in ECEs and schools is variable. The University of Auckland INFORMAS research group is currently conducting research to determine the number and quality of school nutrition policies in New Zealand. The metro-auckland DHBs are supporting this work. For ECEs, University of Auckland research demonstrates that whilst a high proportion of ECEs (82%) have a nutrition policy the policies are insufficient in measures of comprehensiveness and strength.(32) Only 5% of ECEs that provided food daily (over 50% of ECEs), provide food that is of sufficient quantity, variety and quality to meet half of a pre-schooler's nutritional needs using government guidelines. Occasional foods were included in half of weekly menus, although they should only be provided once a term.(48) The Ministry of Education s promoting healthy lifestyles web page has resources for schools including a template for formulating a water-only policy, a link to healthy confident kids guidelines and the food and beverage classification system.(49) There are also guidelines on the Ministry of Education s website for schools to develop policies related to the food environment in their school.(50) The Ministry of Education suggests that schools have a water and milk only approach to beverages. In 2016, this was implemented in 69% of primary schools, but only 13% of secondary schools.(51) The impact of the Food Act needs to be considered in further research of food provision in ECEs and schools

121 The environments outside of schools and where children live can also influence nutrition, especially where high energy and nutrient poor food choices predominate. Across the Auckland region there were on average 2.5 fast-food restaurants within 10 minutes walk of a primary, intermediate or secondary school. Within lower decile neighbourhoods it may be easier to obtain fast food than to visit a grocery store with a gradient of increasing likelihood of excess fast food premises (defined as having access to more fast food premises than grocers) as neighbourhood deprivation increases.(45) 4.2 What do we know about what works? Evidence statement Environments School food environment policies are effective at supporting healthy weight in children.(52) Health promotion Cost effective interventions for children to prevent or manage high BMI include: reducing junk food advertising, education programmes to reduce sugar sweetened drink consumption, multifaceted programmes including nutrition and physical activity, education programmes to reduce television viewing and family-targeted programmes.(53) Obesity prevention Evidence suggests child obesity prevention programmes are effective in reducing BMI z-scores and BMI. The age group in which efficacy has been most clearly demonstrated is age 6-12 years and interventions were predominantly based on behaviour change theories and implemented in education settings. Relevance to the plan Support HAT; engage with primary schools and ECEs through Healthy Families NZ and Heart Foundation, school based health services; continue engagement and support through the Health Promoting Schools initiative. Support HAT; support Healthy Families NZ. Results from a Cochrane review of 55 studies found that children in the intervention group had a standardised mean difference in adiposity (measured as BMI or zbmi) of -0.15kg/m2 (95% CI to ).(52) Whilst these are small in terms of actual change in BMI, at a population level it is anticipated that these small changes are likely to be significant. Interventions are heterogeneous and there is no clear indication for any distinct intervention type or specific programme, particularly given limited evidence in the New Zealand context and with

122 Evidence statement indigenous populations in general.(54) Consequently we can, at best elucidate some consistent principles for intervention delivery which are evidence based. The Cochrane review identifies the following components as important to effective interventions: school curriculum that includes healthy eating, physical activity and body image; increased sessions for physical activity and the development of fundamental movement skills throughout the school week; improvements in nutritional quality of the food supply in schools; environments and cultural practices that support children eating healthier foods and being active throughout each day; support for teachers and other staff to implement health promotion strategies and activities (e.g. professional development, capacity building activities); and parent support and home activities that encourage children to be more active, eat more nutritious foods and spend less time in screen based activities.(52) As the majority of studies have not undertaken long-term follow-up it is unclear to what degree reductions in BMI or BMI z-score are sustained over time. Waters et al. in the Cochrane review further examined studies in the 0-5 years age range, comparing those conducted in, or outside of, educational settings. They observed that effects were greater outside of educational settings (e.g. in home or health-care settings). This may have been due to greater parental involvement in these settings and that effects were observed more consistently for children from less advantaged backgrounds.(52) In a systematic review of nine community-based interventions there was moderately strong evidence that inclusion of a school component was effective for prevention of child overweight and obesity, in that 2 of the 3 studies that involved schools found a statistically significant benefit. Evidence was insufficient to draw any conclusions about the other community based approaches that worked in the community alone or community and other non-educational settings.(55) Obesity treatment Obesity treatment studies have used a variety of interventions including lifestyle programmes and medication. A Cochrane systematic review and meta-analysis of multi-component obesity treatment programmes in 0-6 year olds found a reduction in BMI z-score in the intervention groups compared with controls at the end of intervention: mean difference units (95% CI to ); P < ; this was sustained at months where the mean difference was units (95% CI to -0.19); P = ; and in one trial which reported outcomes at 24 months of follow-up (12 months' post intervention) and found the benefit was maintained Relevance to the plan Develop and request proposals for a new family based intervention for preschoolers. The development of this initiative will incorporate MoH

123 Evidence statement (mean difference units (95% CI to -0.10). Studies are heterogeneous and consequently this result should be interpreted with caution, for example one large study included in this metaanalysis assessed a dairy rich diet traditional to a specific region and this would impact its generalisability.(56) Luttikhuis et al reviewed 54 lifestyle interventions including physical activity, diet or behavioural interventions. Of these 54 studies 37 were conducted in children <12 years and 17 studies included adolescents >12 years of age. For children <12 years they found a mean change in BMI z-score at twelve months follow up of [ 95% CI -0.12, 0.04] with lifestyle interventions. For children >12 years they found a mean change in BMI z-score at twelve months follow up of [ 95% CI -0.18, -0.10] with lifestyle interventions. They concluded while there is limited quality data to recommend one treatment program to be favoured over another, this review shows that combined behavioural lifestyle interventions compared to standard care or self-help can produce a significant and clinically meaningful reduction in overweight in children and adolescents. (57) The following features have been identified in the literature as characteristics of more effective interventions: A multicomponent programme which addresses diet, physical activity and behaviours including decreased sedentary behaviours.(57, 58) Parental and family involvement (particularly for pre-adolescent children) to support whole-of-family lifestyle change.(57, 59) Management of obesity-associated comorbidities; and Strategies to support long-term behavioural change. Relevance to the plan requirements alongside other evidence-based criteria. Promote and expand access to an Active Families type programme for children and adolescents. Assess and make recommendations on delivery of a multicomponent intervention addressing diet, activity and behaviours. Programme will involve parents and the family unit in parenting skills (e.g. sleep hygiene, fussy eating, screen time) and long term behaviour change. Active Families type programme should provide a multicomponent and family-focused intervention as described above. A new pre-school programme will operate on referral from B4SC or primary care. Children will receive a check-up with their GP for obesity related comorbidities prior to referral

124 Evidence statement In obesity prevention studies and obesity treatment studies the overall change in BMI has been small. (52, 57, 58)There are differing opinions on the clinical significance of this change in BMI. A recent meta-analysis showed that lifestyle interventions for children that achieved a reduction in BMI z-score of -0.1 led to significant improvements in low-density lipoprotein cholesterol, triglycerides, fasting insulin and blood pressure up to 1 year from baseline, which should lead to follow-on improvements in cardiovascular and metabolic outcomes.(58) Comprehensive childhood obesity prevention or treatment programmes should aim to increase participation in the following behaviours: moderate-to-vigorous physical activity, light/incidental physical activity, outdoor time, and good sleep hygiene, while discouraging extended sedentary behaviours.(17) Studies, including meta-analyses, show that the reductions in BMI z- score for children receiving intervention programmes were greater than the BMI z-score reductions achieved in adolescent study populations.(52, 58, 60) A multi-centre audit of existing obesity interventions in New Zealand children (motivational interviewing, multidisciplinary teams or familybased nutrition and physical activity programmes) identified that all of these led to a significant reduction in BMI z-score. There were no statistically significant difference in measures of adiposity between the groups and consequently no insights as to the relative merits of one intervention over another can be gained.(60) Ongoing reinforcement is required to enable longer term effectiveness of BMI changes from motivational interviewing.(61) In reviews of evidence for overweight and/or obese children aged 5 to 11 years, where parent only interventions have been considered for weight management it has been found that, for the primary outcome of changes in BMI, when trials compare a parent-only intervention with a parent-child intervention there were no substantial differences in BMI measures at either the post Relevance to the plan Important to balance having programmes that span all age groups with focussing efforts where most gains are anticipated in the early years of life, pre-school and early school years. This will be integrated into referral pathways and guidance for health care professionals. Support brief interventions and ongoing growth monitoring and follow-up in primary care. Parent-only interventions are no more effective than parent-child interventions. As existing interventions

125 Evidence statement intervention follow-up or the longest follow-up period. There were no substantial effects of parent-only interventions on BMI or weight when compared with minimal contact control interventions 7. In trials comparing a parent-only intervention with a waiting list control, there was a treatment effect on BMI in favour of the parentonly intervention at the post intervention follow-up and at the longest follow-up period but generally this was considered to be low quality evidence and further studies are recommended.(62) Overall parent-only interventions may be an effective treatment option for overweight and/or obese children aged 5 to 11 years when compared with waiting list controls. Parent-only interventions had similar effects compared with parent-child interventions and compared with those with minimal contact controls. However, the evidence is at present limited. In meta-analyses of weight loss drug trials, both orlistat and sibutramine, as an adjunct to a lifestyle intervention, led to significant improvements in adiposity in adolescents. It is important to note however that there were significant adverse events associated.(57) There is currently insufficient evidence to determine whether bariatric surgery is an appropriate weight management strategy for adolescents. It will be important to closely monitor adverse outcomes and assess psycho-social indices alongside BMI and metabolic markers for this group to determine treatment safety and efficacy.(63) Relevance to the plan involve parents and children strengthening and expanding these initiatives is a preferred option. Any potential drug therapy should be undertaken on a case by case basis when under care of an appropriately qualified physician. Further evidence reviews will inform ongoing consideration of whether there is any role for bariatric surgery in adolescents. 4.2 MoH Childhood Obesity Plan activities Health-led initiatives within the MoH Childhood Obesity Plan specifically for children that require DHB action include: Ensuring the new health target is met: By December 2017, 95 per cent of obese children identified in the B4SC programme will be referred to a health professional for clinical assessment and family-based nutrition, activity and lifestyle interventions. Improving access for four year olds to nutrition and physical activity programmes Utilising the MoH Clinical Guidance for Weight Management in New Zealand Children and Young People Utilising the updated MoH Active Movement resources for pre-schoolers when available Providing Health Promoting Schools support 7 Defined as mailed information or a workbook or minimal sessions

126 Appendix 2: Stocktake 4.2 A stocktake has been undertaken of DHB, NGO and community physical activity and nutrition activities for children and their families within the metro Auckland DHBs. To date it has revealed a gap with no family-based combined nutrition and physical activity programmes available in Auckland DHB or Waitemata DHB for pre-schoolers identified as obese or overweight at the B4SC with a programme having just recently been commissioned in CM Health The major initiative that has been available across the is Auckland region has been the Green Prescription Active Families programme, which in 2016/17 was funded for 114 children per year in Auckland DHB, 117 children per year in Waitemata DHB and 171 children per year in CM Health. The Active Families programme is designed for children aged 5-18 years and in its existing format is not designed to meet the needs of pre-school children

127 Table 7. Stocktake of community physical activity and nutrition activities for children and their families in Auckland DHB December Initiative Contact Organisation Referrer Target Group Objectives / Targets Website Health Promoting Schools (HPS) Fruit in Schools (FiS) Fonterra Milk for Schools Kick Start Breakfast Programme Enviroschools ADHB: Michelle Hull (Health Promotion Schools Coordinator Starship Community) michellehull@adhb.govt.n z; / ext: info@unitedfresh.co.nz; (09) Fonterra milk for schools; contact@fonterramilkfors chools.com; Kick.Start.Breakfast@font erra.co.nz Anke Nieschmidt (Programme and Projects Coordinator); anke.nieschmidt@enviros chools.org.nz; (07) ext 30 Ministry of Health (MoH) MoH; United Fresh Incorporated Facilitators approach schools or schools selfrefer None Year 1-8 in decile 1-4 schools and those with high Māori and Pacifika rolls. Primary and intermediate school aged children, decile 1-2 schools Fonterra None Primary school aged children Fonterra in conjunction with Sanitarium Toimata Foundation Self-referral ECEs and schools can self-refer Primary, intermediate and secondary school aged children, decile 1-10 schools Children who attend an ECE centre, primary, intermediate or secondary school. HPS facilitators work with school leaders who provide leadership for their whole school community to identify health and wellbeing priorities for their students, and create and implement an action plan to address these priorities and monitor outcomes Initiative provides one piece of fresh produce, fruit or vegetable, to school children daily. Initiative provides milk (200ml tetrapack) to children in all primary schools who wish to take part. Programme providing children at school with a breakfast of Weetbix and milk. The objective is to foster a generation of people who instinctively think and act sustainably through connecting with each other, their cultural identity and land, to create a healthier, peaceful, more equitable society. Facilitators provide ECEs and schools with support and resources. o.nz/our-work/fruit-inschools and /our-work/lifestages/child-health/fruitschools-programme orschools.com/ co.nz/

128 Initiative Contact Organisation Referrer Target Group Objectives / Targets Website Life Education Trust Healthy Heart Award Fuelled 4 Life Food for Thought Vicki Metekingi (Trusts Coordinator): Waitakere@lifeedtrust.org.nz; org.nz/index.php/contactus Sarah Goonan (Food & Beverage Classification System Programme Manager); fuelled4life@heartfoundat ion.org.nz Naomi Sutton (Nutritionist - Upper North Island); Naomi.Sutton@foodstuffs. co.nz; Life Education National Service Centre Heart Foundation (HF) Self-referral None Children at primary and intermediate school Children aged 5 years, who attend an ECE centre. HF None ECEs: Children aged 5 years, who attend an ECE centre. Schools: primary, intermediate and secondary school aged children HF and Foodstuffs Self-referral Primary school aged children (years 5 & 6), HF delivers programme to decile 1-4 schools Foodstuffs nutritionist delivers programme to decile 5-10 schools The objective is to teach children about health, life, themselves, and other people, with the aim of showing them how to reach their full potential. Teachers go into schools and provide education sessions. Bronze, silver, gold awards for ECEs. Programme assists ECEs to create an environment to promote physical activity and healthy eating to children and their families. Healthier foods recommended for use A nutrition education programme designed to assist the teaching of food and nutrition org.nz/ org.nz/ g.nz/ ht.co.nz/ 4.2 Heart Start Award org.nz/index.php/contactus HF Self-referral Primary school aged children Module-based programme for improving environments org.nz/

129 Initiative Contact Organisation Referrer Target Group Objectives / Targets Website Heart Start Excellence Award Heart Schools Award Travelwise Be Healthy, Be Active Food for Kids (Orchards in Schools) org.nz/index.php/contactus org.nz/index.php/contactus Auckland Transport: Nestle Consumer Services; HF HF Auckland Transport All schools with a MoE number can register on HF website All schools with a MoE number can register on HF website Primary school aged children Primary school aged children Primary school aged children and the community Nestle Self-referral Intermediate school aged children (10-13 years) and their teachers Kids Can; (09) KidsCan Self-referral Decile 3 and 4 primary schools enrolled in Kids Can partnership Module-based programme for improving environments Exceptional school completes initiative for improving nutrition or PA environment. School completes up to 12 modules (minimum 5), including nutrition policy development, food service improvement, PA promotion and nutrition education for students and staff. 3 modules are from Food for Thought programme. Programme focuses on road safety education and fun ways to get to school. Aim: to teach children to be safe and encourage active transport. (Programme includes seasonal cycling programmes and courses for all ages) Programme to raise awareness around good nutrition and active lifestyles for intermediate school aged children. Aligned with the NZ Curriculum for health and physical education. Programme provides food at school for thousands of financially disadvantaged children every day. org.nz/ org.nz/ Schools selfrefer active.co.nz/ z/our-work/food-for-kids

