Differences in health outcomes for Pacific peoples (and other ethnic groups) are due to a complicated combination of factors, including socio-economic inequality, access to and quality of health care, and health risk factors – such as tobacco, diet, and other lifestyle factors (Blakely et al, 2007)1.
This section looks at the links between health and the complicated web of influencing factors:
In the March 2010 quarter the unemployment rate for Pacific peoples was 14.4 percent, higher than for all ethnicities. The rise in the unemployment rate for Pacific peoples was greater than the total rise in unemployment.
In 2006/07, Pacific children aged 2–14 years were less likely to have eaten breakfast at home every day, more likely to have consumed three or more fizzy drinks in the last week, and more likely to have eaten fast food at least three times in the last week. Compared with the total population, obesity was 2.5 times more common in Pacific adults, and over 2.5 times more common in Pacific children.
In 2008, 12 percent of all young people aged 14–15 years smoked at least one a month. However, 16 percent of Pacific girls and 12.4 percent of Pacific boys smoke at least monthly, compared with 10 percent of European girls and 7.8 percent of European boys.
In October 2007, nearly 100 percent of Pacific peoples were enrolled with a primary health organisation (PHO) – of these, 15 percent were enrolled with a Pacific PHO and the remainder with a mainstream PHO.
In 2006/07, just over 11 percent of Pacific peoples reported an unmet need for general practitioner (GP) services in the previous 12 months. The most common reason given was cost (33. 4 percent).
For the 12-month period to October 2010, 89 percent of Pacific 2-year-olds were fully immunised, compared with 87 percent of European 2-year-olds.
Source: White, Salmond, Atkinson & Crampton, 2008; Statistics New Zealand, 2010.
Level of economic resources
On average, Pacific peoples have worse economic circumstances than the overall population, with the majority of Pacific peoples living in areas with the fewest economic resources (White, Salmond, Atkinson & Crampton, 2008).
In general, people with fewer economic resources tend to have poorer health outcomes due to a combination of factors, including greater exposure to health risks, reduced access to adequate housing, and difficulty accessing health services. From 2005 to 2007, the life expectancy of people living in areas with the fewest economic resources (decile 10) was 8.8 years shorter for men and 5.9 years shorter for women compared with those with the most resources (decile 1) (Ministry of Social Development, 2009, p23).
Lower incomes2 mean that many of the conditions or factors that support good health, such as good nutrition and quality housing, are less accessible. For example, the proportion of Pacific households (with at least one Pacific adult) spending more than 30 percent of their income on housing was 33 percent in 2009, reflecting a steady increase from 23 percent in 2004 (Ministry of Social Development, 2010, p69).
Students attending schools in communities with fewer economic resources tend to experience less education success than those in more affluent communities (Ministry of Social Development, 2009, p138). Pacific students tend to have poorer education outcomes than other students from the same communities. This is a result of a combination of factors, including lower levels of participation in early childhood education and teaching and learning practices throughout schooling that are less effective for Pacific students(Statistics NZ and Ministry of Pacific Island Affairs, 2010).
Poor education reduces peoples’ employment opportunities. The 2006 Census of Population and Dwellings showed that 35 percent of Pacific peoples had no qualifications, compared with 25 percent of all New Zealanders. The unemployment rate is higher for Pacific peoples (14.4 percent in the March 2010 quarter) than for any other ethnic group (Statistics NZ, 2010). Since the March 2008 quarter, the rise in Pacific unemployment has been greater than the total rise in unemployment. Pacific peoples are over-represented in non-skilled and lower-skilled occupations (Ministry of Pacific Island Affairs, 2010). Evidence from previous recessions also suggests that unskilled workers are hit hardest in times of recession, when unemployment rates for unskilled workers increase more than those for skilled workers (Department of Labour, 2009).
Figure 1 shows that approximately half of all Pacific children and young people live in a crowded house, a higher proportion than other ethnic groups. A child growing up in an over-crowded house will be more susceptible to communicable diseases (Hawker, 2005) and over-crowding can have a detrimental effect on successful learning.
Proportion of children and young people 0–24 years living in a crowded household
New Zealand Census of Population and Dwellings 2001, 2006
Source: Craig et al, 2007, p80
Inadequate housing affects children more than adults, particularly children in low-income families, in larger families, rental dwellings, and more deprived neighbourhoods (Centre for Housing Research, 2010). The quality of housing and household crowding are closely related to the risk of developing ARF, meningococcal disease, respiratory disease, and other infectious diseases.
Due to their low income, many Pacific families live in less affluent communities. The prevalence of factors associated with lower levels of well-being, such as widespread smoking, obesity, hazardous drinking, and non-casino gaming machines, is greater in these communities. Public transport options may also be more limited (Auckland Regional Council, 2005). This reduces access to employment or education opportunities, community activities, and health care.
Improvements in health can be achieved by improving educational performance and other social and economic circumstances. This has been discussed in Education and Pacific peoples in New Zealand (Statistics NZ and Ministry of Pacific Island Affairs, 2010) and will be explored in a future report on economic development.
