Climate Change and Pacific Health

21

02 02

SEPTEMBER 2018

Climate Change and Pacific Health IN THIS VOLUME

The Nexus between Climate Change, Mental Health, Wellbeing and Pacific Peoples Climate change – transitions, tipping points and typhoons The Health Impacts of Climate Change Identifying what healthier lives means to Pacific peoples Health literacy of Pacific mothers in New Zealand is associated with noncommunicable disease risk factors. Mental health and wellbeing of Pacific students starting University in New Zealand The impact of living with type 2 diabetes: a descriptive qualitative case study with four Pacific participants. Engaging Dunedin New Zealand Pacific People in Falls Prevention Rethinking and Establishing a Dental Collaboration in the Pacific Region Cytisine as an alternative smoking cessation product for Pacific smokers in New Zealand. Short history of the post-graduate surgical training in Fiji - where to from here?

E sui faiga ae tumau fa’avae (Samoan) The form changes, but the underlying principles remain Dua ga na siga ni cola qele (Fijian) Be super productive every day

ISSN 2422-8656

Contents

VOLUME 21, ISSUE 2, SEPTEMBER 2018

EDITORIALS Number

Page

The Nexus between Climate Change, Mental Health, Wellbeing and Pacific Peoples Jemaima TIATIA-SEATH, Yvonne UNDERHILL-SEM, Alistair WOODWARD

47-49

Climate change – transitions, tipping points and typhoons Alistair WOODWARD

50-51

The Health Impacts of Climate Change Colin TUKUITONGA

52-53

ORIGINAL RESEARCH Identifying and overcoming barriers to healthier lives Ridvan FIRESTONE, Tevita FUNAKI, Sally DALHOUSIE, Akarere HENRY, Mereaumate VANO, Jacqui GREY, Andrew JULL, Robyn WHITTAKER, Lisa TE MORENGA, Cliona Ni MHURCHU

54-66

Health literacy of Pacific mothers in New Zealand is associated with sociodemographic factors and non-communicable disease risk factors: surveys, focus group, interviews. Losi SA’ULILO, El-Shadan TAUTOLO, Victoria EGLI, Melody SMITH

67-70

Mental health and wellbeing of Pacific students starting University in New Zealand Faafetai SOPOAGA, Jacques VAN DER MEER, Shyamala NADA-RAJA, Tim WILKINSON, Sarah JUTEL

71-79

Engaging Dunedin New Zealand Pacific People in Falls Prevention Troy RUHE, Debra L WATERS, Rose RICHARDS

80-88

SHORT REPORT Cytisine as an alternative smoking cessation product for Pacific smokers in New Zealand. Vili NOSA, Kotalo LEAU, Natalie WALKER The impact of living with type 2 diabetes: a descriptive qualitative case study with four Pacific participants Kirsten COPPELL, Trudy SULLIVAN, Darlene PUPI

89-95

96-102

PERSPECTIVE Short history of the post-graduate surgical training in Fiji - where to from here? Jitoko K. CAMA, Sonal NAGRA

103-107

Rethinking and Establishing a Dental Collaboration in the Pacific Region Le’Roy TATUI, Judith MCCOOL, Vili NOSA

108-110

About the Pacific Health Dialog

111-112

Cover picture: Children amongst damaged house in Tonga after Cyclone Gita. Acknowledge: Agence France Presse

45

Tiatia-Seath J, et al. Pacific Health Dialog 2018; 21(2):47-49. DOI: 10.26635/phd.2018.911

Editorial

OPEN ACCESS

The Nexus between Climate Change, Mental Health and Wellbeing and Pacific Peoples Jemaima TIATIA-SEATH,1 Yvonne UNDERHILL-SEM,2 Alistair WOODWARD3 1Senior Lecturer, Co-Head of School. Te

Wānanga o Waipapa, School of Māori Studies and Pacific Studies, University of Auckland. [email protected] 2Director, New Zealand Institute of Pacific Research, University of Auckland, 3Head of Department, Epidemiology and Biostatistics, University of Auckland

Very few people in the Pacific region will be unmarked by climate change, particularly as half the population live within 1.5 kilometres of the ocean.1 Noticeable rises in sea-level, more frequent cyclones and floods, and changes to seasonal weather are attributable to climate change in the area.2 Extreme weather has significant implications for Pacific peoples’ health outcomes.1 For example, Niue’s only hospital was devastated by cyclone Heta in 2004, extreme flooding in Papua New Guinea in 2008 destroyed vital hospital equipment1 and rises in temperature have contributed to the increasing prevalence of malaria and dengue fever across the Pacific region.3 Much of the health research on climate change in the Pacific is dominated by the vulnerability of ecosystems and only recently have mental health impacts of climate change been recognised by public health experts.4 Although the research is still limited, it is projected that disruption resulting from climate change will have serious damaging effects on mental health worldwide. 5 Impoverishment, political and cultural rigidities, economic dependency and environmental degradation create particular vulnerabilities, which are compounded by the effects of climate change. These five characteristics are variously shared throughout the Pacific, and individually they exacerbate emerging mental health and wellbeing issues related to climate change.6 The fact that the Pacific is commonly affected by natural disasters, even before the onset effects of anthropogenic global warming, provides further rationale to investigate further the interconnection between climate change and mental health risks. Climate change has direct and indirect effects on mental health risks for Pacific peoples.5 A direct impact occurs via the increased frequency and severity of natural disasters.7 This may be a compounding effect; little is known about the impact of natural disasters upon those with a pre-

existing mental health disorder.6 Natural disasters disrupt access to public health services and may obstruct access to appropriate medication and care. Indirect effects of climate change include population movements, as a result of urbanisation, economic collapse, and the degradation of coastal cities.5 Additionally, postdisaster devastation to the physical environment, in turn, may affect social, community and economic factors related to place, which may induce stress, anxiety and displacement.7 Albrecht’s ‘solastalgia,’ is the feeling of distress caused by an environmental transformation affecting a home environment.8 It may be considered a ‘pyschoterratic’ illness, whereby peoples’ mental wellbeing is threatened by the severing of ‘healthy’ connections to their homeland.8 It also draws on the concept of nostalgia where instead of a longing for home when away, it is a longing for a particular ‘state’ or idea of home while living at home. This is caused by changes in the natural environment of one’s home like floodings, droughts, land erosion, or mining. Solastalgia occurs when there is the lived experience of the physical ruin of home.8 It may be a particularly useful concept in describing the nexus between mental health and wellbeing and climate change. As migration is often seen as a ‘last resort,’ it is likely that many will experience solastalgia in the Pacific region, as the effects of climate change continue to increase. The question remains, how do Pacific peoples themselves define this type of distress? In an i-Kiribati study, McIver et al. concluded that climate change poses a threat to i-Kiribati livelihood, their country’s sovereignty and the national identity of its inhabitants. This is further exacerbated because little is known about mental health in Kiribati, which makes it more difficult to understand the magnitude and nature of the impacts of climate change on mental health and wellbeing. This may very well be a recurring theme throughout the Pacific as there is little research and data to draw from.9 47


As mentioned, migration is an indirect impact. An estimated 75 million people from the Asia-Pacific region will be forced to migrate by 2050 as a result of climate change.1 Moreover, New Zealand and Australia will become a potential relocation destination for many Pacific peoples. New Zealand was the first country globally to be tested by ‘climate refugees’ seeking protection and resettlement in another country. In particular, in response to a number of cases from Tuvalu and Kiribati. This call to action is timely as the current government proposes to provide climate migration visas for Pacific peoples displaced by rising sea levels. New Zealand’s 2006 national Mental Health Survey - Te Rau Hinengaro, indicated that Pacific peoples have higher 12 month prevalence rates of mental disorder (25%) in comparison to the general New Zealand population (20.7%).10 Pacific adults had the highest rates of anxiety or depressive disorder (12.9 %) when compared with Māori (10.8 %), Asian (7.7 %) and European/Other (6.1 %) ethnic groups.11 Moreover, Pacific peoples reported suicide attempts that were three times the rate of the general population.10 Evidence suggests that Pacific peoples living in New Zealand suffer from high rates of mental illness, yet are less likely than the remainder of the population to access mental health services.12-18 Reasons vary, depending on age, gender identity, cultural identity, socioeconomic position, religion and spirituality, language capabilities, sexual orientation and stigma. However, the motif amongst this evidence is that Pacific peoples need better-equipped culturally competent and specific services. It is believed that those who will be forced to relocate will be at higher risk of mental disorders, due to the cultural loss and stress of climate induced migration.19 An understanding of this by the mental health and wider public health sector in New Zealand is crucial, particularly with regard to service readiness. Mental health and wellbeing services will need to cater to Pacific climate migrants in culturally inclusive and relevant ways, taking in to consideration the distinct reasoning for migration, and forced relocation as a result of climate change and recognising that this will bring new challenges to the already visible barriers to mental health access and appropriateness of services. As is commonly agreed, the post-migration experience of recent migrants is important in the resettlement process. The sociocultural conditions of a host country can have powerful influence on mental health.20 If cultural dimensions of climate change are disregarded, one can expect that both adaptation

and mitigation responses will fail to be effective as they will not resonate with Pacific.21 Whilst questions around the types of adaption strategies are largely unanswered, the planning starts now.5 REFERENCES 1.

Oxfam. Oxfam briefing paper, the future is here: Climate change in the Pacific. 2009, Australia and New Zealand: Oxfam Australia and Oxfam New Zealand. https://www.oxfam.org.nz/sites/default/fil es/reports/The%20future%20is%20hereOxfam%20report-July09.pdf

2.

Secretariat of the Pacific Community. SPC climate change and disaster risk management support activities in Pacific Island countries and territories: Noumea: Secretariat of the Pacific Community. 2013 http://www.spc.int/sites/default/files/wor dpresscontent/wpcontent/uploads/2017/01/SPC-climatechange-support-activities-in-Pacific-Islandcountries-and-territories.pdf

3.

Costello A, Abbas M, Akken A, Ball S, Bell S, Bellamy R. Managing the health effects of climate change. The Lancet, 2009, 373(9676):1693-1733.

4.

Rice SM, McIver LJ. Letter to editor. climate change and mental health: rationale for research and intervnetion planning. Asian Journal of Psychiatry, 2016:16:1-2.

5.

Page LA, Howard LM. The impact of climate change on mental health (but will mental health be discussed at Copenhagen?). Psychological Medicine, 2010;(40):177– 180.

6.

Woodward A, Hales S, Weinstein P. Climate change and human health in the Asia Pacific region: Who will be most vulnerable? Climate Research.1998; 11:31-38.

7.

Berry H. Pearl in the oyster: climate change as a mental health opportunity. Australasian Psychiatry, 2009;17(6):453-456.

8.

Albrecht G, Sartore G-M, Connor L, et al. Solastalgia: the distress caused by environmental change. Australian Psychiatry, 2007:15:95-98.

9.

McIver L, Woodward A, Davies S, Tibwe T, Iddings S. Assessment of the health impacts of climate change in Kiribati. International Journal of Environmental Research and Public Health, 2014;(11):5224-5240.

10. Oakley Browne M, Wells JE, Scott KM, eds. Te rau hinengaro: The New Zealand mental 48


health survey. Wellington: Ministry of Health. 2006. https://www.health.govt.nz/system/files/d ocuments/publications/mental-healthsurvey-summary.pdf 11. Mental Health Commission. National indicators: Measuring mental health and addiction in New Zealand Wellington: Mental Health Commission, 2012. https://www.hdc.org.nz/media/2769/natio nal-indicators-2012.pdf 12. Tiatia J. Reasons to live: NZ-born Samoan young people's responses to suicidal behaviours [Doctor of Philosophy]. Auckland: Community Health, The University of Auckland; 2003 https://www.researchgate.net/publication/ 232607900_Reasons_to_live_NZborn_Samoan_young_people%27s_response s_to_suicidal_behaviours 13. Tiatia J. New Zealand-born Samoan young people, suicidal behaviors, and the positive impact of spirituality. In: Culbertson P, Nelson Agee M, Ofa Makasiale C, eds. Penina Uliuli: Contemporary Challenges in Mental Health for Pacific Peoples. Honolulu: The University of Hawaii Press.. 2007 ISBN 0824831942 14. Tiatia J. Commentary on 'cultural diversity across the Pacific': Samoan cultural constructs of emotion, New-Zealand born Samoan youth suicidal behaviours, and culturally competent human services. Journal of Pacific Rim Psychology: 2012: 1-5. 15. Tiatia-Seath J. Pacific peoples, mental health service engagement and suicide prevention in Aotearoa New Zealand. Ethnicity and

Inequalities in Health and Social Care, 2014:(3):111-121. 16. Mila-Schaaf K, Hudson M. (2009). The interface between cultural understandings: Negotiating new spaces for Pacific mental health Pacific Health Dialog, 2009:15(1):113119. 17. Tamasese K, Peteru C, Waldergrave C, Bush A.. Ole taeao - the morning: A qualitative investigation into Samoan perspectives on mental health and culturally appropriate services. Aust NZ J Psych, 2005;9:300-309. 18. Tiatia J. Pacific cultural competencies: A Literature review. Wellington: Ministry of Health; 2008.https://www.health.govt.nz/system/fi les/documents/publications/pacificcultural-competencies-may08-2.pdf 19. Howard-Chapman P, Chapman R, Hales S, Britton E, Wilson N. Climate change and human health: Impact and adaptation issues for New Zealand. In: R. A. C.Nottage, D. S. Wratt, J. F. Bornman, K. Jones, eds. New Zealand: Future scenarios and some sectorial perspectives. Wellington: New Zealand Climate Change Centre, 2010:112-121. http://www.climatecloud.co.nz/CloudLibra ry/Climate%20change%20adaptation%20i n%20New%20Zealand%20(NZCCC)%20(A 4%20low).pdf 20. Pernice R, Brook J. Refugees’ and immigrants’ mental health: association of demographic and post-immigration factors. The Journal of Psychology, 1996:136(4):511-519. 21. Adger WN, Barnett J, Brown K, Marshal N, O’Brien K. Cultural dimension of climate change impacts and adaptation. Nature Climate Change, 2013;(3):112-117.

49

Woodward. Pacific Health Dialog 2018; 21(2):50-51. DOI: 10.26635/phd.2018.912

Editorial

OPEN ACCESS

Climate change – transitions, tipping points and typhoons Alistair WOODWARD Professor, Head of Department, Epidemiology and Biostatistics, University of Auckland. [email protected]

As I write Hurricane Florence is approaching the east coast of the US. Here is a storm out of the ordinary. It is most uncommon for such a powerful hurricane to reach so far north. The projected rainfall (up to 1.2 meters) is unprecedented. The tidal surge, which may be as high as 5.5 metres, has been experienced only twice since 1851. On no other occasion has a hurricane combined all these features.1 Florence may turn out to be less severe than forecast. But it is a sign of the new times, an era in which climate change is super-charging familiar threats and delivering novel risks. On the other side of the continent, there are wildfires burning in the northern forests, hotter and wider and more prolonged than previously. The smoke from the fires caused Vancouver authorities to issue air alerts throughout July and August and cancel outdoor events because of health concerns. But it is not just the immediate effects that are important. The extensive fires that now occur in the far north each year might trip a switch. The enormous boreal forests may flip from being a net carbon sink to being a net carbon source. In this setting the greenhouse emissions from combustion exceed the capacity of a disrupted biome to take up carbon, accelerating warming and further promoting fire risk. This is the theme of what may be the most important scientific paper of the year, by Will Steffen from the Australian National University and colleagues.2 Published in July, this paper describes the ways in which human activities now overwhelm the planet’s natural systems, and the prospect of “self-reinforcing feedbacks” that drive the Earth onto unexpected and dangerous trajectories. They identify fires in the far north as one possible “tipping cascade”. Other examples include the die off of ocean coral, melting of ice sheets in the Antarctic and Greenland, and destabilisation of the El Nino Southern Oscillation. Just when these tipping points will occur is uncertain. Steffen et al refer to climate models, paleo-climate data and recent experience of the impacts of climate variability, and they conclude that a potential planetary threshold could be crossed at around 2 degrees Centigrade of global

average warming above pre-industrial. In this case, the world might move abruptly to a zone that was never experienced before and is profoundly hostile to human well-being. Here is one more reason to increase our ambition with climate change mitigation, and to take seriously the goal of holding global warming to no more than 1.5 degrees. The small island states, including Pacific nations, were instrumental in the negotations for the Paris climate accord, when a 1.5 degrees goal was added to the final document. Signatories agreed it was necessary to “keep a global temperature rise this century well below 2 degrees Celsius above pre-industrial levels and to pursue efforts to limit the temperature increase even further to 1.5 degrees”.3 The 1.5 degrees goal is important for the Pacific because those who live in this region are in many respects highly vulnerable to even moderate shifts in global climate. Small low islands, especially those in the tropical cyclone belt, which rely on local food sources, with limited supplies of fresh water, are amongst the first to be affected by increased storm activity, rising sea levels, changing rainfall patterns and the damaging effects on local ecosystems of warmer, more acid oceans. If the world moves onto a “Hothouse Earth” pathway, as Steffen et al outline, then the impacts on communities across the Pacific could be devastating. We saw an example of the impacts on health of extreme weather events in last year’s hurricane season in the northern hemisphere. Hurricane Maria was a category 5 storm (the most severe category) that caused severe damage to Puerto Rico and the Dominican Republic. Estimates of the excess deaths in Puerto Rico related to the hurricane are in the order of 3000-4500.4,5 Most of the deaths were not immediate, but occurred in the weeks and months after the hurricane. They resulted from the breakdown of essential services such as power, transport and health care, and the very slow recovery of normal operating conditions. Most at risk were the elderly and

50

Woodward. Pacific Health Dialog 2018; 21(2):50-51. DOI: 10.26635/phd.2018.912 people with chronic life-threatening conditions such as diabetes and cardiovascular diseases. Every super-destructive hurricane sends a message to the high consumption countries that bear the heaviest responsibility for climate change. Mitigation, primary prevention in public health terms, is essential, and while the Paris Accord points in the right direction, its goals and time-scale are too modest. In the Pacific the threat of climate change is a very good reason to invest more heavily in health systems and public health. Disaster preparedness, secure supply chains, safe location of hospitals and health clinics, robust vector control programmes, information systems that are backed up and accessible in all conditions, these are just some of the elements of resilience in the face of natural disasters. But improvements of this nature have an immediate pay off also. Appreciating the new world of climate change, and making changes necessary to limit casualties, will strengthen health care and deliver cobenefits immediately. REFERENCES 1.

Climate change washing away the world we once knew. NZ Herald 14 September 2018

2.

Steffen W, Rockstrom J, Richardson K et al. Trajectories of the Earth System in the Anthropocene. PNAS 2018;115:8252-8259

3.

https://unfccc.int/process-andmeetings/the-paris-agreement/the-parisagreement

4.

Kishore N, Marques D, Mahmud A et al. Mortality in Puerto Rico after Hurricane Maria. NEJM 2018;379:162-170

5.

https://gwtoday.gwu.edu/gw-researchers2975-excess-deaths-linked-hurricane-maria

51

Tukuitonga C. Pacific Health Dialog 2018; 21(2):52-53. DOI: 10.26635/ phd.2018.920

Editorial

OPEN ACCESS

The Health Impacts of Climate Change Colin TUKUITONGA Director General, Pacific Community, Noumea, New Caledonia. [email protected]

Climate change is having significant and damaging effects on communities and economies of the Pacific nations and projected to get worse over the coming decades. The World Health Organization (WHO) estimates an additional 250, 000 deaths annually between 2030 and 2050 due to malnutrition, malaria, diarrhea and heat stress, and over USD two trillion in lost productivity globally.1

While climate change estimates are usually forward looking, here in the Pacific the impact is already being felt. Over the last 10 years, our region has lost countless lives and more than USD two billion due to disasters such as cyclones, tsunamis, flooding and droughts. In Fiji alone, annual losses due to extreme weather events could reach 6.5 per cent of GDP by 2050, with more than 32,000 people pushed into hardship every year. Today, our region is in the unenviable situation of having five of the top 15 nations considered most vulnerable to climate change impact.2 While debate over the existence of climate change continues in some parts of the world, here in the Pacific it has become a fact of life, and mitigating its effects is no longer a matter of politics, but rather one of survival. The health impacts of climate change come about as a result of direct and indirect exposures as well as social and economic disruption and environmental decline. Adverse weather events cause significant damage to critical infrastructure, including health care facilities and critical public health services.3 Climate change acts as a health risk ‘multiplier’ by affecting the social and environmental determinants of health, including safe drinking water, clean air, sufficient food and safe shelter. The effects of climate change on natural and physical systems, that, in turn, alter the number of people at risk of malnutrition, the geographic range and incidence of vector-borne, zoonotic, and food- and waterborne diseases, and the prevalence of diseases associated with air pollutants. Ocean acidification will have negative impact on the health of coral reefs, a critical source of nutrients for fish and other sea life. This in turn will compromise the most important source of protein for Pacific

communities given the heavy reliance on fish and seafood. Adverse impacts of climate change on Pacific economies and human health is compounded by the high prevalence of non-communicable diseases (NCDs) such as diabetes, heart disease and certain cancers. As with climate change, NCDs are having a disproportionate impact in the Pacific region. NCDs are now the leading cause of death, disease and disability in the region. Eight of the 10 most obese nations globally are Pacific Islands, and diabetes prevalence is three to four times higher than elsewhere in the world. Left unchecked, NCDs will cause serious health and social problems for individuals and their families, overwhelm national health systems, and severely limit the development potential of the entire Pacific region.4 At first glance, climate change and NCDs may appear to be serious, but separate challenges. However, many of the causes and solutions to these challenges are interconnected. Climate change fundamentally changes the social, economic, cultural and commercial determinants of health. These changes, in turn, negatively impact the environment in which people live and work, which increases the risk of NCDs among the most vulnerable populations. Conversely, interventions to combat climate change present key opportunities to effectively address NCDs, and actions to reduce the burden of NCDs may have a positive impact on climate change mitigation. For example, shifting to an increased use of renewable energy and investment in active transport systems would not only reduce greenhouse gas (GHG) emissions and air pollution, but would also promote physical activity, contributing to a reduction in NCD incidence. Or consider how food production is managed. Investing in a sustainable food system, based on locally sourced, unprocessed foods, reduces reliance on imported, highly processed food items, and has clear co-benefits in reducing NCDs and mitigating climate change. 52

Tukuitonga C. Pacific Health Dialog 2018; 21(2):52-53. DOI: 10.26635/ phd.2018.920

While many evidence-based, globally agreed interventions have been adopted to reduce the burden of NCDs, up until now these agreements have been weakly implemented. Similarly, international agreements to counteract the effects of climate change, such as the landmark Paris Agreement, are now under pressure, which threatens to reverse both the health gains from economic development and health benefits that accrue from sustainable development. A public health perspective has the potential to unite all actors behind a common cause. Simply put, by combining the research, expertise and political will behind each of these areas, we can create a stronger voice for positive and sustainable change and help to achieve the common goals of both challenges. As a region currently suffering some of the greatest impacts of both climate change and NCDs, the Pacific is well positioned to take the global lead in bringing these issues together and ensuring a more coordinated approach is taken to finding solutions.

Sustainable Development Goals. In the Pacific we are already integrating our work in these areas and showing how a combined approach can help build understanding and create consensus across nations, and dramatically increase the impact of mitigation work. If the same approach can be adopted globally we have a real chance of creating a cleaner, safer, more sustainable and healthier world. REFERENCES 1. World Health Organization. Climate Change and Health Fact Sheet Feb 2018 2. Lee D. Zhang H. Nguyen C. The Economic Impact of Natural Disasters in Pacific Island Countries: Adaptation and Preparedness. IMF Working Paper WP/18/108 3. Climate change and human health – risks and responses. International consensus on the science of climate and health: the IPCC Third Assessment Report. WMO and UNEP

Climate change and NCDs are key challenges for the global community, and our ability to mitigate these challenges will go a long way in determining if we are able to meet national development objectives and international targets, such as the

4. Kessaram T et al. Noncommunicable diseases and risk factors in adult populations of several Pacific islands: results from the WHO STEPwise approach to surveillance. Aust NZ J Public Health 2015 Aug; 39(4):336-343

53

Firestone R, et al. Pacific Health Dialog 2018; 21(2):54-66. DOI: 10.26635/phd.2018.913

Original Research

OPEN ACCESS

Identifying and overcoming barriers to healthier lives Ridvan FIRESTONE, 1* Tevita FUNAKI, 2 Sally Dalhousie, 2 Akarere HENRY, 3 Mereaumate VANO, 3 Jacqui GREY, 4 Andrew JULL, 4 Robyn WHITTAKER, 4 Lisa TE MORENGA,5 Cliona NI MHURCHU4 ABSTRACT Understanding the key determinants of health from a community perspective is essential to address and improve the health and wellbeing of its members. This qualitative study aimed to explore and better understand New Zealand-based Pasifika communities’ sociocultural experiences and knowledge of health and wellbeing. Fifty-seven participants were involved in six separate focus groups. Community coordinators co-facilitated and transcribed the discussions and conducted thematic analysis. The findings suggested two overarching themes: (1) ‘Pasifika experiences on poor health and wellbeing’: were based on sub-themes: (i) ‘recognisable issues’ (e.g., poor diet and lifestyle behaviours); (ii) ‘systemic issues’ that support the perpetual health issues (e.g., lack of knowledge and education) and; (iii) ‘profound issues’ that are often unspoken of and create long-term barriers (e.g., cultural lifestyle and responsibilities). (2) ‘Hopes and dreams’ to improve health and well-being requires: (i) a family-centric approach to health; (ii) tackling systemic barriers; and (iii) addressing community social justice issues. This study provides deepened insights on Pasifika communities’ understanding healthier living in the context of their cultural environment and family responsibilities. If we are to develop effective, sustainable programmes that prioritises health and well-being based on the needs of Pasifika communities, the findings from this study highlight their needs as step forward in overcoming barriers to healthier lives. KEY WORDS: Pacific Islander health, co-design, culture and health, non-communicable diseases INTRODUCTION When Pacific peoples migrated to New Zealand (NZ) in the 1960-70s, it was for a better start in life, as well as, meeting the NZ labour needs postworld war two. However, adaptions and changes to their lifestyles associated with urbanisation and modernisation had significant implications on the traditional Pacific lifestyle (e.g., living and operating communally as a village), which conflicts with the mainstream western lifestyles in NZ (e.g., living as an independent family unit in a neighbourhood). A key difference was notably in the area of health and well-being perspectives, and the determinants of health. For example, the role food plays in family and community socialisation, and perspectives on body size in relation to health (e.g., being thin was associated with being unwell), differs to that of westernised viewpoints, particularly when they are measured as poor health indicators. Having a large body size in relation to obesity (i.e., body mass index (BMI)>30kg/m 2) has been shown to have major health implications such as

*1Corresponding author: Ridvan Firestone, Senior Research Officer, Centre for Public Health Research, Massey University, PO Box 756, Wellington 6140, New Zealand [email protected]; 2 The Fono, Level 2, 33 Wyndham Street, Auckland City 1010, New Zealand 3 South Waikato Pacific Islands Community Services, 1 Maraetai Road, Tokoroa 3444, New Zealand 4. National Institute for Health Innovation, School of Population Health, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand 5 Department of Human Nutrition, University of Otago, PO Box 56, Dunedin, New Zealand Received: 03.05.2018; Published: 30.09.2018 Citation: Firestone R, et al. Identifying what healthier lives mean to means to Pacific peoples. Pacific Health Dialog 2018;21(2):54-66. DOI: 10.26635/phd.2018.913. Copyright: © 2018 Firestone R, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