130 Initiative Contact Organisation Referrer Target Group Objectives / Targets Website Garden to Table Gardens for Health Maara Kai Nutrition and Dietetic Clinic Vivienne Campbell (Area Coordinator Northland) Richard Main (Programme Manager): gardens@dpt.org.nz; (09) tpk.tamakimakaurau@tpk.govt.nz Julia Sekula (Clinical Director, Nutrition and Dietetic Clinic) j.sekula@auckland.ac.nz; (09) Garden to Table Trust Diabetes Project Trust None Self-referral Primary and secondary school aged children Community groups, organisations, workplaces and schools Te Puni Kokiri None Community groups, e.g. marae, kōhanga reo, Kura, schools and Māori communities University of Auckland GP/Health Professional or self-referral (note: selfreferral is more expensive) Children of all ages and their families School-based programme aimed at assisting children to create a sustainable garden, harvest fruits and vegetables, and cook and share a meal they have produced Programme provides support and advice to community groups or those looking to set up community gardens. Provides financial assistance to community groups wanting to set up sustainable community garden projects. small one-off funding grants of up to $2,000 (GST exclusive) are available to help community groups, such as marae, kōhanga reo, Kura, schools and Māori communities. Funding can be used for garden construction, gardening tools and compost, and education on gardening practices Student dietitians (5th year of the Masters) provide dietetic assessment and intervention, under the supervision of a NZ Registered Dietitian, for children of all ages and their families r-programmes/garden-4- health documents/tpk-maarakai- %20form2016.pdf nd.ac.nz/en/about/ourservices/nutrition-anddietetic-clinic.html

131 Initiative Contact Organisation Referrer Target Group Objectives / Targets Website Green Prescription Active Families Steps for Life Healthy Babies, Healthy Futures TextMATCH Active Families Coordinator Active Families Coordinator: /our-work/preventativehealth-wellness/physicalactivity/greenprescriptions/activefamilies-contacts info@stepsforlife.co.nz; (09) Pacific: Maria Kumitau (Programme Coordinator); maria.kumitau@thefono.o rg.nz; Maori: Danielle Tahuri; danielle.tahuri@healthwe st.co.nz. Asian: Fangfang Chen; fangfangchen@cnsst.org.n z South Asian: Anjileena; Anjileen@asiannetwork.or g.nz Sport Auckland Monty Betham Steps For Life Foundation The Fono, HealthWest, CNSST, The Asian Network GP/Health Professional or self-referral Self-referral GP, community group, maternity services or self-referral Children aged 5-13 years, who are: overweight/obese; have poor eating habits; would benefit from being more active and have the support of whānau/family Overweight secondary school aged children and their families Pregnant Māori, Pacific, Asian and South Asian women with children aged 0-4yrs and their families Children attend regular group sessions (1hr/week for 6 months) with their family at a community centre. Group sessions include PA, parent workshops, and family cooking classes. Families are provided with monthly support from the coordinator towards lifestyle and wellbeing goals. Goals are set and child's progress monitored. Child linked to other activities in community. Programme (5-6hrs/week for 12 weeks) focuses on physical health, healthy food, mind health and healthy family. Includes physical activity sessions, nutrition advice and guided supermarket tour. A text message-based programme providing information on healthy eating and being active for pregnant women and new mothers es-fees/communityservices/healthy-babieshealthy-futuresprogramme/

132 Initiative Contact Organisation Referrer Target Group Objectives / Targets Website Healthy Babies, Healthy Futures Pacific: Maria Kumitau (Programme Coordinator); maria.kumitau@thefono.o rg.nz; Maori: Danielle Tahuri; Danielle.tahuri@healthwe st.co.nz; Asian: Fangfang Chen; fangfangchen@cnsst.org.n z or Bushra; Bushra@asiannetwork.org.nz; (09) The Fono, HealthWest, CNSST, The Asian Network GP, maternity services, community group or selfreferral Pregnant Māori, Pacific, Asian and South Asian women with children aged 0-4yrs and their families Programme (2hrs/week for 6 weeks) focused on providing Pacific mothers with advice and support for raising healthy, safe and happy children. Activities include: learning to cook healthy and affordable Pacific meals, learning about gardening and group exercise classes. Additional workshops, post-natal activity sessions and information about Pacific community events provided. es-fees/communityservices/healthy-babieshealthy-futuresprogramme/ 4.2 FoodStorm North Shore and Northcote: Karl & Kay Reyes (Regional Managers): karlkay@skids.co.nz; West Auckland: Lisa Walker (Regional Manager): west@skids.co.nz; Epsom and Tamaki: Faieka Abrahams: faieka@skids.co.nz; skids (Safe Kids in Daily Supervision) skids centres self-refer Primary school aged children who attend skids centres Programme run from skids before/after school care centres teaches children the fundamentals of healthy eating and cooking. Children learn to cook 12 essential recipes which have been developed to meet Heart Foundation guidelines. odstorm/

133 Initiative Contact Organisation Referrer Target Group Objectives / Targets Website Greater Auckland Aquatic Action Plan (GAAAP) Andrew Tara (Project Manager); andrew.tara@aktive.org.n z; Aktive- Auckland Sport & Rec, Water Safety NZ Self-referral Primary school aged children 7-10 years, decile 1-6 schools Collaboration project that coordinates professionally delivered swimming lessons to primary school children. Children receive 8-10 free swim and survive lessons. People/Greater-Auckland- Aquatic-Action-Plan- GAAAP. 4.2 PlayBall Get Set Go Kai Auckland Adam Brunt (Manager): manager@playball.co.nz; Stephanie Cunningham (Manager): stephanie@athletics.org.n z; Cissy Rock; Kaiauckland@gmail.com PlayBall New Zealand Self-referral Children aged 3 months - 9 years Athletics NZ Self-referral School children aged 4-7 years Kai Auckland Self-referral Children all ages, who are overweight/obese, and their families The main objectives are to improve basic movement, development and refining sport skills and techniques. Classes are held at ECEs, schools and community venues. The objective of the programme is to teach children the fundamental movement and co-ordination skills required for any sport in a way that is structured and fun, for both children and adults. Get Set Go is also designed to provide teachers and coaches with the knowledge and skills they need to incorporate this into their lesson planning and coaching. "People's food movement' offers a cohesive approach to creating connection an nourishment through food. Focuses on reducing systemic poverty, child hunger and social isolation, strengthening individual and community food security and increasing opportunities for volunteering in Auckland communities. Works in partnership with existing initiatives to influence the school setting and create a 'food movement'. /home nz/get-involved/as-a- School/Get-Set-Go

134 Initiative Contact Organisation Referrer Target Group Objectives / Targets Website Healthy Schools GetWize2Hea lth (Diabetes Projects Trust) Angela Tsang (Schools Coordinator): schools@dpt.org,nz; (09) Diabetes Project Trust Self-referral Teachers of secondary school students, and school nurses Programme provides workshop training to teachers, school nurses, and others needing practical tools to help students make better choices around food and PA. Training is curriculum aligned and a comprehensive resource kits are provided. The Trust also supports canteens to improve the nutrition environment for students (e.g. tuckshop) r-programmes/healthyschool

135 Table 8. Stocktake of community physical activity and nutrition activities for children and their families in Waitemata DHB December Initiative Contact Organisation Referrer Target Group Objectives / Targets Website Health Promoting Schools (HPS) Fruit in Schools (FiS) Fonterra Milk for Schools Kick Start Breakfast Programme Enviroschools Erica McKenzie (HPS coordinator, Child & Family Service) erica.mckenzie@waitemat adhb.govt.nz; info@unitedfresh.co.nz; (09) Fonterra milk for schools; contact@fonterramilkfors chools.com; Kick.Start.Breakfast@font erra.co.nz Anke Nieschmidt (Programme and Projects Coordinator); anke.nieschmidt@enviros Ministry of Health (MoH) MoH; United Fresh Incorporated Facilitators approach schools or schools selfrefer None Year 1-8, deciles 1-4 schools and year 1-8, deciles 5-10 schools where there are high numbers of Māori, Pasifika or vulnerable groups in the school s student roll Primary and intermediate school aged children, decile 1-2 schools Fonterra None Primary school aged children Fonterra in conjunction with Sanitarium Toimata Foundation Self-referral ECEs and schools can self-refer Primary, intermediate and secondary school aged children, decile 1-10 schools Children who attend an ECE centre, primary, intermediate or secondary school. HPS facilitators work with school leaders who provide leadership for their whole school community to identify health and wellbeing priorities for their students, and create and implement an action plan to address these priorities and monitor outcomes. Initiative provides one piece of fresh produce, fruit or vegetable, to school children daily. Initiative provides milk (200ml tetrapack) to children in all primary schools who wish to take part. Programme providing children at school with a breakfast of Weetbix and milk. The objective is to foster a generation of people who instinctively think and act sustainably through connecting with each other, their cultural identity and their land, to create a healthier, peaceful, more o.nz/our-work/fruit-inschools and /our-work/lifestages/child-health/fruitschools-programme orschools.com/ co.nz/

136 Initiative Contact Organisation Referrer Target Group Objectives / Targets Website Life Education Trust Healthy Heart Award Fuelled 4 Life Food for Thought chools.org.nz; (07) ext 30 Vicki Metekingi (Trusts Coordinator): Waitakere@lifeedtrust.org.nz; org.nz/index.php/contactus Sarah Goonan (Food & Beverage Classification System Programme Manager); fuelled4life@heartfoundat ion.org.nz Naomi Sutton (Nutritionist - Upper North Island); Naomi.Sutton@foodstuffs. co.nz; Life Education National Service Centre Heart Foundation (HF) Self-referral None Children at primary and intermediate school Children aged 5 years, who attend an ECE centre. HF None ECEs: Children aged 5 years, who attend an ECE centre. Schools: primary, intermediate and secondary school aged children HF and Foodstuffs Self-referral Primary school aged children (years 5 & 6), HF delivers programme to decile 1-4 schools Foodstuffs nutritionist delivers programme to decile 5-10 schools equitable society. Facilitators provide ECEs and schools with support and suite of resources to help them meet the above objective. The objective is to teach children about health, life, themselves, and other people, with the aim of showing them how to reach their full potential. Teachers go into schools and provide education sessions. Bronze, silver, gold awards for ECEs. Programme assists ECEs to create an environment to promote physical activity and healthy eating to children and their families. Healthier foods recommended for use A nutrition education programme designed to assist the teaching of food and nutrition org.nz/ g.nz/ ht.co.nz/

137 Initiative Contact Organisation Referrer Target Group Objectives / Targets Website Heart Start Award Heart Start Excellence Award Heart Schools Award Travelwise Be Healthy, Be Active Food for Kids (Orchards in Schools) org.nz/index.php/contactus org.nz/index.php/contactus org.nz/index.php/contactus Auckland Transport: Nestle Consumer Services; HF Self-referral Primary school aged children HF HF Auckland Transport All schools with a MoE # can register with HF All schools with a MoE number can register on HF website Primary school aged children Primary school aged children Primary school aged children and the community Nestle Self-referral Intermediate school aged children (10-13 years) and their teachers Kids Can; (09) KidsCan Self-referral Decile 3 and 4 primary schools enrolled in Kids Can partnership Module-based programme for improving environments Module-based programme for improving environments Exceptional school completes initiative for improving nutrition or PA environment. School completes up to 12 modules (minimum 5), including nutrition policy development, food service improvement, PA promotion and nutrition education for students and staff. 3 modules are from Food for Thought programme. Programme focuses on road safety education and fun ways to get to school. Aim: to teach children to be safe and encourage active transport. (Programme includes seasonal cycling programmes and courses for all ages) Programme to raise awareness around good nutrition and active lifestyles for intermediate school aged children. Aligned with the NZ Curriculum for health and physical education. Programme provides food at school for thousands of financially disadvantaged children every day Schools selfrefer active.co.nz/ z/our-work/food-for-kids

138 Initiative Contact Organisation Referrer Target Group Objectives / Targets Website Gardens for Health Garden to Table Maara Kai Nutrition and Dietetic Clinic He Oranga Poutama Richard Main (Programme Manager): gardens@dpt.org.nz; (09) Linda Taylor (Executive officer); (09) Vivienne Campbell (Area Coordinator Northland) tpk.tamakimakaurau@tpk.govt.nz Julia Sekula (Clinical Director) j.sekula@auckland.ac.nz; (09) Wiremu Mato Kaihautu (He Oranga Poutama Manager) wiremu.mato@sportwaita kere.nz; (09) or Diabetes Project Trust Garden to Table Trust Self-referral None Community groups, organisations, workplaces and schools Primary and secondary school aged children Te Puni Kokiri None Māori children who attend: marae, kōhanga reo, kura, schools and Māori communities University of Auckland Sports Waitakere GP/Plunket nurse Self-referral Children aged 4-5 years and their families; 1 full-day clinic per month Maori children who attend: kōhanga reo; kura; primary, intermediate & secondary schools; marae; & Māori sports organisations Programme provides support and advice to community groups or those looking to set up community gardens. School-based programme aimed at assisting children to create a sustainable garden, harvest fruits and vegetables, and cook and share a meal they have produced Provides financial assistance to community groups wanting to set up sustainable community garden projects. small one-off funding grants of up to $2,000 (GST exclusive) are available to help Māori communities. Funding can be used for garden construction, gardening tools and compost, and education on gardening practices Student dietitian (5th year of Masters) provides dietetic assessment and intervention, under the supervision of a NZ Registered Dietitian Initiative developed to increase participation and leadership of Māori in sport and traditional physical activity at community level. Kaiwhakahaere (administrators) encourage and provide support for Māori in different settings to become more active through healthier lifestyles, physical recreation and sport. r-programmes/garden-4- health documents/tpk-maarakai- %20form2016.pdf nd.ac.nz/en/about/ourservices/nutrition-anddietetic-clinic.html e.co.nz/programmes- Resources/He-Oranga- Poutama/Key-Settings

139 Initiative Contact Organisation Referrer Target Group Objectives / Targets Website Cycle West Kids Club Green Prescription Active Families Green Prescription Active Teens Rebecca Andrell (Acting Kids Club Coordinator); (09) Active Families Coordinator: Active Families Co-ordinator: /our-work/preventativehealth-wellness/physicalactivity/greenprescriptions/activefamilies-contacts Liz Golding; grx@harboursport.co.nz; (09) Sport Waitakere Harbour Sport Harbour Sport Self-referral GP/Health Professional or self-referral GP/Health Professional or self-referral Pre-school aged children Children aged 5-12 years, who are: overweight/obese; inactive (<5 hours/week), have a stable medical/mental condition that could benefit from PA, and family ready to make lifestyle changes Children aged years, who are: overweight/obese; inactive (<5 hours/week), have a stable medical /mental condition that could benefit from PA The objective is to increase the number of residents choosing to cycle for sport, recreation or transport, and to introduce children to cycling whilst developing and strengthening their crucial gross motor skills. Children bring their bike and helmet to a community space and are taught how to ride and bike skills. Activities are appropriate for all levels of biking. Children referred by a health professional to attend. Group activity sessions with family. Sessions include physical activity, goal setting and review, advice on nutrition, health and well-being, parenting skills and building skills and confidence for sport. Child's progress is monitored. Families receive home visits to get support on nutrition knowledge, activity time, screen time and BMI for the child. Main aim: weight loss and change in body measurements. Group activity sessions 1x/week for 10-weeks in Warkworth, including boxing, weight training and cardio sessions. Focus is on activity, nutrition and personal accountability. Monitoring of nutrition and activity achievements. e.co.nz/programmes- Resources/Get- Active/Cycle-West co.nz/harboursport/active-families/ co.nz/harboursport/active-teens/