Social cohesion and connectedness
Social cohesion means cohesive community relationships with levels of participation in communal activities and public affairs, and a high number of community groups. Evidence shows beneficial links between social cohesion and health. Societies with diminished social cohesion have higher mortality rates and worse social outcomes than those with high levels of social cohesion (Stansfeld, 2006).
Most Pacific communities have strong social connections, often centred on church and community activities. An individual’s identity and well-being are traditionally dependent on family heritage, connections, roles, and responsibilities. Having a strong sense of belonging seems to reduce the likelihood that an individual will consider or attempt suicide (Beautrais et al, 2005).
In the 2006 Census, 83 percent of Pacific peoples stated they had at least one religion, compared with 61 percent of New Zealand overall. Pacific students express the importance of spiritual beliefs (57 percent) much more frequently than European students (20 percent) (Helu et al, 2009). Voluntary work underpins a wide range of groups and organisations whose activities contribute to social well-being. The General Social Survey 2008 showed that 42 percent of Pacific peoples had done voluntary work in the previous four weeks, significantly more than the mainly European ethnic group (Ministry of Social Development, 2010).
The General Social Survey showed that 85 percent of Pacific peoples had at least weekly face to face contact with friends compared to 79 percent of the total population. The Youth 2007 Survey found that 17 percent of Pacific youth had helped others in their community in the last 12 months, (Helu et al, 2009) compared with 14 percent of youth overall (Adolescent Health Research Group, 2008). Pacific peoples in New Zealand maintain strong connections to the Pacific Islands. It is estimated that three-quarters of Pacific peoples in New Zealand send money to family members in the Pacific region (Money Pacific, 2010).
As well as building resilient and supportive communities, social connections also provide useful foundations for community health interventions. Projects that “create and reinforce strong social connections across Pacific communities” (Tait, 2008) provide useful foundations for effective public health action. For example, the success of initiatives such as the MeNZB and HPV vaccination campaigns in Pacific communities has been attributed to these strengths (F Tupu, personal communication, 2009; CBG Health Research Ltd, 2006).
A healthy diet is a key determinant of health outcomes and is particularly important for the growth and development of children and young people.
Food choices are influenced by affordability as well as personal, family, and cultural preferences. Healthier food options are often more expensive than those with high concentrations of fat and sugar, and those that are nutritionally limited. Affordability of food is a significant issue for Pacific households, who were the least likely to report that they could always eat properly. They were also more likely (at nearly 50 percent) than Māori and Europeans to report sometimes running out of food due to lack of money (Ministry of Health, 2003).
The National Children’s Nutrition Survey conducted in 2002 found that Pacific children were the least likely to bring their food from home to school, and most likely to buy it from a canteen, shop, or takeaway.
Pacific children had a lower mean energy intake than Māori children (but higher than European children), and derived a higher portion of their energy intake from fat. The proportion of fat intake increased with a decrease in family resources.
The New Zealand Health Survey 2006/07 found that Pacific children aged 2–14 years, compared with the overall New Zealand population, were less likely to have eaten breakfast at home every day, more likely to have consumed three or more fizzy drinks in the last week, and more likely to have eaten fast food at least three times in the previous week.
Source: Ministry of Health, 2008a; Utter, Scragg, Schaaf, & Fitzgerald, 2006.
Physical activity is known to protect against obesity and cardiovascular disease, particularly in combination with a healthy diet (National Institute for Health and Clinical Excellence, 2010). Physical activity is also important for the healthy growth and development of children. It promotes good mental health and other positive health outcomes that enhance the overall quality of life (Scully, Kremer, Meade, Graham, & Dudgeon, 1998; Hassmen, Koivula, & Uutela, 2000). Social interaction is one of the factors that promote participation in physical activity (De Bourdeauhuiji, 1998), which in turn encourages social cohesion and social well-being.
Pacific children have relatively high levels of incidental physical activity (such as walking to school), although they participate less than other groups in organised leisure and sport. The 2002 National Children’s Nutrition Survey found that Pacific children were more likely than European children to be the most active, and the least likely to be the least active. They were also more likely to walk or bike to school (Ministry of Health, 2003). However, the New Zealand sport and physical activity surveys (conducted in 1997/98, 1998/99, and 2000/01) by Sport and Recreation New Zealand (SPARC) found that Pacific children had higher levels of inactivity than other groups. This may be because Pacific children have higher rates of incidental activity, but lower rates of participation in organised leisure and sport, which is what SPARC measured.
Research findings about adult levels of activity are mixed. The New Zealand Health Survey (Ministry of Health, nd, f) found that only about half of New Zealand’s total population, and slightly fewer Pacific peoples (46.1 percent), were sufficiently active to gain any health benefits3. Pacific peoples were the most sedentary group (undertaking less than 30 minutes of physical activity in the previous week) – 19. 4 percent – and were 40 percent more likely to be sedentary than the total New Zealand population. SPARC’s 2008 Active NZ Survey used the same criteria as the New Zealand Health Survey, and had similar findings.
