Pacific health evidence and outcomes?

Pacific health evidence and outcomes?

Outline Pacific population profile and health indicators Why so little progress? A Pacific family s engagement with primary care Engaging vulnerable consumers to improve the responsiveness and quality of healthcare New models of care Workforce implications

Pacific people in New Zealand Youthful Rapid growth Heterogenous - Most are now NZ born - Increasingly multi-ethnic High level of urbanisation Transcultural and transnational populations Experience systemic inequality in measures of: - Health - Education - Poverty - Employment and income

Health indicators and access to healthcare- a mixed picture Gains Immunisation rates PHC access Diabetes care indicators Community programmes Challenges Life expectancy gap 7.7 years Tobacco Obesity Rheumatic fever

Pacific Health Headlines Good Progress in some areas High rates of Pacific community engagement with health service initiatives: PHO enrolment -nearly 100% Pacific immunisation rates >90%, infants enrolled with Plunket -87.2% in 2006 Enrolment in chronic care programmes e.g. Diabetes Get Checked uptake in 2004: Pacific 92%, European 63%, Maori 27% Improved rates of uptake of cancer screening cervical and mammography Community engagement and mobilisation through church based community action programmes, working with community and church leaders e.g. Lotu Mo ui, Enua Ola, HVAZ

Acute Rheumatic Fever in NZ Acute Fever Rheumatic Admissions in 0-24 Year Olds by Ethnicity, New Zealand 1996-2007 Source: New Zealand Child and Youth Epidemiology Service

Child rheumatic fever rates in NZ Significant disease impact 600-800 admissions p.a. Premature death Rheumatic Fever causes 150-200 deaths p.a. in NZ Rheumatic Fever Incidence rate per 100,000 This is two times the number of people who die from cervical cancer Source: Wilson and Webb, 2012

Pacific obesity rates in Auckland Pacific adult obesity by District Health Board Waitemata DHB 48% Auckland DHB 58% Counties Manukau DHB 78% Morbidly obese (BMI 40+) is increasing e.g. Pacific people make up 31,000 of the 90,000 people in the Auckland region eligible for bariatric surgery. Super obese (BMI 55+) also increasing Pacific people make up 900 of the estimated 2,000 people.

Pacific obesity rates in NZ reflect high rates in Pacific countries Swinburn et al, wwwthelancet.com, 2011

Medications and testing according to guidelines, Pacific diabetes patients in the Northern region DHBs, Apr 2011-Mar 2012

Proportions of metro-auckland people with diagnosed diabetes who had an annual check and also an HbA1c of 64 mmol/mol or less.

CMDHB Diabetes Care Programme 75 73 HbA1c 71 69 67 65 63 61 59 57 55 0 3m 6m 1y 2y 3y 4y 5y 6y 7y 8y 9+y Total Euro/Other Maori Pacific Asian Source: Dr Tim Kenealy, University of Auckland, 2012

Summary Well documented health needs Growing evidence of equal access to care Outcomes have not changed

Context: Addressing economic, social and health issues 2007-2012 Source: Statistics New Zealand 2002 Pacific Progress After the 1987 crash, Pacific unemployment reached 30% Source: Department of Labour 2012 The longest, deepest recession in 40 years started in 2008

Has the policy response been adequate? Legislation NZ Public Health and Disability Act 2000...to reduce health disparities by improving the health outcomes of Maori and other population groups... National strategies - New Zealand Health Strategy 2000 - Primary Health Care Strategy 2001 - Public Health programmes - Pacific Health and Disability Action Plan 2002 and Pacific Provider Development Fund Better Sooner More Convenient Care Quality focus - Evidence based guidelines - Primary health care accreditation - Performance management Research and evaluation Workforce development

Or is the problem with implementation? Funding for Pacific Specific Programmes Public Health and Social Services Public health budgets MSD Pacific 2002/10 2010/11 2011/12 2012/13 5.57m 7.59m 6.9m 5.5m 51 programmes mainly in Auckland and Wellington Exercise, nutrition, tobacco control, oral health, mental health, destigmatisation, sexual health, injury prevention, domestic violence, child health home visiting 2011/12 2012/13 Planning Funding Total Contracting total Planning Funding total Contracting total 6.7m 11.2m 4.7m 8.2m 171 contracted providers 60 providers get less than $20,000 150 providers get less than $100,000 2 providers get more than $500,000 Small, dispersed, short term, limited effectiveness?