54


developing; type two diabetes and, other long term conditions, like cardiovascular diseases, for urbanised Pacific peoples1-6 Also, the meaning of health in Pacific families encompasses a holistic understanding with the well-being of the family being a high priority7. Social-cultural perspectives are important factors to consider when examining the determinants of health conditions (e.g., obesity) in Pacific peoples. The current assumption is that Pacific peoples do not share the same view of body image as Westerners7-9, and thus may not view obesity as a health problem. The prevailing issue is the clash of definitions for, and understanding health from, a Pacific perspective. Migration, colonisation, and westernisation have weakened the Pacific family structure over many decades4 10 11. Regaining and strengthening family connectedness is important to enhance Pacific family dynamics and health and wellbeing, in a westernised environment12 13. It is well established that Pacific people experience barriers to accessing health care services14, and they under-utilise primary health care services15. However, cultural lifestyle factors, values and preferences influence how Pacific peoples view health status and health care1 16 17. Pacific people account for approximately 7.8% of the total population in NZ, with the largest Pacific ethnic group comprised of Samoans (3.6%), Tongans (1.5%) and Cook Islanders and Rarotongans (2.5%) intermediary18. Understanding the reasons and the complex interactions of determinants for poor health is important to delineate better preventative strategies and solutions to preventing chronic disease in Pacific peoples, which have been shown to be successful in previous studies in NZ19-21 and in other countries22-24. The aim of this paper is to describe health and well-being from a Pasifika (i.e., Pan-Pacific) worldview from rural and urban communities, in order to understand how we might collaboratively support communities to lead healthier lives, using co-design as the primary methodological approach to enhance health and wellbeing for indigenous people. For this study, we will be using the term Pasifika peoples, defined as a collective group of people representing different Pacific Island nations predominately from the South Pacific region, recognising that they are not of a homogenous group, but have similar values and protocols. METHODS As part of an overarching study25 we present qualitative data obtained from the focus groups of the Pacific arm of that study. The umbrella project which employed co-design as the

methodology to plan, build, test, and implement an healthy lifestyle support mobile health (mHealth) tool with Māori and Pacific community partners. Co-design differs to Community-Based Participatory Research (CBPR), although the latter approach brings together communities and researchers to improve health collaboratively in the community. CBPR actively engages the community in all aspects of the research process26, builds upon existing community strengths27, and may hold significant promise for implementing effective and sustainable public health strategies28. By promoting long-term, equitable partnerships between researchers and communities, CBPR approaches can create a balance between the science of researcherdriven studies and the rigour associated with specialised indigenous knowledge alongside access to key, relevant local networks. CBPR has been endorsed as vital for increasing relevance and sustainability of multilevel interventions29-36, because it allows community members to be equal partners in research activities, and identify aspects of inquiry that are outside of the expertise of many ‘Western-trained’ theorists and researchers. Co-design, is described as “harnessing the knowledge and creativity of citizens and staff in identifying problems and generating and implementing solutions – it offers the opportunity to uncover the real barriers to, and accelerants of, progress” 37. It is a relatively new method in public health, yet it has considerable potential for the development of novel and relevant intervention programmes. Co-design is a participatory action process that involves engagement with end-users to develop an intervention (or product) that is relevant to the needs, and takes into account the aspirations and desires of the target group, in our case, Pacific peoples living in NZ. Participant recruitment The participants were recruited by our community research partners in Auckland and South Waikato regions, New Zealand. We used a combination of purposive sampling and nominative process, to ensure a wide representation from the community of interest and age groups among Pacific peoples participated in the focus groups (e.g., health experiences, educational and socio-economic backgrounds). Four community co-ordinators were employed to recruit the participants through their community networks. The inclusion criteria included: self-identification of being Pacific38, aged 18 years and older, and with an interest in healthy lifestyles and, or the health of their family and community. The participants

55


were informed of the overall purpose of the study, and they understood the nature of their voluntary participation. Written consent were obtained from all participants. A one-page questionnaire was administered at the initial focus group meeting to collect demographic data on participants. Ethical approval for the overall research project was received on 19/04/2016 from the New Zealand Northern A Health and Disability Ethics Committees (reference 16/NTA/29). Data collection and analyses A total of six separate focus groups were undertaken with members from our Pacific community partner networks, to better understand what is meant by ‘healthier lives’ by examining their ‘health experiences’, ‘the meaning of wellbeing’, and ‘hopes and dreams’ of healthier lives at an individual and community level. A Pacific model of health (Fonofale)39 was used to guide the study framework and inform the data analyses to ensure that the process of engagement with the participants was aligned to a Pasifika world-view. The Fonofale model was considered to be appropriate for this research as it encompasses beliefs and values in relation to family, culture, and spirituality that many Pacific nations (Samoa, Cook Islands, Tonga, Niue, Tokelau, and Fiji) uphold, particularly in relation to mental health and well-being40. The focus group sessions were facilitated by two community coordinators (one facilitator, one note-taker), and hosted at a local venue that was convenient and known to the participants. One focus group was facilitated in Cook Island language to enable better consultation with the older participants in their native language. Each session lasted up to 120 minutes, and they were audio-recorded, transcribed and re-checked by the co-facilitators. The transcriber from each community conducted initial summary analyses per focus group discussion highlighting key themes. These themes were later verified by an independent analysis and interpretation of the overall transcripts by the first named author. Thematic data analysis involved grouping, indexing, interpretation and consensus of the key themes (saturation). Verification of the thematic analyses was checked by presenting the overall summary of themes to the community partners to validate the findings. The facilitators conducted additional analyses of the data by way of providing ‘point of view’ (POV) analytics. An adapted co-design approach which personifies the key themes according to functional themes such as: (i) identifying the key users; (ii) primary needs [of the users]; (iii) insights gained (e.g., how societal structures impact on Pacific people, and social positioning); and (iv) pragmatic use of

the idea (i.e., turning the idea into a good and/or service). Collectively, the thematic and POV analyses ensured the convergence of the key findings. FINDINGS The focus group participants represented a diverse range of Pacific ethnicities including Samoan, Tongan, Cook Islander, Tokelauan, and Fijian, living in the Auckland and Waikato regions of the North Island of New Zealand. The majority were Samoan or Cook Islander. Due to the variety of Pacific Island nations being represented in this study, we will refer to Pacific peoples as ‘Pasifika peoples’, because the term recognises the diversity of Pacific nations and their inherent cultural practices, languages and history that underscore each ethnic group. A total of 57 Pasifika participants took part in the focus groups, 61% (n=37) were female, and the remainder were male (n=20). The age ranged from 18 to over 65 years old. The focus group data were collected over a seven month from June to December in 2016, and no repeat focus groups were conducted, as the broad areas of health and wellbeing had been sufficiently explored by each group. Of note, a fourth focus group was conducted that included representatives from each focus group to consult in-depth on the mobile intervention tool, but this data had not been included in this paper, as it focused primarily on co-designing an intervention and thus it will be published elsewhere. There were two major overarching themes (Figures 1 and 2), each with sub-themes, that emerged from the thematic analyses on identifying and understanding the meaning of health and well-being (Figure 1), and Pasifika peoples’ hopes and dreams of leading healthier lives (Figure 2). For overarching theme one: health and well-being must be family centred – this major theme emerged from the main aim of understanding the participants’ experiences of health and identifying what health aspects are important to Pacific people. For overarching theme two: a desire to live longer and be healthier, highlights potential issues that need to be addressed in order to achieve the desire to live longer and be healthier.

56


Figure 1: Knowledge integration approach to identifying and understanding health and well-being for Pacific peoples

Underpinning the first major theme of health and well-being is a very strong focus on the health of family. Sub-themes have been grouped according to three levels, as depicted in Figure 1. We have used a knowledge integration approach41 to analyse these themes, as it is well-placed to examine different levels of health and wellbeing in relation to personal experiences and inferences. This approach also links personal perspectives and experiences to actionable knowledge (i.e., what can we do with this knowledge), by way of design thinking42. The analogy of a tree was used to categorise each sub-theme41. Sub-theme one is characterised as the ‘obvious and recognisable issues’ (i.e., tree leaves), such as diet, lifestyle behaviours, the conditions of work-life balance that may affect health and well-being of the family, and attaining a healthy attitude. Some examples from our focus group discussions highlight the impact of their lifestyle behaviours on the health of individual: …the holistic things means the whole of the person so if that person doesn’t have all of that it means they’re unwell they can be unwell physically, mentally, spiritually. So if that person’s unwell then the rest are unwell in the family because if you can’t cope, the rest see that, so they don’t have that support to make that person well unless they

get help…” [Participant 1, Female, Focus Group 1, Auckland] … I’m bias toward the nutrition and physical activity part of wellbeing and … my focus … is on the nutritional side and the physical wellbeing side and … I want that for my family … I’m always pushing them to do more activity, eat better foods but … it’s not for me personally, but for my family. It is for that whole mental stability side that mental wellbeing side, I know that they can’t do the physical and the nutrition unless that’s got sorted, [and] they got that cultural side sorted … being in dual culture... [Participant 1, Male, Focus Group 3, South Waikato] Holistic health for Pasifika people encompasses more than just the World Health Organization broad definition of health: “a state of complete physical, mental, and social-wellbeing and not merely the absence of disease or infirmity”43, it pertains to the well-being of the individual and their relationship with the family. Pasifika people in this study rarely referred to body size and weight, as these measures are not key health markers, from a Pasifika perspective, rather there was an inherent desire to live longer in order to look after the younger and older generations, and keep them disease free. Worklife-balance was considered essential to the health and longevity of Pasifika families and generations. … What motivates me to live to a healthier life? To be able to work, cos I want to help my family that are growing up. There’s nothing more [for] me really to enjoy. I have done my part in enjoying my life in the past so I am just looking to give to the younger generation. The intention is to work until I die. I want to be healthy to be able to do that... [Participant 1, male, Focus Group 1, Auckland] …to have a healthy lifestyle, peaceful home … financial was mentioned, healthy lifestyle, my children need to be educated … to live a healthy lifestyle, eat healthy. Stay away from drugs and alcohol. This is the road to wellbeing, these things [drugs and alcohol] are coming in and it is going to get worse. [Participant 4, Female, Focus Group 1, South Waikato] Sub-theme two (of Figure 1) of this theme is characterised by the participants’ views as being the supporting and ongoing issues or the ‘systemic factors’ (i.e., tree trunk) which were encountered by individuals and families, but may not align with their customs or traditions. There may also be other systemic issues such as environmental factors (e.g., no access to fruit and vegetable market, only a corner-shop store), that inhibit their ability to attain health and wellbeing. The majority of participants recognised that individual choice to be healthy is

57


a basic human right, although making an informed lifestyle choice largely depends on having a degree of knowledge, even if it was based on prior experience. Some examples from our focus groups corroborate these points: …Pretty much the basic human rights really, a warm house for her kids, that’s like a human right and when we’re not even meeting the human rights of people like that. It’s quite questionable. [Participant 9, Female, Focus Group 1, Auckland] … Education is the key because we experience all the bad things that we did for ourselves in the past, and affects us, our health now. So we know … and we can show that to the young generation what to avoid. We know now that eating a lot of bad food, sugar and stuff is bad so that’s a message that we can give to our young generation and try to make them see. I remember when growing up I heard that smoking is bad for you. I didn’t stop, keep on smoking for different reasons, peer pressure and other. So until it affect me and affect my singing ability and stuff, I finally stopped. The doctor told me if you smoke another cigarette you will die and so that’s when it stopped. … We want to give our young generation … a better way to understand and to stop before they get into trouble. [Participant 3, Male, Focus Group 1, Auckland] The above example also links education to having a more positive outlook on lifestyle, by increasing capacity and capability of individual members to provide for the family. For instance, if people were able to secure better jobs, then they would be in a better position (financially) to provide for their family. For Pasifika families, a ‘healthy family’ was typically judged by way of family practices – as a ‘state of doing’. For example, how actively involved is the family in church affairs. This differs to ‘family well-being’, which could be viewed as (a ‘state of being’). Health was perceived by the participants by way of what they ‘can do’ or ‘provide’ for their families. Furthermore, overcoming poverty relates to this nuance of education and maintaining job security. …Being able to provide the needs and the necessities of the family. Putting food on the table and providing a warm home. You know being able to care for their needs, like an education,… it’s really sad when I think of everybody that’s needing a warm home which we can’t afford. If the money that they are earning won’t be able to afford that home … a roof [over] their heads …. Seeing a lot of what is happening around in Auckland … people are living in cars and it is their right to live in a home. [Participant 6, Female, ## years old, Focus Group 1, Auckland]

The third sub-theme relates to environmental influences. The participants’ interpretation of the environment has a strong connection with the initial sub-theme particularly with the holistic understanding of wellbeing and that of spiritual dimensions. Notions of: ‘love’ and ‘caring for others’; relying on their ‘faith’ to ensure a balanced spiritual health; having a ‘warm home’, and ‘better access to food choices, health services, and good information’, were all deemed important drivers of good health and wellbeing. The home context was especially important as it was perceived as a setting that promotes health and wellbeing, family and community, and feeling safe and respected, within the home environment. …Good relationships, good family, good happy church. Vibrant community. [Participant 3, Male, Focus Group 1, Auckland] … You’ve got the family at the bottom then you’ve got the pillars of spiritual, mental, physical, emotional, and at the top of that you’ve got your culture and then you’ve got your environment context as well. [Participant 8, Female, Focus Group 1, Auckland] The third sub-theme (in Figure 1) includes crosscutting themes of sub-themes one and two (i.e., holistic wellbeing, balanced health and lifestyle, and cultural lifestyle and responsibilities). However, they were characterised as the issues that have been well established in custom and tradition, which are often ‘unspoken about or difficult to modify due to their deep-rooted nature’ of the issues (i.e., tree roots). These themes were consistently and frequently discussed across all the focus groups (a safe environment), which makes them important challenges for Pasifika peoples. The challenge of how these issues be addressed from a public health perspective will be no easy task, as it requires researchers and communities to work collectively. This approach is often time consuming, particularly in trying to understand and address the needs and benefits of both parties, and then to work in a genuine partnership to fulfil each partners’ needs. Holistic well-being is strongly associated with spiritual wellbeing for Pasifika people, because the health and wellbeing of an individual is often perceived as how well they serve their community, church, and pastor/minister. Many Pasifika people follow a religion and view themselves as created in the image of god44, and thus, health and well-being must also address spiritual health, however that be measured (e.g., tithes, services to the pastor/minister). One participant summarised this theme:

58


…I think it has to be holistic. … If we balance all those three [mental, physical, spiritual], that’s what we call health. Some people they [are] healthy physically but mentally they [are] not healthy –spiritual and physical. So if those are balanced, then I think … that’s what we call healthy. Not people health physically, but mentally they not really good up there. … start from your family only … mum and Dad care by their children, the whole family to be healthy. Then it will come to society and then to the whole nation. And then come to Maori, Pacific communities. If they [think] holistically … it has to be in there those three. It can’t be individualised. [Participant 3, Male, Focus Group 1, Auckland] Cultural lifestyle was also similar to the holisticspiritual well-being notion described above. However, it was viewed as a barrier to progressing health and well-being, because some cultural practices were deemed to limit material and financial resources of Pasifika families who were already in an impoverished position. One participant aligned it to that of an oppression:

family unit and ripples out to the community. When financial security becomes affected due to cultural practices, this impacts poorly on the family’s ability to be and to live in a healthy lifestyle. Figure 2 illustrates the second major overarching theme: ‘hopes and dreams – to live longer and be healthier’. This was the most common theme that was highly discussed across all focus groups. Three sub-themes underpin this major theme: (i) Family support (positive theme); (ii) overcoming barriers; and (iii) addressing social justice within the community. Figure 2: Overcoming barriers to lead healthier lives in Pacific peoples

… to see people under less oppressive religious and cultural practices. So like, fa’alavelave [i.e., in Samoan culture this means ‘anything that interferes with normal life’, and it refers to important events such as funerals, weddings, special birthdays, dedications, and Matai title ceremonies] … I talked to families and it’s just killing them you know. I’m not saying ‘not’ do it, but maybe some freedom in the area of spirituality and culture [is needed]. I don’t know if you can do that, but it’s probably one of my hopes that people have plenty more choice in how they express their culture or their religion. [Participant 2, Female, Focus Group 1, Auckland] This was supported by another comment: …Yes, I also say those … things [are] affecting your health. Because if those things come into you, the cost of those things as well. It affects the cost of you to see the doctor and the cost of your family to buy good food and healthy food. [Participant 3, Male, Focus Group 1, Auckland] … often people struggle with this cultural stuff like when they look at fa’alavelave. I heard a Samoan talk on fa’alavelave, it actually means a lot of love, but people often over-do it. So in terms of health and well-being and what we need to aspire to…What does it look like … often when I look at the kids … [how] does [it] with my kids. [Participant, Male, Focus Group 1, Auckland] In summary, Pacific communities want the family to have better health for the future and this requires a family lifestyle that has a spiritual-physical-mental and work-family balance. Health and wellbeing starts from the

Family support is about prioritising the needs of the family as the highest priority (upward arrow) which must take on a balanced health and wellbeing approach. In particular, enabling the future provisions for the younger generation was paramount to ensure that their health and wellbeing is planned and sustainable. A line of conversation demonstrates this point: …For myself we are looking at my mother’s land and living off the grid. Family gardens, connecting with nature and using land and resource for Rongoa (Maori medicine so getting back and connecting with nature again). As we are aging my family we are looking at living together especially as our children are moving out. Our future is to live together, share and take care of one another. [Participant 2, Female, Focus Group 2, South Waikato]

59


,,,For the community. I mean it’s the same I think that I try and push on my family which is still the physical and the nutrition part but I also realise that, that can’t work solely by itself. It needs the whole support around it in terms of the spiritual, cultural and mental wellbeing around it and as much as I want to push my physical and nutrition side … I would want them [community] to be fitter and healthier in terms of nutrition, … I can keep pushing what I can, but until they’re ready within themselves then changes aren’t going to happen. [Participant 1, Focus Group 3, South Waikato] Overcoming barriers is essential to understand how to attain the hopes and dreams of health and wellbeing. It is a downward facing arrow, because the barriers are not entirely controlled by the family, but related to systemic issues (described earlier). For Pasifika people, it includes having access to all materials, such as healthy food and services. The cost of these resources and the lack of availability were predominant factors for this sub-theme. This theme also relates to individual choices (subtheme one described above for overarching theme one), in particular, with any given knowledge and information, we need to understand how to make the right choices, in order to live well. …My hope and my dream would be that doctor visits would be free. That they would be accessed at reasonable times. [Participant 1, Focus Group 2, South Waikato]. …I think one of my aspirations is that people have a choice to be healthy. In South Auckland where we have our youth, um we run a youth space, and I was thinking that I can go and buy healthy food cos we’ve got the money to go and buy healthy food. But a lot of our kids … they don’t. They choose really unhealthy things because it’s cheap and maybe cos they like the taste now. … I feel bad that I eat healthily and then when we are at youth we get a whole lot of cheap stuff because of the money available to us. So I’ve been thinking about how I want to give my kids healthy food at a reasonable price, so I don’t know if you can make something out of that, but just that it’s accessible to everybody [Participant 2, Female, Focus Group 1, Auckland]. The final sub-theme is addressing social justice issues, which is defined as ‘achieving equitable distribution across a range of factors of wealth, opportunities, and privileges within society’45. Similar to the above sub-theme, it is a downward arrow, because the barriers are less likely to be controlled by the family or at an individual level, and the nature of these issues are embedded from the systemic and deep-rooted issues, as highlighted by the first overarching theme. For

the participants of this study, to address social issues at a community-based level by ‘understanding their needs’ which includes shifting their mind-set from understanding health and wellbeing in order to address the different lifestyles, across the generations. Most participants expressed their desire to change their mind-set with the evolution of culture, because they are living within a dual-culture, and this requires a collective approach based on fairness, justice, taking on a posture of learning to identify and understanding the community needs, and to achieve a sense of belonging and ownership in the change-process. Examples of commentary included: …I think it could be looked at from the other angle as well. … just with the living in a low socioeconomic area the amount of takeaways and bad food available is because of legislation it’s because they’ve allowed it to be, so our environment has been dictated to us because of legislation. If they start to tax and take away that kind of stuff it could be looked at from a different angle. [Participant 7, Female, Focus Group 2, South Waikato]. DISCUSSION This is the first community-based study that has employed a co-design approach with a Pasifika peoples, particularly where the participatory process includes a partnership between the research team and stakeholders, whom both parties are actively involved in working collaboratively towards a common purpose, which is absent in the literature42. This paper will be an important guide for future researchers considering using this method. Several important findings emerged from this qualitative study. Underpinning the first overarching theme of Pasifika health and wellbeing. It was clear from the focus groups that these concepts were strongly dependent on the wellbeing of the family unit, and not merely the individual state of being sick, diseased or suffering from illness. Furthermore, familycentred health was also described as being holistic in nature and including physical, mental, and spiritual wellbeing. It should be noted that wellbeing was not to be perceived as having an illness or disease, but rather the holistic and family-centred viewpoint considers ‘wellbeing’ to be a state of ‘being’ (e.g., feeling motivated to lead a healthier life), and ‘health’ was considered to be the state of ‘doing’ (e.g., having a work-life balance to lead a healthier life). Attaining this state of being and doing was considered essential elements of an environment that supports not just the family, but the community

60


as well to lead healthier lifestyles. Our finding aligns well with other established models of health that are Pacific-based21 39 46 47. Even with the increase in the Pacific population who are New Zealand born (50%)48 49 and who may not be living a traditional Island lifestyle, it still remains evident that a holistic and familyoriented approach to enhancing health and wellbeing is necessary for Pasifika communities in this current day and age. Moreover, Pasifika concepts of health and wellbeing that are familycentric and preventive measures that address a variety of environmental impacts (e.g., information environment, urban environment)50, could achieve positive health changes17, which differs from the typical biomedical model that focuses only on the physical nature of health and disease17. Pasifika peoples’ views lean more towards traditional and indigenous paradigms that include spirituality, and a connection with their natural resources (e.g., land and agriculture)51. However, what is needed are initiatives that require research partnerships with Pasifika communities, and these partnerships must work within or align with indigenous paradigms to meet the needs and ideals of Pasifika people. Further resultant themes were attaining and consolidating knowledge and information, being educated and maintaining job security, which were perceived as basic human rights necessary to lead healthier lives. Recent work has highlighted that non-communicable disease causes, their determinants and outcomes ‘can be framed around human rights principles, norms, and standards emphasizing equality, and nondiscrimination’52. Therefore, by harnessing the ‘power of human rights’ by addressing the social justice issues, action can be strengthened to build prevention and control of noncommunicable diseases such as obesity. Pasifika peoples report ‘more unmet need for health care’, with cost being the most commonly identified barrier to accessing treatment6. Thus, empowering Pasifika communities to develop and lead community-based programmes at a local level could be effective, even essential, to supporting Pasifika populations to understand, identify, and support change in their behaviours and mind-set for better health and wellbeing. Previous work have shown to systematic models of working with and empowering Pasifika communities, in particular utilising the church context for health promotion delivery19. However, there is little knowledge or evidence in how these models have effected behavioural change to improve health and wellbeing, or reduce the high rates of hospitalisations for various health conditions (e.g., respiratory and cardiovascular incidents)53.

Another key finding was having access to good quality food and the knowledge to inform individual choices. These were viewed as important drivers for obtaining balanced healthy lifestyle practices. Interestingly, programmes or a focus on weight management, body size or dietary intake were not a health priority for our Pasifika communities. This reiterates the ideas above regarding the need to tailor health programmes to Pasifika health concepts and ideals of health54, and participation in community affairs41 44. Other indigenous researchers have also reported that a focus on body size, diet and exercise are not significant drivers for engaging healthier lifestyles and achieving positive change51. However, addressing the issues of accessibility to quality food and being empowered (through health education) to change the behaviours of those at risk of disease is a major public health challenge. Although there have been improvements in health services becoming more culturally responsive to the needs of Pasifika peoples, this has only addressed the tip of the iceberg. More understanding of how to improve the health outcomes for Pasifika peoples and their communities is essential. Simply having a responsive health system that is culturally more aware is not sufficient to improve the health and well-being of Pasifika peoples. We need to understand how to empower families and communities to access services and environments that can support leading healthier lives. Shifting the typical health sector mind-set from an ‘individualistic perspective’ to one of ‘collaborating with community partners’ will be the way forward to rightfully address the perpetual state of Pacific health inequities17. The second major overarching theme from this study was to identify ‘how’ to address the issues identified above either directly or indirectly, by examining the ‘hopes and dreams’ of Pasifika communities. The key theme driving this finding was ‘to live longer and be healthier’, and again this theme was heavily focused on the family unit, particularly in enabling the family to work and support each other. Previous research has urgently called for more culturally and integrated programmes to combat the rising problems of lifestyle factors, specifically targeting Pacific children and their families55. Others have piloted family-oriented interventions focusing on promoting healthy behaviours, particularly while children are at home56. Although those researchers reported significant differences in improved consumption of vegetables and a decrease in the unhealthy food intake, the intervention adopted a compulsory approach to maximise participant engagement from their participants. Therefore, it

61


was not primarily a family-oriented approach, and the conforming framework does not align well with Pasifika values and their environmental infrastructure. On the other hand, a community-based lifestyle intervention programme among Native Hawaiians, other Pacific Islanders was designed and developed between six community partners and researchers. It included culturally relevant community-based health education sessions on eating, physical activity, and the programme actively involved family and community members as part of the healthy lifestyle plan24 57. The pilot test of the nine-month intervention showed that 51% of Native Hawaiians and Pacific Islanders involved in the intervention achieved 3% or greater weight loss over 9 months, compared to only 31.4% of those using a standard behavioural programme (SBP, control group) which was a significant between-group difference (p=0.045). Also improvements in systolic blood pressure were associated with losing ≥3% of initial body weight, and intervention participants showed greater improvements in their physical functioning, as measured by a 6-minute walk test, than control participants58-60. The Hawaiian study is potentially the most culturally, integrated programme to date that is community-based involving family and community members as an in-built support structure as part of the intervention. Furthermore, it aligns to Pacific cultural systems where family play a critical role in decision-making20. Thus, much is to be learnt from studies such as the Hawaiian study, and to be replicated among and, or adapted for Pasifika people residing in New Zealand. Other emergent sub-themes included overcoming barriers related to cost and access 61 62. These are not new findings, but they continue to be common recurrent factors highlighted by Pasifika communities14 15, which suggest that current and past approaches to alleviate these barriers for Pasifika people have not been effective or sufficiently addressed. From the communities’ perspective, biomedical health models, the health system and services do not fit well or work for Pasifika communities. Previous qualitative research have also described how existing individualistic approaches are inadequately aligned to indigenous understandings of health44 51. Moreover, in relation to these emergent themes, addressing social justice within Pasifika communities was also an important finding, particularly in addressing the health needs across Pasifika communities (e.g., generational health needs, youth vs elderly), and identifying ways to change the mind-set where the focus on family health needs to be developed and strengthened. Part of

the solution would be to learn from international studies such as that described above24 57, whereby interventions have been culturally adapted into health programmes and then offered in communities to ensure they are more accessible to underserved populations, and enabling self-management of chronic diseases63. Few studies have contextualised health issues for indigenous populations in order to understand and identify potential areas, or how to use and explore this information to develop an informed approach to interventions that are community-based and community-driven. The partnering with communities and researchers from the start of any intervention development could potentially address [in part] the issue of shifting the mind-set (as identified by the participants), so that the focus on empowering the health of the family unit can be consolidated, and the knowledge acquired through that codesign process is an important catalyst for change57. However, understanding how this approach can work in practice over a long period of time will require more investigative work. Cultural practice was identified as a major burden and a barrier to improve the health of Pasifika families. This is a sensitive, yet highly relevant issue because it ties in with financial hardship for families who view their church as the focal point for daily life. Providing money to their church was a natural outcome, particularly when families lose ties with their villages in the islands, and supporting the church is a natural instinct. However, this comes at a huge cost to families who cannot live independently and provide their basic needs and wants for their children and elderly members. Over 80% of Pacific peoples in NZ are affiliated with at least one religious organisation, and they are predominantly people aged over 15 years of age48, who are representative of the working age group. Pacific people contributions to the church is a common and vital social practice64. It has been reported that families are often donating more funds than they can afford, and that Pacific families are particularly vulnerable to debt accumulation due to various characteristics, with the important ones namely: high unemployment and low-paying jobs, limited knowledge and skills in financial management, and living in multi-family households65. Valins (2004) reported that four major consequences of debt for Pacific families include: financial hardship, poor health, family stress and social exclusion, and barriers to employment66. To address this issue, a holistic approach will be necessary, as well as harnessing the strengths of the Pasifika community to be involved, particularly as the community is evolving with the younger generation building better knowledge capacity

62


through education. The church also needs to evolve to understand the modern needs of social pressures on their communities, and be proactive in enabling families to be healthier and independent. Additionally, interventions need to be developed with an awareness of communitysustainability to ensure that they are low cost or free, and easily accessible to all.

Author Contributions

LIMITATIONS

Competing Interests No potential conflict of interest was reported by the authors.

Pasifika communities in this study may not be representative of the general Pacific peoples in NZ. However, the community participants represented both urban and rural communities, including youth, adult and older groups. Furthermore, as Pasifika people are not a homogenous group, it should be remembered that the ethnic and national diversity across the many Pacific Island groups may not represented in this study and readers are encouraged to be mindful of the lack of diversity indicated in this paper. Finally, the qualitative work presented here is based on a small sample and it is possible that the majority of participants were different to the general Pasifika population (e.g., health workers, regular community services users), and therefore their perspectives may differ to that of the general Pasifika peoples, and the meaning of health and wellbeing may be dynamic according to each community. CONCLUSION This study suggests that in order to address the health and wellbeing of Pasifika peoples living in NZ, it requires a Pasifika worldview on understanding these concepts from a Pasifika perspective. Pasifika families and communities continue to function and socialise according to their cultural values and principles, thus familycentric and holistic approaches were found to be important drivers in understanding their health needs, and overcoming longstanding barriers and inequalities. The findings from this study as a result of the qualitative nature and the codesign approach had provided a more informed knowledge base of co-developing an intervention programme with the community partners, and this is an important step for building and tailoring indigenous interventions. Funding This project was funded by the Healthier Lives He Oranga Hauora National Science Challenge of New Zealand.

RF compiled the manuscript, conducted a thematic analysis of the transcripts, SD, TF, AH, MV carried out the data collection and the initial analyses, and validated the final interpretation of the analyses. JG, AJ, RW, LTM, CNM assisted with the interpretation of the analyses and the final write-up of the manuscript.