Life at Faith City
‘Life-changing’ is how participants have described the Life 12 Week Weight Loss Challenge run by Manukau’s Faith City Church.
The first Life challenge was held late in 2010. Thirty-three mostly Pacific women completed the three-month course, which is designed for those who are very overweight and are keen to eat more healthily and be more active.
Life involves training four times a week, sessions with a nutritionist and three weekend retreats to help address the psychological reasons behind obesity and unhealthy lifestyles. The training sessions include gym workouts, weights, running, boxing, aquarobics, and hill running. Day one of the challenge requires participants to push four-wheel drive vehicles around a carpark.
Faith City project manager Essendon Tuitupou says women in last year’s challenge called it “life-changing”. On average, each lost 3.3kg with one woman shedding 18.4kg and 13cm from her waist.
“It’s about a lifestyle, as opposed to a programme, and the community fixing the community’s problems. The biggest thrill for me is when those ladies go away and continue with physical activity themselves.”
Members of the group forged strong friendships and have continued to train together. Several women have participated in, or are training for, long-distance running events and, if they can raise the money, a core group hopes to one day complete the New York Marathon.
Following the successful delivery of Life for women last year, a second Life challenge started in February 2011, with about 30 men taking part.
Faith City received a Fonua Mo’ui Pacific Healthy Lifestyles Community Grant to deliver Life, as part of the Counties Manukau District Health Board’s Creating a Better Future strategy. The Creating a Better Future strategy (www.betterfuture.co.nz) addresses the burden of disease caused by unhealthy diets, lack of physical activity, smoking, and unsafe alcohol use. Fonua Mo’ui grants are designed to improve Pacific peoples’ health by supporting initiatives that promote healthy eating and physical activity.
New Zealand has one of the highest obesity rates among OECD countries (Ministry of Social Development, 2009). Obesity is associated with many adult health conditions such as cardiovascular disease, type 2 diabetes, cancer, and psychological and social problems (Ministry of Health, 2008e). Obesity is primarily caused by poor nutrition and sedentary lifestyles (Ministry of Health, 2008e). Obesity is more prevalent in neighbourhoods with fewer economic resources, and is likely to continue from childhood into adulthood.
In 2006/07, 25 percent of the total New Zealand population aged over 15 years was obese. This is a significant increase from 19 percent in 1997. Of children aged 2–14 years, 8.3 percent were obese. Of Pacific children, 23 percent were obese and another 31 percent were overweight. For Pacific adults, the risk of obesity was 2.5 times higher than that for the overall New Zealand population and over 2.5 times higher for Pacific children (Ministry of Health, 2008a).
Smoking is the biggest single cause of preventable morbidity (the non-death impacts of disease) and mortality in OECD countries, including New Zealand, and is well recognised as the leading risk factor for many forms of cancer, respiratory disease, and cardiovascular disease in adults. Exposure to cigarette smoke (during a mother’s pregnancy and in childhood) is recognised as a major risk factor for sudden unexplained death in infancy syndrome and respiratory illness (Ministry of Health, 2005).
Smoking is an important contributor to inequalities in life expectancy between ethnic groups. Compared to the reference group of decile 1 Europeans with the greatest life expectancy, the total years of life lost were 9.5 years for Pacific men and 7.1 years for Pacific women. Smoking accounted for 37 percent of this loss for men and 13 percent of the loss for women (Ministry of Health, 2001a).
More Māori and Pacific peoples smoke (45 percent and 31 percent, respectively) compared with the total New Zealand population (20.7 percent) (Ministry of Health, 2008k). In line with trends in the total population, the number of Pacific adults who regularly smoke has declined to levels below those of 1996/97. Overall, smoking rates among young people have also declined. However, the Youth 2007 Survey found that twice as many Pacific students are regular smokers compared with European students.
Living in a house with a smoker influences children and young people to take up smoking, and contributes to respiratory and other childhood illnesses. In 2006, 48.1 percent of Pacific children under the age of 15 years lived in a household with a smoker (Craig et al, 2007, p165). Interestingly, the rate of parents ‘smoking at home’ was much lower than overall parental smoking rates, indicating that approximately half of Pacific families with smokers do not support smoking inside the house.
Youth smoking rates are a key predictor of adult smoking behaviour, as taking up smoking early increases the risk of smoking-related diseases. The 2008 Action on Smoking and Health (ASH) Survey (Paynter, 2010) found that 12.0 percent of all young people aged 14–15 years (year 10) smoked at least once a month, and 6.9 percent once a day. Sixteen percent of Pacific girls smoke at least once a month compared with 10 percent of European girls; for boys it is 12.4 percent and 7.8 percent, respectively. Since 1999, the number of smokers in the total New Zealand population has been trending down for all groups including Pacific boys and girls (Paynter, 2010). The Youth 2007 Survey found that Pacific students regularly smoked at twice the rate of European students, and that rates were highest among Samoan and Cook Island students (Helu et al, 2009).