140 Initiative Contact Organisation Referrer Target Group Objectives / Targets Website SportsPasifik Niumovemen t PolySports Equip'd Family Sports and Music Group Alexandria Nicholas (Pacific Island Community Manager); p- isupport@harboursport.co.nz) Pat Green (Pacific Community Advisor); (09) ; patg@harboursport.co.nz Alexandria Nicholas (Pacific Island Community Manager); p-isupport@ harboursport.co.nz) Alexandria Nicholas (Pacific Island Community Manager); p-isupport@ harboursport.co.nz) Gloria Gao (Service Manager and Social Worker); Gloria.Gao@cnsst.org.nz Harbour Sport Self-referral Pacific females aged 12 years Harbour Sport Self-referral Pacific children aged 1-12 years and their familes Harbour Sport Self-referral Pacific children aged 1-12 years Harbour Sport Self-referral Pacific females aged years Chinese New Settlers Services Trust (CNSST) Self-referral or community group referral Low income chinese families SportsPasifik is a package of Pacific wellbeing programmes that includes family fitness classes and support of Pacific churches in weight loss and improving nutrition. 20-week healthy lifestyles programme aims to provide PA sessions for the whole family; nutrition and PA education, cooking demonstrations, cooking classes and fun games provided A free holiday programme aimed at increasing PA and healthy food messages through fun games and activities. 18-week programme aims to improve sports skills, fitness, confidence and self esteem through sports and fitness, nutrition sessions and mentoring Family sport and music activities for low income families with young children. co.nz/harboursport/sportspasifik/ co.nz/harboursport/sportspasifik/ co.nz/harboursport/sportspasifik/ co.nz/harboursport/sportspasifik/ govt.nz/story/chinesenew-settlers-services-trust 4.2 Walking for my Health Healthy Babies, Healthy Rawiri Residents Association: (09) Pacific: Maria Kumitau (Programme Coordinator); maria.kumitau@thefono.o rg.nz; Rawiri Residents Association The Fono, HealthWest, CNSST, The Asian Network Self-referral GP, community group, maternity Children (age not specified) Pregnant Māori, Pacific, Asian and South Asian women with children aged A weekly walking group for mums, dads and children. The walking group aims to bring the community together, increase neighbourhood knowledge and reduce barriers to accessing health services. A text message-based programme providing information on healthy eating and being active for pregnant women and new mothers None available es-fees/community- services/healthy-babies

141 Initiative Contact Organisation Referrer Target Group Objectives / Targets Website Futures TextMATCH Healthy Babies, Healthy Futures Vegetable Garden Project Māori: Danielle Tahuri; danielle.tahuri@healthwe st.co.nz; Asian: Fangfang Chen; fangfangchen@cnsst.org.n z South Asian: Anjileena; Anjileen@asiannetwork.or g.nz Pacific: Maria Kumitau (Programme Coordinator); maria.kumitau@thefono.o rg.nz; Māori: Danielle Tahuri; Danielle.tahuri@healthwe st.co.nz; Asian: Fangfang Chen; fangfangchen@cnsst.org.n z or Bushra; Bushra@asiannetwork.org.nz; (09) The Fono (Health and Social Services); (09) The Fono, HealthWest, CNSST, The Asian Network The Fono services or self-referral GP, community group or selfreferral Community group-referral 0-4yrs and their families Pregnant Māori, Pacific, Asian and South Asian women with children aged 0-4yrs and their families Children aged 5 years and their families Community programme (2hrs/week for 6 weeks) focused on promoting healthy eating and being active for pregnant women and new mothers. Participants explore their health goals, needs and barriers through a healthy conversation. Mothers attend a module every week learning: (1) being healthy for your baby, (2) making healthy food choices, (3) practical food preparation of healthy meals, (4) shopping on a budget, (5) reading food labels and (6) keeping active. Activities are fun and include cooking demonstrations, gardening, tai chi, yoga, group discussion, walking groups, quizzes, presentations and guest speakers. A service provided to families to help them establish their own vegetable gardens. Aim: to increase daily vegetable intake for families. healthy-futuresprogramme/ es-fees/communityservices/healthy-babieshealthy-futuresprogramme/ services-fees/communityservices/nutritionprogramme-vegetablegarden-project/

142 Initiative Contact Organisation Referrer Target Group Objectives / Targets Website FoodStorm Get Set Go PlayBall Play.Sport North Shore and Northcote: Karl & Kay Reyes (Regional Managers): karlkay@skids.co.nz West Auckland: Lisa Walker (Regional Manager): west@skids.co.nz Stephanie Cunningham (Get Set Go Manager) Adam Brunt (Manager): manager@playball.co.nz; Jo Colin (Young Person Participation Lead); jo.colin@sportnz.org.nz skids (Safe Kids in Daily Supervision) skids centres self-refer Primary school aged children who attend skids centres Athletics NZ Self-referral School children aged 4-7 years PlayBall New Zealand Sport NZ Self-referral Children aged 3 months - 9 years Primary, intermediate, and secondary school aged children Programme run from skids before/after school care centres teaches children the fundamentals of healthy eating and cooking. Children learn to cook 12 essential recipes which have been developed to meet HF guidelines. The objective of the programme is to teach children the fundamental movement and co-ordination skills required for any sport in a way that is structured and fun, for both children and adults. Get Set Go is also designed to provide teachers and coaches with the knowledge and skills they need to incorporate this into their lesson planning and coaching. The main objectives are to improve basic movement, development and refining sport skills and techniques. Classes are held at ECEs, schools and community venues. The objective is to improve the quality of young people s experiences of play, physical education, PA and sport. Professional development is provided to teachers, schools are given assistance in working with their community to support and deliver play, sport and physical activity opportunities for all students. odstorm/ nz/get-involved/as-a- School/Get-Set-Go /home z/assets/uploads/2016- SportNZ-Play-Sport- Overview.pdf

143 Initiative Contact Organisation Referrer Target Group Objectives / Targets Website Greater Auckland Aquatic Action Plan (GAAAP) Kai Auckland Movement Matters Healthy Families NZ Waitakere Andrew Tara (Project Manager); andrew.tara@aktive.org.n z; Cissy Rock; Kaiauckland@gmail.com Debbie Pigou: debbiep@harboursport.co.nz; (09) Kerry Allan; kerry.allan@sportwaitaker e.nz; Aktive- Auckland Sport & Rec, Water Safety NZ Self-referral Primary school aged children 7-10 years, decile 1-6 schools Kai Auckland Self-referral Children all ages, who are overweight/obese, and their families Harbour Sport Self-referral Early childhood educators MoH GP/Health Professional Children aged 5 years and their families Collaboration project that coordinates professionally delivered swimming lessons to primary school children. Children receive 8-10 free swim and survive lessons. "People's food movement' offers a cohesive and integrated approach to creating connection an nourishment through food. Focuses on reducing systemic poverty, child hunger and social isolation, strengthening individual and community food security and increasing opportunities for volunteering within Auckland communities. Works in partnership with existing initiatives (e.g. Enviro Schools) to to influence the school setting and create a 'food movement'. Five mobilising initiatives include: vitual hub, physical food hubs, community gardens, schools and education and fruit trees. Physical literacy training for early childhood educators. Specific movement pattern skills for under 5s Aims to develop a dedicated health promotion workforce in Waitakere. The workforce will provide encouragement and support to schools, workplaces, parents and families about making healthier choices People/Greater-Auckland- Aquatic-Action-Plan- GAAAP e.co.nz/about-us/healthy- Families-Waitakere-Team

144 Initiative Contact Organisation Referrer Target Group Objectives / Targets Website Sport Waitakere Trust Healthy Schools GetWize2Hea lth (Diabetes Projects Trust) Lynette Adams; lynette.adams@sportwait akere.nz; (09) Angela Tsang (Schools Coordinator): schools@dpt.org,nz; (09) Train-the- Trainer Active Lifestyles Programme Diabetes Project Trust Self-referral Teachers of secondary school students, and school nurses A train-the-trainer initiative using community champions to provide families with regular PA sessions and nutrition support. Programme provides workshop training to teachers, school nurses, and others needing practical tools to help students make better choices around food and PA. Training is curriculum aligned and comprehensive resource kits are provided. The Trust also supports canteens to improve the nutrition environment for students (e.g. tuckshop) e.co.nz/ r-programmes/healthyschool

145 Table 9. Stocktake of community physical activity and nutrition activities for children and their families in CM Health- December Initiative Contact Organisation Referrer Target Group Objectives / Targets Be Healthy, Be Active Fonterra Milk for Schools Nestle Consumer Services; Fonterra milk for schools; contact@fonterramilkfors chools.com; Nestle Self-referral Intermediate school aged children (10-13 years) and their teachers Fonterra None Primary school aged children Programme to raise awareness around good nutrition and active lifestyles for intermediate school aged children. Aligned with the NZ Curriculum for health and physical education. Initiative provides milk (200ml tetrapack) to children in all primary schools who wish to take part. Food for Kids (and Orchards in Schools) Food for Thought Kids Can; (09) KidsCan Self-referral Food for Kids Decile 1-2 schools. Unable to get numbers of schools easily from Kids Can but prescence in CM Health School Orchards Decile 3 and 4 primary schools enrolled in Kids Can partnership ( only one school Papatoetoe High) Naomi Sutton (Nutritionist - Upper North Island); Naomi.Sutton@foodstuffs. co.nz; HF and Foodstuffs Self-referral Primary school aged children (years 5 & 6), HF delivers programme to decile 1-4 schools Programme provides food at school for thousands of financially disadvantaged children every day. A nutrition education programme designed to assist the teaching of food and nutrition

146 Initiative Contact Organisation Referrer Target Group Objectives / Targets FoodStorm Fruit in Schools (FiS) Fuelled 4 Life Garden to Table Gardens4Health info@unitedfresh.co.nz; (09) Sarah Goonan (Food & Beverage Classification System Programme Manager); fuelled4life@heartfoundat ion.org.nz Linda Taylor (Executive officer); (09) Vivienne Campbell (Area Coordinator Northland) Richard Main (Programme Manager): skids (Safe Kids in Daily Supervision) MoH; United Fresh Incorporated skids centres selfrefer None Foodstuffs nutritionist delivers programme to decile 5-10 schools Primary school aged children who attend skids centres Primary and intermediate school aged children, decile 1-2 schools HF None ECEs: Children aged 5 years, who attend an ECE centre. Schools: primary, intermediate and secondary school aged children Garden to Table Trust Diabetes Project Trust None Self-referral Primary and secondary school aged children. Currently 8 schools in CM Health Community groups, organisations, Programme run from skids before/after school care centres teaches children the fundamentals of healthy eating and cooking. Children learn to cook 12 essential recipes which have been developed to meet Heart Foundation guidelines. Initiative provides one piece of fresh produce, fruit or vegetable, to school children daily. Healthier foods recommended for use School-based programme aimed at assisting school children to create a sustainable garden, harvest fruit and vegetables, and cook and share a meal they have produced Programme provides support and advice to community groups or those looking to set up community gardens

147 Initiative Contact Organisation Referrer Target Group Objectives / Targets gardens@dpt.org.nz; (09) workplaces and schools 4.2 Greater Auckland Aquatic Action Plan (GAAAP) Health Promoting Schools (HPS) Healthy Heart Award Andrew Tara (Project Manager); andrew.tara@aktive.org.n z; CM Health: Venera Ukmata (Operations Manager) Vnera.Ukmata@middlemo re.co.nz Kay Lawrie (Service Manager) Kay Lawrie kay.lawrie@middlemore.c o.nz org.nz/index.php/contactus Aktive- Auckland Sport & Recreation in partnership with Water Safety NZ Ministry of Health (MoH) Heart Foundation (HF) Self-rererral Facilitators approach schools or schools selfrefer None Primary school aged children 7-10 years, decile 1-6 schools Decile 1-4 schools (Year 1-8 schools) and schools with high Māori /Pacifika population (Year 1-8 schools) Children aged 5 years, who attend an ECE centre. Collaboration project that coordinates professionally delivered swimming lessons to primary school children. Children receive 8-10 free swim and survive lessons. HPS facilitators work with school leaders who provide leadership for their whole school community to identify health and wellbeing priorities for their students, and create and implement an action plan to address these priorities and monitor outcomes. Bronze, silver, gold awards for ECEs. Programme assists ECEs to create an environment to promote physical activity and healthy eating to children and their families

148 Initiative Contact Organisation Referrer Target Group Objectives / Targets Healthy Schools (GetWize2Health) (Diabetes Projects Trust) Heart Schools Award (schools) Angela Tsang (Schools Coordinator): schools@dpt.org,nz; (09) org.nz/index.php/contactus Diabetes Project Trust HF Self-referral All schools with a MoE number can register on HF website Teachers of secondary school students, and school nurses Primary school aged children Programme provides onsite group or offsite workshop training to teachers, school nurses, and others needing practical tools to help students make better choices around food and activities. Training is curriculum aligned and a comprehensive resource kit is provided to enable the delivery of a multi-part programme to year 9 students. Advice and support for making changes to the environment, including the Tuckshop, is available. Ongoing visits and telephone support provided. Exceptional school completes initiative for improving nutrition or PA environment 4.2 Heart Start Award (ECEs) org.nz/index.php/contactus HF Self-referral ECEs: Children aged 5 years, who attend an ECE centre. Module-based programme for improving environments Heart Start Excellence Award org.nz/index.php/contactus HF All schools with a MoE number can register on HF website Primary school aged children Module-based programme for improving environments

149 Initiative Contact Organisation Referrer Target Group Objectives / Targets Kai Auckland Kick Start Breakfast Programme Marae Food Gardens Project Cissy Rock; Kaiauckland@gmail.com Kick.Start.Breakfast@font erra.co.nz Kai Auckland Self-referral Children all ages, who are overweight/obese, and their families Fonterra in conjunction with Sanitarium Self-referral None Primary, intermediate and secondary school aged children, decile 1-10 schools Ormiston Primary and others around Auckland "People's food movement offers a cohesive and integrated approach to creating connection and nourishment through food. Focuses on reducing systemic poverty, child hunger and social isolation, strengthening individual and community food security and increasing opportunities for volunteering within Auckland communities. Works in partnership with existing initiatives (e.g. Enviro Schools) to influence the school setting and create a 'food movement'. Five mobilising initiatives include: vitual hub, physical food hubs, community gardens, schools and education and fruit trees. Programme providing children at school with a breakfast of Weetbix and milk. A research team worked with eight urban marae in Tāmaki Makaurau, conducting interviews with representatives involved in various aspects of the gardens. An analysis was undertaken to explore participants motivations for involvement in marae gardens and the multidimensional outcomes of the activity. Particular emphasis on the importance of locational context to indigenous participation in health promotion

150 Initiative Contact Organisation Referrer Target Group Objectives / Targets Taubale/CiCi/Qit o Me Bula (Walk/Play To Live) Travelwise Active Tots Faith City Fitness Healthy Lifestyles Programme Health Promotion Agency (Active Healthy Strong Community Partnerships) Auckland Transport: Brewster Leisure centre Phone: allanbrewsterleisure@auc klandcouncil.govt.nz Drodrolagi Health Trust Auckland Transport Brewster Leisure centre/auckla nd council Faith City Church Mangere Budgeting Services Trust Self-referral Schools self-refer Families in Pacific communities Primary school aged children and the community Family sports days for the Pacific community with PA games and competitions for all ages and activity levels. Sports days help to encourage families to maintain PA as a family. Programme focuses on road safety education and fun ways to get to school. Aim: to teach children to be safe and encourage active transport. (Programme includes seasonal cycling programmes and courses for all ages) Self-referral 2-5 year olds Enhance children's physical and social development with fun introduction to sports 2-5 year olds Although centred around physical activity, this programme also looks at other aspects of life and the influences on health and fitness. A community fitness initiative where all are welcome and don t have to be part of the church. Programme with a specific focus on financial literacy and how to budget in a healthy lifestyle with free supermarket tours, cooking classes and nutritional advice. Funded by CM HEALTH