Acknowledgement We would like to thank all the community participants (anonymised) involved in the study. Without their participation, this research would not have been possible. Furthermore, we would like to acknowledge our Maori community partners community (anonymised). REFERENCES 1. Ministry of Health. Tagata Pasifika in New Zealand. 2016 [http://www.health.govt.nz/ourwork/populations/pacific-health/tagatapasifika-new-zealand.]. accessed 28/6/2016. 2. Ministry of Health. Annual Update of Key Results 2015/16: New Zealand Health Survey. Wellington: Ministry of Health, 2016. 3. The role of advertising and promotion in the marketing of tobacco products. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Washington, DC: US Government Printing Office 1994. 4. Final S, Tukuitonga C, Finau E. Health of Pacificans in Aotearoa. Pacificans and Health. Auckland: Pacific Health Research Centre, 2003. 5. Foliaki S, Pearce N. Prevention and control of diabetes in Pacific people. Bmj 2003;327(7412):437-39. doi: 10.1136/bmj.327.7412.437 6. Ministry of Health. Annual Update of Key Results 2014/15: New Zealand Health Survey Wellington: Ministry of Health; 2015 [http://www.health.govt.nz/publication/an nual-update-key-results-2014-15-newzealand-health-survey]. accessed 9/7/2016. 7. Pollock N. Obesity of large body size? A study in Wallis and Futuna. Pacific Health Dialog 2001;8(1):119-23.

63


8. Metcalf P, Scragg R, Willoughby P, et al. Ethnic differences in perceptions of body size in middle-aged European, Maori, and Pacific people living in New Zealand. Int J Obes Relat Metab Disor 2000;24(5):593-9.

20. Tipene-Leach D CK, Abel S, Pāhau H, Ehau T, Mann J,. Ngāti and healthy: translating diabetes prevention evidence into community action. Ethnicity & Health 2013;18(4):402-14.

9. Teevale T. Body image and its relation to obesity for Pacific minority ethnic groups in New Zealand: a critical analyses. Pacific Health Dialog 2011;17(11):33-53.

21. Tuitahi S. Fanau Ola: A Pasifika perspective on Whanau Ora. In: Agency HP, ed. Auckland: HPFoN, 2011.

10. Durie M. Topic Ten: Diabetes. Maori Health Foundations - Book of Readings. Palmerston North: School of Maori Studies, Massey University 2002. 11. Herdt G, Leavitt SCE. Adolescence in Pacific Island societies. Pittsburgh: University of Pittsburg Press 1998. 12. Resnick Md BPSBR, et al. Protecting adolescents from harm: Findings from the national longitudinal study on adolescent health. JAMA: The Journal of the American Medical Association 1997;278(10):823-32. doi: 10.1001/jama.1997.03550100049038 13. Sua'ali'i-Sauni T, McTaggart S, von Randow M. Pacific families now and in the future: a qualitative snapshot of household composition, wellbeing, parenting and ecnomic decision-making among Pacific families in Auckland 2008. In: 2 R, ed. Wellington: Families Commission, 2009. 14. Ministry of Health. Factors affecting Pacific peoples’ health Wellington2010 [http://www.moh.govt.nz/moh.nsf/indexm h/pacifichealth-health-factors]. accessed 2/07/2010. 15. Ministry of Health. Tupu ola moui: Pacific health chart book 2012. Wellington: Ministry of Health 2012. 16.

Schluter P, Tautolo E-S, Paterson J. Acculturation of Pacific mothers in New Zealand over time: findings from the Pacific Islands Families study. BMC Public Health 2011;11(1):307.

17. Statistics New Zealand, Ministry of Pacific Island Affairs. Pacific Progress: Demographics of New Zealand's Pacific population. Wellington: Ministry of Pacific Island Affairs, 2010. 18. Statistics New Zealand. Census quickstats about national highlights. Wellington: Statistics New Zealand, 2013. 19. Counties Manukau District Health Board. Pasefika LotuMoui Health Programme. Manukau City: Counties Manukau District Health Board, 2010.

22. Hosey G AN, Statterfield D, et al., . The Culture, Science of Type 2 Diabetes Prevention in the US Associated Pacific Islands. Preventing chronic disease: public health research, practice and policy 2009;6(3):A104. 23. Hurst S, Nader P. Building community involvement in cross-cultural Indigenous health programs. International Journal for Quality in Health Care 2006;18(4):294-98. 24. Kaholokula JK, Kekauoha P, Dillard A, et al. The PILI 'Ohana Project: A communityAcademic partnership to achieve metabolic health equity in Hawai'i. Hawai'i Journal of Medicine & Public Health 2014;73(12 Supplement 3):29-33. 25. Ni Mhurchu C TML, Firestone R, Whittaker R, Jull A, Grey J,. Supporting Healthy Lifestyles: a Maori and Pasifika approach (WellText) Auckland: Univesity of Auckland; 2015 [https://healthierlives.co.nz/research/maor i-and-pasifika-health-approach/]. 26. Israel BA, Schulz AJ, Parker EA, et al. Review of community-based research: assessing partnership approaches to improve public health. Annu Rev Public Health 1998;19:173202. 27. Israel BA, Schulz AJ, Parker EA, et al. Community-based participatory research: policy recommendations for promoting a partnership approach in health research. Educ Health 2001;14(2):182-97. 28. Garfield SA, Malozowski S, Chin MH, et al. Considerations for diabetes translational research in real-world settings. Diabetes Care 2003;26:2670-4. 29. Ammerman A, Corbie-Smith G, St George DM, et al. Research expectations among African American church leaders in the PRAISE! project: a randomized trial guided by community-based participatory research. AJPH 2003;93(1720-7) 30. Boyer BB, Mohatt GV, Pasker RL, et al. Sharing results from complex disease genetics studies: a community-based participatory research approach. Int J Circumpolar Health 2007;66(19-30)

64


31. Correa NP, Murray NG, Mei CA, et al. CAN DO Houston: a community-based approach to preventing childhood obesity. Prev Chronic Dis 2010;7:A88. 32. Farag NH, Moore WE, Thompson DM, et al. Evaluation of a community-based participatory physical activity promotion project: effect on cardiovascular disease risk profiles of school employees. Womens Health Issues 2010;20:219-26. 33. Mohatt GV, Plaetke R, Kliejka J, et al. The Center for Alaska Native Health Research Study: a community-based participatory research study of obesity and chronic disease-related protective and risk factors. Int J Circumpolar Health 2007;66:8-18. 34. Pazoki R, Nabipour I, Seyednezami N, et al. Effects of a community-based healthy heart program on increasing healthy women's physical activity: a randomized controlled trial guided by Community-based Participatory Research (CBPR). BMC Public Health 2007;7:216. 35. Reininger BM, Barroso CS, Mitchell-Bennett L, et al. Process evaluation and participatory methods in an obesity-prevention media campaign for Mexican Americans. Health Prom Prac 2010;11(347-57) 36. Wilcox S, Parra-Medina D, Felton GM, et al. Adoption and implementation of physical activity and dietary counseling by community health center providers and nurses. J Phys Act Health 2010;7:602-12. 37. Abuse NIoA, Alcoholism. State of the Science Report on the Effects of Moderate Drinking. 38.

Statistics New Zealand. Census 2013 Wellington: Statistics New Zealand; 2013 [http://www.stats.govt.nz/Census/2013census/profile-and-summaryreports/quickstats-culture-identity/pacificpeoples.aspx ]. accessed 9/7/2016.

39. Pulotu-Endemann K. Fonofale Model of Health. Auckland: Health Promotion, 2001. 40. Mental Health Commission. Pacific Mental Health Services and Workforce: Moving on the Blueprint. Wellington: Mental Health Commission, 2001. 41. Firestone RT TH, Tevita G, Henderson J, Schlser M, Kaholokula K, Ellison-Loshmann L,. Pasifika Youth Empowerment Programme: a potential public health approach in long-term prevention of obesity-health related issues. AlterNative: an international journal of indigenous peoples 2018;14(1):63-72.

42. Eyles H, Jull A, Dobson R, et al. Co-design of mHealth Delivered Interventions: A Systematic Review to Assess Key Methods and Processes. Current Nutrition Reports 2016:1-8. doi: 10.1007/s13668-016-0165-7 43. World Health Organization. Constitution of the World Health Organization. Geneva: World Health Organization, 1948. 44. Firestone R, Tuisano H, Manukia M, et al. Understanding Pasifika youth and the obesogenic environment, Auckland & Wellington, New Zealand. NZ Med J 2016;129 (1434):23-35. 45. United Nations. Social Justice in an Open World: The role of the United Nations. New York: United Nations, 2006. 46. Kupa K. Te Vaka Atafaga. Pacific Health Dialog 2009;15(1):156-63. 47. Tapu-Ta'ala S. Making the transition to insulin therapy: Experiences of Samoa people with Type 2 Diabetes in New Zealand. Victoria University of Wellington;, 2011. 48. Statistics New Zealand. QuickStats about Pacific peoples: 2006 Census. Wellington: Statistics New Zealand, 2010. 49. Statistics New Zealand. National Ethnic Population by Age and Sex at 30 June 1996, 2001, 2006. Wellington: Statistics New Zealand, 2012. 50. World Health Organization. Global Strategy on Diet, Physical Activity and Health Geneva: World Health Organization, 2004. 51. Bell R, Smith C, Hale L, et al. Understanding obesity in the context of an Indigenous population - a qualitative study. Obes Res Clin Pract 2017 doi: http://dx.doi.org/10.1016/j.orcp.2017.04.0 06 52. Gruskin S, Ferguson L, Tarantola D, et al. Noncommunicable Diseases and Human Rights: A Promising Synergy. American Journal of Public Health 2014;104(5):77375. doi: doi: 10.2105/AJPH.2013.301849 53. Novak B. Ethnic-Specific Health Needs Assessment for Pacific People in Counties Manukau. Manukau City: Counties Manukau District Health Board, 2007. 54. Firestone R. Circuit breaker. Journal of Urgent Writing 2016;1(1):100-08. 55. Oliver M, Schluter P, Paterson J, et al. Pacific Islands Families: Child And Parental Physical Activity and Body Size—design and methodology. 122 2009;1298:48-59.

65


56. Duncan S, McPhee JC, Schluter P, et al. Efficacy of a compulsory homework programme for increasing physical activity and healthy eating in children: the healthy homework pilot study. International Journal of Behavioral Nutrition and Physical Activity 2011;8:127-36. 57. Kaholokula JKa, Mau MK, Efird JT, et al. A Family and Community Focused Lifestyle Program Prevents Weight Regain in Pacific Islanders: A Pilot Randomized Controlled Trial. Health Education & Behavior 2012;39(4):386-95. doi: 10.1177/1090198110394174 58. Kaholokula JK, Saito E, Mau K, et al. Pacific Islanders' perspectives on heart failure management. Patient Educ Couns 2008;70:281-91. 59. Kaholokula JK, Townsend C, Sinclair K, et al. Sociodemographic, behavioural, and biological variables related to weight loss in native Hawaiians and other Pacific Islanders. Obesity 2013;21(3):E196-203. 60. Mau MK, Kaholokula JK, West MR, et al. Translating diabetes prevention into native Hawaiian and Pacific Islander communities: the PILI 'Ohana Pilot project. Prog Community Health Partnersh 2010;4(1):716.

61. Habour Sport. Choose Change for a healthier me. Wellington: Ministry of Health, 2015. 62. Wood A, Johnson M. Green prescription Active Families Survey Report. Western Bay of Plenty: Research New Zealand, 2016. 63. Sinclair KIA, Thompson C, Makahi EK, et al. Outcomes from a diabetes self-management intervention for Native Hawaiians and Pacific People: Partners in Care. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine 2013;45(1):24-32. doi: 10.1007/s12160012-9422-1 64.

Auckland Council. Exploring Pacific Economies: wealth practices and debt management. Auckland: Auckland Council, 2015.

65. Anae M, Coxon E, Lima I, et al. Pacific consumers' behaviour and experience in credit markets, with particular reference to the 'fringe lending' market: research findings report and government's response strategy. Wellington: Ministry of Consumer Affairs 2007. 66. Valins O. When Debt Becomes a Problem: A Literature Study. Wellington: Ministry of Social Development, 2004.

66

Sa’uLilo L, et al. Pacific Health Dialog 2018; 21(2):67-70. DOI: 10.26635/phd.2018.914

Original Research

OPEN ACCESS

Health literacy of Pacific mothers in New Zealand is associated with sociodemographic factors and non-communicable disease risk factors: surveys, focus groups and interviews. Losi SA’ULILO,*1 El-Shadan TAUTOLO,2 Victoria EGLI,3 Melody SMITH4 ABSTRACT Introduction: Pacific people living in New Zealand, suffer from inequitably high rates of noncommunicable diseases and their associated risk factors. This disease burden may be compounded by low health literacy levels. The objectives of this research were: (1) measure relationships between health literacy, socio-demographic factors and non-communicable disease risk factors in a large sample of Pacific mothers living in New Zealand and (2) gain in-depth understanding of social and cultural factors contributing to these relationships. Methods: Logistic regression was employed to investigate health literacy and: acculturation, socioeconomic status, physical activity, education, smoking status, health status, and alcohol consumption. Semi-structured focus groups were conducted with Pacific mothers and interviews with Pacific health professionals adopting the culturally appropriate talanoa, and kakala methods, within the Fonofale framework. Findings: Associations between low health literacy and age, ethnicity, acculturation, employment, education, smoking status, and alcohol status were shown. Novel findings from the focus groups were: the use and comprehension of health information and what constitutes preferred information and health service delivery modes. Conclusions: Findings suggest current health related information is not being used to its fullest extent by Pacific mothers. This may be due to underlying socio-demographic factors. This is the first study to examine the factors related to health literacy among Pacific mothers in NZ. Findings should be used to inform future interventions and delivery of public health nutrition messages. KEY WORDS: Health literacy; Pacific; Mothers; socio-economic status

INTRODUCTION Pacific people living in New Zealand (NZ), suffer from inequitably high rates of non-communicable diseases (NCDs) and their associated risk factors.1 An estimated 66% of Pacific adults are obese compared with 32% in the total NZ population; Pacific people consume higher amounts of foods high in saturated fat, sugar and salt and drink more sugar-sweetened beverages compared to non-Pacific people 1. Pacific adults are 30% more likely than non-Pacific adults to be insufficiently physically active for health than their non-Pacific counterparts.1

*1Corresponding author: Losi Sa’uLilo, Masters student, Faculty of Health and Environmental Sciences, Auckland University of Technology, New Zealand (NZ) losi.sa'[email protected] 2 Center for Pacific Health and the Pacific Islands Families Study, Auckland University of Technology, NZ 3 Faculty of Health and Environmental Sciences, Auckland University of Technology, NZ 4 The School of Nursing, The University of Auckland, NZ Received: 05.03.2018; Published: 30.09.2018 Citation: Sa’uLilo L. et al. Health literacy of Pacific mothers in New Zealand is associated with sociodemographic factors and non-communicable disease risk factors: Detailed findings from surveys, focus groups and interviews. Pacific Health Dialog 2018;21(2):67-70 DOI: 10.26635/phd.2018.914. Copyright: © 2018 Sa’uLilo L, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

67


Individuals with low health literacy are less likely to manage ill health including type 2 diabetes, 3,4 seek professional medical assistance,2 or interpret nutrition related information.5 Low levels of literacy is common among Pacific people worldwide, including in the Pacific Islands, Australia, the United States of America 6 and NZ.1 The specific objectives of this study were to: (1) measure the relationships between health literacy and socio-demographic factors and NCD risk factors in a large sample of Pacific mothers living in NZ, and (2) gain an understanding of social and cultural factors contributing to these relationships through culturally appropriate qualitative research methodologies. To the authors best knowledge, to date there is no evidence to show that health literacy is related to NCD risk factors among Pacific people in NZ. Further, no studies showing associations between health literacy and health outcomes with Pacific people in NZ has been published. This research aims to close the current knowledge gap with a specific focus on Pacific mothers.

Measurement constructs and their items can be seen in Table 1. Analysis Bi-variable logistic regression was used to investigate the relationship between health literacy (low or high) and the following factors: acculturation, socioeconomic status, physical activity, education, smoking status, health status, and alcohol consumption. Data were entered into, cleaned, and analysed using SPSS Statistics 22.0 and confidence intervals were set at 95%. Qualitative Study Two focus groups with Pacific mothers and two individual interviews with Pacific health professionals were conducted in December 2014. Interviews with health professionals took place at a convenient and comfortable setting of their choosing at (a local café and workplace). Participants

METHODS This research used 1. quantitate survey data from mothers whose children were participants in the 14-year phase of the Pacific Island Families study and 2. focus groups with Pacific mothers and interviews with Pacific health professionals. Ethical approval to conduct this research was provided by the Central Health and Disability Ethics Committee on 28th July 2014 (14/108) and the Auckland University of Technology Ethics Committee on the 14th of October 2014 (12/291). Data was collected between 01 April 2014 and 10 August in 2014 inclusive. Quantitative Study Data from the maternal interviews of the 14-year phase of the Pacific Island Families study was used for this study. The Pacific Island Families study is a robust, longitudinal, birth cohort study of 1398 infants born in 2000 at Middlemore hospital in Auckland, NZ.7 Study protocols detailed elsewhere.7,8 Eligible participants were mothers who affiliated themselves with Pacific Island heritage. Mothers of non-Pacific ethnicity and male participants were excluded. All eligible, non-excluded mothers, with valid contact details were invited and agreed to participate. The questionnaire was administered in person, and objective physical assessments (height and weight) were taken by trained researchers.

Focus groups. Mothers of Pacific Island descent that completed the Pacific Island Families Study 14-year maternal survey (see above and Table 1.) were randomly selected from two different health literacy categories; those with low health literacy (SILS score of 0 – 2; n = 20) or high health literacy (SILS score of 3 – 5; n = 20). In total, 40 Pacific mothers were randomly selected and invited to participate in focus groups. Information sheets and consent forms were mailed to the home address of each potential participant. Interviews. Pacific health professionals with experience working with Pacific people in a professional setting for at least five years were identified through personal contacts of the lead researcher and invited via email and telephone to take part in this study. Prior to attending the interview, health professionals were given an information sheet and consent form. Procedure This research adopted the talanoa, and kakala methods, which are both qualitative Pacific research approaches which utilise semistructured processes to elicit information.16,17 Talanoa is an effective and culturally appropriate Pacific research method which uses conversation as a way to create a healthy environment for both the researcher and the participant.17 Kakala is based on the traditional process of fragrant garland making, it is based on the principals of reciprocity, sharing, respect and collectivism.18 68


Table 1. Quantitative measurement constructs and included items. Measurement Construct

Item/s and scoring

Socio-demographic information

Demographic information including sex, age, ethnicity, employment status, and qualification level (self report).

Health literacy

The single-item literacy screener (SILS) “How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?” 9. Participants were asked to rate their perceptions using a scale from never-1 to always-5. Scores of 12 were classified as high health literacy, and scores of 3-15 classified as low health literacy.

Acculturation

The Pacific Island acculturation measure (PIACCULT) and the NZ acculturation measure (NZACCULT) was used to assess acculturation 10.

Socioeconomic deprivation

The NZ Index of Deprivation for individuals was used to classify deprivation status into five categories ranging from a high (i.e. no deprivation characteristics) to low (i.e., five or more deprivation characteristics) socioeconomic status 11.

Physical activity

The NZ Physical Activity Short Form was used 12. Respondents were classified into one of four categories based on the number of days they reported achieving at least 30 minutes of moderate activity or at least 15 minutes of vigorous activity: 0 – 2 days per week (low active), 3–5 days per week, and 6 – 7 days per week (high active).

Health status:

A single item from the General Health Questionnaire-12 was used to measure health status “Would you say your health is…?” Responses were coded as 1 = good, or 0 = fair or poor 13.

Smoking status

The single item “Over the past week, how many cigarettes on average did you smoke a day?” Scores were then coded as either 0 = No (non-smoker) or 1 or more = Yes (current smoker).

Alcohol consumption:

A single item from AUDIT- C “how often did you have a drink containing alcohol in the past 12 months?” Responses were classified as: 0 = No drinks in last 12 months and 1 - 5 = Yes (had alcoholic drink(s) in the last 12 months) 14.

Body Mass Index (BMI)

The standard formula was used to calculate BMI: weight in kilograms/height in meters squared. Height was measured to the nearest 0.1 cm using a stadiometer and weight was measured to the nearest 0.1 kg using digital scales. Ethnic-specific thresholds were applied to classify BMI of participants 15

65


These conversations aligned with the Pacific epistemological views best described as the Fonofale framework.19 The first author conducted all focus groups and interviews, they were recorded on an audiotape recorder. Focus groups and interviews took between 30-60 minutes and each participant received a NZ$30 shopping voucher upon completion. Interview guide. Drawing from the findings from the quantitative study and an earlier literature review 20 a semi-structured interview guide containing a list of key points of enquiry was generated. This allowed for some form of flexibility for participants to discuss selfidentified issues which may have influenced their experiences 21. The Fonofale framework was also used to identify specific topics that directly or indirectly influenced an individual’s health literacy status. Analyses Data was transcribed verbatim, and imported into NVivo 11 (QSR International, Burlington, MA) for thematic analysis. Thematic content analysis was used to pinpoint and examine common themes within the data.22 FINDINGS Quantitative study Of the 549 maternal participants who took part in the maternal survey sample, 11 were male and 35 participants were of non-Pacific ethnicity. Following their exclusion this left a final sample of 503 Pacific mothers. Full demographic information for participants included in analyses is provided in Table 2. More than half of the Pacific mothers reported having high health literacy (65.1%, n=328) and 61.3%, n=309 reported they had good health status. Health behaviour patterns were relatively good with 70.4% n= 355 reported they did not have a cigarette in the past seven days, 60.7% n= 306 did not consume alcohol in the past 12 months. However, 47.6% n=240 of Pacific mothers met the recommendations for physical activity two days or less. Table 3 provides the results of bi-variable analysis for associations between health and health and demographic variables in Pacific mothers. Statistically significant relationships (p < 0.05) were found between health literacy and

age, ethnicity, acculturation, employment, education, smoking status and alcohol status. Pacific mothers aged 40-49 years, and over 50 years were significantly less likely to have high health literacy in comparison with younger mothers. Compared with mothers identifying as being of Samoan ethnicity, mothers of Tongan ethnicity were 60% less likely to have high health literacy but no significant differences were found between the reference group and participants who were of other Pacific ethnic groups. Compared with Pacific mothers classified as having an assimilationist acculturation style, those with a separationalist or marginal style were significantly less likely to have high health literacy. Pacific mothers classified in the ‘other’ employment status category (e.g. self-employed, full-time mother (unpaid), student, retired and other) were significantly less likely to have high health literacy, compared with those who reported being employed. Smokers were four times more likely to have high health literacy compared with non-smokers. Similarly, this trend was observed for those who did not consume alcohol in the previous twelve months versus those who did. Qualitative study Table 4 shows the demographic characteristics of focus group and health professional participants. Health professionals interviewed were females of Pacific ethnicities who had at least five years’ experience working with Pacific peoples (including Pacific mothers) in health professional settings. Four key themes were identified; behaviours, empowerment, relationships and policy change. Theme 1: Behaviours Reading and using health pamphlets or brochures. When asked the question “Do you currently use public health related information such as brochures or pamphlets?”, the initial response from each mother was “no”. One reason given was information relayed was either too brief or did not encourage them to read information fully. Many participants reported an existing understanding of their (or their child’s) condition and no need for further information: “I don’t need those pamphlets because I already know what my symptoms are” (P6). Most agreed that they would be more inclined to use public health information if the information in the pamphlets or brochures was relevant or important to them and their families.

65


Table 2. Descriptive information for demographic variables of participants included in the quantitative study (n = 503) Variable Age < 39 40 –49 > 50 Ethnicity Samoan Tongan Cook Island Other Pacific BMI status Normal Overweight Obese I Obese II Obese II Health literacy (frequency with which support is needed to read health literature) Never (high health literacy) Rarely Sometimes Often Always (low health literacy) Health Status Good Fair Poor Acculturation Assimilationist Separationalist Integrator Marginal Income ($NZ) Up to NZ $40,000 NZ $40,001 to $80,000 NZ $80,001 to $100,001 Employment Employed Unemployed Other Education Secondary Tertiary No qualifications Smoking status (previous 7 days) No Yes Alcohol (any) in the last 12 months No Yes Physical Activity Less than 2 days 3 to 5 days 6 to 7 days Socioeconomic Status High (No Deprivation Characteristics) One Two Three or Four; Low (Five to Eight Deprivation Characteristics) Key: n = number; SD = Standard Deviation

Total n

%

(mean)

(SD) (6.77)

38.5 45.2 16.1 50.4 25.2 18.1 6.2

(42.64) 194 228 81 254 127 91 31

3.0 9.1 29.0 15.3 25.0

(37.10) 15 46 146 77 126

(7.45)

65.1 14.7 15.9 1.2 1.8

328 74 80 6 9

61.3 33.7 3.6

309 170 18

36.5 33.7 11.5 16.3

184 170 58 82

24.0 24.6 16.9

121 124 85

53.4 5.4 40.3

269 27 203

47.4 32.7 17.9

239 165 90

70.4 28.2

355 142

60.7 37.9

306 191

47.6 38.7 11.9

240 195 60

11.3 14.7 20.4 32.3 20.0

57 74 103 163 101

503

503

410

497

497

494

330

499

494

497 497 495

498

66


Use of Pacific language and images. Both health professionals felt resources needed to suit the language attainment of Pacific peoples with the use of Pacific written language or pictures, so that Pacific people could better understand the information. The availability of this information using only a European context was highlighted as a main reason Pacific mothers did not use the information more often. Use of technology for health information. Health professionals reported Pacific people were becoming more inclined to using technology such as mobile phones, to access the internet as a credible source of health-related information. Health professionals wanted to understand how to tailor information about health-related issues in a format that was easily accessible and easy to use internet sites for Pacific peoples in particular Pacific mothers to use because of the increasing demand. Selecting healthy food. Selecting food items for their families was based on perceived food palatability, food expiry date, or whether foods were inexpensive (regardless of their nutritional value) among all mothers. Participants reported knowing which food items were healthy and

agreed they wanted to lead a healthy lifestyle for themselves and their respective families. Yet, almost all mothers agreed that their financial circumstances and food palatability determined the types of foods purchased: “We want to make sure our children are eating the right foods…but it’s whatever we can afford” (P4). Participants’ financial circumstances determined the food items brought into the home: “I’m not going by what’s healthy what we should be eating… we’re tight….so we just make week to week with what we can… so I don’t go by what’s recommended” (P2). Reading nutrition information labels. Mothers said they did not look at food nutrition panels or the details within these panels. Fat, salt and sugar were identified as three main micronutrients to be aware of for health concerns, but overall participants did not understand what the numbers meant within these labels. Thus, participants felt more inclined to prioritise purchasing food items based on palatability and cost: “I look at price… I don’t even bother with it [the nutrition information label] …. whatever tastes good…. whatever’s cheaper…. just skim right through it [the label]” (P4).

Table 3. Odds ratios of having high (versus low) health literacy by demographic and health variables pVariable Total n n % OR (95% CI) value Age (years) < 39 40 – 49 > 50 BMI Normal Overweight Obese I Obese 2 Obese 2I Ethnicity Samoan Tongan Cook Island Other Pacific Health Status Good Fair Poor Acculturation Assimilationist Separationalist Integrator Marginal Income Up to NZ$40,000 NZ$40,001 to $80,000 NZ$80,001 or more Employment

496

0.001 193 225 78

38.9 45.7 15.7

Reference 0.33 0.23

(0.19, 0.59) (0.12, 0.46)

0.001 0.001 0.456

15 46 146 75 126

3.7 11.3 35.8 18.4 30.9

Reference 1.26 0.59 0.49 0.69

(0.22, 7.29) (0.13, 2.78) (0.10, 2.36) (0.14, 3.26)

0.795 0.509 0.372 0.639 0.001

250 126 89 31

50.4 25.4 17.9 6.3

Reference 0.41 1.26 5.88

(0.25, 0.67) (0.63, 2.52) (0.78, 44.38)

0.001 0.516 0.086 0.789

308 169 18

62.2 34.1 3.63

Reference 1.17 1.26

(0.72, 1.90) (0.35, 4.49)

0.529 0.721 0.001

181 166 58 82

37.2 34.1 11.9 16.8

Reference 0.16 0.82 0.20

(0.09, 0.32) (0.28, 2.41) (0.09, 0.42)

0.001 0.718 0.001 0.095

120 124 85

36.5 37.7 25.8

Reference 0.82 3.32

(0.38, 1.79) (0.92, 12.04)

0.618 0.068 0.002

408

496

495

487

329

497

65

Sa’uLilo L, et al. Pacific Health Dialog 2018; 21(2):67-70. DOI: 10.26635/phd.2018.914 Employed 267 53.7 Reference Unemployed/seeking work 27 5.4 1.33 (0.381, 4.63) 0.656 Other 203 40.8 0.46 (0.29, 0.73) 0.001 Education 429 0.001 Secondary 237 55.2 Reference Tertiary 165 38.5 9.19 (3.86, 21.83) 0.001 No formal qualifications 90 21.0 0.77 (0.450,1.308) 0.330 Smoked cigarette(s) in previous 495 week 0.001 No 353 71.3 Reference Yes 142 28.7 4.19 (2.10, 8.33) 0.001 Alcohol (any) in the last 12 495 months 0.001 No 304 61.4 Reference Yes 191 38.6 4.60 (2.52, 8.37) 0.001 Physical activity* 494 0.209 Less than 2 days 240 48.6 Reference 3 to 5 days 195 39.5 1.26 (0.78, 2.04) 0.336 6 to 7 days 59 11.9 2.05 (0.88, 4.79) 0.096 Socioeconomic status** 496 0.085 High (No deprivation characteristics) 57 11.5 Reference One 74 14.9 1.56 (0.53, 4.60) 0.42 Two 102 20.6 0.71 (0.29, 1.75) 0.46 Three to Four 163 32.9 0.58 (0.25, 1.33) 0.19 Low (Five to Eight deprivation 100 20.2 0.49 (0.20, 1.17) 0.11 characteristics) Key: n = number; OR = Odds Ratio; BMI = Body Mass Index *Number of days in the previous week that the individual reported meeting physical activity recommendations (at least 30 minutes of moderate activity or at least 15 minutes of vigorous activity per day) **Classified using the NZiDep, calculated as the sum of positive responses to eight items used to assess socioeconomic deprivation.