The 2006 Census showed that there are sub-group differences within the Pacific population. Fijians are the least likely to be regular smokers (20.3 percent). Tokelauans are the most likely to be regular smokers, followed by Cook Islanders (38 percent), Niueans (33 percent), Tongans (29 percent), and Samoans (28 percent). Young Pacific men smoke more than young Pacific women. Smoking is particularly common for young Samoans and Cook Islanders, older men, Pacific-born men – particularly Tongan men, and younger New Zealand-born women, particularly Tokelauan and Cook Island women.
Traditionally, Pacific men were more likely to be smokers than Pacific women. Men born in the Pacific Islands are more likely to smoke than their New Zealand-born counterparts (60.8 percent and 45.7 percent, respectively). However, more women now smoke, particularly in the younger age groups. Pacific women are more likely to smoke if they are born in New Zealand compared with those born in Pacific countries (54.3 percent and 39.2 percent, respectively). This may be due to the fact that smoking was traditionally a male activity in the Pacific Islands. It appears Pacific women born in New Zealand have been influenced by local smoking behaviour.
Potentially hazardous drinking carries a high risk of damage to physical and mental health; including death and injury due to traffic accidents, drowning, suicide, and violence. Alcohol problems are also associated with high-risk sexual behaviour and consequent problems.
Fewer Pacific peoples drink alcohol than the general population. Pacific peoples who drink alcohol are more likely to be New Zealand-born and young (Alcohol Advisory Council of New Zealand, 2009). Those who do drink alcohol have nearly double the hazardous drinking rate of Europeans. More Pacific men than women drink in a hazardous way (Ministry of Health, 2008a)4. Overall, Pacific adults experienced greater levels of harmful consequences subsequent to drinking and those who drank reported greater alcohol consumption (Huakau et al, 2005).
According to the results of a 2003 Alcohol Advisory Council (ALAC) survey that looked at youth access to alcohol, Pacific young people are more likely to be non-drinkers compared with other ethnicities. The survey found that about two-thirds of Pacific young people (compared with just under half of young people overall) are non-drinkers (McMillen, Kalafatelis & De Bonnaire, 2004). However, among young people who do drink, Pacific youth consumed, on average, 6.9 standard drinks. Overall, those surveyed consumed 4.7 drinks (Ministry of Health, 2008i). The proportion of Pacific young people (32 percent) who reported ‘binge drinking’ at least once in the previous four weeks was slightly lower than European young people (Helu et al, 2009).
Drinking alcohol at an early age is associated with greater adverse health outcomes (Odgers et al, 2008). Drinking socially at an early age can cause increased short-term harm such as motor vehicle injuries and deaths, suicide, as well as longer-term harm from alcohol dependence, abuse, and related medical conditions (Alcohol Advisory Council of New Zealand, 2002). Among young people, Cook Islanders are the heaviest drinkers with the most harmful drinking patterns, while Samoan men and women, and Tongan women are the least likely to drink (Ministry of Health, 2008i). An ALAC study also found that Pacific young people, born and raised in New Zealand, consumed alcohol more frequently, pointing to the influence of acculturation factors (Alcohol Advisory Council of New Zealand, 2009).
Problem gambling can result in a range of negative effects for the gambler, their families, and the wider community. These include financial, relationship, and employment difficulties, adverse physical and mental health outcomes, and higher rates of crime (Francis Group, 2009).
The 2006/07 New Zealand Health Survey classified 1.7 percent of all Pacific adults as ‘problem gamblers’, 3.5 times the proportion of problem gamblers in the total adult population. Similarly, 7.6 percent of the Pacific population reported experiencing problems as the result of someone else’s gambling, double the number of adults in the total population who reported being affected by someone else’s gambling. Overall, those aged 35–44 years had the highest prevalence of problem gambling (Ministry of Health, 2008a). The Youth 2007 Survey showed that 3 percent of Pacific students reported spending more than 30 minutes a day gambling compared with 0.5 percent of European students.
National prevalence studies conducted between 1991 and 2006/07 have shown that Pacific peoples are at substantially greater risk of developing gambling problems than the general population. Most of the gambling-related harm experienced by Pacific peoples (65.1 percent of Pacific men and 83.0 percent of Pacific women) is associated with non-casino gaming machines. These machines are concentrated in more deprived communities (Francis Group, 2009). Those Pacific people who used face-to-face counselling services were experiencing more severe harm5 than those from other ethnic groups (Francis Group, 2009).
Beliefs, behaviours, attitudes, and knowledge
People’s beliefs and practices in relation to health and illness influence the ways they engage in health-promoting behaviours and access health services. Pacific peoples’ understandings tend to be characterised by a holistic perspective, where healthy and strong families are the basis for the well-being of individuals and communities.
Pacific peoples’ beliefs and practices may be different from mainstream understandings about health and illness. Suicide, for example, can be seen as the “ultimate rejection of one’s family” and a bereaved family can experience a “sense of failure to adequately care for and support the individual who is ill” (Beautrais et al, 2005). Suicide prevention, support, and other interventions must therefore be tailored to work with and within existing beliefs and attitudes.