A Pacific family model of care Misi family health genogram

Summary of Misi family use of health services in 12 months Engaged with health system at least 34 times Enrolled with 3 separate general practices Went to accident and emergency by ambulance 5 times 4 of the 5 children have not had their health needs met e.g. 2 do not have up-to-date immunisation The 27 year old mother in the second trimester of her pregnancy has had no antenatal care

Research in to Pacific peoples access to primary health care HRC funded project 18 months Engaged over 300 Pacific peoples nationally 36 focus groups with different Pacific ethnic communities

Pacific and Primary Care Worldviews Worldviews and issues that shape Pacific peoples interactions with PHC Spirituality Relationships Family Poverty Language Health literacy Health needs Frustrated hopes Worldviews and issues that shape Pacific peoples interactions with PHC Biomedical Transactional Individual Business language Pacific literacy Health needs Frustrated caring

Engaging vulnerable mothers in improving maternity care at CMH Response to high perinatal mortality rates and reviews Recommendation to establish a Maternity Care Consumer Panel Interviewed 61 mothers with unmet health needs Included teen mothers, mothers in CYFS supported accommodation, mothers from consumer panel, 10 Pacific mothers with English as a second language

Consumer voice and patient centred care 2012 External Review by Ron Paterson recommended prioritisation and targeting of care for mothers with high needs But for CMH 80% of the maternal population meet the PMMRC criteria for vulnerability Patient and family engagement in health services planning and quality improvement can lead to: Enhanced patient self management, education and health promotion Improved service design and quality of care Strengthened local accountability

Maternal characteristics by ethnicity Maternal characteristics Median age Teenage Birth rate per 100,000 NZ dep 06 deciles 9&10 LMC care Late registration trimester 2 or 3 Pacific 28 years 49 58% < 66% 60% European 31 years 13 10% 92% Total 29 years 43.9 28% 86% 41%

Access to care I took my first test with my school nurse my school nurse took me to my first scan without my parents knowing I got asked if I had a midwife and I was six months then I said no and they just gave me a list of names. I was like yeah and I didn t call any of them I was looking out the hospital window in my room and I could see my Mum sitting in the dark at Middlemore hospital train station and we were both crying It s good Middlemore is by the train station and my family can come and see me, but at Botany it s not so easy

Experience of care They think I don t care about my baby but the truth is I can see they don t talk to me properly, but with my Mum they talk more serious than they are with me, give her more information and I know this will help my baby more. So I let them think I don t care so my baby gets help

Summary of key findings Issues Young/Teen Mothers Most vulnerable mothers Pacific and older Mothers Engaged Mothers Access Reliant on maternity information & access from family / friends Will make active choices whether or not to engage Multiple barriers, low health literacy Are self-motivating & are accessing care appropriately Smoking High rates of smoking Less likely to give up while pregnant Low rates of smoking Likely to give up while pregnant Nutrition Family members control decision making Diet & exercise are not high priorities Living in obesogenic environment Most describe being in control of nutrition/exercise Contraception Information from trusted source (eg. friend, teacher etc.) Complex social and health needs Impact of cultural and religious values Access information & make informed decisions

Transactional and relational Patient centered care Compassion, empathy and responsiveness (R) Co-ordination and integration (T) Information, communication (T&R) Physical comfort (T&R) Emotional support, relieving fear and anxiety (R) Involvement of family and friends (T&R) dimensions of care Source: Institute of Medicine, Crossing the Quality Chasm

This is even more important for populations with high health and social needs, and vulnerability who must navigate complex and often fragmented health, community and social services. From a patient s perspective, it is health services which are hard to reach.

Patient-centred care A key priority and dimension of quality in the New Zealand health and disability system. Engaging and working collaboratively with families and communities are key strategies to achieve this. There is increasing international recognition for the central role of patient voice and stories in the design and delivery of health services which are more informed and compassionate (Kings Fund, 2011).

Connecting with communities and innovative models of care

Engaging Pacific Worldviews Families Reciprocity Respect Relationships Spirituality

Summary Pacific people are a significant population in New Zealand. Pacific people experience persisting disparities in health outcomes, higher rates of chronic disease and risk factors for health, and lower access to quality health services that they require to meet their needs. Current health system responses are inadequate. Consumer voice and community engagement are an important part of the required solutions.

Summary Increasing the Pacific health workforce and developing Pacific models of care has been an important response to health inequalities in NZ. We need Pacific focused research and robust evaluation and monitoring of programmes to ensure an understanding of the underlying economic, environmental and social determinants of health informs policy and implementation. We need top down policy AND bottom up community and consumer input.

Soifua