Table 4. Characteristics of qualitative study participants Focus Group Participants P1

Age

Ethnicity

59

Samoan

P2

43

Cook Island

Low

P3

36

Cook Island

Low

Assimilationist (High score, low Pacific score)

P4

38

Samoan

High

P5

37

Samoan

High

P6

42

Tongan

High

Marginal (Low NZ score, low Pacific score) Assimilationist (High NZ score, low Pacific score) Assimilationist (High NZ score, low Pacific score) Workplace

Health Professional Participants HP1

Gender

HP2

Female

Female

Health literacy Low

Acculturation Marginal (Low NZ score, low Pacific score) Assimilationist (High NZ score, low Pacific score) NZ

Pasifika Integrated Health Care Ltd Ministry of Health NZ

66


Theme 2: Relationships Social support. Seeking help from family members was commonly cited as a method of gathering support with health issues. These included, help to read or interpret pamphlets or brochures written in English, or advice on traditional remedies. The first author’s second language was English therefore she required assistance with reading and understanding health related information. Half of the participants stated they would either ask someone they knew within their family to help treat low-grade conditions such as cuts, grazes or eye infections, but not others, such as asthma. Theme 3: Empowerment Mother’s influence upon her respective family members. Almost all mothers reported their health, their child’s health, and their families’ health was a priority. As mothers, they would implement their role by encouraging their children to make healthier choices to lead healthier lifestyles. Even though the term empowerment was not mentioned, the theme arose from the influential nature of their roles when discussing their experiences with healthrelated ideas. Cultural identity. Both health professionals acknowledged that being a Pacific person as a health professional was an asset to helping Pacific people with their health-related purposes. As a qualified health professional, HP2 felt as though being of Pacific ethnicity and grasping the value of her heritage was an essential component to supporting other Pacific people. Theme 4: Policy Change Recommendations for health and nutrition related information. Overall, most mothers wanted to make recommendations to the Ministry of Health regarding health-related information. Suggestions included creating clinics within small community groups to better understand health related issues as well as nutrition related information. In agreement of this statement, P3 and P4 added, using a coding system with the use of colours or a traffic light system could help people understand which food items to select: “Yes…there needs to be other ways to help our people practically rather these pamphlets and things because I never use them”. With regards to using pamphlets and brochures, when the researcher probed whether the language should be translated into their native language, they agreed this would be helpful, although there was more emphasis on suggesting practical changes such as a community clinic. Based on HP2’s experience, she suggested creating health care clinics that catered to traditional Pacific related

illnesses that provided Pacific herbal remedies, Pacific masseurs, or spiritual healers. DISCUSSION The aim of this research was to explore issues around health literacy in Pacific mothers residing in NZ, findings revealed associations between low health literacy and age, ethnicity, acculturation, employment, education, smoking status, and alcohol status. The qualitative discussions revealed different philosophical views, strengths, weaknesses, attitudes and behaviours towards health-related situations, summarised within four key themes: behaviours, relationships, empowerment, and policy change. Most were expressed and explained in the context of Pacific health and wellbeing, aligning with the Fonofale framework. A number of novel findings emerged, pertaining to the use of health information, comprehension of information, preferred information and health service delivery modes. Overall, a mismatch was observed between health literacy and use of health information. In line with findings from Wolf et al. 23, no significant relationships were found between health literacy and BMI, self-reported health status, or physical activity. Positive relationships were found between health literacy and smoking status and alcohol consumption in the quantitative analyses. While counterintuitive, these findings align with those of Arnold et al. 24 who investigated the health risk behaviours among low-income pregnant woman and found older females with adequate health literacy were more likely to have higher rates of smoking compared to those of low health literacy. Those who had low health literacy were more likely to report never having smoked. These observations are also similar to a study conducted with Australian mothers, where despite having adequate health literacy and a good understanding about healthy nutrition behaviours, these mothers continued to consume unhealthy processed foods.25 Corresponding with earlier research 26, findings revealed a need to prioritise face-to-face meaningful talanoa for provision of health information with Pacific people. Meaningful talanoa must be expressed in a way that incorporates the values and belief of the individual to develop a sense of trust. This then allows the individual to have the confidence to express their opinions confidently through deep and meaningful talanoa 27. Vaioleti 17 explains establishing relationships with talanoa must integrate aspects of the Kakala such as the beliefs and cultural values imbedded within quality conversations with Pacific people. There is a need 67


for increased Pacific capacity in the health workforce, and for appropriate time allocation for adequate talanoa.28 Internet use for health-related reasons has been associated with young age, female gender, and higher education status.29,30 Often there is an assumption that internet access and usage is low among communities of lower socioeconomic status and ethnic minority groups.29 This research does not support that assumption, participants in the current study reported insisting on using their mobile device to access the internet because of its convenience and availability of easy to use websites to access health information. Health professionals understood this behaviour was becoming increasingly popular among their Pacific clients, in particular young Pacific mothers, and encouraged this behaviour. All participants identified a need to create and design health based websites that incorporate Pacific specific information to cater to all Pacific groups. Understanding, acknowledging, and respecting an individual’s values when sharing health information consistently arose as a key priority. Elder family members were important sources of health information, and this information often aligned with mainstream health messages 31. In keeping with previous research 32 ethnicity and acculturation were associated with health literacy. These findings highlight the importance of the Fonofale framework in understanding Pacific health issues. Aside from education, no associations were found between socio-economic status or income with health literacy in this study, this is at odds with previous research,23,33,34 however, socioeconomic factors came across clearly in the qualitative discussions when talking about nutrition. Despite their health literacy levels, purchasing food items for their respective homes was based on perceived food palatability, food expiry date, and price. Comprehension of nutrition labelling was reported as problematic either because participants didn’t understand it or it was not a priority for them. These results have clear implications for delivery of public health nutrition messages in NZ. Indeed, participants proposed their own solutions to create culturally appropriate community clinics to increase comprehension of public health messages warranting further research and investigation. Environmental interventions to improve availability and accessibility of healthy foods may be a worthwhile strategy to improve quality of nutritional intake for Pacific people. Examples include policies that restrict the number of fast food outlets available in most

deprived areas.35 and tax incentives that reduce the cost of healthy foods.36 Strengths and Limitations A key strength of this research are the unique insights gained from a Pacific perspective utilising Pacific specific culturally appropriate research methodologies. These included the use of focus groups and interviews which enabled generating new insights beyond the quantitative research findings, and helped to contextualise and understand the quantitative results. Established and validated measures and protocols were employed, using current best practice. It is acknowledged that some measures could be improved by testing and validating for a Pacific population, where this has not already occurred. The findings are limited to the population group of Pacific mothers living in NZ. Differing concepts of health literacy and measures of health literacy exist, and it is possible that the tool used in this study to measure health literacy did not adequately capture health literacy for this population. Given the low rates of health literacy among Pacific people globally, future research to develop, validate and ensure cultural appropriateness of a health literacy screening tool specifically for use among Pacific people is needed. Upon completion of the focus group meetings and interviews the first author critically reflected upon her research practice and noted that the participants’ desire to openly express their ideas and concerns seemed limited at times. The conclusion was drawn this was due to the researchers relatively young age. In future focus groups and interviews with Pacific mothers, and health professionals researchers should consider having an older and more experienced researcher preferably also of Pacific descent conduct the qualitative research to minimise potential participant discomfort and facilitate more open discussion. CONCLUSION This is the first study to examine the factors related to health literacy for Pacific people living in NZ. Findings suggest current health related information is not being used to its fullest extent by Pacific mothers. In part, this may be due to underlying socio-demographic, cultural, and religious factors. Proposed solutions include community health initiatives, Pacific-specific services, harnessing mobile and internet technologies, clear and accurate food labelling, 68


and reducing the cost of healthy foods. Acknowledgements Mālō 'aupito, Fa’afetai Lava, Fakaaue lahi, Māuruuru roa, Meitaki (thank you greatly) to all the Pacific mothers and Pacific health care workers who participated in this research. The researchers would also like to thank the Pacific Island Families study team and Auckland University of Technology. Conflict of Interest The authors declare no conflict of interest. REFERENCES 1. Ministry of Health. Annual Update of Key Results 2014/15: New Zealand Health Survey. Wellington, New Zealand: Author, 2015. 2. Organisation WH. Health Literacy: The solid facts. 2013 [Available from: http://www.euro.who.int/__data/assets/pd f_file/0008/190655/e96854.pdf. 3. Harris MI. Health care and health status and outcomes for patients with type 2 diabetes. Diabetes care 2000;23(6):754-58. 4. Kim S, Love F, Quistberg DA, et al. Association of health literacy with self-management behavior in patients with diabetes. Diabetes care 2004;27(12):2980-82. 5. Services. USDoHaH. A quick guide to health literacy: fact sheets, strategies, resources. 2005 [Available from: http://www.health.gov/communication/lite racy/quickguide/Quickguide.pdf. 6. Panapasa S, Jackson J, Caldwell C, et al. Community-based participatory research approach to evidence-based research: Lessons from the Pacific Islander American Health Study. Progress in community health partnerships: research, education, and action 2012;6(1):53. 7. Paterson J, Percival T, Schluter P, et al. Cohort profile: the pacific islands families (PIF) study. International Journal of Epidemiology 2007;37(2):273-79. 8. Rush E, Oliver M, Plank L, et al. Cohort profile: Pacific Islands Families (PIF) growth study, Auckland, New Zealand. BMJ open 2016;6(11):e013407. 9. Morris NS, MacLean CD, Chew LD, et al. The Single Item Literacy Screener: evaluation of a brief instrument to identify limited reading ability. BMC family practice 2006;7(1):21.

10. Borrows J, Williams M, Schluter P, et al. Pacific Islands Families Study: The association of infant health risk indicators and acculturation of Pacific Island mothers living in New Zealand. Journal of Cross-Cultural Psychology 2011;42(5):699-724. 11. Salmond C, Crampton P, King P, et al. NZiDep: a New Zealand index of socioeconomic deprivation for individuals. Social science & medicine 2006;62(6):1474-85. 12. Boon RM, Hamlin MJ, Steel GD, et al. Validation of the New Zealand physical activity questionnaire (NZPAQ-LF) and the international physical activity questionnaire (IPAQ-LF) with accelerometry. British journal of sports medicine 2008:bjsports52167. 13. Zulkefly NS, Baharudin R. Using the 12-item General Health Questionnaire (GHQ-12) to assess the psychological health of Malaysian college students. Global Journal of Health Science 2010;2(1):73. 14. Bush K, Kivlahan DR, McDonell MB, et al. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Archives of internal medicine 1998;158(16):1789-95. 15. Rush EC, Freitas I, Plank LD. Body size, body composition and fat distribution: Comparative analysis of European Maori Pacific Island and Asian Indian adults. British Journal of Nutrition 2009;102(4):632-41. doi: doi: 10.1017/S0007114508207221 16. Trumbull M. Qualitative research methods: Integrating quantitative and qualitative methods in research. Maryland, USA: University Press of America, Inc 2005. 17.

Vaioleti T. Talanoa methodology: A developing position on Pacific research. Waikato Journal of Education 2006;12(1):2134.

18. Thaman KH. Decolonizing Pacific studies: Indigenous perspectives, knowledge, and wisdom in higher education. The Contemporary Pacific 2003;15(1):1-17. 19. Nonu-Reid E, Lui D, Erik M, et al. The Lotofale development of the Fonofale model of health, 2000. 20. Sa’uLilo L, Tautolo E, Smith M. Health Literacy among Pacific mother’s in NZ; A review of the literature. (Unpublished literature review). Auckland University of Technology, Auckland, NZ 2017 69


21. Grant BM, Giddings LS. Making sense of methodologies: A paradigm framework for the novice researcher. Contemporary nurse 2002;13(1):10-28. 22. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative research in psychology 2006;3(2):77-101. 23. Wolf MS, Gazmararian JA, Baker DW. Health literacy and health risk behaviors among older adults. American journal of preventive medicine 2007;32(1):19-24. 24. Arnold CL, Davis TC, Berkel HJ, et al. Smoking status, reading level, and knowledge of tobacco effects among low-income pregnant women. Preventive medicine 2001;32(4):313-20. 25. Hesketh K, Waters E, Green J, et al. Healthy eating, activity and obesity prevention: a qualitative study of parent and child perceptions in Australia. Health promotion international 2005;20(1):19-26.

therapies in HIV patients of low health literacy. Journal of general internal medicine 1999;14(5):267-73. 34. Sudore RL, Mehta KM, Simonsick EM, et al. Limited literacy in older people and disparities in health and healthcare access. Journal of the American Geriatrics Society 2006;54(5):770-76. 35. Sushil Z, Vandevijvere S, Exeter DJ, et al. Food swamps by area socioeconomic deprivation in New Zealand: a national study. International Journal of Public Health 2017:19. 36. Swinburn B, Kraak V, Rutter H, et al. Strengthening of accountability systems to create healthy food environments and reduce global obesity. The Lancet 2015;385(9986):2534-45.

26. Vaioleti TM. Talanoa research methodology: a developing position on pacific research. Waikato Journal of Education 2006;12:21-34. 27. Suaalii-Sauni T, Wheeler A, Saafi E, et al. Exploration of Pacific perspectives of Pacific models of mental health service delivery in New Zealand. Pacific Health Dialog 2009;15(1):18-27. 28. 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. Wellington, New Zealand: Pacific Perspectives, 2012. 29. Kamalu N. Internet use among racial/ethnic groups in the United States. . Faculty Working Papers, 2012:1-21. 30. Sayakhot P, Carolan-Olah M. Internet use by pregnant women seeking pregnancy-related information: a systematic review. BMC pregnancy and childbirth 2016;16(1):65. 31. Bassett‐Clarke D, Krass I, Bajorek B. Ethnic differences of medicines‐taking in older adults: a cross cultural study in New Zealand. International Journal of Pharmacy Practice 2012;20(2):90-98. 32. Lawes E. Literacy and Life Skills for Pacifika Adults: Results from the adult literacy and life skills (ALL) Survey. In: Unit. CER, ed.: Research Division, Ministry of Education., 2009. 33. Kalichman SC, Ramachandran B, Catz S. Adherence to combination antiretroviral 70

Sopoaga F, et al. Pacific Health Dialog 2018; 21(2):71-79. DOI: 10.26635/phd.2018.916

Editorial

OPEN ACCESS

Mental health and wellbeing of Pacific students starting University in New Zealand Faafetai SOPOAGA,*1 Jacques VAN DER MEER,2 Shyamala NADA-RAJA,3 Tim WILKINSON,4 Sarah JUTEL1 ABSTRACT Aim : To explore mental health status and factors that impact on the wellbeing of Pacific students in their first year at University. Methods : Twenty Pacific students who enrolled to study in the Health Sciences First Year at a University in New Zealand in 2015 were randomly selected to participate in this research. Participants were interviewed three times during their first year at University. The Pacific research methodology Talanoa was used for the data collection process. Of the 60 planned interviews, 59 were able to be completed. Interviews were recorded, transcribed and uploaded to NVivo to assist data management. Data was analysed using a thematic approach. Results Pacific students reported on their experiences of various stresses during the year. Some stress was related to their own personal expectations and others due to expectations of others. Students experienced a range of emotions and symptoms in response to these stresses. Many had developed skills or effective management strategies to deal with these stresses. For many, resilience contributed to maintaining wellbeing. In addition, families, friends, peers, mentors, supportive staff and targeted Pacific support services played critical roles in supporting the mental health and wellbeing of Pacific students in the first year at University. Conclusion There is increasing concern worldwide about students’ mental health and wellbeing in higher education. Pacific students felt stressed for many reasons which affected their mental health in the first year at University. Their resilience and other coping skills and connecting to a wide support network enabled them to maintain wellness. Pacific students or those from minority groups are likely to require different and or more support to enable them to adapt to the higher education environment. Strengthening and facilitating access to support networks and culturally relevant services, and increasing connectedness and sense of belonging, are important for Pacific students’ mental health and wellbeing in the tertiary environment. KEY WORDS: Mental health, Well-being, Pacific students, New Zealand

INTRODUCTION There is increasing international concern about the mental health and wellbeing of students in higher education. Wellbeing is a reflection of an individual’s assessment of life in a positive manner, and the result of an individual’s response to challenges and opportunities in life. 1 There are increasing stresses and emotional problems faced by tertiary students internationally 2-12, along with rising demands on student health services. 2,10 Additionally, the types of issues for which

students are seeking help have changed from minor concerns to more severe psychological problems. 10 The prevalence of depression is 15% in North American medical students 11,13, similar to 14% in undergraduate tertiary students in Malaysia. 14 Research suggests that students in higher education have poorer wellbeing compared to the general population. 2

71

Sopoaga F, et al. Pacific Health Dialog 2018; 21(2):71-79. DOI: 10.26635/phd.2018.916 *Corresponding author: Faafetai Sopoaga [email protected] 1. Centre for Pacific Health, Va’a o Tautai, Division of Health Sciences, P.O. Box 913, Post Code 9054, University of Otago, Dunedin, NZ 2. College of Education, P.O. Box 913, Post Code 9054, University of Otago, Dunedin, NZ 3. Department of Preventive and Social Medicine, P.O. Box 913, Post Code 9054, University of Otago, Dunedin, NZ 4. Otago Medical School, P.O. Box 913, Post Code 9054, University of Otago, Dunedin, NZ Received: 28.7.2018 Published : 30.09.2018 Citation: Sopoaga F, et al. Mental health and wellbeing of Pacific students starting University in New Zealand. Pacific Health Dialog 2018;21(2):71-79. DOI: 10.26635/ phd.2018.916 Copyright: © 2018 Sopoaga F, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Mental disorders are a significant health concern and an increasing burden for Pacific peoples particularly among youth in NZ. 15-19 The NZ Health Research Strategy identified mental health as a priority area of concern. The NZ Mental Health Survey for adults 16 years and over reported the prevalence of mental illness in Pacific peoples to be 25% compared to 21% for the total NZ population. 20 The most common hospital admissions for young Pacific people in the 15-24 years age group (2007-2011) included depression and bipolar disorders. 21 Data from the Ministry of Health (MoH) reported the suicide rates for Pacific youth aged 15-24 years were significantly higher compared to all other ethnic groups 17. Research looking at suicide mortality (1996-2013) reported the prevalence of suicide in Pacific youth to be a significant concern. 22 The Youth’12 report on the Health and Wellbeing of Secondary School Students in NZ found approximately 13% of Pacific students had experienced clinical depressive symptoms 23. These students were more likely to report selfharm, and three times more likely to have attempted suicide compared to their NZ European peers. Young people in the Pacific Youth Leadership and Transformation (PYLAT) Council are now speaking out about the importance of their mental health and specific needs within the education sector. 19 There is sparse information about tertiary students’ mental health and wellbeing in New Zealand (NZ). The New Zealand Union of Students’ Associations published recently a report on the state of mental health of students in higher education. 24 The report was based on the findings of an online survey completed by 1762 respondents from more than 13 different

institutions. The Kessler Psychological Distress Scale 25 mean score for all students was 28.1 (moderate level of psychological distress). Other studies in New Zealand have also reported psychological distress or stress amongst University students. 26,27 First year Health Sciences students at the University of Otago reported experiencing stresses which impacted on their engagement and involvement in university life. 27 Researchers at the University of Auckland reported sleep disorders in undergraduate students, and 17% and 20% reporting depression and anxiety, respectively. 28 In another study psychological distress in students was found to be associated with alcohol use and alcohol-related harms. 26 There is even less information about Pacific youth in tertiary institutions. Previous research found Pacific students experienced stress and anxiety in their first year at university. 29 Pacific peoples migrated from the Pacific Islands to New Zealand for better education and employment 30 opportunities. However, they are disproportionately represented in poor health and education outcomes. 31 Understanding how best to support Pacific students’ health and wellbeing in higher education is likely to contribute to better education outcomes and employment opportunities. The aim of this study was to explore the mental health status and factors that impact on the wellbeing of Pacific students in their first year at University. METHODS Students are able to nominate up to three ethnic groups they identify with when they enrol at the University. All students who identified with at least one Pacific ethnic group and enrolled to study the Health Sciences First Year (HSFY) programme in 2015 were eligible to participate. The data on all eligible students (n=106) was obtained and randomised stratified by gender and ethnicity. Twenty Pacific students from the randomised list were identified and invited to participate in three interviews at different time points during their first year. The University calendar year is divided into two semesters. The first interview was held during the Orientation period, the second six weeks into Semester 1 and the third two weeks into Semester 2. The University offers an Early Orientation Programme for all Pacific HSFY students prior to the official University-wide student orientation programme. Of the 20 participants, 15 had participated in the Pacific Early Orientation Programme and 5 had not. Of all students 72

Sopoaga F, et al. Pacific Health Dialog 2018; 21(2):71-79. DOI: 10.26635/phd.2018.916 approached, two declined to participate, and a further two were selected who agreed to be involved. For those who were selected and wished to participate, specific times and venues were organised for their interviews. All participants were given an information sheet with opportunities for questions, before completing the consent form prior to the first interview. During the recruitment process, it was emphasised that it was important for them to be available for all interviews. The interviews focussed on exploring students’ experiences, expectations and views about their health and wellbeing during their first year at University. The Talanoa methodology 32 was used as the approach for data collection. Talanoa means to share through conversations. It is the pathway through which Pacific knowledge and traditions have been passed down through generations. Talanoa provides the cultural context and environment where participants feel able to share stories and experiences in a meaningful way. Interviews were conducted by a Pacific researcher and lasted approximately one hour. All interviews were audio-recorded and transcribed. The transcripts were returned to each student for checking. The final data from each interview was uploaded to NVivo for data management purposes. Data were analysed thematically and chronologically to determine key emerging ideas and themes. The data was initially coded into subthemes, which were further analysed to determine the main themes. Interviews from each participant were also analysed chronologically across the three interview periods to explore any changing patterns across key themes identified. Ethics approval was granted by the University of Otago Human Ethics Committee. Reference : 15/007. RESULTS This research is part of a doctoral study exploring the journey of Pacific students in their first two years at University. The results presented here focus on their mental health and wellbeing, a subtheme within the broader key theme of Health and Wellbeing. Twenty participants were evenly divided in terms of gender and represented nine Pacific ethnic groups. Eleven participants had sole Pacific ethnicity. All except one mature student were aged between 19-20 years. Most were staying in a University Residential College. Three participants had entered Health Sciences First Year through the University Foundation programme, two were from overseas, and the rest entered directly from

NZ secondary schools. Five participants were from low decile schools, five from high decile schools, and ten from mid-decile schools. All had left their home environments for tertiary studies. Of the 60 possible interviews, 59 were able to be completed. The results below are organised into four areas and are from data across the three time points; Experience and Expectations, Mental Health and Wellbeing, Personal Development, and Support Networks. Experience and Expectations Participants reported a range of causes of stress, and many started the year with mixed emotions. Some of the stressors were a result of their own expectations of themselves, while others were due to the expectations of others. Following are some illustrative examples of how participants shared about their experiences: “It’s quite overwhelming, feel exciting, that’s why I’m like “oh my gosh I’m the first one to get into Uni” so I feel like the pressure is on me to do better, for others to come, yeah…the other thing that’s on my mind coming…. (is) for a better future of my family, so I try to accomplish the best for my family to uplift the standard of living, as well and help our community.” P15, male “I don’t feel pressured by my family to get in, but it’s just like myself, it’s something that I know I’ve always wanted to do. I know I have other courses but it’s not really where I want to go. Med’s really what I want to get into, so it’s more like selfpressure if that makes sense to you.” P16, female “I grew up with my Dad always like after I got a test or an exam saying “oh what happened to the other 1%” and you know like typical Island parent… “why didn’t you get 100?” it’s like “I got 99 Dad” that sort of thing, it really messed my mind up at one point but it also made me want to get that 100%.” P3, male The cause of the most stress experienced by students, was directly related to the academic work. They described the workload as being heavy, the challenges of adjusting to the new learning environment, and awareness of the implications of their academic achievements for their future career pathways. “The first couple of weeks was overwhelming like I was calling Mum saying “I don’t know how I’m going to do this! I don’t know how it’s going to be 73

Sopoaga F, et al. Pacific Health Dialog 2018; 21(2):71-79. DOI: 10.26635/phd.2018.916 possible for me to like get through the year because in one lecture we would cover what we do in School in a month!” you know, it was just a completely different standard and even though I’d heard so much about how hard it is, I don’t think you could ever understand until you are actually doing it like how full on it is.” P1, female “Yeah, when I say that it feels like two weeks, I think it’s just because everything has gone so fast. I noticed that in one of my classes we covered a topic that back in High School took us an entire term (so 12 weeks) and we did it in two, so things just go really really fast.” P8, female “I did this in the Chemistry mid-term, I was thinking the whole time, “this is meaning whether you are going to be a Doctor or not – this test right now is meaning whether you are going to be a Doctor or not” and then that is just sooo bad when you are taking the test because then I couldn’t… it just got so much.” P1, female There was also stress related to social integration, adjusting to living in a different environment and getting to know new people. “So I think it was just before the Orientation Programme kind of thing. I was with my parents inside my room and I was sitting there. I was pretty scared and I said to them “I’m scared”…I can’t remember what my parents said, they just said parenty things you know, like “ah it’ll be alright.” P9, male “I remember the first few days. It was like, it was really really scary because I still didn’t know anyone that well, and so I like sort of just sat in my room at my hall, like wondering what to do.” P6, male. In addition, there was stress related to developing and managing relationships in a new environment. Others felt stressed by observing stress in others. “I’d been living with my friend and then like the second test came along, and then she’s like been playing up, so like I couldn’t say it wasn’t really comfortable going home …and then it just like went downhill and downhill and downhill. The place was mine so I told her she has to go if she’s going to be like this because I can’t study, so she’s leaving today.” P13, female “Oh yeah, the hall is good but it’s just like my friends…’coz like I have to catch up on work and most of the time I focus on school work that I don’t

notice that I’m going further away from them yeah. So sometimes they’d like go to dinner or do things …and they don’t let me know” P15, female “It (exam) was horrible. Probably because the chick next to me was crying, and then I go to the bathroom to have a bit of a break and someone was vomiting so I was like “ah….!!” So it was real, I don’t know if it was anxiety or everything I just felt like I didn’t know anything.” P5, female Mental Health and Wellbeing Students described their experiences over the year as like being in a roller coaster or in the midst of a storm. Emotional responses to these experiences varied between students. For some this affected their ability to respond in the way they would normally approach a difficult situation, while others were able to respond in a considered way to their circumstances. “It was a bit of a roller coaster really, because I felt like we studied hard. I don’t know if we over did it. I couldn’t figure out what was important, what was not. For me it was like “everything is important, you need to know this and this and this” and I just panicked. I think and did everything rather than what I should have been doing.” P5, female “It’s like you’re on the edge of craziness but your still sort of like, you’re strangely calm. I feel like you’re standing in the eye of the storm you know. There’s like things happening around you and it’s like you can either join the storm, or you can be calm and just go on and sort of have your own plan.” P18, female The symptoms students described in relation to their mental wellbeing were mainly related to concerns over academic integration and achievement. These included feeling overwhelmed, depressed, fear of failure, lack of confidence and self-doubt. In addition, some developed physical symptoms such as tiredness, over-eating and insomnia. “I was just really overwhelmed in the lectures. Beginning of the year I didn’t know what was needed, like they were just talking really fast and a lot of stuff they were talking about I was like “What is that? What do I need to know?.” P10, female “The majority of my friends want to get into Med, so they feel like “Ah my gosh! you know, someone got this amount of points. I know we did the same 74