Similarly, culturally-based attitudes towards sex mean that Pacific youth often have reduced access to information regarding sexual health. Parents are less available to provide advice, as it is considered culturally inappropriate for children to discuss sexual health with their parents. Teenagers are concerned that parents will discover that they are sexually active. Pacific young people are less likely to access sexual health services as they are concerned that others may find out (Ministry of Health, 2008i). Appropriate sexual and reproductive health information needs to be made available by alternative means.
The relatively low success rate of smoking cessation programmes among Pacific peoples may be related to the belief, held by a relatively large number of Pacific smokers (24. 6 percent), that nicotine replacement therapy is more harmful than smoking cigarettes. Pacific smokers are also most likely to believe that smokers should be able to quit without the assistance of a programme (Ministry of Health, 2009a). These findings show that beliefs regarding the nature of nicotine addiction and cessation options need to be changed in order to increase the number of Pacific people who give up smoking. Nicotine replacement therapies are considered ineffective by a large number of Pacific peoples, and a relatively low proportion of Pacific peoples in south Auckland made claims for subsidised nicotine replacement therapies. Although more Pacific people are likely to smoke, 60 percent fewer Pacific people used nicotine replacement therapies compared with Europeans (Thornley, Jackson, Mcrobbie, Sinclair, & Smith, 2010). A Counties Manukau study of Pacific and Māori parents showed that these groups had a low awareness of other available cessation options (Glover & Cowie, 2010). This clearly indicates that these groups of smokers need to be better informed.
The traditional respect for authority figures in Pacific communities can make it more difficult for Pacific people to question their health professionals and demand more effective services (Statistics NZ and Ministry of Pacific Island Affairs, 2010). This can lead to Pacific peoples being disempowered in the health system, not receiving services as needed, and therefore experiencing poorer outcomes.
Effectiveness of health services for Pacific peoples
Differences in health outcomes are also influenced by Pacific peoples’ access to health services and their experience of effective preventive initiatives, treatment, and/or management of health conditions.
Primary health-care services
Access to timely and effective health care is an important determinant of health outcomes, for both death rates and the impact that chronic conditions have on Pacific peoples. Primary care refers to health care that is provided in the community. It includes the provision of health education and prevention services, coordination and treatment of less serious illnesses, and referral to secondary care.
Other than emergency departments, primary care services are the first step into the health system. They are crucially important in identifying serious illnesses that are then managed in conjunction with secondary and tertiary services. Primary care services have historically been centred around GP and practice nurse services, but more recently these have been expanded to involve multi-disciplinary teams and a broader range of services.
Pacific peoples do access preventative child health services. In 2006, just over 90 percent of New Zealand infants were enrolled with Plunket, which provides clinical assessment, health promotion and parent education services. Pacific infants (87.2 percent) were less likely than European, but more likely than Māori infants to be enrolled (Craig et al, 2007, p121).
Immunisation provides protection against a range of communicable diseases, and is considered to be one of the most cost-effective public health interventions.
For the 12 months to October 2010, 89 percent of Pacific two-year-olds were fully immunised, compared with 87 percent of European two-year-olds. Furthermore, the seven District Health Boards (DHBs) with the largest Pacific populations all had immunisation rates between 85 and 93 percent.
Immunisation rates are high in the Pacific Islands, where immunisation is considered to be an ingrained practice.
From 2004, the ‘MeNZB’ vaccination campaign was implemented in response to the meningococcal disease epidemic that started in 1991. The campaign achieved high vaccination coverage for Pacific peoples, above those for other ethnic groups.
Overall, coverage for three doses for the under-five-years age group – immunised through primary care services – was 74 percent but the coverage within the Pacific population was 83 percent.
Similarly, for those aged 5–17 years – immunised through school health services – the overall coverage for three doses was 86 percent, but the coverage within the Pacific population was 97 percent.
The results demonstrate that effective means are available to engage with Pacific peoples and deliver care services.
Source: Ministry of Health nd, a, nd, b; CBG Health Research Ltd, 2006.
Screening identifies potential health problems at an early stage in people who do not show any symptoms. Screening improves health outcomes by offering effective interventions before diseases become advanced. Effective screening is dependent on well-structured and organised processes and the monitoring of indicators of process quality.
Breast and cervical cancer screening programmes
Breast and cervical cancer screening programmes have been effective in reducing mortality in the general population. An increase in the uptake of cervical screening and the introduction of the HPV vaccination programme in 2008 (which has reported high coverage among Pacific girls (Minister of Pacific Island Affairs, 2010) should contribute to lower incidence of, and deaths from, cervical cancer in the future.