151 HOPE Initiative Contact Organisation Referrer Target Group Objectives / Targets reception@diabetesauckla nd.org.nz Diabetes New Zealand HOPE (Healthy Options = positive eating) is a family / whānau centred health promotion programme delivered in community settings over four sessions 4.2 Keeping Kidz Active Raise Up South Asian Health Promotion Programme Steps for Life Brewster Leisure centre Phone: allanbrewsterleisure@auc klandcouncil.govt.nz Brewster Leisure centre Phone: allanbrewsterleisure@auc klandcouncil.govt.nz ProCare info@stepsforlife.co.nz; (09) Brewster Leisure centre/auckla nd council Brewster Leisure centre/auckla nd council Monty Betham Steps For Life Foundation Self-referral Youth Overweight secondary school aged children and their families programme designed to keep kids active. Includes a variety of exercise, games, sports and guided nutritional plan to ensure your child maintains a healthy lifestyle youth drop in baseketball, table tennis, squash A South Asian Physical Activity Leader is contracted, in partnership with East Health, to facilitate healthy eating education sessions in a variety of South Asian languages for the Manukau comnity. Programme (5-6hrs/week for 12 weeks) focuses on physical health, healthy food, mind health and healthy family. Includes physical activity sessions, nutrition advice and guided supermarket tour

152 Appendix 3: Population demography and Obesity data 4.2 Table 1. Four year old children identified with obesity (BMI 98th percentile) at B4SC 01 January December 2016 by ethnicity WDHB Number Percentage of ethnic group that had B4SC ADHB Number Percentage of ethnic group that had B4SC CM Health Number Percentage of ethnic group that had B4SC Māori % % % Pacific % % % Asian % % % Other % % % Total % % % Table 2. Four year old children identified with obesity (BMI 98th percentile) at B4SC 01 January December 2016 by socio-economic deprivation quintile WDHB Number Percentage of ethnic group that had B4SC ADHB Number Percentage of ethnic group that had B4SC CM Health Number Percentage of ethnic group that had B4SC Quintile % % % Quintile % % % Quintile % % % Quintile % % % Quintile % % % Total % % %

153 Table 3. Four year old children identified with overweight or obesity (BMI 91st percentile) at B4SC 01 January December 2016 by ethnicity 4.2 WDHB ADHB CM Health Percentage Percentage of ethnic of ethnic Number Number Number group that group that had B4SC had B4SC Percentage of ethnic group that had B4SC Māori % % % Pacific % % % Asian % % % Other % % % Total % % % Table 4.Four year old children identified with overweight or obesity (BMI 91st percentile) at B4SC 01 January December 2016 by socio-economic deprivation quintile WDHB ADHB CM Health Number Percentage of ethnic group that had B4SC Number Percentage of ethnic group that had B4SC Number Percentage of ethnic group that had B4SC Quintile % % % Quintile % % % Quintile % % % Quintile % % % Quintile % % % Total % % %

154 Appendix 4: Health Equity Campaign Healthy Weight, Healthy Kids Project Name Descriptor Service/Organ isation Weigh While We Wait - Healthy weight gain during pregnancy Healthy Mums, Healthy Babies 4 life Prepare Together Diabetes Care Before Pregnancy Child s play Kidz First ED Screening Braking the cycle Kura Kai Ora Planned Pregnancy: It s a woman s choice To work with one GP practice/lmcs to test promotion of healthy weight gain in pregnancy To test whether a lifestyle intervention for obese pregnant women leads to anticipated changes in diet and physical activity. To develop a best practice approach to deliver group education sessions for women planning pregnancy with diabetes and individualised education and pregnancy planning for women with complex diabetes To co-design with mothers and whānau, the delivery of Fundamental Movement Skills interventions for children from birth to 5 years To develop a brief screening programme in Kidz First ED/ inpatient to identify obese and overweight children To form a bike club for 5-14 year olds to increase physical activity To co-design key messages with Māori and Pacific children (& Toi Tangata and Pacific heartbeat) to develop a toolkit of health promotion messages for schools To reduce childhood obesity by facilitating improved preconception care and maternal weight through planned pregnancy and maternal messaging. Dawson Road GP (ETHC), CM Health CM Health CM Health Counties Manukau Sport CM Health Otara Health NHC - Mana Kidz CM Health Project Team Lead Sue Tutty Deirdre Nielsen Lesley Maclennan / Elaine Chong Russell Preston / Sheryl Law Teuila Percival John Coffey Alicia Berghan Sue Tutty

155 Appendix 5: Monitoring and Evaluation Monitoring and evaluation is critical to any new programme or activity. It allows us to assess whether we have delivered on the goals, aims and objectives of the programme, whether we have achieved the desired outcome and to assess the relative contribution of different components or processes. The goals of obesity prevention and treatment at an individual level will be different to the goals for the heath sector when considering the population as a whole. The distinctions have been captured by the Institute of Medicine and supported by the findings of the WHO Commission on Ending Childhood Obesity see table below. 4.2 Goals of obesity prevention and treatment in children and adolescents Source: adapted from Institute of Medicine, USA, 2012 (64) Individual Children and adolescents Population of children and adolescents A healthy weight trajectory A healthy diet (quality and quantity) Appropriate amounts and types of physical activity Achievement of physical, psychosocial and cognitive growth and developmental goals A healthy body image and the absence of potentially-adverse weight concern or restrictive eating behaviours For those affected by obesity, a reduction in level of overweight, improvement in obesity-associated comorbidities, and improvement in risk factors for excess weight gain Reduction in the incidence of childhood and adolescent obesity Reduction in the prevalence of childhood and adolescent obesity Reduction of mean population BMI levels Improvement in the proportion of children and adolescents meeting dietary guidelines Improvement in the proportion of children and adolescents meeting physical activity recommendations Reduction in health-care costs associated with obesity in children and adolescents Achievement of physical, psychological and cognitive growth and developmental goals In this area, where evidence is limited, there is a particular need for robust monitoring and evaluation. Programmes should be able to demonstrate improvements in weight outcomes and/or clearly identified surrogate measures of the pathway to unhealthy weight, such as sugar-sweetened beverage consumption, and physical activity levels. Other process measures may be useful such as the utilisation of the Auckland Regional Health Pathway (ARHP). Within individual programmes instituted as part of the Childhood Healthy Weight Action Plan it is expected that monitoring and evaluation plans will be developed and clear linkages back to this plan articulated. Programmes should ensure data is collected including anthropometric measures that will describe a child s weight trajectory over the course of the programme, as well as measuring physical activity and diet and any comorbid disease. Alongside these

156 measures it will be important to assess for possible detrimental effects including assessing psychosocial wellbeing indices. 4.2 These different goals will lead to the institution of different targets and different measures for programmes and for measuring the collective impact of the Metro Auckland Healthy Weight Action Plan. Obesity should be situated within the wider context of healthy lifestyles across the life course and consequently it will be important to identify related goals in maternal health and wellbeing

157 References 1. Organisation for Economic Cooperation and Devleopment (OECD). Obesity Update In: (OECD) OfECaD, editor.; Health Mo New Zealand Health Survey: DHB results for children. Data tables. In; Ministry of Health. Childhood obesity plan. In; Flynn J. The changing face of pediatric hypertension in the era of the childhood obesity epidemic. Pediatr Nephrol 2013;28(7): Pot M, Sadler L. National Women s Annual Clinical Report In: Board ADH, editor.; Healthy Auckland Together. The Healthy Auckland Together Plan In; Simpson J, Oben G, Craig E, Adams J, Wicken A, Duncanson M, et al. The Determinants of Health for Children and Young People in the Northern District Health Boards. Dunedin: University of Otago; McKinsey Global Institute. Overcoming obesity: an initial economic analysis: The McKinsey Global Institute World Health Organization. Report of the commission on ending childhood obesity. In. Geneva; Lee YS. Consequences of childhood obesity. Ann Acad Med Singapore 2009;38(1): Singh AS, Mulder C, Twisk JW, van Mechelen W, Chinapaw MJ. Tracking of childhood overweight into adulthood: a systematic review of the literature. Obes Rev 2008;9(5): World Health Organisation. Population-based Approaches to Childhood Obesity Prevention. In; Nader PR, O'Brien M, Houts R, Bradley R, Belsky J, Crosnoe R, et al. Identifying risk for obesity in early childhood. Pediatrics 2006;118(3):e Ministry of Health. New Zealand Health Strategy: Future Direction; Kelsey MM, Zaepfel A, Bjornstad P, Nadeau KJ. Age-related consequences of childhood obesity. Gerontology 2014;60(3): Ministry of Health. Health Loss in New Zealand: A report from the New Zealand Burden of Diseases, Injuries and Risk Factors Study, In: Health Mo, editor. Wellington; The ad hoc working group on science and evidence for ending childhood obesity. Consideration of the evidence on childhood obesity for the Commission on Ending Childhood Obesity: report of the ad hoc working group on science and evidence for ending childhood obesity. In. Geneva, Switzerland. : World Health Organisation; Jones CP, Jones CY, Perry GS, Barclay G, Jones CA. Addressing the social determinants of children's health: a cliff analogy. Journal of Health Care for the Poor and Underserved 2009;20(4A): Swinburn B, Sacks G, Hall K, McPherson K, Finegood D, Moodie M, et al. The global obesity pandemic: shaped by global drivers and local environments. Lancet 2011;378(9793): Excellence. NIfHaC. Weight management: lifestyle services for overweight and obese children and young people.. In; Wood A, Johnson M. Green Prescriptons Active Families Survey report. In; Hawkes C, Smith TG, Jewell J, Wardle J, Hammond RA, Friel S, et al. Smart food policies for obesity prevention. The Lancet Huang TT, Cawley JH, Ashe M, Costa SA, Frerichs LM, Zwicker L, et al. Mobilisation of public support for policy actions to prevent obesity. The Lancet

158 24. World Health Organization. Global strategy on occupational health for all: The way to health at work. Geneva, Switzerland: World Health Organization; Weng SF, Redsell SA, Swift JA, Yang M, Glazebrook CP. Systematic review and metaanalyses of risk factors for childhood overweight identifiable during infancy. Archives of disease in childhood 2012;97(12): Hanson MA, Gluckman PD. Early developmental conditioning of later health and disease: physiology or pathophysiology? Physiol Rev 2014;94(4): Arenz S, Rückerl R, Koletzko B, von Kries R. Breast-feeding and childhood obesity a systematic review. International journal of obesity 2004;28(10): Dewey KG. Is breastfeeding protective against child obesity? Journal of Human Lactation 2003;19(1): Harder T, Bergmann R, Kallischnigg G, Plagemann A. Duration of breastfeeding and risk of overweight: a meta-analysis. American journal of epidemiology 2005;162(5): Owen CG, Martin RM, Whincup PH, Davey-Smith G, Gillman MW, Cook DG. The effect of breastfeeding on mean body mass index throughout life: a quantitative review of published and unpublished observational evidence. The American journal of clinical nutrition 2005;82(6): Weng SF, Redsell SA, Swift JA, Yang M, Glazebrook CP. Systematic review and metaanalyses of risk factors for childhood overweight identifiable during infancy. Arch Dis Child 2012;97(12): Gerritsen S, Wall C, Morton S. Child-care nutrition environments: results from a survey of policy and practice in New Zealand early childhood education services. Public Health Nutrition 2016;19(9): Oteng-Ntim E, Varma R, Croker H, Poston L, Doyle P. Lifestyle interventions for overweight and obese pregnant women to improve pregnancy outcome: systematic review and meta-analysis. BMC medicine 2012;10(1): Streuling I, Beyerlein A, von Kries R. Can gestational weight gain be modified by increasing physical activity and diet counseling? A meta-analysis of interventional trials. The American journal of clinical nutrition 2010:ajcn Thangaratinam S, Rogozińska E, Jolly K, Glinkowski S, Roseboom T, Tomlinson J, et al. Effects of interventions in pregnancy on maternal weight and obstetric outcomes: meta-analysis of randomised evidence. BMJ 2012; Nascimento SL, Surita FG, Cecatti JG. Physical exercise during pregnancy: a systematic review. Current Opinion in Obstetrics and Gynecology 2012;24(6): Kramer MS, Matush L, Vanilovich I, Platt RW, Bogdanovich N, Sevkovskaya Z, et al. Effects of prolonged and exclusive breastfeeding on child height, weight, adiposity, and blood pressure at age 6.5 y: evidence from a large randomized trial. Am J Clin Nutr 2007;86(6): Sinha B, Chowdhury R, Sankar MJ, Martines J, Taneja S, Mazumder S, et al. Interventions to improve breastfeeding outcomes: a systematic review and meta analysis. Acta Paediatrica 2015;104(S467): Haroon S, Das JK, Salam RA, Imdad A, Bhutta ZA. Breastfeeding promotion interventions and breastfeeding practices: a systematic review. BMC Public Health 2013;13 Suppl 3:S Skouteris H, Nagle C, Fowler M, Kent B, Sahota P, Morris H. Interventions designed to promote exclusive breastfeeding in high-income countries: a systematic review. Breastfeed Med 2014;9(3): Ingram L, MacArthur C, Khan K, Deeks JJ, Jolly K. Effect of antenatal peer support on breastfeeding initiation: a systematic review. Cmaj 2010;182(16):

159 42. Jolly K, Ingram L, Khan KS, Deeks JJ, Freemantle N, MacArthur C. Systematic review of peer support for breastfeeding continuation: metaregression analysis of the effect of setting, intensity, and timing. Bmj 2012;344:d Education Counts. ECE Directory. In: Counts E, editor Education Counts. Schools Directory. In: Counts E, editor Healthy Auckland Together. Annual Monitoring Report Baseline data; Gerritsen S, Morton S, Wall C. Physical Activity and Screen use Policy and Practices in Childcare: Results from a Survey of Early Childhood Education Services in New Zealand. Australian and New Zealand Journal of Public Health, 2016;40(4): Gluckman P, Nishtar S, Armstrong T. Ending childhood obesity: a multidimensional challenge. The Lancet;385(9973): Gerritsen S, Dean B, Morton S, Wall C. Do childcare menus meet nutrition guidelines? Quantity, variety and quality of food provided in New Zealand Early Childhood Education services Australian and New Zealand Journal of Public Health 2017;41(4): Ministry of Education. Promoting healthy lifestyles? In Ministry of Education. Food and nutrition for healthy, confident kids The University of Auckland. Benchmarking Food Environments 2017: Progress by the New Zealand Government on implementing recommended food environment policies and priority recommendations, Auckland: The University of Auckland; Waters E, de Silva Sanigorski A, Hall B, Brown T, Campbell K, Gao Y, et al. Interventions for preventing obesity in children (review). Cochrane collaboration 2011(12): Lobstein T, Jackson-Leach R, Moodie ML, Hall KD, Gortmaker SL, Swinburn BA, et al. Child and adolescent obesity: part of a bigger picture. The Lancet Laws R, Campbell KJ, van der Pligt P, Russell G, Ball K, Lynch J, et al. The impact of interventions to prevent obesity or improve obesity related behaviours in children (0 5 years) from socioeconomically disadvantaged and/or indigenous families: a systematic review. BMC Public Health 2014;14(1): Bleich SN, Segal J, Wu Y, Wilson R, Wang Y. Systematic review of community-based childhood obesity prevention studies. Pediatrics 2013;132(1):e Colquitt JL, Loveman E, O'Malley C, Azevedo LB, Mead E, Al-Khudairy L, et al. Diet, physical activity, and behavioural interventions for the treatment of overweight or obesity in preschool children up to the age of 6 years. Cochrane Database of Systematic Reviews 2016(3). 57. Oude Luttikhuis H, Baur L, Jansen H, Shrewsbury VA, O'Malley C, Stolk RP, et al. Interventions for treating obesity in children. Cochrane Database of Systematic Reviews 2009(1). 58. Ho M, Garnett SP, Baur L, Burrows T, Stewart L, Neve M, et al. Effectiveness of Lifestyle Interventions in Child Obesity: Systematic Review With Meta-analysis. Pediatrics 2012;130(6):e1647-e Obesity: Preventing and Managing the Global Epidemic: Report of the World Health Organization. Geneva: WHO;