Sopoaga F, et al. Pacific Health Dialog 2018; 21(2):71-79. DOI: 10.26635/phd.2018.916 amount of study yet they did so much better, so what’s wrong with me?” It’s getting them down.” P16, female “Failing does scare me, it’s one of my biggest driving factors but also one of my biggest fears, and that is one of the only things that will make me crumble, is failing.” P3, male “Last semester I actually had really bad insomnia and so that like messed me up a lot. I’ve had it on and off for like a few years. What happens is like I’ll be good but if I stuff it up, my sleeping pattern once it kind of triggers, I just can’t sleep for like ages.…like you are really tired so I’d go to bed and then I’d just be lying there and then next thing you know the sun’s coming up and you’re just like “I still haven’t slept!” (chuckle).” P6, male Personal Development Despite the challenges students faced adjusting to a new learning environment, living away from their usual support networks, the heavy workload and a high stakes academic year, many were resilient and relevant coping skills that enabled them to complete the year successfully. “I’ve grown up to be independent and have a strong sense of understanding about who I am, and when I am surrounded by people that don’t understand me, I’ll go find someone that does kind of thing.” P8, female “ I don’t really get stressed in a way. When I’m in stressful situations I’m the sort of person that says “Well ok that’s happened, what am I going to do about it?.” P18, female “I’m generally a pretty optimistic person. I’m not the type of person who just feels they have to just sleep all the time because you are so low about... “oh I’m so behind and I feel down.” P16, female Many shared about the need to find the balance between academic, social and personal lives. They had various ways to do this, which included doing things they enjoyed. “What I find the most enjoyable is also the most challenging. So I love learning stuff all the time, but it’s also the most challenging part because there’s always something new to learn. I think that’s where the balance comes in. Like you have to be able to find a balance between…your enjoyment and your challenges.” P8, female “You don’t just study full time and get sick of it. Like you still want time to go for a walk, or chat with your friends or just sit outside, go to the museum or just walk around campus. Because if you are in the library every day, like every time,

you’ll just get sick and lose motivation. So like having the balance of being able to do things that you like, just keeps you a bit more sane.” P12, female “I find like exercising helps but then sometimes it doesn’t. Then I kind of have to address what’s making me stressful and how I can decrease that chance of it happening again.” P2, female Support Networks Support from families, friends and peers was a critical factor in maintaining students’ mental health and wellbeing during the year. “I manage stress calling my family and they’re like “how’s it going?” just being honest with everyone, “I’m feeling stressed, I’m feeling like I’m stuck, I need help.. ” P10, male “My friend on my floor has a car and sometimes we go out to beaches. So that’s been really cool this year and just hanging out with my friends is probably the highlight” P1, female “Mentoring was my favourite part (chuckle). I think because you’re so stressed during the week, the mentoring was just kind of an opportunity to relax and gather your thoughts again. The mentors were really good in just calming you down and talking you through things. It’s like having that older brother or older sister there, just giving you advice. It’s good just to have someone to talk to and have someone there that’s been through it, that understands the stress but they also know what’s about to come. So they were able to tell you, “yes I know you are stressed at the moment, but it gets better, it’s not going to be like this forever.” P8, female Other factors identified as playing an important role in maintaining students’ wellbeing during the year included the support provided by Pacific staff and through accessing support services. “I had an Academic Health Check about two weeks ago I think and that was really good. Just getting some things out that otherwise would just stay bottled up kind of thing, and being able to talk about where I am, like emotionally as well as mentally and stuff like that.” P8, female “I really love going to POPO. I love, love going to those because I’ve just met sooo many people, and I think that’s really helped … to be honest I don’t think I could have done it without it, without POPO there. Because when I do feel a bit low, there’s always someone there to talk to, helping 75

Sopoaga F, et al. Pacific Health Dialog 2018; 21(2):71-79. DOI: 10.26635/phd.2018.916 me out, giving me some advice. Just friends here that you know, tease you up so, I always feel better when I’m around them. I honestly think that yeah…definitely made a big different, BIG difference.” P16, female “Having people my own age, all in the same situation from both the POPO programme as well as back in the (Residential) College really helps. Because if someone is feeling one way then you are almost guaranteed that someone else is going to be feeling something similar. So you can talk it out with people and it’s a good support system. Sometimes you can feel lost, but there’s always someone there to help like pick you up, and it’s quite good.” P8, female DISCUSSION This is an in-depth study to explore the mental health and wellbeing of Pacific students in New Zealand, during their first year of study at university. All of these students had left their cultural and family support networks to undertake tertiary studies. Many are the first in their families to study at university. All were adapting to new study approaches, adjusting to an increase in class size from 30 to 500 students, in addition to enrolling in a high stakes programme which determines eligibility for entry into health professional programmes such as medicine and dentistry. This research found that Pacific students experienced a number of stresses which affected their mental health and wellbeing in their first year at University. These stemmed primarily from their own expectations of themselves or the expectations of others on them. Those who were the first in their families to attend university had the added pressure to do well as role models for others in their families. Their hopes for success in education was not just for themselves, but also to benefit their families and wider community. Previous research suggested that students from non-traditional backgrounds may require different or more support to enable them to transition well and be successful in higher education. 2 There are specific areas institutions can target to minimise stress. For example, ensuring the academic workload for first year students is manageable. The HSFY programme has since been review with changes to the programme planned. In addition, careful consideration about how best to provide support for students is helpful. For non-traditional students, this may require different or additional approaches to meet their needs.

The University runs a targeted support programme, the Pacific Orientation Programme @ Otago (POPO), for Pacific students transitioning into the first year in Health Sciences. 33,34 POPO is the Samoan word for coconut and has three meanings. POPO is a young coconut that is ready for planting. PŌPŌ means to nurture and POPŌ is to capture. POPO encapsulates the essence of what this support programme seeks to do. It supports Pacific students to thrive in the new learning environment, nurtures their growth in a culturally helpful manner, and enables students to capture and utilise what the institution has to offer them to achieve their own aspirations. This support programme delivered within a Pacific cultural framework with support from the NZ Ministry of Health, has enabled Pacific students to “feel at home” quickly and contributed to marked academic success for students at the University. 35 This research also identified a number of factors that supported students’ mental health and wellbeing. These included their own personal skills and strengths as well as connecting with the support from their families, friends, peers and staff. The Pacific population is a young and rapidly growing migrant population in NZ, making up 7.4% of the total population. 36 Pacific families migrated to NZ for better employment and education opportunities. Education is a key determinant of health and a predictor of economic wellbeing through better employment opportunities 37 Pacific peoples however are disproportionately represented in poor health and education outcomes, and have higher unemployment. 17,31,38 Despite these challenges, this research suggests that Pacific students are resilient. They are independent, optimistic, understand the need for balance and have various approaches to reduce stress in their lives. In addition they realise the importance of interdependence and interaction with other students and staff. The Fonofale model of health 39 identifies family as an important aspect of Pacific peoples’ health. For these students their families were critical in maintaining their mental health and wellbeing. Friends and peer mentors were a vital part of their support network. Previous research had identified peers 40,41 and mentors 42 as having an important role in supporting students’ transition to university. This helped with social integration, provided a sense of connectedness and belonging, and contributed to their overall health and wellbeing. Senior Pacific students functioned as peer mentors for the POPO programme. This had a positive impact on the mentees, who felt encouraged simply by connecting with other successful Pacific students who were fully 76

Sopoaga F, et al. Pacific Health Dialog 2018; 21(2):71-79. DOI: 10.26635/phd.2018.916 integrated into university life as their role models. Furthermore, the support from Pacific and other academic staff was also appreciated by students. Tinto 43 also articulated the importance of the role of faculty or staff for student support. Of the 20 students who participated in this research, 4 have since graduated, 8 are studying medicine, 3 are studying pharmacy, and 4 are working towards completing other degrees. Of those who have graduated, all are completing a second degree (two are in the medical programme). Three have since left the University. One has enrolled in engineering in another institution, and the other two in fulltime employment.

2.

Brown P. The invisible problem ? Improving students' mental health: Higher Education Policy Institute; 2016.

3.

Field R, Duffy J, Huggins A. Supporting transition to law scholl and student wellbeing : The role of professional legal identity. The International Journal of First Year in Higher Education. 2013;4(2):15-25.

4.

Field R, Kift S. Addressing the levels of psychological distress in law students through international assessment and feedback design in the first year law curriculum. The International Journal of First Year in Higher Education. 2010;1(1):65-76.

5.

Hussain R, Guppy M, Robertson S, Temple E. Physical and mental health perspectives of first year undergraduate rural university students. BMC Public Health. 2013;13(849).

6.

Flatt AK. A suffering generation : Six factors contributing to the mental health crisis in North American higher education. College Quarterly. 2013;16(1).

7.

Hunt J, Eisenberg D. Mental health problems and help-seeking behaviour among College students. Journal of Adolescent Health. 2010;46:3-10.

8.

Zivin K, Eisenberg D, Gollust SE, Golberstein E. Persistence of mental health problems and needs in a college student population. Journal of Affective Disorders. 2009;117:180-185.

9.

Cranford JA, Eisenberg D, Serras AM. Substance use of behaviors, mental health problems, and use of mental health sevices in a probability sample of college students. Addictive Behaviors. 2009;34:134-145.

CONCLUSION There is increasing concern worldwide about students’ mental health and wellbeing in higher education. Pacific students felt stressed for a number of reasons which affected their mental health and wellbeing in their first year at University. Resilience and connectedness to a Pacific support network enabled students to maintain wellness. Tertiary institutions have a responsibility to provide effective support for students’ transitioning into higher education. Pacific students or those from minority or underrepresented groups are likely to require different or more support to enable them to succeed in tertiary institutions. Strengthening and facilitating access to support networks and culturally relevant services, and increasing connectedness and sense of belonging, are important for Pacific students’ mental health and wellbeing in the tertiary environment. Funding: This research was funded by the NZ Health Research Council. Competing interests: The authors declare that they have no competing interests. Authorship: FS is the lead author and was responsible for the overall structure and development of the manuscript. JvM, SN, TW and SJ were all involved in the write up of the manuscript. All authors read and approved the final manuscript. REFERENCES 1.

Mental Health Foundation of NZ. Wellbeing. www.mentalhealth.org.nz/home/ways-towellbeing/

10. Kitzrow MA. The mental health needs of today's college students : Challenges and recommendations. NASPA Journal. 2003;41(1):167-181. 11. Givens JL, Tija J. Depressed medical students' use of mental health services and barriers to use. Academic Medicine. 2002;77(9):918921. 12. Mori SC. Addressing the mental health concerns of international students. Journal of Counselling. 2000;78(Spring 2000):137-144. 13. Wimsatt LA, Schwenk TL, Sen A. Predictors of depression and stigma in medical students. American Journal of Preventive Medicine. 2015;49(5):703-714. 14. Mey SC, Yin CJ. Mental health and wellbeing of the undergraduate students in a research University : A Malaysian experience. Soc. Indic Res. 2015;122:539-551. 77

Sopoaga F, et al. Pacific Health Dialog 2018; 21(2):71-79. DOI: 10.26635/phd.2018.916 15. Teevale T, Lee A, Tiatia-Seath J, et al. Risk and protective factors for suicidal behaviours among Pacific youth in New Zealand. Crisis 2016. 16. Tiatia J, Coggan C. Young Pacifican suicide attempts : a review of emergency department medical records, Auckland, New Zealand Pacific Health Dialogue,. 2001;8(1):124-128. 17. Ministry of Health. A strategy to prevent suicide in New Zealand, Draft for public consultation 2017. 18. Kokaua J, Schaaf D, Wells JE, Foliaki S. Twelve-month prevalence, severity, and treatment contact of mental disorders in New Zealand born and migrant Pacific participants in Te Rau Hinengaro : The New Zealand Mental Health Survery. Pacific Health Dialogue. 2009;15(1):9-17. 19. Tualamali'i J. Pacific Youth Calls for Mental Health in Schools. https://www.leva.co.nz/news/pacificyouth-call-for-mental-health-education-inschools2017. 20. Foliaki S, Kokaua J, Schaaf D, Tukuitonga C. Twelve months and lifetime prevalences of mental disorders and treatment contact among Pacific people in Te Rau Hinengaro : The New Zealand Mental Health Survey Autralian and New Zealand Journal of Psychiatry 2006;40(10):924-934 21. Craig E, Dell R, Reddintog A, et al. The determinants of Health for Pacific Children adn Young People in New Zealand (2012): New Zealand Child and Youth Epidemiology Service, University of Otago; 2013. 22. Tiatia-Seath J, Lay-Yee R, Von Randow M. Suicide mortality among Pacific people in New Zealand, 1996-2013. NZMJ. 2017;130(1454):21-29. 23. Clark T, Fleming T, Bullen P, et al. Health and wellbeing of secondary school students in New Zealand. Trends between 2001, 2007, and 2012. J Paediatr Child Health. 2013;49(111):925-934. 24. New Zealand Union of Student's Association. Kei Te Pai ?. Report on Student Mental Health in Aotearoa 2018. 25. Kessler RC, Andrews G, Colpe LJ, Hiripi E. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med. 2002;32(6):959-976. 26. Doran G. Psychological distress in New Zealand university students and its

association with alcohol University of Otago; 2015.

consumption:

27. Jameson M, Smith J. Voices of students in competition. NZMJ. 2011;124(1338):55-66. 28. Samaranayake CB, Arroll B, Fernando AT. Sleep disorders, depression, anxiety and satisfaction with life among yoing adults : a survey of university students in Auckland, New Zealand. NZMJ. 2014;127(1399):13-22. 29. Teu A. The barriers, enablers and influences around the transition to university experiences of Pacific students in Health Sciences First Year programme at the University of Otago: University of Otago; 2015. 30. Friedsen W. Tangata Pasifika Aotearoa : Pacific Populations and identity in New Zealand. New Zealand Population Review. 2000;26(2):105-125. 31. Ministry of Health. 'Ala Mo'ui Progress Report : December 2015. 2015. 32. Vaioleti T.M. Talanoa Research Methodology : A developing position on Pacific research. Waikato Journal of Education. 2006;12(2124). 33. Sopoaga F, van der Meer J. Building a Pacific health workforce in New Zealand : Initial findings from a transition project in first year health sciences at University The International Journal in the First Year at Higher Education. Vol 22011. 34. Kokaua J, Sopoaga F, Zaharic T, Van der Meer J. The development of a pre-enrolment screening tool to inform targeted support services in the first year in health sciences The International Journal in the First Year in Higher Education. 2014;5(1):55-66. 35. Crampton P, Weaver N, Howard A. Holding a mirror to scoiety ? Progression towards achieving better sociodemographic representation among the University of Otago's health professional students. NZMJ. 2018;131(1476):59-69. 36. Statistics New Zealand. Pacific peoples ethnic group 2013. 37. Diener E, Sandvik E, Seidlitz L, Diener M. The relationship between income and subjective wellbeing : Relative or absolute. Social Indicators Research. 1993;28:195-223. 38. Ministry of Education. Progress against Pasifika Education Plan targets. 2016; http://www.educationcounts.govt.nz/statist ics/pasifika_education/progress_against_pa sifika_education_plan_targets#12. 78

Sopoaga F, et al. Pacific Health Dialog 2018; 21(2):71-79. DOI: 10.26635/phd.2018.916 39. Fuimaono K Pulotu-Endeman. The Fonofale Health Model. 1984; http://www.hpforum.org.nz/resources/Fon ofalemodelexplanation.pdf. 40. Everett M.C. Fostering first-year students’ engagement and well-being through visual narratives. Studies in Higher Education. 2017;42(4):623-635. 41. Maunder R.E. Students’ peer relationships and their contribution to university adjustment: the need to belong in the

university community. Journal of Further and Higher Education. 2018;42(6):756-768. 42. Yomtov D, Plunkett, S. W., Efrat, R., Marin, A. G. . Can peer mentors improve first-year experiences of university students? Journal of College Student Retention: Research, Theory & Practice. 2017;19(1):25-44. 43. Tinto V. Dropout from Higher Education : A Theoretical Synthesis of Recent Research. Review of Education Research. 1975;45(1):89-125.

79

Ruhe T, et al. Pacific Health Dialog 2018; 21(2):80-88. DOI: 10.26635/phd.2018.917

Original Research

OPEN ACCESS

Engaging Dunedin New Zealand Pacific People in Falls Prevention Troy RUHE, 1 Debra WATERS,2 Rose RICHARDS3 ABSTRACT Introduction: Falls are a common cause of injury in New Zealand. However, falls risk and prevalence have not been investigated in Pacific peoples. To address this knowledge gap, a literature review, falls risk screening, and attitudes towards exercise as falls prevention questionnaires were conducted in a Pacific population in the southern regional town of Dunedin. Aims: To identify the attitudes towards strength and balance exercise as falls prevention within Pacific Islands peoples in Dunedin, New Zealand. Methods: Participants aged 55+ were recruited from Pacific Trust Otago, flyers at church groups and existing exercise classes. Falls screening was assessed by the New Zealand Health Quality and Safety Commission’s Ask, Assess, Act questionnaire. Attitudes towards exercise as falls prevention intervention, was assessed using a culturally adapted version of the Attitudes to Falls-Related Intervention Scales (AFRIS). Both questionnaires were verbally administered in the participants’ native tongue. Results: Fifty respondents (mean age: 68.69, males: 39.58%, females: 60.42%) completed the questionnaires. Just over 56% indicated falls risk (62.07% female and 52.63% male) and 30% reported a fall in the last 12 months (31.03% females and 21.05% males). Readiness to engage in strength in balance exercise was high (AFRIS mean score 6.69 out of 7), however, difficulty in finding ways to engage in strength and balance exercise for falls prevention was perceived to be high. The total mean AFRIS score was 38.96 out of a possible 42 which indicates a willingness to engage in strength and balance exercise as falls prevention. Conclusions: Self-reported falls in the past year and risk within this population was comparable to other groups and highlights the need for falls prevention that caters to cultural needs. The positive response to adding strength and balance exercise provides supporting evidence of incorporating strength and balance exercises into existing programmes. KEWORDS: Pacic health, falls prevention, Pacific elderly, exercise INTRODUCTION There continues to be a dearth of falls research among older Pacific peoples in New Zealand. Falls have been reported as the most common injury in both Pacific and Europeans in New Zealand, however, the data on Pacific injury from falls was identified from a Pacific study of traumatic brain injuries (TBI) where falls were not the primary outcome.1 A consistent theme in the literature is that falls are the most common and costliest cause of injury for older people.2 Falls impact physical function and decrease psychological function by increasing the inherent fear of a re-occurring fall.3 Although these findings are not specific to Pacific peoples, it has been consistently reported across a range of different ethnicities and cultures. 4

*Corresponding author: Troy Ruhe, [email protected] 1. School of Physical Education, Sport and Exercise Science, University of Otago, New Zealand. 2. Director of Gerontology Research, School of Physiotherapy and Department of Medicine, University of Otago, New Zealand 3. Associate Dean Pacific, School of Medicine, University of Otago, New Zealand. Received: 28.07.2018 Published.30.09.2018 Citation: Ruhe T, et al. Engaging Dunedin New Zealand Pacific People in Falls Prevention. Pacific Health Dialog 2018;21(2):80-88. DOI: 10.26635/phd.2018.917 Copyright: © 2018 Ruhe T, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

80

Ruhe T, et al. Pacific Health Dialog 2018; 21(2):80-88. DOI: 10.26635/phd.2018.917 There has been limited falls research among people of the Western Pacific and none have addressed people of Pacific populations in the South Pacific. We must also acknowledge the diversity within Pacific communities, with Polynesia encompassing 1000 islands grouped into 22 countries from which Pacific communities draw their ancestry.2,4,5 Themes from the Literature Review A literature review of falls incidence and risk factors for Pacific peoples across New Zealand was conducted using the key phrases (pacific* OR pasifika*) AND (fall* OR trip* OR slip* OR unintentional injury*). Keywords were searched in the subject heading field to limit the search and grey literature. Falls as a cause of injury and mortality. Falls are the leading cause of injury in older people, leading to injuries such as fractures of the wrist, femur, hips and ribs.2 Lagolago established falls as the most common cause of injury among Pacific peoples (36.8%) and NZ Europeans (39.4%) in New Zealand.1 The Accident Compensation Corporation (ACC), reports approximately 30% of people aged 65+ fall annually in New Zealand.6 This is consistent with the findings in the context of community-dwelling older peoples.7 Falls risk. There is typically more than one factor that contributes to a fall.8 Commonly reported risk factors include age, sex (females at higher risk than males), lower body strength and balance deficits, polypharmacy and previous falls.9,10,11,12,13,14 A systematic review examining the relationship between muscle weakness and falls concluded that muscle weakness is a modifiable risk factor in older persons at risk of falling.14 Further, fallers in one study were those with the lowest physical function and, although statistically insignificant, were also those who reported sedentary behaviour.15 It was also noted that sedentary behaviour is commonly associated with muscle weakness.11 When examining falls in conjunction with a disease, evidence of diabetes as a risk factor for falls is emerging, although it is rarely identified as an independent risk factor for falls.16 Of the studies included, all identified Type II Diabetes as a falls risk factor through lack of glycaemic control and peripheral neuropathy causing poor

balance, lower standing balance scores and fearassociated activity restriction.10,17 Although these studies do not directly feature Pacific peoples, they are likely to be relevant given that Pacific peoples are three times more likely to be diagnosed with Type II Diabetes than other populations in New Zealand.5 Effective Prevention Within the prevention studies examined, a clear theme was the need for the involvement of a trained practitioner to provide education on falls and falls risk.18 Although Gillespie deemed the benefits of falls education as a single prevention intervention to be inconclusive, smaller studies have suggested that it is the delivery of the education, rather than the education itself that hinders effectiveness.8,9 Ang et al. noted that the delivery of an educational session from a trained falls researcher significantly reduced the risk of falling compared to patients receiving only educational material.19 A systematic review of falls in communities reported that multiple component exercise groups significantly reduced the rate of falls and falls risk.10 Peer-led strength and balance classes proved to be effective and also provided positive reinforcement for adherence through socialconnection, within the Dunedin region Steady As You Go (SAYGO) demonstrates the acceptability of local community group exercise for falls prevention.10,20 This was also seen in a study assessing perceptions of water-based activities for falls, participants valued the social aspect of group fitness.19 Again, these studies did not specifically include Pacific peoples, but the social relationship and community elements of these studies are likely to be relevant, given the importance of social connections within Pacific cultures.5 In the context of New Zealand, a programme currently under evaluation is ‘Langi Mai’ which is an exercise programme, in Manukau New City, for older Pacific peoples (55+) which incorporates traditional Pacific dance as a part of the exercise component. One report showed improvement in lower limb strength and flexibility as well as evoking a strong sense of identity, which aided in programme adherence.21 The literature review highlighted the fact that no falls research within the Pacific Islands community had been conducted which is concerning and Pacific people, like all ethnicities in New Zealand, may potentially benefit from strength and balance exercise as falls prevention.

81

Ruhe T, et al. Pacific Health Dialog 2018; 21(2):80-88. DOI: 10.26635/phd.2018.917 METHODS The participants were a convenience sample of 50 males and females, aged 55+ years. Inclusion criteria included cognitively intact respondents, in order to provide informed consent and comprehend the questionnaires. No other exclusion criteria were applied. The Pacific Trust Otago (PTO) provided recruitment assistance. PTO is a Dunedin based Pacific Health provider who provides education, social and health advocacy. Participants were also recruited through PTO weekly exercise classes, church groups, and other associated contacts identified by the PTO. Flyers were posted at the University of Otago School of Physiotherapy. All participants signed a consent form which was approved by the University of Otago School of Physiotherapy Ethics Committee (SOP/EC/2015/05) To create a comfortable environment, the questionnaires were verbally administered with each question on a power point and with the assistance of native Pacific speakers to ensure full comprehension. Confidentiality was assisted by administering individual ID numbers to each participant. To understand the risk of falls the New Zealand Health Quality and Safety Commission ‘Ask, Assess, Act’ (AAA) questionnaire was administered.22 It was created by a synthesis of the National Institute for Health and Care Excellence (NICE), the American and British Geriatric Society (AGS/BGS) clinical guidelines, and the US Centres of Disease Control and Prevention STEADI toolkit.23,24,25 It has three Yes/No questions: 1. Have you fallen over at least once this year? 2. Do you use your hands to get out of a chair? 3. Have you stopped doing some activities because you are afraid of losing your balance? An affirmative answer to any of these questions indicates an increased risk of falling. For the purpose of this research, as defined by Masud & Morris, a fall was defined as ‘unintentionally coming to rest with the ground, floor or other lower level’.26 Falls literature typically categorises older persons as individuals 65+, but health disparities experienced by Pacific people associated with premature aging recommend aged 55+ to be identified as older persons.27 Attitudes towards exercise as falls prevention intervention, was assessed using the ‘Attitudes to Falls-Related Interventions Scale’ (AFRIS)

questionnaire.28 The AFRIS is a validated questionnaire based on the Theory of Planned Behaviour Change and has 6 items. Items are related to ‘Attitudes’, ‘Subjective Norm,’ ‘Perceived Behavioural Control, ‘Identity,’ and ‘Intention.’ There is a total score (possible range 6 to 42) and it is a measure of how receptive the participant is to an intervention to prevent falls. The overall scoring is calculated on this number of options. To mitigate language barriers and increase understanding of the options, the questionnaire for the Pacific peoples' study was adapted with "smiling-frowning faces" to replace the worded answers for all 7 options providing a visual representation. To check the appropriateness of the measure for a migrant Pacific population, the questions and answering options were approved by PTO staff prior to administering the questionnaires. Statistical Analyses: Descriptive data were expressed as means, percentages, and range, as appropriate. The AFRIS scoring was broken down into each item to determine whether participants had a positive, neutral or negative attitude on that component. The literature review was analysed thematically. Questionnaire data were analysed using Excel (Microsoft Office Suite 2010, Microsoft Excel, 2014). RESULTS Participant Demographics In total, a sample of 50 respondents from church groups and community exercise classes provided informed consent and completed the questionnaires. A sample of 30 participants was planned, but a greater response rate was achieved. Of those who responded, all questionnaires were completed. Two questionnaires were excluded because these participants were not of Pacific descent. Table 1 shows the participant demographics. In summary over half (60.4%) of the respondents were female. Ethnic groups belonged to five different Pacific Island backgrounds. The largest proportion of participants was Cook Island (37.5%) and the lowest Niuean (6.0%). Of the total number of self-reported health conditions that were included, 62.5% had 1 to 2, 12.5% had more than 2 and 25.0% reported no health conditions. Of the 69 total cases of various health conditions reported, diabetes and overweight were most prevalent.

82

Ruhe T, et al. Pacific Health Dialog 2018; 21(2):80-88. DOI: 10.26635/phd.2018.917 Table 1: Participant Demographics Variable Age

All Male Female

Mean

SD

68.7 69.4 68.2

9.0 10.3 8.3

N

%

Gender

Male Female

19 29

39.6 60.4

Ethnicity

Cook Island Niuean Samoan Tokelauan

18 2 14 3

37.5 4.2 29.2 6.0

Tongan

11

22.9

Heart Disease Overweight High Blood Pressure

9 18

18.8 37.5

15

31.0

Osteoarthritis Type II Diabetes Total

9 18 69

18.8 37.5

None

12

25.0

1 to 2 >2

30 6

62.5 12.5

Health Condition

Total Medical Conditions

Falls Risk Assessment Results of the Ask Assess, Act questionnaire are shown in Table 2. An affirmative response to one or more of the AAA questions indicates an individual is at risk of falling. Results of the Attitudes towards Falls Prevention Intervention are shown in Table 3. The mean score for each question was between six and seven. The highest mean (6.7) was in regards to individual readiness of strength and balance exercise, and the lowest

(6.4) was in regards to the ease of participating in these exercises and kind of person to do strength and balance exercise. The total mean for the AFRIS was 39.0 out of a possible 42. Over half (56.3%) of the respondents answered ‘Yes’ to one or more of the questions (62.1% of females and 52.6% of males). Almost 30% reported that they had fallen within the last 12 months (31.0% of females and 21.1% of males).

83

Ruhe T, et al. Pacific Health Dialog 2018; 21(2):80-88. DOI: 10.26635/phd.2018.917 Table 2: Ask, Assess, Act (AAA) questions. Question Have you fallen over at least once in the last year?

N Male Female

Do you push with your hands when getting out of a chair? Male Female

Have you stopped doing some activities because you are afraid of losing your balance? Male Female Affirmative response to ≥1 N= number of respondents

Yes No Yes No

4 15 9 20

% 21.1 78.9 31.0 69.0

Yes No Yes No

9 10 10 19

47.4 52.6 34.5 65.5

Yes No Yes No

4 15 8 21 10 18

21.1 79.0 27.6 72.4 52.6 62.1

Male Female

Table 3: Attitudes to Falls-Related Interventions Scale’ (AFRIS) questionnaire. Statement Doing strength and balance exercises would be good for me.

Mean 6.7

SD 0.6

Doing strength and balance exercises would make me feel confident.

6.5

0.8

Other people whose opinions matter to me would think it is a good idea for me to do strength and balance exercises.

6.5

0.6

If I wanted to, it would be easy for me to do strength and balance exercises.

6.4

0.9

I am the kind of person who should do strength and balance exercise.

6.4

0.7

I intend to do strength and balance exercises if I am offered the opportunity.