BreastScreen Aotearoa (BSA)
Biennial coverage rates (or the number of women receiving a mammogram) from 2007 to 2009 for women aged 45–69 years were 55.9 percent for Pacific women compared with 66.7 percent for non-Māori, non-Pacific women (Page & Taylor, 2010). The levels of coverage are below the target of 70 percent of all eligible women, but there has been a sustained increase in coverage for Pacific women. One of the providers, BreastScreen South, has reached the 70 percent target for both Māori women and Pacific women (National Screening Unit, nd, a). BreastScreen South used a communications campaign where Māori and Pacific women were the priority audience, as it was apparent they were groups who were less familiar with the service (National Screening Unit, nd, b).
National Cervical Screening Programme
Participation in cervical screening differs markedly between population groups. In 2007, 47.5 percent of eligible Pacific women (aged 20–69 years) reported having had a cervical smear in the last three years, compared with 71.5 percent of non-Pacific women. For the overall population, the target coverage is 75 percent (Massey University, Centre for Public Health Research, 2008). From 2011, the coverage target will be 80 percent (National Screening Unit nd, e).
Since 2007, National Cervical Screening Programme communications campaigns have been particularly focused on encouraging more Māori and Pacific women to have regular smears (National Screening Unit nd, c). From August 2007 to April 2008, the National Screening Unit reported a 9.9 percent increase in uptake among Pacific women, compared with a 2.4 percent increase in uptake for the total population, in addition to greater awareness of the importance of having regular smears and the screening services available (National Screening Unit nd, d).
Enrolment in primary care (with a dedicated provider) has contributed to improved access to screening. Programmes with a strong community-support focus, including provision of transport to attend appointments, have also had a positive effect on cervical screening participation rates.
Cost is recognised as a continued barrier and the Ministry of Health supports subsidised cervical screening for groups where the uptake of screening services is lower (H Lewis, personal communication, October 2010).
The Primary Health Care Strategy (Ministry of Health, 2001b) established primary health organisations (PHOs) to provide structures for the local delivery of primary health-care services. Each PHO has an enrolled population, and is responsible for providing services to this population.
In October 2007, nearly 100 percent of Pacific peoples were enrolled with a PHO6. Craig et al (2007) reported that Pacific children and young people had higher enrolment rates compared with non-Pacific people. Fifteen percent of Pacific peoples were enrolled with a Pacific PHO and the remainder with a mainstream PHO (Ministry of Health, 2010c). Seven PHOs had over 10,000 Pacific peoples enrolled. All of these were in Auckland6.
The development of Pacific health providers is a success story. Pacific primary care providers deliver integrated services that include health promotion, primary care, secondary care, and social services. They aim to provide services that incorporate Pacific cultural care and language components to ensure the services are more appropriate for, and responsive to, Pacific peoples. Access to care has been improved through lowering fees, providing local facilities, and giving nurses a greater role in primary care. Pacific providers have shown better results for the management of patients with long-term conditions than other providers (Ministry of Health, 2010c).
Accessibility of services
The National Primary Medical Care Survey of 2001/02 showed that on average, Pacific peoples reported one less visit to a GP than the whole sample (Davis, Suaalii-Sauni, Lay-Yee, & Pearson, 2005). Subsequently, however, the New Zealand Health Survey 2006/07 (Ministry of Health, 2008d) showed that the adult age-standardised average number of visits in the previous 12 months to a primary health-care service was 3.6 for Pacific peoples, and 3.1 for the whole population. Pacific children were as likely to access care as other groups. Improvements in the annual consultation rate coincide with the implementation of the Primary Health Care Strategy (Ministry of Health, 2001b) and the reduction in fees to access primary care.
To access services, people must first be aware that the services are available and that they are needed. Evidence suggests that many Pacific peoples are often unaware of the government services available to them (Koloto & Associates Ltd, 2007; Paterson et al, 2004). This demonstrates ineffective communication by health information services and providers.
In the New Zealand Health Survey 2006/07, just over 11 percent of Pacific peoples reported having an unmet need for GP services in the previous 12 months. The main reason cited was cost (33. 4 percent), followed by lack of time, lack of availability of a suitable appointment, and not wanting to make a fuss. Pacific peoples were significantly more likely than non-Pacific people to cite cost as a reason for an unmet GP need. Cost is also a factor in the collection of prescribed medications (Jatrana, Crampton, & Norris, 2010). Although subsidies for primary care services have been increased, there is evidence that cost is still a barrier for Pacific peoples, and the consultation rate may not reflect Pacific peoples’ true level of health-care need.
In 2006, the proportion of Pacific children and young people aged under 18 years who received Accident Compensation Corporation funding (the Independence Allowance or a lump sum payment) to support physical disabilities was around half that of the rest of the population (Clark, MacArthur, McDonald, Simons, Carlson, & Caswell, 2007). This may be due to a combination of factors, including poor communication of services by providers and difficulties managing the required application processes. For example, in education, difficulty with application processes was one of the main reasons identified for poor access to supplementary support (particularly when language is a barrier) (Clark et al, 2007; Rivers, 2005). Providers not communicating their services well to Pacific parents and communities (Fa’amausili-Banse cited in Coxon, Anae, Mara, Wendt-Samu & Finau, 2002) and different attitudes to illness and disability were also identified as barriers for Pacific peoples (Rivers, 2005; Statistics NZ and Ministry of Pacific Island Affairs, 2010).