160 60. Anderson YC, Cave TL, Cunningham VJ, Pereira NM, Woolerton DM, Grant CC, et al. Effectiveness of current interventions in obese New Zealand children and adolescents. Obesity Research & Clinical Practice 2014(8): Broccoli S, Davoli AM, Bonvicini L, Fabbri A, Ferrari E, Montagna G, et al. Motivational Interviewing to Treat Overweight Children: 24-Month Follow-Up of a Randomized Controlled Trial. Pediatrics 2016:peds Loveman E, Al-Khudairy L, Johnson RE, Robertson W, Colquitt JL, Mead EL, et al. Parentonly interventions for childhood overweight or obesity in children aged 5 to 11 years. Cochrane Database of Systematic Reviews 2015(12). 63. Ells LJ, Mead E, Atkinson G, Corpeleijn E, Roberts K, Viner R, et al. Surgery for the treatment of obesity in children and adolescents. Cochrane Database of Systematic Reviews 2015(6). 64. Committee on Accelerating Progress in Obesity P, Food, Nutrition B, Institute of M. In: Glickman D, Parker L, Sim LJ, Del Valle Cook H, Miller EA, editors. Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation. Washington (DC): National Academies Press (US) Copyright 2012 by the National Academy of Sciences. All rights reserved.;

161 5.1 Planning, Funding and Outcomes Update Recommendation: That the report be received. 5.1 Prepared by: Wendy Bennett (Manager Planning and Health Intelligence), Trish Palmer (Funding and Development Manager Mental Health and Addiction Services), Ruth Bijl (Funding and Development Manager Child, Youth and Women s Health), Tim Wood (Funding and Development Manager Primary Care), Kate Sladden (Funding and Development Manager Health of Older People), Aroha Haggie (Manager Maori Health Gain), Lita Foliaki (Manager Pacific Health Gain), Bruce Levi (Pacific General Manager), Samantha Bennett (Manager Asian Health Gain) and Jane McEntee (General Manager, Auckland Regional Public Health Service) Endorsed by: Dr Debbie Holdsworth (Director Funding) and Dr Karen Bartholomew (Acting Director Health Outcomes) Glossary ARC - Aged Residential Care ARDS - Auckland Regional Dental Service ARLA - Alcohol Regulatory and Licencing Authority ARPHS - Auckland Regional Public Health Service ASH - Ambulatory Sensitive Hospitalisations HAT - Healthy Auckland Together HBHF - Healthy Babies Healthy Futures HCSS - Home and Community Support Services HVAZ - Healthy Village Action Zones MHA - Mental Health and Addictions PHAP - Pacific Health Action Plan PHO - Primary Health Organisation PLAP - Provisional Local Alcohol Policy 1. Executive Summary This report updates the Community and Public Health Advisory Committee (CPHAC) on Auckland and Waitemata DHB s planning and funding activities and areas of priority, since its last meeting on 21 June It is limited to matters not already dealt with by other Board committees or elsewhere on this meeting s agenda. Highlights The Hospices of Auckland have formed an alliance to develop and implement a regional palliative outcomes initiative. This will better meet the needs of patients with life limiting illnesses who would benefit from the community based palliative care services provided through general practices and Aged Residential Care facilities. Both Auckland and Waitemata DHBs have successfully achieved the primary care Better Help for Smokers to Quit and More Heart and Diabetes Checks health target in Q4, 2016/17, The Raising Healthy Kids target continues to be exceeded and the Immunisation target was achieved for Auckland DHB. During Q4 2016/17, all PHOs were able to report their practice level data except for Auckland PHO (two practices) and Alliance Health Plus (one practice) against the Diabetes and Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 161

162 Cardiovascular disease (CVD) clinical indicators to the Metro Auckland Clinical Governance Forum. All care and support workers in the aged care workforce started receiving their new pay rates under the Pay Equity Settlement on 1 July This was a significant undertaking for the Ministry, DHBs and Providers to ensure all components were in place for the 1 July start date. A regional Pacific Health Science Academy camp was held on July 18 and 19 at Te Mahurehure Marae, as part of the Ministry of Health Workforce pipeline activities to increase the Pacific workforce. 40 year 13 students from Waitakere College, Onehunga High School, Tangaroa College and Wesley College participated in this programme, which included focus on: o o o o o Resilience Health professional rotations Tertiary essentials, delivered by AUT, Auckland and Massey Universities, Unitec and MIT Physical challenges Study and time management. Two Health Excellent finalists were from Pacific Health Projects: o o Malcolm Andrews, Health Science Acadamies presentation. Athena Tapu and Linda Taberner, Pacific Best Practice training presentation Planning 2.1 Annual Plans Each Board met earlier this month to discuss 2017/18 budgets and financial plans. Consequently, financial information is now being developed for inclusion in the 2017/18 Annual Plans for both DHBs. Once finalised, both Plans and the Northern Regional Health Plan will be submitted to the Ministry of Health. 2.2 System Level Measure Improvement Plans The Metro-region 2017/18 System Level Measures (SLM) Improvement was finalised and submitted to the MoH for review. It has also been presented as information to each of the August Boards. Reporting is under development in both static format and using a dynamic web-based tool. 2.3 Auckland and Waitemata DHB Quarterly Performance Scorecard The Auckland and Waitemata DHB Scorecard is a standardised tool used by both DHBs to internally review and track performance against a range of measures including National Health Targets. The Scorecard shows for each measure the actual performance of both DHBs for Quarter four of the 2016/17 year. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 162

163 Health Targets - Auckland DHB Auckland and Waitemata DHB Quarterly Performance Scorecard CPHAC Outcome Scorecard June /17 Health Targets - Waitemata DHB Actual Target Trend Actual Target Trend a. Better help for smokers to quit - primary care 92% 90% a. p Better help for smokers to quit - primary care 90% 90% p 5.1 Increased immunisation (8-month old) Increased immunisation (8-month old) Total 95% 95% p Total 92% 95% Maori 88% 95% q Maori 84% 95% Pacific 95% 95% p Pacific 95% 95% p Asian 98% 95% p Asian 97% 95% Other 94% 95% q Other 92% 95% Raising Healthy kids Raising Healthy kids Total 100% 80% p Total 100% 80% Maori 100% 80% Maori 100% 80% Pacific 100% 80% Pacific 100% 80% Asian 100% 80% p Asian 100% 80% Other 100% 80% p Other 100% 80% Child, Youth and Women - Auckland DHB Child, Youth and Women - Waitemata DHB Actual Target Trend Actual Target Trend b. b. Rheumatic Fever rate Rheumatic Fever rate Total q Total q Māori q Māori q Pacific q Pacific q Other q Other q Oral Health - % utilisation by 2 years Oral Health - % utilisation by 2 years Total 54% 75% p Total 63% 75% Māori 28% 75% Māori 38% 75% p Pacific 47% 75% p Pacific 41% 75% p Asian 69% 75% p Asian 69% 75% q Other 56% 75% p Other 74% 75% Cervical Screening Cervical Screening Total 69% 80% q Total 74% 80% q Maori 55% 80% Maori 59% 80% Pacific 71% 80% q Pacific 73% 80% Asian 56% 80% q Asian 69% 80% p Other 75% 80% q Other 76% 80% q Primary Care - Auckland DHB Primary Care - Waitemata DHB Actual Target Trend Actual Target Trend PHO enrolment PHO enrolment Total 84% 95% Total 92% 95% Māori 76% 95% Māori 81% 95% Pacific 106% 95% Pacific 100% 95% Asian 69% 95% Asian 85% 95% p Other 91% 95% Other 95% 95% q b. b. Diabetes management Diabetes management Total 55% 61% Total 30% 69% Māori 64% 61% Māori 35% 69% Pacific 59% 61% Pacific 31% 69% Other 53% 61% Other 29% 69% Health of Older People - Auckland DHB Health of Older People - Waitemata DHB c. Actual Target Trend Actual Target Trend HBSS clients with Clinical interrai in last 2 yr 93% 75% q c. HBSS clients with Clinical interrai in last 2 yr 78% 75% q ARC residents LTCF interrai w/in 230 days of previous 87% 75% p ARC residents LTCF interrai w/in 230 days of previous 82% 75% p ARC residents HC interrais prior to LTCF interrai 86% 98% q ARC residents HC interrais prior to LTCF interrai 77% 98% q How to read Performance indicators: Trend indicators: Achieved/ On track Substantially Achieved but off target p Performance improved compared to previous month Not Achieved but progress made Not Achieved/ Off track q Performance declined compared to previous month Performance was maintained Key notes 1. Most Actuals and targets are reported for the reported month/quarter (see scorecard header). 2. Actuals and targets in grey bold italics are for the most recent reporting period available where data is missing or delayed. 3. Trend lines represent the data available for the latest 12-months period. All trend lines use auto-adjusted scales: the vertical scale is adjusted to the data minimum-maximum range being represented. Small data range may result small variations perceived to be large. a. Source MOH quarterly report. b. December 2016 c. March 2017 A question? Contact: Victoria Child - Reporting Analyst, Planning & Health Intelligence Team: victoria.child@waitematadhb.govt.nz Planning, Funding and Health Outcomes, Waitemata DHB 3. Primary Care 3.1 Regional Palliative Outcomes initiative, Hospices of Auckland Background In May 2015, the MoH funded hospices across the country to develop new initiatives to improve access to community based palliative care services for people with life limiting illnesses ($3.1 million during 2015/16 and $7.0 million per annum between 1 July 2016 and 30 June 2019). The Hospices of Auckland have been working in collaboration as an alliance to develop a new regional Palliative Outcomes Initiative across the Auckland region. The Hospices of Auckland includes: Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 163

164 Franklin Hospice Hospice West Auckland Mercy Hospice Auckland North Shore Hospice Hibiscus Hospice Totara Hospice South Auckland. 5.1 The Palliative Outcomes Initiative was developed in November 2016 in consultation with the key stakeholders from DHBs, aged residential care (ARC) and primary care. The purpose of this initiative is to support primary care and ARC providers in the Auckland region to better meet palliative care needs of people with life limiting illness and their families/whanau. The MoH endorsed the Palliative Outcomes Initiative for implementation in January The Palliative Outcomes Initiative aligns with the New Zealand Health Strategy 2016 and the Palliative Care Action Plan Key outcomes for the Palliative Outcomes Initiative include: a) Improved end of life care for patients and whanau will experience: i. Appropriate and timely assessment of patients palliative care needs. ii. More consistent and equitable care and social support across the variety of care settings. iii. An effective palliative approach with consideration to cultural needs including development of a specific Maori palliative care framework. b) Improved access to specialist palliative care advice and support for primary care and ARC providers. c) Improved capability in palliative approaches with the development of better workforce skills and care systems. d) Improved and appropriate use of hospital and specialist palliative care services. e) Consistent data reporting across the Auckland region to inform continuous quality improvement. f) Improved collaboration between hospices, DHBs, primary care and ARC providers to operate strategically and provide whole of system leadership for palliative care. The metro Auckland DHBs have developed the Palliative Outcomes Initiative regional contract with the Hospices of Auckland and Totara Hospice South Auckland will be responsible for administering this contract on behalf of the Hospices of Auckland. The metro Auckland DHBs agreed that Waitemata DHB will be responsible for the administration of the Palliative Outcomes Initiative regional contract. The proposed Palliative Outcomes Initiative contains the following key elements: Palliative Pathway Activation The Palliative Pathway Activation is aimed at better meeting the needs of patients who are likely to benefit from the community based palliative care approach but do not need to be admitted to a specialist service. Currently, there are people in the community with life limiting illnesses who often do not receive palliative care in a timely manner. The Hospices of Auckland will work with General Practitioners and ARC providers to develop and implement a standardised tool for early identification of the patients likely to benefit from a palliative care approach both in primary care and ARC environment. Hospices of Auckland will provide support to clinicians to develop an individualised Palliative Pathway Activation plan with their patients and family/whānau. As a result, these patients and their families/whanau will have appropriate access to palliative care and support in community to enjoy and celebrate life while transitioning towards the time of death. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 164

165 Proactive Advisory Service The Hospices of Auckland will also develop and provide a Proactive Advisory Service to support primary care and ARC providers. The aim of this service will be to discuss the Palliative Pathway Activation plan and provide specialist advice to ensure the patient and family has an effective agreed plan in place, along with support based on the patient needs for their end-of-life journey. 5.1 Multi-Disciplinary Team In-Reach The Hospices of Auckland will also form new multi-disciplinary in-reach teams. The primary role of this team will provide planned and responsive mentoring and coaching support to ARC, community and primary care providers to increase the capability of these providers in providing clinical, psychosocial and culturally appropriate palliative care. Workforce Development Hospices of Auckland will train general practitioners with special interest in palliative care. Psychosocial internships will also be offered to address the shortage of psychosocial care providers with understanding of specialist palliative care. Currently, there are no formal programmes offered to gain the knowledge and experience related to palliative care environment. Therefore, a hospicebased internship programme will be developed and offered to allied health professionals interested in palliative care i.e. social workers, counsellors, occupational therapists and physiotherapists. Maori Palliative Care Framework As part of the Palliative Outcomes Initiative, Totara Hospice South Auckland will work in partnership with Mary Potter Hospice in Wellington to trial a Maori Palliative Care framework. This framework will be developed by the Maori Te ORA Hospice. Overall, the development and implementation of the Palliative Outcomes Initiative is likely to improve access to appropriate palliative care services for people with life limiting illnesses in the metro Auckland DHBs region. 3.2 The Community Pharmacy Waste Management Service Disposal Process Background Interwaste has been providing a Community Pharmacy Waste Management Service across the metro Auckland DHBs region since February The service includes the collection and disposal of pharmaceutical, sharps and cytotoxic waste from all community pharmacies. Consumers can easily access the service by bringing any unwanted, expired or unused medicines to any community pharmacy in the metro Auckland region for free and safe disposal. Interwaste provides separate waste containers for pharmaceutical, sharps and cytotoxic waste. Community pharmacies can call Interwaste at any time for the collection of full bins. Interwaste collects and replaces the waste bins during a single delivery run within three working days. A detailed update on the service was provided to the last meeting of this Committee. The Committee requested further information on unwanted medicines and how each product is disposed of which is provided in the following sections. Pharmaceutical and sharps waste disposal: Sterilisation and deep burial Medical waste disposal companies in New Zealand have invested heavily in autoclave technology to treat medical and clinical waste. Autoclave technology is an internationally approved method of sterilising medical and clinical wastes (other than cytotoxic and radioactive wastes) before disposal of the sterilised residual solid waste at the landfill. This is currently the only available medical and Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 165

166 clinical waste treatment and disposal option in New Zealand. Interwaste s current sterilisation and disposal practices follow international best practice. Following sterilisation, the residual solid waste is considered non-hazardous waste and can be disposed of at a Grade 1 landfill by way of a deep burial. The deep burial process ensures that the residual waste is covered over immediately when it is deposited at the landfill. Grade 1 Landfills have rigid monitoring and compliance processes in place to ensure compliance with consent conditions. This includes landfills being fully lined to ensure that no leachate or other contaminants can enter the waterways. 5.1 Cytotoxic waste: High-temperature incineration At present Interwaste s cytotoxic waste is shipped to Australia for incineration. Incineration is the preferred method for disposing of pharmaceutical waste as per the World Health Organisation s 2011 best practice guidelines. The operation of a high-temperature hazardous waste incinerator is prohibited in New Zealand under the Resource Management (National Environmental Standards for Air Quality) Regulations No new high-temperature hazardous waste incineration facilities in New Zealand can be granted resource consent. The last major incinerator in New Zealand that was able to dispose of medical waste was located at Auckland International Airport. This plant was closed approximately ten years ago due to environmental concerns regarding dioxins and significant environmental opposition. Controlled Drugs: Disposal on pharmacy premise through dilution The disposal of Class B controlled drugs follows a strict and legally binding protocol: The particular quantity of discarded Class B controlled drug is recorded on a Controlled Drugs Register. The Controlled Drugs Register is countersigned by another pharmacist or a responsible person. The pharmacist renders the dosage forms unfit for human consumption by crushing and dissolving with water. The waste is disposed of on-site by pouring the waste down the sink. Since few, if any, community pharmacies have waste disposal facilities on-site, most of these drugs are crushed and dissolved in hot water and poured down the sink. Community pharmacists tend to break ampoules and flush the contents down the sink with water and also pour liquids such as methadone and morphine down the sink. The current service across the metro Auckland DHBs does not mitigate the environmental risk caused by Controlled Drugs. The DHBs are in discussion with the MoH to find an alternative method of disposal in the near future. Environmental Risks A major contributor to the cause of pharmaceutical residues in the waterways is the current practice of the dilution of pharmaceutical and medical waste as a method of disposal (liquid pharmaceutical waste and Controlled Drugs, as mentioned above in Section 6). Dilution is an established practice for disposal of small amounts of medical and pharmaceutical waste by hospitals, respite carers, home carers and pharmacies. Dilution will render some pharmaceutical waste harmless to the environment, but that may not always be sufficient, and treatment may be required. There is still work to be done with the disposal of Controlled Drugs. This will include a wider collaboration between the current stakeholders and the MoH. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 166