6.5

0.7

Total 39.0 4.3 SD= standard deviation, 1-Strongly Disagree 2- Disagree 3- Slightly Disagree 4- Neither Agree or Disagree 5- Slightly Agree 6- Agree 7-Strongly Agree. Maximum score is 42.0 DISCUSSION This study enrolled a small sample of community members from multiple Pacific backgrounds, the main groups being from the Cook Islands, Tonga and Samoa with others

from Niue and Tokelau, in a single geographical location to gather evidence of falls risk, attitudes towards strength and balance exercise as falls prevention, and overall health. Not all Pacific backgrounds were represented; however, the 84

Ruhe T, et al. Pacific Health Dialog 2018; 21(2):80-88. DOI: 10.26635/phd.2018.917 incorporation of church groups within the area ensured representation of the larger Pacific communities in Dunedin, as well as gender balance.

independent falls risk factor and obesity is associated with poor balance and function, particularly if combined with low muscle mass.26,17

A key finding is that almost 30% of the participants reported a fall in the last 12 months. This may be an under-representation of the true incidence due to individual variation in interpreting a ‘fall' as well as the effect of recall bias from remembering the past year, rather than one year prospective falls data collected by a calendar, which is the gold standard.7,29 However, it is consistent with wider New Zealand statistics as well as other community-dwelling older peoples and reflects the need for effective falls prevention within this Pacific population.5,10 In addition, a larger proportion of females experienced a fall in the last 12 months as well as being more at risk of falling. This is in agreement with the literature reporting females as having an increased risk of falling.9,13,30

A meta-analysis reported that older people tend to reject falls prevention to preserve independence.31 However, in our study, the AFRIS scores identified the readiness of this particular cohort to participate in strength and balance exercises. Almost half of the participants attended the PTO exercise class, but when controlling for this variable by comparing the scores with those who did not attend, there was no statistically significant difference in the AFRIS score (data not reported). There was a consensus amongst these older Pacific peoples that incorporating strength and balance exercises would be beneficial. However, such a finding should be interpreted with caution in such a small and possibly biased sample size. Nonetheless, the positive response is encouraging as strength and balance exercises are known to decrease the risk of falling.3,10 Further, the enthusiasm to have it incorporated to the existing exercise class might also improve adherence to the programme.

Pushing out of a chair indicates lower extremity weakness and our data suggests this to be the highest risk factor within this cohort.14 A higher percentage of males exhibited the need to push when getting out of a chair; however, this may be due to the effect of an older mean age for males. Although over half were at risk of falling, less than 30% reported activity modification due to fear of losing their balance. This finding potentially may highlight a lack of falls risk awareness, which with falls education, in conjunction with strength and balance exercises, could decrease the risk of reoccurring falls. A positive finding was that a large proportion of the cohort was physically active, which may help to mitigate muscle weakness as well as other modifiable health conditions.6,11 However, this result may be biased and not generalizable to the wider older Pacific population as a source of recruitment was through exercise classes. Diabetes and being overweight were the most prevalent health conditions, although the selfreported prevalence was lower than national averages for Pacific peoples.27 It is possible that the use of self-reporting resulted in under-reporting of these health conditions.31 However, the findings agree with reports showing these health-conditions to be of particular concern in Pacific peoples.5 Not only do these pose negative health implications of their own, but emerging work is beginning to identify Type II Diabetes as an

The Pacific population in New Zealand has only 4% aged 65+, in which the majority of this age group migrated to New Zealand, and English is a second language.5 Given the difference in social upbringing and access to medical services, we cannot assume falls epidemiology and prevention will be similar to all Pacific Islanders around New Zealand.4 Findings from this study may assist in developing an effective Pacific orientated falls prevention model. The interconnectedness of Pacific communities needs to be recognised and incorporated into any model, as a noted barrier to exercise participation within Pacific communities is family and other local community commitments.5 This highlights the need for family incorporation, be it in decision making or participation within the exercise classes, which can be achieved by targeting those 55+ without exclusion of those under 55 years of age. Further, physical activity programmes with a Pacific culture foundation, integrating traditional dance and music, such as ‘Langi Mai’ in Auckland and ‘Culture X’ in Samoa, have shown positive Pacific uptake and adherence as well as physical improvement.5,22

85

Ruhe T, et al. Pacific Health Dialog 2018; 21(2):80-88. DOI: 10.26635/phd.2018.917 CONCLUSION To our knowledge, this is the first study investigating Dunedin Pacific people falls risk and attitudes towards falls prevention in New Zealand. We found that crude self-reported falls in the past year and risk within this population is comparable to national statistics, with females being at higher risk, and highlighting the need for falls prevention that caters to cultural needs. The positive response to adding strength and balance exercise provides supporting evidence of incorporating strength and balance exercises into their existing programmes. The findings from this project have been presented back to the community involved to acknowledge them as co-owners of the knowledge and information. More studies that enroll participants from multiple ethnic backgrounds in a single geographical area are needed for direct comparisons to be made. Acknowledgements This project was funded by the Health Research Council as a Pasifika Summer Studentship Scholarship (Ref: 16/465) and in-kind by the Pacific Trust Otago. The authors would like to thank all the participants for their time and contribution to this study. REFERENCES 1. Lagolago, W, Theadom, A, Fairburn-Dunlop, P, Ameratunga, S, A, Dowell., McPherson, K, . . . Feigin, V. (2015). Traumatic brain injury within Pacific people of New Zealand. New Zealand medical journal, 128, 29-38. 2. Hua, Fu, Yoshida, Sachiyo, Junling, Gao, & Hui, Peng. (2008). Falls Prevention in Older Age in Western Pacific Asia Region: World Health Organization. 3. Cameron, ID, Gillespie, LD, Robertson, MC, Murray, GR, Hill, KD, Cumming, RG, & Kerse, N. (2012). Interventions for preventing falls in older people in care facilities and hospitals (Review). Cochrane database of systematic reviews(12). doi: 10.1002/14651858.CD005465.pub3. 4. Han, B. H., Ferris, R., & Blaum, C. (2014). Exploring ethnic and racial differences in falls among older adults. J Community

Health, 39(6), 1241-1247. 10.1007/s10900-014-9852-8

doi:

5. Heard, E. M., Auvaa, L., & Conway, B. A. (2016). Culture X: addressing barriers to physical activity in Samoa. Health Promot Int. doi: 10.1093/heapro/dav119 6. ACC. (2006). Standing up to falls: your guide to preventing falls and protecting your independence. In A. C. Corporation (Ed.). 7. Hauer, K., Lamb, S. E., Jorstad, E. C., Todd, C., Becker, C., & Group, Profane. (2006). Systematic review of definitions and methods of measuring falls in randomised controlled fall prevention trials. Age Ageing, 35(1), 5-10. doi: 10.1093/ageing/afi218 8. Hill, A., McPhail, S., Francis-Coad, J., Waldron, N., Etherton-Beer, C., Flicker, L., . . . Haines, T. (2015). Educators' perspectives about how older patients can engage in a falls prevention education programme: a qualitative process evaluation. BMJ Open, 5. doi: 10.1136/bmjopen-2015009780 9. Hosseini, H, & Hosseini, N. (2008). Epidemiology and prevention of fall injuries among the elderly. Hospital topics: research and perspectives on healthcare, 86(3), 15-20. 10. Gillespie, LD, Robertson, MC, Gillespie, WJ, Sherrington , C, Gates, S, Clemson, LM, & Lamb, SE. (2012). Interventions for preventing falls in older people living in the community (Review). John Wiley & Sons, Ltd: The Cochrane Collaboration. 11. Kendrick, D, Kumar, A, Carpenter, H, Zijlstra, GAR, Skelton, DA, Cook, JR, . . . K, Delbaere. (2014). Exercise for reducing fear of falling in older people living in the community (Review). In T. C. Collaboration (Ed.). The Cochrane Library: Cochrane database of systematic reviews 2014. 12. Richardson, K., Bennett, K., & Kenny, R. A. (2015). Polypharmacy including falls risk-increasing medications and subsequent falls in community-dwelling middle-aged and older adults. Age Ageing, 44(1), 90-96. doi: 10.1093/ageing/afu141 13. Rubenstein, L. Z. (2006). Falls in older people: epidemiology, risk factors and

86

Ruhe T, et al. Pacific Health Dialog 2018; 21(2):80-88. DOI: 10.26635/phd.2018.917 strategies for prevention. Age Ageing, 35 Suppl 2, ii37-ii41. doi: 10.1093/ageing/afl084 14. Moreland, J, Richardson, J, Goldsmith, C, & Clase, C. (2004). Muscle Weakness and Falls in Older Adults: A systematic review and meta-analysis. J Am Geriatr Soc, 52, 1121-1129. 15. Leavy, B., Byberg, L., Michaelsson, K., Melhus, H., & Aberg, A. C. (2015). The fall descriptions and health characteristics of older adults with hip fracture: a mixed methods study. BMC Geriatr, 15, 40. doi: 10.1186/s12877-015-0036-x 16. Maurer, M, Burcham, J, & Cheng, H. (2005). Diabetes mellitus is associated with an increased risk of falls in elderly residents of a long-term care facility. Journal of Gerontology: medical sciences, 60A(9), 1157-1162. 17 Roman de Mettelinge, T., Cambier, D., Calders, P., Van Den Noortgate, N., & Delbaere, K. (2013). Understanding the relationship between type 2 diabetes mellitus and falls in older adults: a prospective cohort study. PLoS One, 8(6), e67055. doi: 10.1371/journal.pone.0067055 18. Gerberding, J, Falk, H, Arias, I, Wallace, D, & Ballesteros, M. (2008). Preventing Falls: How to develop community-based fall prevention programs for older adults. Atlanta, Georgia: National Center for injury prevention and control. 19. Ang, E., Mordiffi, S. Z., & Wong, H. B. (2011). Evaluating the use of a targeted multiple intervention strategy in reducing patient falls in an acute care hospital: a randomized controlled trial. J Adv Nurs, 67(9), 1984-1992. doi: 10.1111/j.1365-2648.2011.05646.x 20. Robertson, L., Hale, B., Waters, D., Hale, L. & Andrew, A. (2014). Community peerled exercise groups: Reasons for success. Internet Journal of Allied Health Sciences and Practice, 12(2), 9. 21. Motulalo, F, & Ager, L. (2009). Langi MaiFall Prevention for Pacific Older Adults. Manukau City, New Zealand: Accident Compensation Corporation. 22.Kenny, R., Rubenstein, L., Tinetti, M., Walker, E., Brewer, K., Cameron, K., Capezuti, E., John, D., Carney, C., Lamb, S.,

Martin, F., Rockey, P., Suther, M. (2011). Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc, 59(1), 148-157. doi: 10.1111/j.1532-5415.2010.03234.x 23. National Institute for Health and Care Excellence. (2013). NICE Clinical guideline 161 Falls: assessment and prevention of falls in older people. URL: http://publications.nice.org.uk/fallsassessment-and-prevention-of-falls-inolder-people-cg161 (accessed 10 July 2013). 24. Kenny, R., Rubenstein, L., Tinetti, M., Walker, E., Brewer, K., Cameron, K., Capezuti, E., John, D., Carney, C., Lamb, S., Martin, F., Rockey, P., Suther, M. (2011). Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc, 59(1), 148-157. doi: 10.1111/j.1532-5415.2010.03234.x 25. Stevens, J (No Date) Development of STEADI: a fall prevention resource for health care providers. Health Promot Pract. 2013;14(5):706–714. 26. Masud, T, & Morris, RO. (2001). Epidemiology of falls. Age and ageing, British Geriatrics Society, 30(4), 3-7. 27. Blakely, T., Tobias, M., Robson, B., Ajwani, S., Bonne, M., & Woodward, A. (2005). Widening ethnic mortality disparities in New Zealand 1981-99. Soc Sci Med, 61(10), 2233-21. doi: 10.1016/j.socscimed.2005.02.011 28. Yardley L, Donovan-Hall M, Francis K, Todd C. Attitudes and beliefs that predict older people's intention to undertake strength and balance training. J Gerontology Psych Sci Soc Sci 2007: 62B(2): P119-25. 29. Moody, J, Hale, L, & Waters, D. L. (2012). Perceptions of a water-based exercise programme to improve physical function and falls risk in older adults with lower extremity osteoarthritis: barriers, motivators, and sustainability. New Zealand journal of physiotherapy, 40(2), 64-70. 30. Schwenk, M, Laurenroth, A, Stock, C, Moreno, R, Oster, P, McHugh, G, . . . Hauer, 87

Ruhe T, et al. Pacific Health Dialog 2018; 21(2):80-88. DOI: 10.26635/phd.2018.917 K. (2012). Definitions and methods of measuring and reporting on injurious falls in randomised controlled fall prevention trials: a systematic review. BMC Medical Research Methodology, 12(50). 31. Hong, G. R., Cho, S. H., & Tak, Y. (2010). Falls among Koreans 45 years of age and older: incidence and risk factors. J Adv Nurs, 66(9), 2014-2024. doi: 10.1111/j.1365-2648.2010.05384.x

88

Nosa V, et al. Pacific Health Dialog 2018; 21(2):89-95. DOI: 10.26635/phd.2018.919

Short Report

OPEN ACCESS

Cytisine as an alternative smoking cessation product for Pacific smokers in New Zealand. Vili NOSA,1 Kotalo LEAU,2 Natalie WALKER3 ABSTRACT Introduction: Pacific people in New Zealand have one of the highest rates of smoking. Cytisine is a plantbased alkaloid that has proven efficacy, effectiveness and safety compared to a placebo and nicotine replacement therapy (NRT) for smoking cessation. Cytisine, like varenicline, is a partial agonist of nicotinic acetylcholine receptors, and blocks the rewarding effects of nicotine. Cytisine is naturally found in some plants in the Pacific region, and so may appeal to Pacific smokers wanting to quit. This paper investigates the acceptability of cytisine as a smoking cessation product for Pacific smokers in New Zealand, using a qualitative study design. Methods: In December 2015, advertisements and snowball sampling was used to recruit four Pacific smokers and three Pacific smoking cessation specialists in Auckland, New Zealand. Semi-structured interviews where undertaken, whereby participants were asked about motivations to quit and their views on smoking cessation products, including cytisine (which is currently unavailable in New Zealand). Interviews were recorded and transcribed verbatim, with thematic analysis conducted manually. Findings: Pacific smokers reported wanting to quit for loved ones and family, but did not find currently available smoking cessation products effective. Almost all participants had not previously heard of cytisine, but many of the Pacific smokers were keen to try it. Participants identified with cytisine on a cultural basis (given its natural status), but noted that their use would be determined by the efficacy of the medicine, its cost, side-effects, and accessibility. They were particularly interested in cytisine being made available in liquid form, which could be added to a “smoothie” or drunk as a “traditional tea”. Participants thought cytisine should be promoted in a culturally-appropriate way, with packaging and advertising designed to appeal to Pacific smokers. Conclusions: Cytisine is more acceptable to Pacific smokers than other smoking cessation products, because of their cultural practices of traditional medicine and the natural product status of cytisine. KEYWORDS: Smoking Cessation; Health Promotion; Cytisine; Pacific health

INTRODUCTION Tobacco smoking is the single largest cause of preventable morbidity and mortality in New Zealand, killing an estimated 4,300 people annually. Pacific peoples in New Zealand carry a disproportionate burden of smoking-related harm, due to their higher prevalence of daily smoking compared to the general population (21.8% in adults aged ≥15 years in 2016/17 compared to 13.8%).1 Pacific men smoke more than Pacific women (25.4% vs 18.4%).1 Pacific peoples encompass a diverse range of ethnicities, with the largest ethnic groups represented in New Zealand being Samoans, Cook

*1Corresponding author: Vili Nosa, Associate Professor, Pacific Health, School of Population Health, University of Auckland, Private Bag 92019, Auckland, New Zealand. Email: [email protected] 2 Summer student, Pacific Health, School of Population Health, University of Auckland, Private Bag 92019, Auckland, NZ 3 Associate Professor, National Institute for Health Innovation, School of Population Health, University of Auckland, Received: 23 07.2018; Published: 30.09.2018 Citation: Nosa V, et al. Cytisine as an alternative smoking cessation product for Pacific smokers in New Zealand. Pacific Health Dialog 2018;21(2):89-9 DOI: 10.26635/phd.2018.919. Copyright: © 2018 Nosa V, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

89


Islanders, Tongans, Niueans, Tokelauans, and Fijians. Differences in smoking prevalence exist both within and between Pacific cultures. Cook Island and Tokelauan adults (aged ≥ 15 years) have much higher smoking prevalence’s (32% and 30% respectively), compared to Niuean (26%), Tongan (23%), Samoan (22%) and Fijian (13%) adults.2 Cook Island and Tokelauan women and men smoke at similar rates, but women smoke at much lower rates than men for the other Pacific ethnicities.2 In 2012/13, Pacific smokers reported low levels of engagement with smoking cessation services (e.g. only 11% had sought help or advice from Quitline for their last quit attempt), and low uptake of currently available smoking cessation medications (e.g. only 23.4% had used NRT for their last quit attempt, and 4.9% had used another medication such as varenicline [Champix] or bupropion [Zyban]).3 A proposed alternative to these treatment options is cytisine, which is a plant-based alkaloid that has similar properties to nicotine, but acts as a partial agonist to the nicotine receptors.4 Cytisine interferes with nicotine binding and blocks the rewarding effects of the nicotine.4 Cytisine has been used in Central and Eastern Europe since the 1960s.5 Trials have shown cytisine to be more effective than both placebo6 and NRT7 at helping people to quit smoking, and is significantly cheaper than other smoking cessation medications.6 Cytisine is found naturally in some plants in the Pacific region, such as the Māmane (Sophora cyrsophylla) in Hawaii8 and the New Zealand Kōwhai (Sophora tetraptera).8-9 Pacific cultures as a whole place a high value on traditional healing as an alternative or dual system of care to Western medicine.10 This type of healing tends to prioritise the use of the natural world, such as herbs and plants for use in drinks, oils, and massage. Even within New Zealand, traditional healing is a well-utilised and supported practise among Pacific peoples.11 The aim of this study was to investigate the acceptability of cytisine as an alternative smoking cessation product for Pacific smokers in New Zealand, using a qualitative study design. We hypothesised that cytisine would be more acceptable to Pacific smokers compared to other smoking cessation products because of their cultural practices of traditional medicine and the natural product status of cytisine.

recruit four Pacific smokers and three Pacific smoking cessation specialists in Auckland, New Zealand. Participants Current smokers were recruited through community organisations (such as Pacific sports and churches, and community groups), and were eligible to take part if they were: a current smoker, aged ≥ 18 years, of Pacific ethnicity, able to speak English, and were motivated to quit smoking. Smoking cessation specialists were recruited through healthcare and community organisations, and were eligible to take part if they were: aged ≥ 18 years, of Pacific ethnicity, and worked as a smoking cessation specialist or Pacific traditional medicine specialist. Procedures All participants were interviewed at a location of their choice, with the interview conducted by a Samoan woman. The interviews were semistructured and focused on: the use of smoking cessation products by Pacific people; motivations and barriers to smoking cessation for Pacific people; cytisine and its role in smoking cessation for Pacific people; and the potential cultural impact of cytisine. Participants were given a brief description of cytisine, including the fact that cytisine is found naturally in some Pacific plants, and the marketed product were shown (packaged as Tabex® [brown pills] and Desmozan® [white and blue gel capsules] for smoking cessation). Interviews were audio-taped and transcribed verbatim. Thematic analysis was conducted manually using the general inductive method. Ethics Ethical approval was granted by University of Auckland Human Participants Ethics Committee (04/12/2015 Ref: 016177). FINDINGS Four Pacific smokers and three Pacific smoking cessation specialists were recruited (Table 1). The majority of participants identified as Samoan, and no traditional healers were identified.

METHODS In December 2015, advertisements and a snowballing sampling process were used to 90


Table 1: Characteristics of Participants

Sex Male Female Age (years) 18-30 31-44 45-60 Location Urban Rural Smoker Yes No

Pacific smokers (N=3)

Pacific smoking cessation specialists (N=4)

1 3

2 1

2 2 0

1 0 2

3 1

3 0

4 0

0 3

Thematic Analysis Motivation to quit Participants saw smoking as a major issue for the Pacific population in New Zealand. They identified a number of barriers to quitting, including the use of smoking as a form of stress relief and to enhance other activities (such as the taste of alcohol). Many of the participants also discussed fears of nicotine withdrawal or gaining weight, as well as cravings and difficulties in changing habits. “I thought yeah I can smoke and then as soon as all this is, you know the festive season is done, yeah then I can do it again” (Pacific Smoker 2) Participants in the Pacific smokers group said their motivation to quit was to promote a better sense of wellbeing, and to live longer for the sake of loved ones “I gotta look out for me, for the sake of my family” (Pacific Smoker 2) Many said that smoking was currently preventing them from achieving certain goals and led to negative symptoms (such as nausea and asthma symptoms). Participants said motivation also came from family members; either through their encouragement or seeing a family member battling a smoking-related illness. One participant noted that their work environment was not conducive to smoking where “you almost feel like an outsider going out for a smoke”.

Smoking cessation products Participants in the Pacific smoker group reported that the smoking cessation products currently available in New Zealand had been largely ineffective for them, and raised concerns with respect to the side-effects of NRT, which include nausea, sweatiness, and nicotine withdrawal. Some participants reported that the product had no effect. Taste was also a concern for the Pacific smokers, with lozenges and gums being described as “yucky” by many participants. Participants were also put off by the usage instructions (‘chew and park’), and felt these were too different from the normal method of using regular chewing gum. “There’s just something about these products that can switch me off trying to use them regularly” (Pacific Smoker 1) Alternative smoking cessation methods, such as liquid detoxes and herbal tree cigarettes, appealed to some participants as a way of improving overall health, but they did not feel these were effective long-term. One participant had tried a self-help book, but found this ineffective. Other participants reported finding prayer and will power to be the most important and effective methods for quitting smoking. Acceptability of cytisine Most participants had not heard of cytisine prior to taking part in the study. One participant in the Pacific smoking cessation specialists group had heard of cytisine previously at a conference. After a brief description, all participants said that cytisine sounded attractive from both a cultural and practical perspective. “I would probably look more into it, you know it sounds appealing particularly when you’re talking that its natural extracts from, you know, resources that we have” (Pacific Smoker 4) The main themes that promoted acceptability of cytisine were around the “home-grown” and “natural” status of cytisine. Most of the participants commented that the connection to cytisine would be enhanced by knowing which plants in the islands contained cytisine because “that’s our plant, it’s at home”. “I think it will be good, the fact that it’s natural, the fact that it has a better connection” (Pacific Smoker 1)

91


Participants said that having a “cultural meaning” to the plants containing cytisine, such as the Māmane in Hawaii, would add to the appeal and use of the product. Participants also thought that giving cytisine this “local” status would endear the product to Pacific Island culture where “we just like things naturally… we like our natural environments”, because it is what is familiar when thinking of life back home in the islands. One participant said this would “make people more confident” as it “brings us back closer to the earth”. Overwhelmingly, participants said that they would find cytisine more appealing if it was delivered in a different form. Specifically, they suggested that it would increase the appeal of cytisine in liquid forms similar to traditional medicine “in liquid form or can make it a liquid form” similar to “vais [liquids] that we have for fofos [traditional healing].” In terms of type of liquids, participants had an array of suggestions, with the younger participants (those under 30 years old) preferring to drink cytisine as part of a smoothie “getting it like a normal vegetable and blending it in … as a juice” or a powder, “mixed in with some fruits”. They thought that this would appeal to Pacific peoples as a way to not only stop smoking, but increasing overall health, gaining “other beneficial nutrients”. One participant also thought that this method would fit well with popular Pacific health programmes that sell herbal supplements and products in New Zealand. Older participants (≥ 45 years old) preferred cytisine to be presented in more traditional liquid form, to match more traditional ways of using and drinking plant extracts, such as drying it and making “a lau ti [teabag] out of it”. This group also noted that there may be generational or cultural differences around views on cytisine, with preference dependent on taste and access to traditional healers. One older male participant also suggested to “get the seed, mix it, crush it and put it in kava” as a way to appeal to older male smokers because “kava and smoking are good friends”. Participants expressed preference for obtaining cytisine directly from its natural source over manufactured forms. “It’s a natural extract - give it to me in its most natural form” (Pacific Smoker 4) Most of the older participants also thought having cytisine as lozenges, patches, or mints, could help broaden its appeal. Participants thought these forms might be more appealing than tablets, with fewer side-effects and more adaptability to a working lifestyle. Some participants expressed concern that manufactured forms may dilute the

cultural appeal of cytisine, or reduce the ability for people to make the connection between the manufactured product and its natural source. Comparison of cytisine to other products Most of the participants suggested that a “userfriendly” approach would be appealing for cytisine. In comparing cytisine to other products, two important themes emerged: the efficacy of cytisine, and cytisine as “a more natural approach”. Most the participants said that cytisine would appeal to them if it had worked for them or someone they knew. “Ultimately if the product works, that would be like the biggest incentive for someone to try it” (Pacific Smoker 1) Many of the Pacific smoker participants had tried other types of smoking cessation products with limited success and were more open to cytisine as “an alternative to what we already have”. Some participants were also more drawn to cytisine than the current products as it was not nicotine based. Cytisine was seen as “a more natural approach” with a view that it contained less harmful artificial chemicals. “I guess being plant based, possibly a more natural approach to giving up cigarettes as opposed to a more chemical type product” (Pacific Smoker 2) Many participants were wary of current smoking cessation products and what chemicals were in them “because you never know what they put in there”. One participant thought that synthetic products could increase dependence on them so “the effects of that actual product no longer works on you” without a change in dosage. Barriers to using cytisine When comparing cytisine to other products, participants noted issues that may arise with cytisine, such as cost, side-effects, false advertising, and possible usage issues. Many of the Pacific smokers pointed out that Pacific families are usually large, and have many expenses such as family, village, and church commitments, in addition to bills and other everyday costs. Therefore, cost may be a major factor when choosing a smoking cessation product. Participants suggested that uptake of cytisine might be limited if cytisine could only be accessed via prescription, compared to NRT’s which are available through Quitline and other 92


smoking cessation services. One smoking cessation specialist felt cytisine should be subsidised or free.

connotations. One participant noted that pills give the perception that they are sick rather than of promoting health.

“Especially PI [Pacific Island] people. It’s all about money… I wouldn’t buy it, unless I know for sure that it’s worked on someone I know” (Pacific Smoker 2)

“Thing is with medication is that people become sceptical just thinking, oh yup - they’re going to come up with something new, then it doesn’t work” (Pacific Smoking Cessation Specialist 2)

Some participants talked about side-effects as a potential barrier to using cytisine.