Effectiveness of services
The benefits of health care are dependent upon the quality of care received as well as accessibility of care. The quality of health care is in part determined by interpersonal care; the interaction between health-care professionals and health-care users or their caregivers. Underlying good interpersonal skill are communication skills, the building of trust, understanding and empathy, the discussion and explanation of the patients’ symptoms, and involvement in decisions regarding management or treatment of a patient’s condition (Campbell, Roland, & Buetow, 2000). Patient-centred care improves health outcomes, and encompasses concepts such as “shared decision making” and “informed choice” (Robb & Seddon, 2006).
The National Primary Medical Care Survey showed GPs were less likely to report high rapport with Pacific patients. It was considered that this may reflect the difficulties of working through caregivers during the consultation, or generational or cultural differences (Davis et al, 2005). The New Zealand Health Survey 2006/07 showed continuing lower levels of interpersonal communication measures between Pacific peoples and their GPs, compared with the overall population. During primary care consultations, 87.2 percent of Pacific adults reported that they were treated with respect and dignity all the time, and 68.2 percent reported that their health-care professional had discussed their health care and treatment as much as they wanted (Ministry of Health, 2008d).
Health literacy refers to the ability to understand and use health information. It impacts on the ability of an individual to communicate with health professionals, to discern what good advice is, and to translate this into action. Those with limited health literacy have worse health status than those with adequate health literacy. Older people, those with more limited education, lower socio-economic groups, and those whose primary language is not local tend to have more limited levels of health literacy (Adams et al, 2009). The Adult Literacy and Life Skills Survey 2006 showed that, overall, the literacy of Pacific peoples was lower than other ethnic groups (Statistics NZ and Ministry of Pacific Island Affairs, 2010). Pacific peoples experience other factors that contribute to limited health literacy, such as lower socio-economic status and language difficulties.
The average time spent annually with GPs during visits is a key indicator of access and use of primary care. The National Primary Medical Care Survey found that Pacific, Māori, and Asian people spent significantly less time with GPs, after controlling for a range of other variables. Overall, Pacific patients spent an average of 18.8 minutes less time annually with GPs than European patients. This increased to an average of 24.1 minutes less time among those living in areas with the fewest economic resources (Crampton, Jatrana, Lay-Yee, & Davis, 2007). These findings are concerning given the documented high health needs of Pacific peoples, particularly the prevalence of chronic health conditions.
Cultural competence is the ability of individuals and systems to understand and appreciate the differences and similarities within and among groups. Services can be tailored to patients’ needs by drawing on cultural components. Cultural competence training of professionals improves patient satisfaction and the number of patients continuing with agreed medical care plans. The New Zealand Health Practitioners Competence Assurance Act 2004 requires professional bodies to ensure that set levels of cultural competence are met by practitioners (Tiatia, 2008). This applies to both nurses (Nursing Council of New Zealand, nd) and doctors (Medical Council of New Zealand, 2006). The Medical Council of New Zealand has highlighted and promoted cultural competence with reference to Pacific peoples, (Medical Council of New Zealand, 2010) and supporting Pacific cultural competence initiatives is one of the actions identified in ‘Ala Mo’ui: Pathways to Pacific Health and Wellbeing 2010–2014 (Minister of Health & Minister of Pacific Island Affairs, 2010).
The evidence in the ‘Overall Health of Pacific peoples in New Zealand’ section of this report, particularly the high amenable mortality rates, suggests that Pacific peoples receive less effective preventive and treatment services from the health system. Ambulatory-sensitive hospitalisations (ASH) are admissions that are potentially avoidable through primary care interventions. These are a key indicator of the effectiveness of the primary health-care system. Between 1996/97 and 2003/04, the rate of ASH increased for Pacific peoples more than three times as rapidly as it did for Europeans. In 2006/07, the ASH rates for Pacific peoples were the highest of all ethnic groups, and twice that of non-Māori, non-Pacific people. However, rates did decline for Pacific children aged 0-4 years (Ministry of Health, 2008c).
There is some evidence that the delivery of effective health care to Pacific peoples is improving. Between 2001 and 2007, the proportion of people with diabetes receiving an annual check through the Get Checked Programme has increased, including for Pacific peoples, who have higher coverage than other ethnic groups. Prescription of statin medication also increased markedly for all ethnic groups, including Pacific peoples (Ministry of Health, 2008b). In a study of people with both type 1 and type 2 diabetes in Counties Manukau, access to tests and appropriate medication was consistent across ethnic groups (Smith et al, 2010). A study of patients with type 2 diabetes in south and west Auckland showed Pacific peoples, who visited a regular GP, had a higher average number of consultations, equivalent frequency of testing, but worse glucose control. They were less likely to be on a statin, despite higher serum lipids compared with the total population (Robinson et al, 2006).