167 It is inevitable that some pharmaceutical waste will end up in wastewater systems. For example, pharmaceutical waste disposed down the drain by consumers or healthcare providers, and the unavoidable excretion of drug-derived compounds after use. Wastewater treatment systems separate the waste stream into two general components wastewater and bio-solids. Some biosolids are landfilled, while most wastewater (and some bio-solids) are treated and discharged onto land, into waterways or the sea. 5.1 The metro Auckland DHBs will continue to monitor the service provided by Interwaste and the amount of waste disposed of through community pharmacies. Overall, autoclave methodology is used to sterilise all pharmaceutical and sharps waste before disposing of the residual solid waste at landfill. This is currently the only available medical and clinical waste treatment and disposal option available in New Zealand. Cytotoxic waste is shipped to Australia for incineration as there is no cytotoxic waste disposal facility available in New Zealand. These processes carried out by Interwaste are compliant with current New Zealand legislation and guidelines. 3.3 Regional Community Pharmacy Clozapine Workforce Training Programme Community pharmacists have an important role in the supply of clozapine by monitoring adverse effects and reviewing blood test results. Clozapine is a high-risk antipsychotic medicine that is considered the gold standard for treatment of resistant schizophrenia. There are clear benefits associated with clozapine use; however use is carefully monitored due to potential safety issues. The quality requirements under the Community Pharmacy Services Agreement 2012 require at least annual training for all staff involved in the provision of the clozapine services. Upon further scoping and engagement with mental health pharmacy teams at Auckland and Waitemata DHBs, it was noted that there were inconsistencies in the service protocol/guideline and provision of training to community pharmacists. In response to the inconsistencies identified above Waitemata DHB has partnered with major stakeholders (pharmaceutical supplier, Pharmaceutical Society of NZ and the NZ Hospital Pharmacists Association) to develop a standardised regional protocol and online training programme to further support and develop the workforce to ensure implementation of best practice. The training programme will be launched this month and is likely to achieve consistency across the metro Auckland region to enable safe, effective and high-quality delivery of clozapine services to the population. 3.4 National Health Targets Better Help for Smokers to Quit DHB Target: 90% of PHO enrolled patients who smoke have been offered help to quit smoking by a health care practitioner in the last 15 months. Both Auckland and Waitemata DHBs have successfully achieved the primary care Better Help for Smokers to Quit health target in Q4, 2016/17. Final results provided by the MoH, showed Auckland DHB performance at 92.2% and Waitemata DHB at 90.4%. Nationally, Auckland DHB is ranked third highest performing DHB and Waitemata DHB is ranked seventh for Q4. All PHOs have successfully achieved the target, except for Waitemata PHO. Results by PHO are as follows: Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 167

168 Table 1: PHO Results for Better Help for Smokers to Quit 90% Target, Q4, 2016/17 Auckland DHB Auckland PHO 92.8% Alliance Health Plus 90.9% National Hauora Coalition 90.7% ProCare 92.5% Waitemata DHB ProCare 92.6% Waitemata PHO 87.7% 5.1 All of the PHOs have had a strong focus on achieving the target by tasking their dedicated project teams to ensure that people who smoke receive advice and help to stop smoking. Both the DHB and PHOs worked in collaboration to maintain consistent performance over 2016/17. The results are also shown in the Scorecard under Health Targets as well as in Figure 1 below: Auckland DHB %, 1.8% from the previous quarter Waitemata DHB 90.4% 2.4% from the previous quarter. Ethnicity based data sourced from the MoH remains relatively inaccurate. The primary care team is working with the PHOs to improve the reliability of reporting by ethnicity for the Smoking Brief Advice target. Figure 1: Auckland and Waitemata DHBs Better Help for Smokers to Quit performance (Q4, 2016/17) 100% % Better Help for Smokers to Quit - Primary Care Source: MoH DHBSS Reports 80% 60% 40% 20% 0% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 2015/ /17 ADHB - Overall WDHB - Overall MoH - Target Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 168

169 3.5 Diabetes Management DHB Target: A minimum of 75% of people who have had a Diabetes Annual Review will have an HbA1c of <= 64mmol/mol. There are a number of ongoing data quality issues (extraction and matching) both at a practice and PHO level as reported previously in March 2017 Community and Public Health Advisory Committee report. 5.1 These issues are impacting DHB s ability to accurately identify the number of enrolled people with diabetes and with good diabetes management (HbA1c <64mmol/mol) in Auckland and Waitemata DHBs. For example, according to the MoH Q 4, 2016/17 report, the percentage of enrolled patients with diabetes (aged 15 to 74 years) who have good or acceptable glycaemic control (HbA1c 64mmol/mol) was 71% for Auckland DHB, showing 3% increase since the previous Q3. For the same period, good or acceptable glycaemic control for Waitemata DHB declined from 68% in Q3, 2016/17 to 36% in Q4, 2016/17. This decline is possibly attributable to the known data extraction and matching issues. In addition, the data received from the PHOs for quarter 4, 2016/17 identifies a diabetic population significantly different to that identified by the MoH Virtual Diabetes Register. For the Auckland DHB area PHO data identifies 62% of the virtual register numbers and in Waitemata DHB only 33% are identified. This further highlights issues relating to data integrity and quality. To help resolve these issues and get a better understanding of the diabetes management of the diabetic population a number of activities are being undertaken. The agreement to share Diabetes and Cardiovascular disease clinical indicator data and reporting at the Metro Auckland Clinical Governance Forum is identifying improvement opportunities. During Q4 2016/17, all PHOs were able to report their practice level data except for Auckland PHO (two practices) and Alliance Health Plus (one practice). Key outcomes from this data sharing include: 1. The number of people with diabetes and related data have increased with each data upload as more practices are able to report 2. Practice level reported data showed that all PHOs have at least 60% of their patients with diabetes with a systolic blood pressure under 140mmHg highlighting good blood pressure control 3. Across the three metro Auckland DHBs 68% of people with diabetes and microalbuminuria have been on an ACR or ARB in the last 18 months. The regional target for management of microalbuminuria is to have 90% of patients on one of these medications 4. CVD management for those with known CVD history or CVD risk >20%, is better in those with diabetes compared to the population without diabetes. It is envisaged that all PHOs will be able to report data related to all of their practices in Q1 2017/ Cardiovascular Disease Since September 2014, both Auckland and Waitemata DHBs have achieved and sustained the 90% More Hearts and Diabetes Checks target (see Figure 2) for all population groups except for Māori (whose screening coverage is currently 88.9% in Auckland DHB and 86.7% in Waitemata DHB of the eligible population). Currently, the primary care team is working with the PHOs to achieve and sustain the 90% CVD risk assessment target in Maori by shifting the focus of current CVD funding. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 169

170 Figure 2: Auckland and Waitemata DHBs More Heart and Diabetes Checks 90% target performance (Q4, 2016/17) 100% % More Heart and Diabetes Checks (Source: MoH Quarterly Report) % 80% 70% 60% 50% 40% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 2012/ /14 Overall - ADHB 2014/ /16 Overall - WDHB 2016/17 Target - ADHB Target - WDHB 4. Children, Youth and Women 4.1 Immunisation Health Target The Immunisation Health Target was achieved in Q4 for Auckland DHB (95%) but not for Waitemata DHB (93%). Both DHBs achieved an increase on the previous quarter. A 90 day action plan has been prepared to address the lower rate for Maori tamariki, this has been presented to Manawa Ora and the Maori Provider Forum. The Maori Health Gain team will lead the ongoing work. The plan has six key action areas: 1. Co-design project Developing Maori communications 2. Engaging priority practices in a Quality Improvement process 3. Developing Maori Champion(s) to promote immunisations 4. Developing whanau-led community and whanau champions 5. Deep dive analysis Outreach services and babies immunisation after eight months 6. Investigate mechanisms to support non-dhb funded members of the Waitemata Maori Case review group to attend more regularly The Waitemata Board endorsed an Immunisation position statement on 16 August. Waitemata s position on immunisation is that: Immunisation is a safe and effective way to protect individuals and the community from serious vaccine preventable diseases. The Waitemata District Health Board actively supports and encourages immunisation in line with the New Zealand National Immunisation Schedule and World Health Organisation recommendations. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 170

171 4.2 Obesity Health Target Raising Healthy Kids The Raising Healthy Kids target continues to be exceeded. Work continues to: Finalise the Metro Auckland Healthy Weight Action Plan for Children Engage with each family identified using the BeSmarter brief intervention. Train general practice and other health providers working with young children in how to effectively monitor BMI and utilise the brief intervention tool. Maintain referrals to achieve and exceed the Raising Healthy Kids Target of 95%. 5.1 Funding has been provided by the MoH to support a range of initiatives, which are in the planning phase. Initiatives that are likely to be implemented during 2017/18 include: Scoping and implementation of a positive parenting and active lifestyle programme. Aligning oral health and healthy weight key messages. Scoping a possible Raising Healthy Kids liaison to oversee the care management for every child identified under the health target. A programme of evaluations to inform continuous quality improvement cycles. 4.3 Rheumatic Fever Information has been provided to the Auckland DHB Finance, Risk and Compliance Committee regarding Rheumatic Fever, including the latest data. The Figure below is a cumulative count of rheumatic fever cases for the metro Auckland region (compiled by Auckland Regional Public Health Service). At both Counties Manukau Health and Auckland DHB the cumulative 2017 data is trending higher than 2015 and 2016 notifications. At Waitemata DHB, where there are less cases, the cumulative data is tracking below 2016 levels. Of particular concern is the large rise of cases in Counties Manukau, as high as before programme was introduced. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 171

172 5.1 Negotiations with primary care are nearly complete and will see a change in the Rapid Response model. All clinics will be asked to provide sore throat management services including case finding in Pacific children and making bicillin an option for those that need a course of antibiotics. At this stage, funding for a programme in primary schools has not been confirmed, research funding avenues will be pursued. The MoH remains keenly interested in the programme across metro Auckland. 4.4 Cervical Screening Education, practical support and promotion of the use of NSU data match lists for use by General Practices to recall women for screening continues to be provided. This supports more targeted recall efforts by primary care. We support and encourage PHOs and practices to promote screening and to utilise opportunistic screening strategies as well as broadening available clinic hours (weekend clinics etc.). This is supplemented by a number of pop up clinics. Funding for cervical screening to PHOs targeted to high priority women who have either never been screened, or are overdue for five or more years continues to be provided. We collaborate with Well Women and Family Trust to promote outreach screening in community locations as well as support to services for screening for women who have proven difficult to recall for primary care. A new action plan has been developed in consultation with key stakeholders. This contains some new initiatives that need to be further developed with potential providers. 5 Health of Older People 5.1 Age Residential Care We have had two closures of Auckland DHB age residential care (ARC) facilities. Hutton Park Rest Home (15 residents) closed at the end of June 2017 and Caughey Preston (129 residents) announced Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 172

173 its closure on the 31 July The DHB has been supporting residents and families with transfers to new facilities. Neither of these closures has been due to the introduction of pay equity despite media coverage making this claim. The ARC payment mechanism for Pay Equity remains contentious despite this being the mechanism originally proposed and supported by the ARC sector. ARC providers are receiving pay equity funding via the daily bed rate, which means there will be overs and unders in terms of how individual providers fare. The Ministry has undertaken modelling to understand the impact of this allocation method, which shows there are seven facilities in Auckland DHB and six facilities in Waitemata DHB that will be disadvantaged. However, the ARC sector is challenging the methodology used by the Ministry as they believe disadvantaged facilities will be more widespread. A more detailed analysis is now being undertaken for a randomly selected subset of facilities. 5.1 The Early Warning System Pilot undertaken in two Auckland DHB facilities finished in August. Early warning systems are used for early detection of deterioration of a person s health condition by using a tool that prompts review. The objective after reviewing the pilot information is to develop training and an implementation package for roll out to the ARC sector. There has been good engagement of ARC providers in the regular forums across the two DHBs, which are providing the opportunity to be responsive and have open dialogue about issues as they emerge. Recent topics include understanding enduring power of attorneys and other arrangements; discharging from acute hospital to ARC and areas to improve; pay equity questions; and palliative care support. 5.2 Aged Residential Care Audits There were a total of 23 audits across both Auckland DHB and Waitemata DHB for Quarter four, with a total of 10 of these facilities having no corrective actions. 2016/17 Quarter 1 Quarter 2 Quarter 3 Quarter 4 ADHB WDHB ADHB WDHB ADHB WDHB ADHB WDHB Number of audits Average number of corrective actions per audit Facilities > 5 corrective actions Corrective actions relating to health and safety (% of total CAs) Facilities with no corrective actions Facilities achieving continuous improvement* 4 (22%) 21 (49%) 16 (59%) 16 (42%) 25 (48%) 23 (60%) 17** (59%) 3 (15%) Number of complaints the DHB received on ARC * The gold standard attainment against an audit criterion is continuous improvement (CI). CI is achieved when a criterion is fully attained and continuous improvements against the Health and Disability Sector Standards are demonstrated indicating quality improvement processes in place against service provision and consumer safety or satisfaction. ** Health and safety corrective actions (17) related to two new builds and prior to occupancy as the buildings were still under construction at the time of the audit. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 173

174 5.3 Home and Community Support Services (HCSS) The Medication Management Guidelines for HCSS were developed as a collaborative initiative between the HCSS providers and Waitemata DHB. The final draft of the Guidelines has been submitted to the HOP Steering Group and HealthCERT; the latter will be leading the process to develop the Guidelines as a national document Mental Health and Addictions 6.1 Innovate Innovate is the Auckland district s Executive Leadership Group for Mental Health and Addiction (MHA). Membership is open to senior MHA staff of Auckland DHB provider arm services, NGOs, Primary Care, and the Funder. Innovate was established in late 2014 to encourage innovation, shared decision making and better communication between services. To achieve this, a number of project groups have been established, two key current projects are Service Mapping and developing a closer working relationship with the Waitemata DHB Provider Executive Group. In August 2017 Innovate completed a Service Mapping project of Auckland DHB MHA services. This project collected information from service users and service providers of secondary and primary MHA care over a six month period. The outcomes of this project include: A comprehensive list of provider services What works well (e.g. the growing relationships with primary care) What does not work well (e.g. multiple referral processes) What should be done differently (e.g. transitions between services) With the completion of the Service Mapping Innovate will work to prioritise the follow up actions to be undertaken. Innovate has organised a combined meeting with Waitemata DHB Provider Executive Group for September 2017.The purpose of this meeting is to maximise collaboration and minimise duplication between the two bodies through: The sharing of the 2017/18 work plans Discussion of the projects currently underway Working together to connect with external agencies (examples include the Police and MSD) If agreed regular meetings will scheduled between the two bodies. 6.2 Waitemata MHA Stakeholder Network The Waitemata MHA Stakeholder Network are holding their second annual Hui on 6 December The purpose of the annual Hui is for the six Waitemata Stakeholder Network work streams (Māori, Pacific, Child and Youth, Asian, Older Adult, and Adult) to update the wider stakeholder group on progress. The wider stakeholder group is made up of those who co-designed the Waitemata Stakeholder Network s Strategic Plan ( ), this group includes service users, whānau, MSD, the Police, school Principles, MHA services. Over 100 stakeholders attended the 2016 Hui. Work stream highlights for the year to date include: The publication of Growing Stronger Together Activity Book (Asian work stream) The establishment of seven employment specialists within existing NGO Support Hours services (Adult work stream) Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 174