Promotion of Cytisine to Pacific peoples

“Side effects too… If people have a negative experience of the medication… they’ll be less likely to use it” (Pacific Smoking Cessation Specialist 2) However, the Pacific smoker group thought that side-effects would come with any product, so it would not strongly reduce the appeal of cytisine in comparison to other products. Furthermore, the smoking cessation specialists usually emphasised the importance of understanding the potential for side-effects, because then “you can actually explain it” and patients can then make their own informed decisions about using cytisine. One participant questioned whether cytisine found in plants in the islands would actually be used for a cytisine product in New Zealand. The participant was concerned that using European cytisine plants could reduce the trust of Pacific smokers in the product. The emphasis on native plant sources while using European sources could be construed as false-advertising. “They might say it’s misleading. They’ll say cytisine yeah it’s in the kowhai plant but it’s not the kowhai plant that’s used for the cytisine we’re taking” (Pacific Smoking Cessation Specialist 2) Many of the smoking cessation specialists noted that current products have complicated dosing regimen. With respect to cytisine, one smoking cessation specialist thought that clear, easily understandable instructions would be needed for proper use, especially when promoting its plant status in the islands. Cytisine in tablet form When shown two brands of tablets containing cytisine, participant views were mixed. In general, participants thought having a tablet form of cytisine could be effective because “at least you know everything goes in”. However, some participants thought that having a tablet had negative associations, such as illness and medical

All the participants thought that cytisine could be promoted in ways that appeal more to Pacific smokers, particularly through packaging and promoting it in culturally competent ways. For example, by using warm colours, rather than “clinical colours”, and by using green for the tablets to emphasise that cytisine is plant-based. Participants also suggested using pictures and coloured labels to help smokers take the tablets at the right time. Some participants noted that different Pacific islands have their own culture, and therefore promotional material might be tailored to the particular culture and the local plants in order to improve acceptability. “For any cytisine products. Yeah give it the ownership if it’s plant based from the tropical plants from the Pacific” (Pacific Smoking Cessation Specialist 1) Younger participants thought that using people of the same ethnicity who used cytisine to successfully quit smoking would be a powerful tool to promote uptake of cytisine. Participants noted the importance of treating elders with regard and to use respectful language, emphasising the importance of “knowing your boundaries” when communicating across ages and cultures. A smoking cessation worker emphasised translation as key to helping not only Pacific smokers in New Zealand, but in those in the islands too. Involving family and promoting at churches was also highlighted by the participants as ways to help maintain cytisine’s appeal by ensuring that the support networks for the smokers are strong. “With our people… its just informing them… we’re face to face people. Talk us through it” (Pacific Smoker 4) DISCUSSION Participants in this study were motivated to quit for their health and loved ones, but reported that current cessation products were largely ineffective aids to quitting. Although cytisine was unheard of for most participants, many were keen 93


to try it. As we hypothesised, participants identified with cytisine on a cultural basis, through the “home-grown” connection. Participants were also attracted to the “natural” branding of cytisine, seeing it as a more natural alternative to current products. Participants tended to favour the idea of having cytisine in a form that could be added to a smoothie or made into a tea (similar to traditional healing methods). However, some participants were unsure whether Pacific smokers would actually connect with cytisine just because of its link with the Pacific. Participants suggested that their incentive for using cytisine would be determined by its efficacy, but also saw the natural-status as a positive incentive. Participants also thought that the appeal of cytisine could be enhanced by presenting the produce in culturally acceptable ways and using promotional material that appealed to Pacific peoples. However, participants raised concerns that cost and sideeffects could be a barrier to wide spread use. Additionally, participants raised concern that the promotion of cytisine as a product found in Pacific plants could be misleading if used to advertise cytisine produced in Europe. Complexity of usage, such as the ‘chew and park’ method might also be a barrier to widespread use. Due to limitations of time and the sampling methods used, it was not possible to recruit a more culturally diverse sample of participants. Therefore, the themes that emerged from this study may not be generalizable to other Pacific peoples (given each Pacific ethnicity has their own unique cultural customs and traditions). Furthermore, no traditional healers were identified for the study but are an important group to consider given their cultural knowledge and expertise around herbal medicine. A strength of the study is the diversity of participants, in terms of age, gender, and location (urban versus rural). This study is the first to look at the acceptability of cytisine as an alternative smoking cessation product for Pacific Island smokers in New Zealand. The research follows on from a similar qualitative study in which the acceptability of cytisine to Māori smokers was explored and the same conclusions drawn.12 This study adds to the field of smoking cessation, showing the positive views of Pacific people towards plant based cessation products such as cytisine as a way of combatting the addictive effect of nicotine. Further research is needed to explore any contextual differences that might exist between different Pacific ethnicities, and between pacific

peoples living in New Zealand and those living in the Pacific islands. CONCLUSION Overall, Pacific smokers and smoking cessation specialists find cytisine acceptable and attractive. Further research should be undertaken looking at different modes of delivery for cytisine, and how the medication might be promoted in culturally appropriate way for Pacific smokers. Our findings support the licencing of cytisine for use as a smoking cessation medication in New Zealand. Funding: Funding for this study was provided by a University of Auckland summer studentship. Competing Interests: All authors have no competing interests. NW and VN conceived the research question and obtained ethics approval, KL collected the data and analysed the information, all authors contributed to the writing of the paper. REFERENCES 1. Ministry of Health. Annual update of key results 2015/16: New Zealand Health Survey. Wellington: Ministry of Health; 2017. https://www.health.govt.nz/publication/an nual-update-key-results-2015-16-newzealand-health-survey 2. Statistics New Zealand. 2013/14 Census. Wellington: Statistics New Zealand; 2014. http://archive.stats.govt.nz/browse_for_stat s/snapshots-of-nz/nz-socialindicators/Home/Health/tobaccosmoking.aspx 3. Ministry of Health. Tobacco Use 2012/13: New Zealand Health Survey. Wellington: Ministry of Health; 2014. https://www.health.govt.nz/publication/to bacco-use-2012-13-new-zealand-healthsurvey 4. Zatonski W, Cedzynska M, Tutka P, West R. An uncontrolled trial of cytisine (Tabex) for smoking cessation. Tobacco Control. 2006 Dec 1;15(6):481-4. https://www.ncbi.nlm.nih.gov/pmc/articles /PMC2563682/ 5. Etter JF, Lukas RJ, Benowitz NL, West R, Dresler CM. Cytisine for smoking cessation: a research agenda. Drug & Alcohol Dependence. 2008 Jan 1;92(1):3-8. 94


https://www.sciencedirect.com/science/art icle/pii/S0376871607002748?via%3Dihub 6. Leaviss J, Sullivan W, Ren S, Everson-Hock E, Stevenson M, Stevens JW, Strong M, Cantrell A. What is the clinical effectiveness and costeffectiveness of cytisine compared with varenicline for smoking cessation? A systematic review and economic evaluation. Health Technology Assessment. 2014 May; 18: 1–120. https://www.journalslibrary.nihr.ac.uk/hta /hta18330/#/abstract 7. Walker N, Howe C, Glover M, McRobbie H, Barnes J, Nosa V, Parag V, Bassett B, Bullen C. Cytisine versus nicotine for smoking cessation. New England Journal of Medicine. 2014 Dec 18;371(25):2353-62 https://www.nejm.org/doi/full/10.1056/n ejmoa1407764 8. Rollema H. The smoking cessation aid varenicline (Chantix, Champix): Drug discovery inspired by natural Products. Planta Medica. 2013 Jul;79(10):IL3. https://www.researchgate.net/publication/ 270858629_The_Smoking_Cessation_Aid_Va renicline_Chantix_Champix_Drug_Discovery_ Inspired_by_Natural_Products 9. Godley E. Introducing Kowhai. Styx report. Christchurch: Landcare Research, 2006. 10. Ministry of Health. Improving Quality of Care for Pacific Peoples. Wellington: Ministry of Health, 2008. https://www.health.govt.nz/system/files/d ocuments/publications/improving-qualityof-care-for-pacific-peoples-may08.pdf 11. Sundborn G, Taylor S, Tautolo ES, Finau S. Utilisation of Traditional Pacific Healers by mothers and children of the Pacific Islands Families Study. Pacific Health Dialog. 2011 Sep;17(2):105-118. https://www.readbyqxmd.com/read/2267 5808/utilisation-of-traditional-pacifichealers-by-mothers-and-children-of-thepacific-islands-families-study 12. Thompson-Evans TP, Glover MP, Walker N. Cytisine's potential to be used as a traditional healing method to help indigenous people stop smoking: A qualitative study with Māori. Nicotine & Tobacco Research. 2011 Mar 8;13(5):353-60. https://academic.oup.com/ntr/article/13/5 /353/1167609

95

Coppell K, et al.. Pacific Health Dialog 2018; 21(2):96-102. DOI: 10.26635/phd.2018.915

Short Report

OPEN ACCESS

The impact of living with type 2 diabetes: a descriptive qualitative case study with four Pacific participants Kirsten COPPELL,1* Trudy SULLIVAN,2 Darlene PUPI3 ABSTRACT Introduction: Diabetes is a common among Pacific peoples. The personal cost of diabetes is substantial with the indirect costs shown to outweigh the direct costs in some instances. The aim of this case study was to identify and describe the personal cost to four Pacific people living with type 2 diabetes in New Zealand. Methods: Two Pacific men and two Pacific women with type 2 diabetes were recruited with the assistance of the Pacific Island Centre and the Pacific Research Student Support Unit, University of Otago, Dunedin, New Zealand. The participants were interviewed (three in Samoan and one in English) using an open question approach. Appropriate cultural protocols were observed, and interviews were audiorecorded and transcribed. Samoan interviews were translated into English. A thematic analysis was undertaken using an inductive approach. Findings: Participants’ ages ranged from mid-30s to 75 years. . The two retired participants had difficulty paying their prescription fees and three participants considered healthy food expensive. Other costs included time off work and family members moving towns to take care of participants and their diabetes. Pacific community members provided time, gifts and money at times when participants were less well. At the same time, participants considered they had a role in educating their community about diabetes prevention. A diagnosis of diabetes triggered healthful lifestyle changes for one participant. Conclusions: The personal cost associated with diabetes is broad and complex, with particular implications for roles and responsibilities among Pacific communities. Key words: Pacific people, Type 2 diabetes, Cost of illness, Indirect costs

INTRODUCTION Diabetes mellitus is a common chronic illness. In New Zealand (NZ) the prevalence of diabetes among those aged 15 years and over is 7%, with the highest prevalence rate in Pacific people (15.4%) compared with Māori (9.8%) and NZ European (6.1%).1 The average age at diagnosis is younger among Pacific people (49 years) and Māori (43 years) than in NZ Europeans (55 years).2 Adolescents and young adults are increasingly diagnosed with type 2 diabetes (T2DM), particularly among Pacific.3

*1Corresponding author: Kirsten Coppell, Senior Research Fellow, Department of Medicine, University of Otago, Dunedin, New Zealand. Email: [email protected] 2 Health Economist, Department of Preventive and Social Medicine, University of Otago, Dunedin, NZ 3 Medical student, University of Otago, Dunedin, NZ Received: 21 05.2018; Published: 30.09.2018 Citation: Coppell K, et al. The impact of living with type 2 diabetes: a descriptive qualitative case study with four Pacific participants. Pacific Health Dialog 2018;21(2):96102. DOI: 10.26635/phd.2018.915. Copyright: © 2018 Coppell K, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

96


The economic cost of diabetes is substantial.4, 5 The direct costs of managing and treating the disease and its associated complications, as well as the indirect costs such as productivity loss and intangible costs such as the psychological cost of having diabetes, all contribute to the cost of having diabetes. A large part of the direct cost of diabetes is due to the treatment of complications, including diabetic eye disease, cardiovascular disease, diabetic foot disease and lower limb amputation, and diabetic nephropathy, which can progress to end stage renal failure requiring costly dialysis.6 It is now recognised that the indirect cost of diabetes can outweigh the direct costs. In Italy the estimated total economic cost of diabetes in 2012 was €20.3 billion, with 54% associated with indirect costs, and 46% associated with direct costs.7 Similarly, a study in the United States (US) estimated the direct costs of diabetes to be US$44 billion per year, and indirect costs US$54 billion.8 Few studies have examined the economic impact of diabetes in Pacific populations, but the available information suggests diabetes is costly in these communities. An estimated 20% of the Government’s health budget in the Solomon Islands and Nauru is spent on health care relating to diabetes.9 At an individual level, the main costs associated with diabetes management in Vanuatu are over-the-counter-medications, transport to hospital facilities and the extra cost of recommended foods as part of diabetes management.10 In NZ, Pacific peoples make up almost 8% of the population, and while they have disproportionately high rates of diabetes, there is no research that looks at the personal cost of diabetes in this group. This study sought to explore and provide an understanding of the personal cost to Pacific peoples with T2DM by identifying and describing the costs faced by four Pacific people with T2DM living in NZ. METHODS This qualitative case study was conducted in Dunedin, NZ, between December 2016 and February 2017. The research interviewer (DP) was a Samoan university student living in Dunedin. The University of Otago Human Ethics Committee approved this study (D16/377).

Participant Recruitment Four Pacific people with T2DM resident in Dunedin were recruited with the help of the Pacific Island Centre and the Pacific Research Student Support Unit, University of Otago, Dunedin. Potential study participants were given the study information sheet and asked to provide their contact phone number if they were interested in participating in the study. Their names and contact details were forwarded to DP who arranged a time and place for an interview. Participants were given a choice as to where they were interviewed, (their home, a café, or the University), and whether the interviews were conducted in Samoan or English. They were invited to ask questions about the study and written consent was obtained. Data collection All participants were interviewed at the University, three in Samoan and one in English. An open-ended question approach was used and appropriate cultural protocols were observed during the interview process. The interviews, with consent, were audio-recorded. The length of each of interview ranged from 30-60 minutes and after each interview, the participant was offered a $50 grocery voucher. DP translated and transcribed the three Samoan audio-recordings and transcribed the English audio-recording. Data Analyses All three investigators read the transcripts multiple times. A demographic description including gender, age, occupation, and living situation, including who lives with them, was summarised for each participant. A thematic analysis was undertaken using an inductive approach.11 Text was coded and categorised manually. Codes and categories were discussed, and main themes highlighted. RESULTS The demographic characteristics and duration of diagnosed diabetes for each participant are presented in Table 1. Each participant had a unique role in their household and in their community. The context of having diabetes was different for each participant. Diabetic retinopathy was the only complication reported.

97


Table 1. Demographic characteristics of participants Participant 1

Participant 2

Participant 3

Participant 4

Gender

Female

Male

Female

Male

Age (years)

65

75

Mid 30s

59

Pacific group

Samoan

Samoan

Samoan

Fijian

Interview language

Samoan

Samoan

Samoan

English

Years (unable to recall exactly)

One year

About five years

Retired

Administrator

Caterer

Duration of About 2 years diagnosed diabetes (unable to recall exactly) Occupation Retired

Personal costs and ‘benefits’ for participants Both costs and ‘benefits’ (that is, positive aspects) following a diagnosis of diabetes were identified. Costs included diabetes medicines, general practice visits, extra costs for healthy food, costs to the family, costs to the community, and productivity loss, while benefits following a diagnosis of diabetes included adoption of a better lifestyle and assuming a responsibility to help others in the community better manage their diabetes or avoid getting diabetes. Personal costs Medication costs: All participants were taking Metformin for blood glucose control. Unlike the younger working-age participants, the two retirees could not always afford the prescription fee and often negotiated with their pharmacists to make the payment at a later date. General Practitioner visits: A regular cost for the participants were general practitioner (GP) consultations for a diabetes review and a repeat Metformin prescription every three months. GP visits were six-monthly for one participant, whose blood glucose was well-controlled. Attending GP visits was easier for retired participants as they had more time, compared with those who were working. Extra food costs: All participants considered eating a healthy diet was more expensive than an unhealthy diet, which limited food choice at times, causing additional stress. “There’s a lot more cost to eating healthy.” [Participant 3]

“Sometimes, whatever is left in the cupboard is all we’ve got…so we just eat rice and bread…” [Participant 1] The cost of food for other household members was also a consideration, particularly if they did not want to eat different meals. “You know it’s not just you, it’s a family of four, so you have to cater for all those other people as well.” [Participant 3] Costs to the family The cost of diabetes to the family was widereaching. One participant took early retirement because of diabetes (and other health issues). This created financial stress as they were the sole provider for their family. As a result, one child in the household had to take a year off school to undertake paid employment. The niece of another participant moved from elsewhere in NZ to live closer and help with household chores. For the two retirees, their children or another family member usually took them to doctors’ and hospital appointments. These family members took time off work to do this, and to care for them when they were sick. Sometimes children travelled or wanted to travel from afar to help. “My children were so worried… My oldest boy was going to come down…I told him ‘no don’t come’, cause it’s really far, 26 hours flight, and they have young children with them.” [Participant 1]

98


Cost to the community

Family and community

The impact of participants being unwell extended beyond the immediate family to affecting the local Pacific community. Commonly, if participants were hospitalised or too sick to go to church, people from their church, including the pastor, visited, bringing food. These times of incapacitating sickness limited participants’ ability to fulfil their specific roles in the Pacific community and the church, for example, Sunday school teacher, deacon, leader of the youth group, or elder of the community which involves making decisions for the community.

A community elder, who said he was not ashamed of having diabetes, believed that Pacific peoples need to know that diabetes is a huge health problem. Since being diagnosed with diabetes, he has tried to educate and encourage family and community members to lead a healthy lifestyle to prevent diabetes, by sharing his story with them. He has also tried to influence what is eaten by people with diabetes when they have community feasts.

Intangible costs A common feeling shared amongst the participants was the shock and disappointment following a diagnosis of diabetes, particularly if they had been asymptomatic. They did not understand why they had developed diabetes. “It saddens me that I have it…and now I have to suffer because of this… I don’t know the reason I have it.” [Participant 1] Diabetes negatively impacted on the quality of life for most participants. The participants who worked found diabetes was just another burden placed upon them that they had to fit into their busy work and family schedules. Diabetes had triggered early retirement for one participant, and had prevented another from doing things he used to love, like cooking for the church and family, fishing, and playing rugby. Attendance at ‘toona’i’ or ‘church lunch’, which is held at least once a month, was stressful because of the expectation for everyone to eat. Participants found it difficult to maintain a healthy diet, when unhealthy food was on offer. Better diet One participant explained that he quit smoking and alcohol after being diagnosed with diabetes, which saved money. He used this money to buy healthy foods. “…the biggest budget I had was alcohol, the biggest money spent was on alcohol, and cigarettes … all of that is gone, so that’s a lot of money, compared to the price that I have to pay in terms of food …no I didn’t spend more money, I actually spent less...” [Participant 4]

Another participant described that one benefit of being part of a close community was the feeling of never being alone. Knowing that other people in the church also suffered from diabetes was a comfort. Future health One participant considered being diagnosed with diabetes was more of a blessing rather than a curse. The diagnosis was a wake-up call, which triggered a lifestyle change. “When I found that I had diabetes it’s a wake-up call, you know, do something with your lifestyle, so I completely turned it around and said no more alcohol, because that’s the cause of all the high sugar, you know …. And then ever since I’ve been really happy with you know, with what’s happened since then…” [Participant 4] DISCUSSION This case study sought to identify and describe the personal cost of diabetes among four Pacific people with T2DM living in NZ. The personal costs identified were medications, GP consultations, and cost associated with healthy food choices and the additional roles and responsibilities that family members and the wider community had to fulfil at times. Although this case study comprised only four people, the personal costs described by participants were similar to those identified by Tin et al (2015)9 among Pacific people in Nauru and the Solomon Islands. The direct cost of diabetes is significant, but the indirect costs may be even larger.7, 8 Diabetes can be a significant burden on the individual and this burden can vary depending on an individual’s family circumstances, social situation and background, and can cause significant stress.12 This study, which explored the impact of diabetes on four Pacific people, allowed us to describe and acknowledge the complexity of the cost of diabetes among Pacific families. It was evident 99


that the personal cost of diabetes extends beyond the person with diabetes to include the family, as well as the wider Pacific community. When personal costs are taken into account, the economic cost of diabetes is likely to be greater than current estimates of the cost of diabetes.8

stopped smoking and drinking alcohol, and had made dietary changes to reduce the risk of diabetes progression and development of complications. It was beyond the aim of this study to determine what factors helped facilitate the adoption of a healthy lifestyle.

One unique cost of diabetes amongst Pacific peoples is the cost it places on the family. In Pacific culture, ‘aiga’ or family is prioritised above everything, so if one person in a Pacific family is sick, the impact extends to the whole family.12, 13 Younger family members, as found in this study, often lived with the person with diabetes to help with household chores and keep them company. This commitment sometimes involves moving from another town or country. Moreover, extended family and members of the community find time and money to visit and bring gifts, as a sign of love and care.

People with diabetes are usually aware that they need to eat a healthy diet but it can be costly, particularly when there are other costs associated with having diabetes such as GP consultations and prescription fees.16 These additional costs can create stress especially when trying to adopt a healthier lifestyle, and particularly within a family setting.12 This means that people may not always eat and drink recommended foods for diet-related conditions, but will consume what is affordable and available to them.

In Pacific culture, elders are highly respected, and their needs and wants are prioritised within the Pacific community.14 Sometimes when immediate family are unable to help, church community members take up the carer role for the sick person, giving money and time which can necessitate taking time off work. This is not an obligation, but rather the nature of the Pacific culture where everyone in the community becomes family (biological or non-biological). These sociocultural practices, which we identified in this study, emphasise the uniqueness and potentially greater economic impact diabetes has among Pacific peoples. Food is an important part of Pacific culture, and is always present at Pacific gatherings, whether it is a celebration such as a wedding or a funeral, church lunches, or visiting someone.12, 14, 15 In the Pacific culture offering food can be a sign of a gift or respect and in Samoan is called ‘faaaloalo’. While it is polite to accept these foods or the ‘faaaloalo’, this cultural practice can be a challenge for people with diabetes. In our study, one participant described that when they attended ‘toona’i’ or ‘church lunch’, it was difficult to maintain a healthy diet when people brought unhealthy food. Despite knowing that a poor diet has an impact on glycaemic control, it was difficult to resist the temptation of unhealthy food, and refusing the ‘faaaloalo’ could be considered rude. This difficulty with diabetes management has been previously described as a source of stress for Pacific people with diabetes.12 In contrast, one participant was able to decline the ‘faaaloalo’ at gatherings by explaining that he had diabetes and was not able to eat unhealthy foods. This person was, however, highly motivated to change their lifestyle, and had

A limited budget, lack of time and a negative mindset or lack of personal motivation are barriers to implementing a healthy lifestyle.15 In this study changing one’s mindset was considered a barrier because lifestyle changes were difficult to make, and that to implement these changes, the whole family has to agree and follow the changes too. A suggested and previously recommended solution for Pacific people was to involve family members in the treatment and management plan of the person with diabetes.12 The same concept might also be useful to consider in health promotion – to not only target the person with diabetes but also the family members, as well as the wider Pacific community. A common, and previously described theme,17 amongst all four participants was the shock of learning they had diabetes. Two participants did not understand why they had diabetes because they thought they had always eaten healthily. The news of having diabetes did not make sense to them, and initially, they did not change their diet. They later become more aware of their diet, eating more fruits and vegetables, however that was the only change, and they did not necessarily reduce their intake of unhealthy foods. This was similar to findings in a study by Green et al (2007),18 where people diagnosed with T2DM had positive attitudes and good knowledge to make changes to their lifestyle, however most did not take action in regard to their diet, exercise and weight loss. Strengths and limitations A key strength was that the interviewing researcher was Pacific (Samoan). This helped participants to feel more comfortable during the research process, particularly for three participants whose interview was conducted in 100


Samoan. The implication is that they may have been more willing to share information, thereby providing rich data for analysis. A limitation was that recall of lifestyle changes made following a diagnosis of diabetes was difficult for those participants who had had diabetes for a long time, particularly if these changes have become normalised as part of their lifestyle. This small qualitative case study did not include the quantification of any actual costs. As household and family members were not interviewed, not all personal costs may have been identified. Three of the four participants were Samoan, and the findings may not be generalisable to all Pacific ethnic groups. Indeed, though informative, the findings may not be generalisable to the wider Pacific community given the small number of participants in this case study. CONCLUSION The economic cost of diabetes among Pacific is wide-reaching, and has a huge cultural aspect. Among Pacific peoples there appears to be a significant cost to not only the person with diabetes but also family and community members. A diagnosis of diabetes can have a positive outcome, whereby the diagnosis triggers a dramatic lifestyle change, and can lead to individuals being a positive influence on family and the community. More research is needed to better understand and quantify the cost of diabetes among Pacific people, and to tailor diabetes prevention and treatment programmes to reduce the personal and economic cost of living with diabetes. Acknowledgements We thank the four participants who took part in this study, and the Pacific Island Centre and the Pacific Research Student Support Unit, University of Otago, Dunedin who helped to facilitate recruitment. REFERENCES 1. Coppell KJ, Mann JI, Williams SM, et al. Prevalence of diagnosed and undiagnosed diabetes and prediabetes in New Zealand: findings from the 2008/09 Adult Nutrition Survey. The New Zealand Medical Journal. 2013; 126:23-42. https://www.nzma.org.nz/journal/readthe-journal/all-issues/20102019/2013/vol-126-no-1370/articlecoppell

2. Simmons D, Shaw LM, Scott DJ, Kenealy T, Scragg RK. Diabetic nephropathy and microalbuminuria in the community. The South Auckland Diabetes Survey. Diabetes Care. 1994; 17:1404-10. https://doi.org/10.2337/diacare.17.12.140 4 3. Hotu S, Carter B, Watson PD, Cutfield WS, Cundy T. Increasing prevalence of type 2 diabetes in adolescents. Journal of Paediatrics and Child Health. 2004; 40:201-4. https://doi.org/10.1111/j.14401754.2004.00337.x 4.

da Rocha Fernandes J, Ogurtsova K, Linnenkamp U, et al. IDF Diabetes Atlas estimates of 2014 global health expenditures on diabetes. Diabetes Research and Clinical Practice. 2016; 117:48-54. https://doi.org/10.1016/j.diabres.2016.04. 016

5. Zhang P, Gregg E. Global economic burden of diabetes and its implications. The Lancet Diabetes & Endocrinology. 2017; 5:404-5. DOI: 10.1016/S2213-8587(17)30100-6 6. Ng CS, Lee JY, Toh MP, Ko Y. Cost-of-illness studies of diabetes mellitus: a systematic review. Diabetes Research and Clinical Practice. 2014; 105:151-63. https://doi.org/10.1016/j.diabres.2014.03. 020 7. Marcellusi A, Viti R, Mecozzi A, Mennini FS. The direct and indirect cost of diabetes in Italy: a prevalence probabilistic approach. The European Journal of Health Economics : HEPAC : health economics in prevention and care. 2016; 17:139-47. https://link.springer.com/article/10.1007% 2Fs10198-014-0660-y 8. American Diabetes Association. Economic costs of diabetes in the U.S. in 2012. Diabetes Care. 2013; 36:1033-46. https://doi.org/10.2337/dc12-2625 9. Tin ST, Iro G, Gadabu E, Colagiuri R. Counting the Cost of Diabetes in the Solomon Islands and Nauru. PloS One. 2015; 10:e0145603. https://doi.org/10.1371/journal.pone.0145 603 10. Falconer DG, Buckley A, Colagiuri R. Counting the cost of type 2 diabetes in Vanuatu. Diabetes Research and Clinical Practice. 2010; 87:92-7. https://doi.org/10.1016/j.diabres.2009.09. 022 101


11. Braun V, Clarke V. Using thematic analysis in psychology Qualitative Research in Psychology. 2006 3:77-101. http://dx.doi.org/10.1191/1478088706qp0 63oa 12. Elstad E, Tusiofo C, Rosen RK, McGarvey ST. Living with Ma'i Suka: individual, familial, cultural, and environmental stress among patients with type 2 diabetes mellitus and their caregivers in American Samoa. Preventing Chronic Disease. 2008; 5:A79. http://www.cdc.gov/pcd/issues/2008/jul/ 07_0101.htm. 13. Norris P, Fa'alau F, Va'ai C, Churchward M, Arroll B. Navigating between illness paradigms: treatment seeking by Samoan people in Samoa and New Zealand. Qualitative Health Research. 2009; 19:146675. https://doi.org/10.1177/10497323093483 64 14. Mavoa HM, McCabe M. Sociocultural factors relating to Tongans' and Indigenous Fijians' patterns of eating, physical activity and body size. Asia Pacific Journal of Clinical Nutrition. 2008; 17:375-84. https://www.ncbi.nlm.nih.gov/pubmed/18 818156 15. Wang CY, Abbott L, Goodbody AK, Hui WT, Rausch C. Development of a communitybased diabetes management program for Pacific Islanders. The Diabetes Educator. 1999; 25:738-46. https://doi.org/10.1177/01457217990250 0506 16. Bernard DM, Banthin JS, Encinosa WE. Health care expenditure burdens among adults with diabetes in 2001. Medical Care. 2006; 44:210-5. DOI: 10.1097/01.mlr.0000199729.25503.60 17. Braginsky N, Inouye J, Wang CY, Arakaki R. Perceptions related to diet and exercise among Asians and Pacific Islanders with diabetes. Hawaii Medical Journal. 2011; 70:196-9. https://www.ncbi.nlm.nih.gov/pmc/articles /PMC3233401/ 18. Green AJ, Bazata DD, Fox KM, Grandy S. Health-related behaviours of people with diabetes and those with cardiometabolic risk factors: results from SHIELD. International Journal of Clinical Practice. 2007; 61:1791-7. https://doi.org/10.1111/j.17421241.2007.01588.x 102

Cama J, et al. Pacific Health Dialog 2018; 21(2):103-107. DOI: 10.26635/phd.2018.918

Perspective

OPEN ACCESS

A short history of the post-graduate surgical training in Fiji - where to from here? Jitoko CAMA,1* Sonal NAGRA2 ABSTRACT Post-graduate surgical training at the Fiji National University (FNU), previously known as the Fiji School of Medicine) has recently been updated by incorporating elements from the Royal Australasian College of Surgeons (RACS) training curriculum. The revised curriculum maintains strong contextual relevance to the needs and pathologies of the Pacific Island nations. This paper outlines why the FNU surgical postgraduate training programme should be applauded as a successful programme in the training of surgeons for the region. Keywords: postgraduate, surgical training, Fiji National University HISTORY OF POST-GRADUATE SURGICAL TRAINING: The Fiji School of Medicine (FSM) was first established in 1885.[1] It has grown in strength over the last 132 years and is now part of the College of Medicine, Nursing and Health Sciences (CMNHS) under the Fiji National University. The introduction of the Bachelor of Medicine and Bachelor of Surgery (MBBS) programme with its first graduates in 1987, led to ongoing development with various Pacific Island nations and stakeholders initiating the concept of postgraduate training in 1994.1This was part of the FSM Development Plan, endorsed by the then Fiji government which paved the way for high-level discussions by consultants, Pacific Island government representatives, major organizations and donors during the Pacific Ministers of Health Meeting held in 1995 at Yanuca Island.2 The outcome of that meeting recommended the introduction and establishment of the postgraduate Diploma and Masters programmes in Medicine, Surgery, Anaesthesia, Paediatrics, Obstetrics, and Gynaecology.2 A draft programme was established between 1996 and 1998. This included a 4-year training programme, similar to the Master’s course at the University of Papua New Guinea (UPNG) that trains general surgeons to be competent in treating and managing surgical patients in a limited resource setting. The post-graduate curriculum for surgery at FSM was strengthened by the appointment of qualified, well established

local and expatriate surgical consultants and advisors from Australia and New Zealand.2 The guiding principles at that time included distance learning where part of the post-graduate diploma training could be taught at the trainees’ home countries. This was especially critical during the pioneering period of the course when there were a limited number of doctors, and relocating them to Suva would have had a significant impact on health care delivery in their home countries. Trainees had to complete a 1year post-graduate diploma in surgery of which the first 6 months was undertaken in their respective Pacific Island countries. This postgraduate diploma programme utilised the Royal Australasian College of Surgeons (RACS) Surgical *Corresponding author: Mr Jitoko Cama, [email protected] 1. Paediatric Surgery Department, Waikato Hospital, Hamilton, New Zealand. 2. Consultant Surgeon, University Hospital, Geelong, Victoria. Senior Lecturer in Rural General Surgery, Deakin University Received:20.08.2018 Published: 30.09.2018 Citation: Cama J, et al. Short history of postgraduate surgical training in Fiji – where to from here? Pacific Health Dialog 2018;21(2):17-26. DOI: 10.26635/phd.2018.918 Copyright: © 2018 Cama J, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