Overall, Pacific peoples receive less effective care. Access to care and the quality of care is improving but outcomes are not equivalent to other ethnic groups. The reasons for this are complicated, and seem to include a combination of late presentation, receiving appropriate medication and treatment less often, and less effective ongoing management. This is influenced by the cultural attitudes and expectations of both Pacific peoples and those in the health system, and by levels of financial resources. Improved cultural competence of services will improve the quality of consultations and services, promote improved health-care delivery, and improve health outcomes.
Secondary care services
Secondary care includes services provided by specialists, as well as in-patient and out-patient care in public and private hospitals. Secondary care services are normally accessed by referral from primary care or hospital emergency departments.
According to the 2006/07 New Zealand Health Survey, just over one in five Pacific peoples reported using public hospital services (including emergency departments) in the previous 12 months. This was similar to the number of non-Pacific people who used public hospital services. Pacific peoples were however, significantly less likely to use private hospitals. Only 21.2 percent of Pacific adults compared with 31 percent of non-Pacific adults used medical specialists in the previous 12 months. Pacific peoples were even less likely to visit medical specialists when the specialist was located at a private facility. Similarly, medical insurance, which can allow more timely access to health care, is held by half as many Pacific (19 percent) as non-Pacific adults (38. 6 percent) (Ministry of Health, 2008a).
‘Did-not-attend’ rates for out-patient appointments appear to be consistently higher among Pacific peoples. For example, the Capital and Coast DHB found that the proportion of Pacific peoples who did not attend out-patients appointments was 17.1 percent, compared with an overall rate of 9.1 percent. The higher rate among Pacific peoples may reflect the barriers Pacific peoples face in accessing services, including getting time off work, transport difficulties, cultural beliefs, and a lack of cultural responsiveness (Ministry of Health, 2008f).
Surgical admissions (which tend to be elective rather than emergency) are lower for Pacific peoples. Access to coronary artery bypass grafts (CABG) operations, angioplasties, and major joint-replacement operations has improved (Ministry of Health, 2006b). While the number of admissions for coronary operations is low compared with the need experienced by Pacific peoples (Tukuitonga & Bindman, 2002), the inequalities in angioplasty operations are narrowing. Between 1999 and 2005, there was a larger growth in the number of Pacific peoples receiving angioplasties than in the number of non-Māori, non-Pacific peoples receiving angioplasties (Ministry of Health, 2006b). The incidence of ischaemic heart disease among Pacific peoples suggests that this group would have a greater need for angioplasties. However, among Pacific peoples, the standardised discharge rates for angioplasties were about 20 percent lower than rates for the general population.
Health is strongly influenced by a broad range of cultural, social, economic, and environmental factors. In general, people with fewer socio-economic resources tend to have poorer health outcomes due to a combination of reduced material resources, greater exposure to health risks and behaviours, greater psychosocial stress, and reduced access to health services.
Many Pacific peoples have not experienced success in the education system, and therefore tend to have lower incomes and live in communities with the fewest economic resources. Despite this, Pacific peoples are actively involved in their communities and have strong social and cultural resources with strong family ties, church affiliation, and community support. These community ties provide protection from some of the worst consequences of illness, and health services can be promoted to Pacific peoples through community organisations.
Lower incomes mean that many of the conditions or factors that support good health, such as good nutrition and quality housing, are less accessible. Pacific peoples experience greater exposure to risk factors such as smoking, alcohol, and poor nutrition, with Pacific youth being particularly at risk. Exposure to these risk factors contributes to a greater incidence of chronic diseases (such as diabetes, stroke, and ischaemic heart disease) among Pacific peoples. Alcohol consumption is associated with a greater risk of injury through accidents and violence. Addressing these risk factors will improve Pacific peoples’ health outcomes.
People’s beliefs and practices in relation to health and illness influence their behaviour and how they access health services. For example, attitudes to sexual health act as a barrier to Pacific peoples accessing sexual health services and protecting their sexual health. Lack of knowledge of tobacco addiction and smoking cessation interventions may prevent Pacific peoples accessing cessation services and traditional respect for authority may prevent Pacific peoples demanding the best care within the health system.
1. The estimate of the socio -economic contribution is based on analysis undertaken in relation to the impact of socio-economic inequality on the difference between the Māori and the European or other ethnic group in the NZ Census-Mortality Study. The Pacific population sample was insufficient to allow for the same analysis.
2. The average hourly wage for the June 2009 quarter was $18.92 compared with $22.96 for the total New Zealand population, and the average weekly income was $761, compared with $930. (Statistics New Zealand, 2009). From this low base about 85 percent of Pacific peoples are sending remittances overseas (Money Pacific, 2010).
3. That is, they were physically active for at least 30 minutes a day, for at least five days in the previous week.
4. The survey uses AUDIT, which is a ten-item questionnaire covering alcohol consumption, abnormal drinking behaviour, and alcohol-related problems.
5. As determined by ‘SOGS-3M’ screening scores.
6. This data is from the Enriched CBF Register produced by HealthPac at the Ministry of Health.