175 PeerZone workshops in West Auckland (Adult work stream). PeerZone is a series of three hour face-to-face workshops facilitated by and for people with experience of mental distress and/or addiction, where people explore recovery and whole of life wellbeing. A full update of the WSN work streams will be available following the 2017 Hui Look-Up 2017 Exploring Relationships The LookUp youth mental health and wellbeing event was hosted on Thursday 10 August, at the Fickling Centre, Three Kings. Registrations were planned around a target of 250, but increased to 290 in the final days before closing. LookUp grew out of a recommendation from the Auckland DHB Integrated Child and Youth Mental Health and Addiction Direction It has become an annual event sponsored by Auckland DHB, and organised in partnership with NGO and PHO partners, and is now in its third year. LookUp is free to participants (young people, school staff and providers) as a daylong event, focussed on inspiring innovative ways to wellbeing with the target audience of young people aged 13 to 25. This year the theme was Relationships. Starship Foundation contributed $5,000 sponsorship to the day to fund spot prizes and other expenses on the day. Auckland DHB contracted Affinity Services Ltd to provide the event coordination and project management, in collaboration with Connect Supporting Recovery, Odyssey House and Toi Ora Trust. Nicole Symons, a youth advisor with Affinity, was Project Event Manager, she was supported by a Steering Group (with ProCare, Connect Supporting Recovery, Affinity, and Funder representatives), an Action Group (comprising of young people from wide ranging organisations) and a volunteer team (primarily Affinity staff). Six workshops were run in total, with two workshops running concurrently, allowing people to attend up to three workshops. The themes for each set of workshops were Let s Connect! Exploring Identity; Keeping Safe! Healthy Communication; Creating Change! Inside and Out. Stall holders included; Auckland Sexual Health Service, Youthline, Unitec, Youthline, YouthLaw, Netsafe, CADS Altered High, Odyssey House, SPARX, CAYAD, HELP, Rainbow Youth, Connect and Affinity. Attendees seemed engaged in the programme, workshops were full, and all stalls well attended. Preliminary evaluation feedback is overwhelmingly positive, on questions such as I learnt things about identity that I didn t know before; I learnt some good self-care strategies; I learnt about rights and responsibilities in positive sexual relationships; and I have learnt skills that will help me behave respectfully in my relationships. A full report and evaluation will be tabled at the next Auckland DHB Board meeting. 6.4 Pay Equity, Mental Health Workers The Care and Support Worker Pay Equity Settlement Agreement came in to effect on 1 July 2017.This agreement covers care and support workers employed by Providers funded by the Crown, DHBs or ACC, working in ARC; community residential living ;or home and community support services. Mental Health Services were specifically excluded from the agreement. Eight Mental Health and Addictions NGO providers across the country have been challenged by Unions who have submitted a statement of problem to the Employment Relations Authority. The problem the Unions are seeking a solution to is what does equal pay pay rate mean for mental health support workers? Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 175

176 Platform, the peak national representative body for MHA NGOs has been mandated to lead negotiations on behalf of the NGO sector. Named NGOs in the submission are required to have legal representation which potentially could become very costly. Ron Dunham (DHB Lead CE for mental health services), and Jon Shapleski, (Programme Director, HOP, DHB Shared Services) are meeting regularly with the MoH, NGO provider representatives and Unions looking at the decision to exclude care and support workers in mental health from the Settlement. MHA funders across the country were asked to provide a detailed breakdown, by provider and service line, of the numbers of care and support workers, and their level of qualification for a meeting on 15 August 2017, to inform the discussion around potential numbers and the overall funding required should the parties reach a view that such workers should have been included in the Settlement. 5.1 Given the current inequity between the pay of those workers covered by the agreement, and those not covered, the NGOs are highly aware of the risk to workforce recruitment and retention, and are already noting a significant decrease in responses to recruitment. 6.5 Suicide Prevention Suicide Prevention and Postvention Action Plan (SPPAP) Waitemata and Auckland DHB Suicide Prevention Action Plan 2015/17 is currently under review. The revision process of the plan will build off the current action plan, and align to the new national Suicide Prevention Strategy 2017/27. Feedback on the Draft Suicide Prevention Strategy 2017 A draft of a new Suicide Prevention strategy has been developed by the MoH, and was released for public consultation on 12 April The public consultation process closed on 26 June This draft Strategy was presented at various forums and Networks for feedback throughout Waitemata and Auckland DHBs which included: Suicide Prevention and Postvention Advisory Committee Suicide Prevention and Postvention Inter-agency Working Group Innovate Group (Auckland DHB) Providers Exec Group (Waitemata DHB) Waitemata Stakeholders Network Waitemata DHB Providers Forum Auckland DHB Providers Forum Soalaupule (Pacific Forum) National body of Family Advisors Asian, Migrant and Refugee Health team and Asian Health Services Feedback from these groups was collated and comprehensive reports were produced to capture the richness of information provided by members of these forums, three reports were submitted to the MoH. Suicide Prevention and Postvention Inter-agency group (SPPIG) The SPPIG have recently worked closely with the Clinical Advisory Services Aotearoa to support schools and community organisations within the Waitemata and Auckland DHB area to reduce the risk of contagion. In particular there has been a spike of suspected suicides within the Asian community reported through the notification pathway with the coroner service. Therefore a number of meetings conducted with relevant service providers, and facilitated by the Suicide Prevention programme manager in partnership with the Clinical Advisory Services Aotearoa, provided vital Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 176

177 support for the effected community. Action plans were developed from these meetings with leading services/agencies identified. This process continues to demonstrate the importance of establishing a collective effort to prevent suicides. Suicide Prevention workforce training There has been coordinated work to develop a Northern Region DHB Suicide Prevention Training Framework to support workforce develop. The Northern Region Suicide Prevention Training Framework will align with international best practice, the New Zealand MoH Strategic direction and with local planning and initiatives. This project aims to develop a framework which will address Regional need and maximise the opportunity for training consistency and resource efficiency while maintaining local diversity which recognises the uniqueness of each local DHB. This piece of work will also conduct a stocktake of current suicide prevention training programmes. 5.1 Zero Suicide The suicide prevention Programme Manager and some members of the suicide prevention advisory group attended a National Zero Suicide Forum on 27 July. The foundational belief of Zero Suicide is that suicide deaths for individuals under care within health and mental health systems are preventable. It presents both a bold goal and an aspirational challenge. This aspect of suicide prevention has been explored by the Suicide Prevention and Postvention Advisory Group in a robust manner since the forum. Further consultation and discussion with relevant groups need to be facilitated before a definitive decision is reached. 7 Maori Health Gain 7.1 Maori Health Plan A key highlight is the completion of the 2017/18 Māori Health Plan for Auckland and Waitemata DHBs. For the first time we have combined both DHBs Māori Health Plans into a single Plan, the final plan is available on both DHBs websites. 7.2 Integrated Contracts The Māori Health Gain Team has recently completed Phase 3 of the integrated contracting process with Māori providers. This process was designed to reduce reporting requirements, initiate alignment of outputs to outcomes and support whānau ora model of care delivery. Phase 1 occurred between December 2014 and June 2015, Phase 2 between July 2015 and June 2016, with Phase 3 being implemented over the July 2016 to June 2017 period. Phase 3 included the delivery of the following activities: Regular Quarterly Performance Management Hui with each provider. A review of current Māori Providers performance management reporting framework with the aim to apply more consistency. Introduction of funding changes to the Well Child Tamariki Ora contracts requiring contract variations to reflect changes to National Specifications with the current bulk funding model being replaced by a Relative Value Unit (RVU) model. Integrated performance monitoring in partnership with the Child, Youth and Women s health team. 7.3 Abdominal Aortic Aneurysm and Atrial Fibrillation Screening Following the successful Abdominal Aortic Aneurysm (AAA) screening pilot with three General Practices in Waitemata DHB, we have extended the programme to screen all Māori males aged years and Māori females aged years enrolled in General Practices in Auckland and Waitemata Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 177

178 DHB. We have also added screening for Atrial Fibrillation (AF), and have progressed well after changing the innovative AF detection device. As of 9 August 2017 we have screened approximately 1,100 people across both DHBs in the extended AAA and AF screening project. This represents a 32% participation rate after one invitation round is nearly complete. We are aiming to screen an additional 1,340 participants which will provide a coverage rate of 70%, and will begin a range of active follow up activities to achieve this shortly. We are currently planning the AAA extension to be complete in March Pacific Health Gain 8.1 PHAP Priority 1 Children are safe and well and families are free of violence A proposal to the MoH for funding of a Healthy Lifestyles Triple P parenting programme for children who are identified as obese in the B4SC Programme, including Pacific children, was successful. We are working with the Child Health team to design and implement the programme. In relation to the Pacific component of the Healthy Babies Healthy Futures (HBHF) programme, the annualised results are identified below (across Waitemata and Auckland DHB areas). West Fono is the provider for both DHBs. A target is set for each of the five main components of the programme. The table below shows actual numbers in relation to targets for each component: Activity Actual % of Target Staff trained 48 (West Fono staff and community) 100% Mothers briefed % Healthy conversations % TextMATCH enrolments % CLP completed 89 99% E - Newsletters 4 100% There have been challenges engaging with pregnant mothers and an effective referral process between Lead Maternity Carers (LMCs) and the HBHF service is not strong, although a number of meetings have taken place. A referral process between Plunket and HBHF is in place, which will hopefully result in more referrals in the future. Direct community engagement continues to be the major source of women for the service. HBHF is currently being evaluated by COGO Consulting. The latest evaluation report (July 2017) shows: HBHF project appears to be having a positive impact on the eating behaviours of participants: 91% of respondents have made at least two positive changes, e.g. fewer/no sugary drinks, eating more fruit/vegetables, with 51% having made six changes and 72% four changes. The programme s target was a very high 90% and so this is an excellent result for the HBHF project. The results for changes in physical activity are not as positive: 51% of respondents reported that they are physically active more often while the target is 75%. In our view, however, the target of 75% is very high particularly given that many women participating in the programme are new mothers. Overall, the HBHF project is having positive impacts on participants. For example, 63% reported feeling better about themselves and 58% feel more confident. 47% said they are now more confident they can cook healthy meals and 42% have fewer serious medical concerns. This is an excellent result for the project. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 178

179 Comments from the evaluator are not specific for Pacific participants, but for all HBHF participants, Pacific Maori, South Asian, Chinese, Korean and Japanese. The MoH is satisfied with the progress that HBHF has made and the programme is being funded for the 2017/18 financial year, however, there is no guarantee of funding for subsequent years. 5.1 The HBHF programme manager is actively involved in the development of the new contract with the MoH to support children who are identified as obese in the B4SC to ensure that there is coherent linkage between HBHF and the new program. Alliance Health Plus PHO is continuing to fund community based rheumatic fever awareness programmes and two events were held in the last month by the Catholic Tongan communities, one in the Mt. Wellington/Ellerslie/Greenlane area and one in Glen Innes/Panmure area. Over 200 people, from young children to grandparents attended each of the events. Rheumatic fever messages were clearly conveyed by the groups through drama, poetry and songs. The short coming of the messages is that a high number of children/young people do not develop a sore throat to act as an alert for parents to take their children to be checked, which is what the current messages advise. We continue to work closely with the child health team to address the ongoing challenges faced by the rheumatic fever programme. One Triple P parenting program is being implemented in the Orakei area and one Living without Violence programme is being implemented in an Ellerslie church. Both will be completed during September. 8.2 PHAP Priority 2 Pacific People are smoke-free As of the end of the 2016/17 financial year, 49 of the 58 churches (84%) who are part of the Enua Ola and HVAZ programmes and who own their own church properties are smoke free (halls and grounds). This is an increase from 71% from the 2015/16 year. We did set a target of 100% smoke free churches, but new churches joined the programmes and they take time, through education, to get their members to agree to go smoke free. A church minister did remind us, that although church leaders do agree to having smoke free church properties, that they cannot ban or make smokers feel unwelcomed in churches, but with education they will come to understand the harmful effect they have on others and not just themselves. 8.3 Priority 3 Pacific people are active and eat healthy Weekly exercise programmes continue to be run for free in HVAZ churches with 20 to 30 participants attending each week on average. 8.4 PHAP Priority 4 People seek medical and other help early The integrated services Fanau Ola contract that we have with AH+ is now able to measure pre and post intervention clinical measures. The contract set a target of Fanau Ola/household family assessments for 329 families within a period of 12 months. As of 30 June 2017, 354 assessments have been done, consisting of 1,491 individuals. The service can report on pre and post clinical measures including HbA1C, blood pressure lipids and weight. It can identify DNA at primary care/gp level as well as ED presentation, hospitalisation and hospital length of stay. We have received initial data these. This is a major improvement on what the service was able to report on previously. We will invite Alliance Health Plus to present to the Primary Care team to further interrogate the data and will work on service pricing further, now that we are able to relate input into some outcomes. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 179

180 8.5 PHAP Priority 5 - Pacific people use hospital services when needed Bariatric Surgery As well as the support for our DHB bariatric surgery review the Pacific team are also supporting Dr Tamasin Taylor in her qualitative exploration of factors affecting preoperative attrition in Pacific clients who are eligible for publically funded bariatric surgery from the perspective of health professionals. The aim of this research is to identify the reasons behind why Pacific clients are not engaging as often as other ethnic groups in publicly funded bariatric surgeries from the perspective of health professionals and stakeholders to assist in generating questions for the interviews with bariatric clients. 5.1 Apart from the recent DHB patient experience workshops, to date there have been no studies that have investigated the reasons why Pacific clients are not engaging as often as other ethnic groups in publicly funded bariatric surgeries in NZ. This population is more likely to withdraw in the preoperative stage. This first phase of the three year post-doc project funded by the HRC aims to use face-to face interviews to identify and explore in detail the reasons why Pacific clients are withdrawing from the surgery program from the perspective of relevant health professionals and health providers. This information will be used to inform the second phase, involving interviews with Pacific clients who have been referred to the Bariatric services in the past and have or have not completed surgery. This phase will commence in As part of the larger Bariatric Service Project patient experience work, a video has also been developed on a Pacific and a Māori patient. Pacific Best Practice training (target 200 staff per year) We continue to pursue the Organisation s vision to have a culturally competent workforce. To improve Patient engagement and experience for Pacific patients and their families through training Pacific best Practice fundamentals training. Period: Jan to July 2017 Auckland DHB Waitemata DHB 122 (Starship, Women s health) 206 Total: 164 (including non-dhb staff) Total: 286 (including non DHB staff) Pacific Best Training to be offered to: Auckland Radiology Group, TBC North Shore Hospice, TBC 6,050 Patient and family contacts in hospital July 2016-July 2017 Auckland DHB Waitemata DHB 3,934 2,116 DNA rates Pacific peoples DNA rate at Waitemata DHB is sitting at 12.9% (target 10%), Auckland DHB is currently at 18.71% (target 9%). The Tautai Fakataha Pacific team are focussing on high readmission diabetes patients in assertive outreach approach for Waitemata DHB and Oncology clinics and clubfoot cases in Auckland DHB. Approximately 1,000 calls are made per month to remind patients from clinics with high DNA rates. This would contribute to the lower DNA rates for Medical and Hospitalisations of Older People Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 180