103


graduate diploma programme utilised the Royal Australasian College of Surgeons (RACS) Surgical Trainees Educational Modules (STEM), while a large portion of the course was case-based problem solving and self-directed learning. Trainees needed to attain a minimum overall grade of B+ in each module in their final assessment to proceed to the Master of Medicine in Surgery (MMED-Surgery) Programme. The Masters' programme was a further 3 years of more supervised, hands-on training and face to face education with regular assessments. Due to the vast needs of the Pacific, trainees were taught principles and management of patients in relation to General Surgery, Orthopaedics, Neurosurgery, Plastic and Reconstruction, Urology, Paediatric Surgery and even Gynaecology/Obstetrics for the benefit of surgeons from the smaller regional islands. A public health component was incorporated into the syllabus and the successful completion of an original research study was mandatory in the final year.3 This research was submitted as a minor thesis and presented to a selected panel of lecturers and senior hospital staff. Additionally, trainees were required to pass an exit exam to be able to graduate with the Master of Medicine degree.1 These resulted in graduates’ competencies in a broad range of surgical knowledge and skill, making this a unique training as opposed to the model of subspecialised training abroad. Many of these trainees would return to work in isolation until further successful trainees joined the service, often being the solitary health professional with surgical expertise. Pioneers of the Postgraduate Surgical Training: The development and delivery of the curriculum required appropriate supervision of students locally and abroad. In 1998, under the supervision and guidance of Associate Professor Eddie McCaig with the assistance of Mr Frank Piscioneri and Mr Fred Merchant, the first seven trainees of the post-graduate Diploma in Surgery (PG Dip Surg) graduated which included Dr Sitiveni Vudiniabola (Fiji), Dr Santos Wari (Vanuatu), Dr Chester Kuma (Solomon), Dr Faka’osi Pifeleti (Tonga), Dr Kamlesh Kumar (Fiji), Dr Kelemedi Uluitoga (Fiji) and Dr Sainimere Matararaba (Fiji). The military coup in 2000 disrupted training resulting in only three trainees (Sitiveni Vudiniabola, Chester Kuma and Faka’osi Pifeleti) completing the Master's degree in December 2001. Dr. Kuma left surgery to pursue a career with the Seventh Day Adventist Church, while Dr. Pifeleti currently practices in the United Kingdom. Dr Vudiniabola was employed as a senior lecturer in Surgery until

2013, where he was instrumental in the delivery of the surgical education curriculum in both the undergraduate and postgraduate programmes. Dr Robert Hakwa from Vanuatu completed the MMED-Surgery in 2002, returned home for a short period and is now working in Australia. More surgical trainees from Fiji and the Pacific region have successfully completed the Masters' programme and have either travelled abroad for further specialized training with some staying back in developed countries or have become leaders, mentors and surgical teachers in their respective countries. Sub-specialisation -Fiji Trainees and Fiji Experience: With the success of the programme and the steady increase in the number of graduates, the programme encouraged trainees to undertake a further 2-3 years of sub-specialised training abroad in an area of surgical specialty that interests them. Training abroad increased the chance of trainees not returning home after training. However, it also encouraged the health system to adjust policies and structure to reduce the frustrations of trained surgeons and to have clear career progression pathways to retain the trained surgeons in the Pacific.4 The two years spent overseas working and training meets the assessment requirements of the Fiji Medical Council (FMC) for vocational registration in general surgery. Sub-specialisation within surgery in a developing nation such as Fiji is challenging. The obstacles include a lack of infrastructure, equipment and consumables; lack of monitoring and evaluation of the specialists to attain and maintain a standard threshold required of sub-specialisation by a registered college such as RACS; and the lack of specialised training of other essential allied health workers such as nurses and physiotherapists. The first to be recognized with sub-specialization within surgery is Dr Sireli Vakadravuyaca who has vocational registration as a urologist after returning to Fiji in 2011. Pacific Island surgeons who have attained the MMED-Surgery degree have become specialist surgeons in various surgical sub-specialties and leaders in health in their respective Pacific Island countries. In Fiji, Dr Ifereimi Waqainabete, is a general surgeon who specialises in gastrointestinal, breast and endocrine surgery. He served as medical superintendent of the Colonial War Memorial Hospital (CWMH) from 2009 to 2011 and is currently the President of the Fiji Medical Association, the FNU Associate Professor of Surgery and lead clinician in the post-graduate surgical teaching programme. He

104


is assisted by Dr Basharat Munshi who is a general surgeon and Senior Lecturer. Recently, the Fiji Medical Council (FMC) recognised vocational registration in sub-specialist training in Neurosurgery (Dr Allan Biribo), Plastic and Reconstruction (Dr Semesa Matanaicake Jnr), Urology (Dr Rajeev Patel), Orthopaedics (Dr Vaigalo Eddie McCaig, Dr Pauliasi Bauleka, Dr Alipate Natoba) and Paediatric Surgery (Dr Josese Turagava and Dr Savenaca Rusaqoli) after their return from clinical attachments abroad with accompanying satisfactory references. These surgeons are leading the way forward in FNU’s sub-specialty training in the CWM Hospital and Lautoka Hospital. Furthermore, general surgeons – Dr Maloni Bulanauca, Dr Jaoji Vulibeci, and Dr Ali Ahktar - are recognized surgical leaders and trainers at the Western and Northern Divisional Hospitals. Dr Esala Vakamacawai, Dr Ronal Kumar, Dr Fane Lord, and Dr Warren Thagard are currently pursuing further training in New Zealand or Australia and would be returning to Fiji in a few years. The Pacific and MMed Surgeons in the region In the Pacific region, surgical graduates of the FSM/FNU are in leadership roles within and beyond surgery in their countries. The Honorable Dr Saia Piukala is currently the Minister for Health in Tonga, while Dr Kolini Vaega is a consultant surgeon in Nuku’alofa. Dr Richard Leona (on secondment to Nauru), Dr Trevor Culwick, Dr Basil Leodoro, and Dr Samuel Kemual are in Vanuatu and have increased the scope of practice in their country. The late Dr Oten Bwabwa and Dr Kabiri Itaka took over the surgical services in Kiribati which was previously managed by expatriates. Dr Deacon Teapa is the solitary surgical graduate in the Cook Island’s and is now heading surgery at the National Rarotonga Hospital. Since Dr Aleki Fuimaono first completed the post-graduate diploma in 2000, Dr Dyxon Hansell from Samoa completed the MMEDSurgery in 2012 and has contributed to surgical services and expanded this to teaching, becoming the Senior Lecturer in Surgery at the National University of Samoa. He has recently been supported by Dr Joe Toloa and two recent graduates, Dr Sione Pifeleti (Tongan) and Dr Petueli Emose (Fijian) who are permanent residents of Samoa due to marital commitments. Dr Alito Soares who is the first graduate from East Timor has opened the doors for other trainees to follow suit and is currently the Chief of Surgery in Timor Leste. Apart from the few that have left for further studies abroad or have migrated, the training has achieved most of its goals, in training and retaining surgeons in the Pacific region to provide

adequate, accessible and affordable surgical care. A major success of the programme has been that training was led locally with mentorship and assistance from surgical colleagues in New Zealand and Australia. A local training hub in Fiji leads to ownership of the curriculum as in other developing countries and is the most important aspect in retention and development of the medical workforce is training.5 Local Champion of the Programme – Associate Professor Eddie McCaig The success of any surgical training is dependent on the ownership and commitment of the surgical teachers and mentors. One is not able to talk about the postgraduate surgical training at the FSM and later FNU without mentioning the hard work and leadership of Associate Professor Eddie McCaig. Being one of the few surgical fellows of the RACS who returned to the Pacific and is still in Fiji, he took it upon himself to mentor and supervise the trainees since the inception of the programme in 1998. He has collaborated well with RACS and much of the success of the surgical training programme is attributed to his commitment, dedication, and diligence. His outstanding contribution to surgery in the Pacific was recognized by a prestigious college award in June 2014 when he was awarded the ESR Hughes Award from RACS, a first for a Pacific Island surgeon. DEVELOPMENT OF THE NEW POSTGRADUATE SURGICAL PROGRAMME: Under the administration of the CMNHS of FNU since January 2010, the post-graduate surgical training programme came to an abrupt suspension in 2014. This was a period of turmoil for the programme which caused a lot of anxiety to existing trainees and alumni. Despite the stringent requirements of the FNU and the Higher Education Commission in Fiji, a lot was discussed about motives behind the suspension of this successful surgical training. Senior surgeons in the region, including Associate Professor McCaig, Lord Viliame (Bill) Tangi, and Mr. Kiki Maoate through the assistance of RACS, revised the surgical curriculum and restructured training. This restructure and further developments allowed training to resume in January 2015 and formed part of a succession plan where the previous supervisor, Associate Professor McCaig, took on more mentorship role, handing over the day to day running of the programme to Drs Ifereimi Waqainabete and Basharat Munshi. This is recognized as a success of the programme where trainees will in future, be supervisors and mentors to trainees. To assist in the succession of

105


training leaders, senior trainees would have assisted in the supervision of the first-year postgraduate trainees at FNU. This contributes to the leadership qualities of senior trainees who will eventually become leading surgeons and teachers in the region. The new curriculum dictated an increase in teaching and supervision which is challenging where there is a small academic faculty. CRITICAL ANALYSIS OF THE POST-GRADUATE TRAINING The programme has graduated at least 35 surgeons over 16 years with more than 75% of these graduates serving in the Pacific. Information on the quality of training and supervision with the new curriculum will be available after an evaluation is undertaken in the next few years, and will hopefully achieve a similar- if not better- success story than now. The continued involvement of RACS in providing advice and an external examiner ensures the quality of the training programme. The programme is further strengthened with specialist visits via visiting teams, particularly through the Pacific Island Project (PIP). A thorough evaluation will provide useful and important information to different stakeholders including trainers, trainees, university management, government, professional bodies, funders, and other academic institutions.6 One can judge the impact of the training program in terms of the process of developing knowledge and skills, attitudes towards particular conception, actual behavior change, and even more long-term impact.[6] This Kirkpatrick’s four-level model, which consists of four evaluation criteria: reaction, learning, behavior, and results[6]and each criterion measures different levels of impact will need to be formally done as a separate evaluation study. However, the greatest impact is having all the surgeons in the Pacific with the Masters of Surgery as the minimum requirements. We believe that in the future, these surgeons, together with the Pacific Island Surgeons Association (PISA) would enable members to be honorary fellows of a surgical college abroad. WEAKNESSES OF THE POST-GRADUATE TRAINING Every training programme will have weaknesses which when highlighted can allow for changes and improvement. For the surgical training, this includes but is not limited to:

1. Lack of research dissemination including publication in peer-reviewed journals and presentation by the trainees, surgeons, and academics in local, regional and international meetings and conferences 2. Loss of surgical trainees overseas/brain drain. This will be an ongoing issue that will be very challenging to control as people migrate for various reasons. It could also reflect the success of the surgical training where trainees are considered capable of working and successfully completing further training overseas. Fiji has lost six surgeons while Vanuatu, Solomon Islands, and Tonga have all lost a surgeon each to developed countries. Finding a placement overseas for further surgical training in Australia and New Zealand has not been an issue for those who successfully completed medical council requirements including a pass at the International English Language Testing System (IELTS). The loss of surgeons to overseas countries should not be considered a total loss as many still contribute in various ways to Pacific health and surgery as educators via the Pacific Island Project and other funding organizations as well as being focal points for placement for future trainees. 3. Surgeons who have returned from their overseas attachments have not been paid appropriately for prolonged periods. Senior surgical posts are limited in number and there is a need to expand the national surgical service and build more capacity for the future. 4. Lack of opportunities for continuous professional development (CPD). PISA has a regional meeting every 2 years where sponsored surgeons attend. Otherwise, surgeons rarely have another opportunity unless a workshop or a meeting involving a few surgeons is held. There is a potential for PISA in the future to host CPD activities with better internet access and over social media. CONCLUSION Post-graduate surgical training in FSM/FNU has come a long way and can be considered a success with graduates who are now providing surgical services in the Pacific region. Surgeons are contributing to the betterment of surgical care as health leaders. Future trainees of the surgical programme at the FNU will hopefully continue to succeed, be supported and retained in the Pacific. It is the responsibility of all the senior surgeons in the Pacific and to mentor, train and supervise the upcoming surgeons. PISA will continue to

106


strengthen collaborations with colleagues in New Zealand and Australia to assist with training in the Pacific. Research and the dissemination of findings in peer-reviewed journals is an area that needs strengthening. The future is bright and we wish the surgical trainees a better training, professional development, and career in the Pacific. Acknowledgements: We would like to acknowledge and thank the RACS, the Pacific Island Programme of the RACS, Health Specialist Limited, Pasifika Medical Association and other donors or individuals who have supported the post-graduate surgical training in the Pacific. We acknowledge Dr Anasaini Cama and Dr Balbindar Nagra for their advice and input on the content of this paper, and to thank Professor Alec Ekeroma for his kind assistance. REFERENCES: 1

Cama J, Cama A, Qovu J. Perspective from the pioneers of the “Problem-Based Learning” and a tribute to the late Dr Jimione Samisoni: the Guinea Pig. Pac Health Dialog 2012;18:133–4.

2

Clunie GJA, Mccaig E, Baravilala W. The Fiji School of Medicine postgraduate training project. Med Educ 2003;179:631–2.

3

Fiddes T. Fiji School of Medicine Diploma and Masters programmes. Pac Health Dialog 2000;7:84–5.

4

Oman K, Usher K, Moulds R. Lack of coordination between health policy and medical education: a contributing factor to the resignation of specialist trainees in Fiji? NZMJ 2009;122:28–38.

5

Wilks L, Leather A, George P, et al. Medical Officers in Sierra Leone: Surgical Training Opportunities, Challenges, and Aspirations. Surg Educ 2018;1931–7204:30688–8. doi:10.1016/j.jsurg.2018.01.003.

6

Chan K. A critical analysis of a program evaluation: A case study on the effectiveness of a teacher training program. Asian J Educ Res 2016;4:24–33.

107

Tatui L, et al. Pacific Health Dialog 2018; 21(2):108-110. DOI: 10.26635/phd.2018.921

Perspective

OPEN ACCESS

Rethinking and establishing a dental collaboration in the Pacific Region Le’Roy TATUI,1* Judith MCCOOL,2 Vili NOSA3 Oral health services are an essential component of a comprehensive, quality health system. As the link between oral health and other health conditions is well established, affirming the need for population access to timely, affordable, quality oral health services s an essential component of Universal Health Coverage.1 In the Pacific Island countries and territories (PICTs) challenge of limited human resource capacity and a corresponding low investment in maintaining access to high quality, accessible health services.2 We argue here that there are significant opportunities to build effective connectivity among the oral health sectors for the benefit of the PICTS. These will necessarily involve: building upon existing networks, sharing human and technology resources and growing leadership with the oral health sector to continue to advocate for oral health as a population health priority. A situational analysis of dental health services across the Pacific Islands region was conducted to a). examine existing capacity and capabilities within the oral health sector with the view to b). explore the potential for drawing together the collective expertise and resources for a regional oral health workforce. Our analysis is based on a literature review and a series of four key stakeholder discussions with leading oral health professionals from the Cook Islands, Niue, Tonga and Vanuatu. These are presented here to capture the diverse needs and development context challenges for oral health services. This include the barriers and opportunities for collaboration amongst oral health professionals in the Pacific region. This viewpoint advocates an approach to achieve effective and meaningful partnerships, leadership and the importance of evidence to underpin development within the dental profession in the region. The concept of a regional collaboration among dental professionals in the Pacific region has been explored previously.3 In 2014, the formation of the Oral Health Pacific Islands Advisory Forum (OPIA) saw a renewed commitment to improve professional networks, cooperation and

leadership for the region.4 The OPIA supported the relaunch and strengthening of oral health activities and promote leadership roles in Pacific countries.4 Stakeholders agreed that there was scope for the improvement of collaboration and to determine the optimal way forward. The geographic spread and isolation of 22 PICTs presents a challenge. Disparities between and within the PICTs in terms of distribution of human resources is a case in point.5 For example, the oral health workforce in Vanuatu is small and concentrated in urban areas which leaves populations in the rural areas underserved. Conversely, Niue, one of the smaller Pacific states, has a sufficient oral health workforce for the whole population. Reasons for the inequitable distribution of oral health workers in the PICTs is most likely those that explains the maldistribution of health care workers in other disciplines – migration, professional training sites, a lack of modern equipment (to maintain professional development), outdated policies and inherent political and economic factors. There was little doubt that the PICTs should enjoy the benefits of accessible, affordable, quality oral health services. Yet the context within which the health workforce in the PICTs has evolved, based on an overreliance on international development assistance for targeted programmes, a tendency *1Corresponding author: Dr Le’Roy Tatui, Principal Dental Officer, Niue 2. Associate Professor, Population Health, University of Auckland, New Zealand 2. Pacific Health, Associate Professor, Population Health, University of Auckland, New Zealand Received:20.08.2018 Published: 30.09.2018 Citation: Tatui L et al. Rethinking and establishing a dental collaboration in the Pacific Region. Pacific Health Dialog 2018;21(2):108-110. DOI: 10.26635/phd.2018.921 Copyright: © 2018 Tatui L, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

108


for supplementary arrangements (short term medical missions)6 and a chronic lack of resources has undermined the opportunities to develop a sustainable, fit-for-purpose oral health service.7 The need for innovative, cost effective solutions for delivering oral health is vital. There is a need for effective coordination of existing human resources. Effective mechanisms of procurement and funding is needed across the region. One approach is to build practical alliances between the health services sector and academic institutions in the region. Initiatives such as placement of undergraduate students in Pacific countries (Cook Islands, Fiji and Tonga) may increase the chances of students returning to their home countries. Professional development and training opportunities need strengthening. Leadership within the oral health workforce has been underdeveloped. Building health leadership and management skills strengthens effective communication, resource utilisation and strategies to support collective action for the integration of oral health into the general health system. Inadequate research capacity have hindered long term gains in oral health.4 Investment to improve oral health research capacity is important as it informs evidence-based practices and policies. Incountry capacity to provide continuing education and professional development for the dental workforce varies across the region. Some of the PICTs provide opportunities for continuing professional development. For example, Fiji is comparatively well resourced for training and development opportunities from the Fiji National University and the Fiji Dental Association.8 The majority of the oral health professionals in the Pacific are graduates from Fiji. Their access to lifelong learning is a priority need for workforce development. Oral health initiatives established by charitable organisations have shown success by creating sustainable partnerships in the Pacific. In Vanuatu, a Friend of Kokorosa initiative has seen the establishment of well-resourced and environmentally friendly dental establishments that may be suitable for most Pacific contexts. Similarly, the Smiles of the Pacific programme have facilitated training of local oral health professionals in Lautoka. Some training institutions have also formed partnerships with a number of countries with a mutual objective of providing clinical training for dental undergraduates in the Pacific. Informants believe that there are economies of scale to be achieved by establishing oral health partnerships and networks throughout the region. This may inform through diplomatic relations donor funding

support provided by New Zealand and Australia to the Pacific region. The historical development of the dental profession has somewhat followed the western societal paradigm of being predominantly a private orientated service. Most of the oral health workforce in the Pacific work for the respective health ministries. As a public health service, they exist to serve the people who struggle to live in developing economies. Growing evidence have highlighted the inherent link between oral and general health and subsequent need for integration in the delivery of health services. With the Pacific configuration of a public service provider, integration of health services is appropriate for this purpose. This also reinforces the role and scope of practice that is appropriate for the geographical features and prudent resource allocation practices of the Pacific countries. The research overall show that there is sufficient evidence to learn from the past experiences of dental health services providers. Through planned innovative ideas and the willpower to accept positive changes, over time we can improve our dental health services today and for the future. Although it may seem complex and rather ambitious, collaboration can be simple and effective. Strengthening collaborative networks can be viewed through the lens of the shared values model.9 The shared value model is vital from the collaborative, health equity and professional advocacy viewpoints. International advocacy and leadership have been providing immense assistance to the region, and yet most of the issues are beyond the scope of the region’s capacity, capabilities and resources. As health professionals, we all share the common goal and values associated with the attainment of the highest possible standard of health for the Pacific population. There is also an acknowledgement of the motivation and aspiration of the Pacific islands stakeholders to become more inclusive and self-sufficient. Relational activities are paramount to the success of the implementation and sustainability of partnerships for collaboration. Stakeholders need to share the same values for improving the Pacific population health, as well as, advocating for the best professional performance level and job security. Collaboration across the Pacific region can be complicated due to competing interests, structural, political, cultural and institutional arrangements. Economic and finance system variations shape how countries implement actions for country-specific needs.10 The way forward may be challenging, but solutions that benefit the oral health for all PICTs populations

109


will necessitate the building of a collective agreement that agrees to the equitable distribution of scarce resources. Most importantly, we must draw upon our shared Pacific values and professional goals in order to build a health system for the future. With improved coordination of our limited resources, building on our expertise, growing strong leadership, we are better equipped to ride the inevitable wave of change in a young developing region. We recognize however that we can draw upon technical support of our New Zealand, Australian and health networks and training institutions so that we can move forward to improving oral health services in the Pacific region. REFERENCES: 1. Marthur M.R., Williams, D.M., Reddy, K.S., Watt, R.G. Universal Health Coverage: A Unique Policy Opportunity for Oral Health. 2015. Available from: https://doi.org/10.1177%2F0022034514565 648 2. World Health Organization., Health Workforce Development in the Pacific. 2017. Available from: http://www.wpro.who.int/southpacific/pic_ meeting/2017/documents/12thphmm_sessio n04_03_hwf_16aug.pdf 3. Tuisuva, J., Morse, Z., Pushpaangaeli, B. Pacific Oral Health Summit – “A call for action”. 2001. Pacific Health Dialog, 10 (1) 111-13. Available from: http://pacifichealthdialog.org.fj/Volume2010 /No120Oral20Health20In20The20Pacific/Or al20Health/Conference20Report20Pacific20o ral20health20summit2020A20call20for20act

ion202001.pdf 4. Oral Health Pacific Islands Advisory Forum. (2014). Suva Declaration on Improving Oral Health in the Pacific Islands Region. 2-4. 5. World Health Organization., Global Strategy on human resources for health: workforce 2030. 2016. Available from: http://www.who.int/hrh/resources/global_st rategy_workforce2030_14_print.pdf?ua=1 6. Martiniuk, A., et al., Brain Gains: a literature review of medical missions to low and middleincome countries. BMC Health Services Research, 2012. 12(134). 7. Peres, M.A., Brennan, D.S., Balasubramanian, M., Oral health inequalities and health systems in Asia Pacific: A call for action. 2017. Available from: https://www.natureasia.com/en/nindia/pdf/ specialissues/Oral_Health_Inequalities_Health_Syste ms_in_Asia-Pacific 8. Fiji Dental Association. https://www.fdiworlddental.org/members/r egular/fiji-dental-association 9 Porter, M. E., Kramer, M. R. The big idea: Creating shared value. 2011 10 Pacific Islands Forum Secretariat. The Framework for Pacific Regionalism. 2014. Available from: https://www.adb.org/sites/default/files/link ed-documents/pacific-robp-2015-2017sd.pdf

110

The Pacific Health Dialog is an independent publication of the Pasifika Medical Association. The Journal began publishing in March 1994 when it was known as the ‘Journal of Community Health and Clinical Medicine for the Pacific’. Two issues were published every year until 2014. It prided itself as the only Medline listed medical journal in the Pacific region. It was published by Resource Books until 2004 and then it was transferred to the then Fiji School of Medicine in 2009 until 2013 when it was bought by the Pasifika Medical Association The Journal has published wide ranging articles on Pacific health and was the main reference and citation source for many scholars and researchers doing research in the Pacific. In 2010, the Impact Factor was a respectable 0.43. It has since slid 0.39 in 2014. The Pacific Health Dialog provides an avenue for Pacific clinicians and researchers wherever they are to share their stories within the region and with the world. Dissemination of Pacific evidence is value-added with a vehicle that was sympathetic to Pacific development and capacity building. The Journal will aid research collaboration in the region. The Journal welcomes manuscripts from all areas of health. We prefer manuscripts that have the potential to inform clinical practice and policy decisions in the low-resource setting. We will publish original research, literature reviews, perspectives, short reports, clinical audit, Talanoa articles, Pacific specific means of communication whether they be poems, Talanoa, art or music - as long as they are appropriate to health. All manuscripts, except invited papers, are peerreviewed by experts in the field to ensure robustness in methods and interpretation of findings. All authors should read the Information for Authors and follow them closely. We will offer limited assistance to new authors, but we expect established authors to follow the Journal’s guidelines. The Journal is ISSN registered and as a member of the Cross-Ref community, all published articles have a DOI, which is disseminated by Google Scholar and Medline within three days to three weeks of publication. Disclaimer: The Publisher, Pasifika Medical Association (PMA) and Editors cannot be held responsible for an error or any consequences

arising from the use of information contained in the Journal. The views and opinions expressed are not necessarily those of the Publisher, PMA and Editors. Address for correspondence: [email protected] [email protected] Pacific Health Dialog, 195L Main Highway, Ellerslie, Auckland. P.O. Box 11445, Ellerslie Auckland, 1542 NZ. F: +649 5235253; M: +64 (0)21 2767975 O: +646 250 5761. SUBMISSIONS Submissions through the Journal portal is preferred although those residing in countries with limited internet access can email them to the Journal Manager. Letters to the Editor are welcomed. INDEXING The Journal is indexed online. All manuscripts are published in the PSRH website as well. We welcome suggestions as to how to make the Journal and Website more informative and exciting. REVIEWERS and INSTITUTIONAL EDITORS We welcome reviewers for the Journal and applications from researchers in key institutions and countries to assist us in this important venture. EDITORIAL BOARD The Editorial Board comprise renowned and active reproductive health clinicians, researchers, academics and health policy experts from the Pacific region. Professor Alec Ekeroma, MBBS, DipObs, MBA, FRCOG, FRANZCOG, MInsD, PhD Editor in Chief, Head of Department of Obstetrics & Gynaecology & Women’s Health, University of Otago, Wellington, New Zealand; [email protected]

111

Dr Jitoko Cama, FRACS Chair of the Pasifika Medical Association Membership Ltd. Fellow of the Royal Australasian College of Surgeons, Paediatric Surgeon at Waikato DHB and Honorary Senior Clinical Lecturer, University of Auckland. [email protected] Dr Rosalina Risale Richards Hessell, PhD Co-Director, Senior Research Fellow, Cancer Society Social and Behavioral Research Unit. Associate Dean Pacific, Dunedin School of Medicine/Te Kura Whaiora o Ōtepoti. [email protected] Dr Kiki Maoate, ONZM, FRACS Dr Kiki Maoate ONZM, FRACS is a Paediatric Surgeon and Paediatric Urologist based in Christchurch. He is currently the Chair of Pasifika Futures Ltd, the Whanau Ora Commissioning Agency for Pacific families and Chair of Pasifika Medical Association Ltd. He is Associate Dean Pacific Health University of Otago based in Christchurch. Dr Maoate is Clinical Director for the Pacific Island Project, Royal Australasian College of Surgeons. Kiki has served as a member of the New Zealand Health Research Council, Pacific Health Research Council and the University of Canterbury Council. He is an advisor to the Cook Islands Ministry of Health and provides advice and support across the Pacific region to clinicians. [email protected] Associate Professor Faumuina Fa’afetai Sopoaga, FNZCPHM, FRNZCGP, MPH, DPH Associate Dean (Pacific), Division of Health Sciences, University of Otago. Director of the Pacific Islands Research and Student Support Unit. [email protected]

Assistant Professor Maile Taualii, BA, MPH, PhD Department of Public Health Sciences, Hawai‘inuiā kea School of Hawaiian Knowledge, University of Hawaii. [email protected] Dr El-Shadan Tautolo. PhD Director of the Centre for Pacific Health at Auckland University of Technology and Head of the Pacific Island Family Study. [email protected] Dr Jemaima Tiatia-Seath PhD Senior Lecturer of School and Head of Pacific Studies (Acting) Te Wānanga o Waipapa. School of Māori Studies and Pacific Studies. The University of Auckland. [email protected] Associate Professor Vili Nosa PhD Head of Pacific Health Section and Associate Professor from the University of Auckland. Member of the Pacific Health Research & Development Foundation Trust, Pacific Prostate Cancer Foundation Board. [email protected] Associate Professor Donald Wilson Head of School & Associate Professor Epidemiology & Biostatistics School of Public Health & Primary Care, College of Medicine, Nursing & Health Sciences Fiji National University Journal Manager Dr Silipa Naiquiso, MBChB, DipOG, MRANZCOG Silipa graduated from the University of Auckland. She is completing her training in obstetrics and gynaecology. [email protected] Mrs Melissa Fidow BCS Executive Officer of the Pasifika Medical Association. [email protected]

112