181 Waitemata DHB Waitemata DHB 12 months snapshot (July 2016/17) Pacific total admissions Total Admissions Pacific total Admissions % Total DNA rate Pacific DNA rate Child and Women and Family 3,646 33, % 8.50% 18.90% Surgical and Ambulatory 5,116 78, % 9.60% 18.40% Medical, Health of Older People 17, , % 8.40% 11.9% 5.1 Auckland DHB The overall Pacific DNA rate shows a reduction from 19.45% to 18.71% with five of the eight directorates showing a decrease in DNA rate. The Tautai Fakataha team continues to contact Pacific patients in Oncology clinics which appears to be having a collective positive impact on the DNA rates. Medical Oncology and Haematology Daystay clinics had the highest DNA rates which the team are liaising with schedulers to discuss further. A meeting has been scheduled with the Long Term conditions team to progress the recommendations of the Pacific diabetes project completed late The Women s health directorate have undergone Pacific best training modules as part of the Greenbelt project lead by Nurse unit manager Pauline Fakalata. This training endeavours to improve patient engagement with Pacific peoples. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 181

182 Auckland DHB hospital provider Pacific dashboard. 5.1 The percentage of hospitalised Pacific smokers offered advice and support to quit has improved, reaching the target, this has been the result of a concerted effort across the system to stay on track. Auckland and Waitemata DHB Monthly Performance Scorecard Pacific Health Outcome Scorecard June 2016/17 Health Targets - Auckland DHB Health Targets - Waitemata DHB Pacific Target Trend Non-Pacific/Non-Maori Pacific Target Trend Non-Pacific/Non-Maori 92% 95% (94%) 97% 95% (97%) Shorter Waits in ED q Shorter Waits in ED Faster cancer treatment (62 days) 70% 85% p (91%) Faster cancer treatment (62 days) 100% 85% (92%) Increased immunisation (8-month old) 95% 95% p (96%) Increased immunisation (8-month old) 95% 95% p (94%) Raising Healthy kids 100% 80% (100%) Raising Healthy kids 100% 80% (100%) Access- Auckland DHB Access - Waitemata DHB Pacific Target Pacific Target Trend Non-Pacific/Non-Maori Improving Outcomes Trend Non-Pacific/Non-Maori 71% 80% (69%) Cervical Screening 73% 80% (76%) Cervical Screening q Breast screening 73% 70% q (63%) Breast screening 74% 70% q (66%) MH Access Rates 0-19 years 2.9% (3.4%) MH Access Rates 0-19 years 2.4% (3.7%) MH Access Rates years 4.9% (3.5%) MH Access Rates years 4.2% (3.5%) AOD Access Rate years 2.1% (1.0%) AOD Access Rate years 1.9% (1.1%) POAC Referrals 208 POAC Referrals h. h. Well Child core contact within first year - % of enrolled 95% Well Child core contact within first year - % of enrolled 95% b. b. Oral health - % infants enrolled by 1 year 55% 95% (75%) Oral health - % infants enrolled by 1 year 71% 95% (97%) b. b. B4 school checks for 4 year olds 92% 90% p (92%) B4 school checks for 4 year olds 92% 90% p (93%) Preventable Hospitalisation Preventable Hospitalisation e. Ambulatory Sensitive Hospitalisations (ASH) (5940) e. Ambulatory Sensitive Hospitalisations (ASH) (4639) Ambulatory Sensitive Hospitalisations (ASH) (2485) Ambulatory Sensitive Hospitalisations (ASH) (3538) Quality - Auckland DHB Quality - Waitemata DHB Improving outcomes Pacific Target Trend Non-Pacific/Non-Maori Pacific Target Trend Non-Pacific/Non-Maori More Heart & Diabetes 92% 90% (92%) 91% 90% (92%) Checks More Heart & Diabetes Checks p b. b. Diabetes management 55% 61% q (70%) Diabetes management 60% 69% q (71%) CVD on Triple therapy (dispensed) 60% (52%) CVD on Triple therapy (dispensed) 57% (51%) InterRAI assessments 97% p (96%) InterRAI assessments 92% p (92%) 100% 95% Older patients Falls Risk Assessed 100% 90% p (93%) Older patients Falls Risk Assessed 93% 90% q (99%) Patient Experience Patient Experience Net Promoter Score Inpatient rated care as very good or excellent 83% 90% (85%) FFT p (78) g. i. Pacific contacts with cultural service 249 Pacific contacts with cultural service 147 p Outcome - Auckland DHB Outcome - Waitemata DHB Key Topics Pacific Target Trend Non-Pacific/Non-Maori Key Topics Pacific Target Trend Non-Pacific/Non-Maori d. d. Rheumatic fever rates q (1.7) Rheumatic fever rates q (1) b. b. Oral Health - Children caries free at 5yr 33% 72% (70%) Oral Health - Children caries free at 5yr 43% 72% (72%) b. b. Oral Health - Mean rate DMFT at school yr Oral Health - Mean rate DMFT at school yr c. c. Exclusive breastfeeding at 3 mths (Plunket) 60% Exclusive breastfeeding at 3 mths (Plunket) 60% Percentage of children who are obese Percentage of children who are obese 17% (4%) 21% (3%) Hospital falls resulting in NOF fracture 0 0 (6) Hospital falls resulting in NOF fracture 0 0 (5) f. b. Surgical site infection rate (0%) Surgical site infection rate (2%) Mortality Mortality a. a. Overall Mortality ASR per (315) Overall Mortality ASR per (291) Managing our Business - Auckland DHB Managing our Business - Waitemata DHB Workforce Actual Workforce Actual Pacific management 4% Pacific management FTE as % of total workforce FTE as % of total workforce 3% Pacific clinical FTE as % of total workforce 3% Pacific clinical FTE as % of total workforce 3% Pacific administrative FTE as % of total workforce 8% Pacific administrative FTE as % of total workforce 5% Pacific other FTE as % of total workforce 4% Pacific other FTE as % of total workforce 9% How to read Performance indicators: Trend indicators: p Performance Achieved/ On track bstantially Achieved but off target improved compared to previous month Not Achieved but progress made Not Achieved/ Off track q Performance declined compared to previous month Performance was maintained 1. Most Actuals and targets are reported for the reported month/quarter (see scorecard header). 2. Actuals and targets in grey bold italics are for the most recent reporting period available where data is missing or delayed. 3. Trend lines represent the data available for the latest 12-months period. All trend lines use auto-adjusted scales: the vertical scale is adjusted to the data minimum-maximum range being represented. Small data range may result small variations perceived to be large. Key notes a. 2 yr aggregated data as at Dec 16 b. Dec 2016 c. June 2016 data d. Initial cases per year, per Dec 2016 e. Dec 2016 data - Total Target from AP f. Bi-annual - latest data Sep 16 g. May 17 data h. Core contacts June 16, Non-Pacific/Non-Maori data N/a = total i. April 17 data A question? Contact: Victoria Child - Reportinging Analyst, Planning & Health Intelligence Team: victoria.child@waitematadhb.govt.nz Planning, Funding and Health Outcomes, Waitemata DHB Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 182

183 Faster Cancer treatment (62 days) The Faster Cancer treatment 62-day indicator improved in Auckland DHB over the last quarter, but at 70% remains below the 85% target. The Pacific provider and funding teams met with Dr Richard Sullivan and Barbara Cox from the Auckland City Hospital Cancer service to discuss Faster Cancer Targets for Pacific to better understand the barriers and identify potential areas of intervention. Recommendations moving forward include investigating how the Waitemata DHB Pacific cancer nurse role could be used as a model for care across both DHBs to improve access for Pacific people across the cancer pathway. 5.1 POAC referrals POAC referrals continue to be low for Pacific people, particularly at Auckland DHB. POAC is working with Auckland Hospital ED and with inner city general practices to facilitate improved utilisation of POAC services in the Auckland population. Ambulatory Sensitive Hospitalisations 0-4 and years Waitemata DHB and Auckland DHB have an integrated primary care approach to improve ASH rates in four areas: improving acute care; better long term condition management; better preventive care; improving integration between primary care and other areas of the health and non-health sector that impact on ASH. Oral health Enrolments by 1 year, Caries free at age 5, Mean DMFT at school year 8 An Auckland regional Preschool Oral Health Action Plan has been developed to address disparities in oral health outcomes for Pacific and Māori children and is considered elsewhere on the agenda. An automatic enrolment process into the service from birth across all three DHBs will make it easier for families to have their children examined. Auckland Regional Dental Service (ARDS) is currently working with Plunket to look at opportunities to deliver services together (e.g. have a mobile clinic on site when a well-child clinic is being provided) so families can access both services at the same time. ARDS has begun collaborating with child health providers to refer children who have not attended appointments (and where there are concerns about their oral health). ARDS is also developing an outreach programme where staff provide fluoride varnish (a preventative treatment) to high needs children and a role where a staff member proactively follows up children who have not attended appointments. Extended hours clinics are currently being provided by 11 ARDS sites across the metro Auckland area. In late 2016, the Browns Rd Dental Clinic in Manurewa introduced a weekly clinic each Saturday to improve access to the service. Given the success of this clinic, planning is currently underway to extend Saturday clinic provision to other communities. 8.6 PHAP Priority 6 That Pacific people live in houses that are warm and are not over crowded We have not made any further progress on this priority other than assist the Kainga Ora Healthy Homes Initiative to build and maintain connections with Pacific providers. 9. Asian, Migrant and Refugee Health Gain 9.1 Increase the DHBs capability and capacity to deliver responsive systems and strategies to targeted Asian, migrant and refugee populations We are developing a regional Asian and MELAA Primary Care Action Plan in partnership with Counties Manukau Health and the Auckland Regional Asian and MELAA Primary Care Working Group. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 183

184 9.2 Increase Access and Utilisation to Health Services Indicators: Increase by 2% the proportion of Asians who enrol with a PHO to meet 71% (Auckland DHB) and 87% target by 30 June, 2018 (current rates 69% (Auckland DHB) and 85% (Waitemata DHB) as at Q1 2017/18) 80% of eligible Asian women will have completed a cervical sample by 2020 (current rates 56% (Auckland DHB) and 69% (Waitemata DHB) as at June 2017) 5.1 Campaign Healthcare where should I go? We have completed the evaluation of the Auckland DHB targeted Healthcare-where should I go? multi-lingual social media campaign (see Figure 1). Of note, using the population projected based on 2016 Update, and taking into consideration that the denominator to determine the Asian PHO rate includes international students which are primarily living in the Auckland district, the Asian PHO enrolment has remained stable at 69% between Quarter /17 and Quarter /18 with 1,511 new enrolees. The rate also remains stable in Waitemata DHB (85%) with 2,511 new enrolees. Next steps We are continuing to work with PHOs, Central Business District General Practices, university health centres, Private Training Establishments and settlement partners on healthcare messaging via their communication channels. We are planning various health seminars/events to increase awareness of the health system and enrolment with a family doctor (GP) for Asian sub-groups including Chinese older adults, Burmese and Japanese. Two Asian Health and Wellbeing Days will roll out in September (Auckland DHB) and November (Waitemata DHB) respectively in partnership with The Asian Health Incorporated and PHOs. A targeted health and wellbeing event is planned for Shri Ram Mandir temple s South Asian faith-based community in West Auckland in collaboration with Healthy Families Waitakere, Sport Waitakere and The Asian Health Incorporated. We are rolling out two focus groups to Chinese and South Asian women in Quarter /18 as part of the Massey University s broader HPV self-sampling study in collaboration with The Asian Health Incorporated and the Chinese New Settlers Service Trust. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 184

185 Figure 1: Healthcare where should I go? Campaign evaluation (Auckland DHB) 5.1 Indicator: Increase opportunities for participation of eligible refugees enrolled in participating general practices as part of the Refugee Primary Care Wrap Around Service funding Professional development opportunities for primary health and the frontline workforce to up skill them on the soft skills and cultural competencies required to support refugee families at the practice level include the Refugee health network forum delivered to primary health professionals on 5 September. An evaluation of the Primary Care Refugee Wrap Around Service Agreements (Auckland DHB, Waitemata DHB, Counties Manukau Health) is being conducted by a third year AUT refugee background student who will provide a refugee lens on the evaluation of the Agreements. The report aims to be completed by end October Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 185

186 10. Auckland Regional Public Health Service (ARPHS) 10.1 Disease Management Mumps outbreak update Since 1 January 2017, ARPHS has been managing the mumps outbreak in the Auckland region. The community spread of mumps is well established, also occurring elsewhere throughout New Zealand, although the burden is borne by Auckland (72% of cases). 5.1 As at 9 August 2017, there have been 213 confirmed or probable cases of mumps notified to ARPHS, of whom 53% were male. Children and young people are commonly affected. Pacific peoples and Māori are overrepresented. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 186

187 5.1 There have been nine cases of mumps who have been hospitalised, mostly for orchitis (inflammation of the testicles), and one who had aseptic meningitis. While the majority (51%) of mumps cases have resided in the Waitemata DHB area (mostly West Auckland), new cases of mumps are now becoming more common in the Counties Manukau Health and Auckland DHB areas. Almost three quarters of mumps cases reside in the most deprived areas of Auckland NZDep13: quintile 4 (22%) and 5 (52%). MMR vaccination is the best way to protect against mumps. It is noted that proportion of Auckland mumps cases who have been partially vaccinated (15%) or not vaccinated (58%) with the MMR vaccine remains high. Furthermore, Auckland continues to receive mumps cases imported from other countries (n=31, representing 14% of all mumps cases in Auckland), in particular the Pacific Islands, where the mumps antigen is not included in their routine immunisation schedule. While Fiji was the common source of overseas incursions from January 2017 to May 2017, Tonga (currently experiencing a mumps outbreak) is now the main source of imported mumps to Auckland. With community-wide spread of mumps in Auckland, the ARPHS response is focussing on promoting MMR vaccination and protecting those who are vulnerable or at risk of catching mumps and/or its serious complications. To support the mumps outbreak, Dr Julia Peters (Clinical Director ARPHS, Auckland DHB)recorded eight radio interviews and appeared in two television interviews. The Mumps Facebook campaign has reached over 12,000 people and posts promoting vaccination shared over 100 times. ARPHS has also shared its management protocol and flow charts with other Public Health Units. Following one case of imported mumps at the refugee centre, ARPHS proactively vaccinated 138 people at the centre with MMR because there are several vulnerable and high risk people in the refugee intake, and the centre is not suited for isolating individuals. Seasonal increase in Meningococcal disease Each year there is a seasonal increase of invasive meningococcal disease from Neisseria meningitidis in the Auckland region, typically observed in winter and early spring from June to September. As at 17 August, there have been 14 cases of Meningococcal since June this year, including one death. These numbers are within the expected range for this time of the year. There are around 28 cases of meningococcal disease in Auckland each year. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 187

188 Apart from two cases that lived in the same household, there are no apparent links between the cases. However, ARPHS is continuing to investigate and monitor the situation. At the moment, there is no need for a public call to action, although ARPHS has information on this seasonal increase available on its website. ARPHS has reminded health professionals to be vigilant at this time of year Synthetic cannabis surveillance ARPHS is supporting the three Auckland metro DHBs, St Johns and the Police by compiling information on the synthetic cannabinoid situation in Auckland, which started in early July. Most affected people have been seen at Auckland Hospital Emergency Department, but there have been cases from Middlemore and Mental Health and Addiction services. ARPHS has combined and analysed information from DHB services and the coroner with the aim of getting a clear description of the situation as it develops, as well as identify some of the risk factors. Preliminary analysis indicates that four of the deaths occurred early (July 9, 11, 14, and 16), before the marked rise in presentations. Daily presentations notified between 7 July - 3 August 2017 from Auckland DHB and Counties Manukau Health Note: the black bordered bars indicate weekends Further work is needed on completion and verification of records and cross-checking of information, information presented here needs to be interpreted cautiously. For instance, we are still awaiting data from Waitemata DHB Decision on Provisional Local Alcohol Policy appeal The Alcohol Regulatory and Licencing Authority (ARLA) released a decision on Auckland s Provisional Local Alcohol Policy (PLAP) appeal on 19 July Throughout the PLAP appeal process ARPHS (through the Medical Officer of Health), the Police and Alcohol Healthwatch aimed to provide support to Auckland Council and balance to the industry appeals. This has proven successful with the majority of the PLAP being found reasonable. Auckland and Waitemata DHBs Community and Public Health Advisory Committee Meeting 13/09/17 188