Introduction
The Te Kahui Whai Ora (TKW) initiative was a health promotion program initiated by an indigenous health care organization, the Te Orenganui Iwi health authority (Gifford, 2010, p. 7). Its main aim was to promote healthy lifestyle changes through improved nutrition and increased physical activity in order to reduce obesity among the Maori children, the target population. The program used a whanau or a family based approach. This paper discusses the TKW initiative in relation to its framework, planning and implementation, and the evaluation criteria adopted based on the key principles, which guide health promotion initiatives implementation. It also covers the strengths and weaknesses of TKW with regard to the best practice principles.
Child Obesity among Maori population
Obesity is prevalent in Maori with about 43% of Maori adults being obese as at 2006/2007. In contrast, obese New Zealand European adults comprised approximately 23% of the general population in the same period (Gifford, 2010, p. 8). Furthermore, obesity among children 5-14 years in 2006/2007 reflected the ethnic pattern prevalence rates. Child obesity increases the risk of obesity in adulthood and overweight-related complications later in life. The Te Kahui Whai Ora health promotion intervention was a community-based intervention initiated by Te Oranganui Iwi Health Authority, an indigenous healthcare organization. The aim of the project was to promote healthy lifestyles among the Maori and reduce the risk of adult obesity.
The Te Kahui Whai Ora Health Promotion Initiative
The initiative involved a collaboration forming the Whanganui wellbeing forum with a major aim of promoting healthy lifestyles though improved nutrition and physical activity among the Maori population. According to the Ottawa charter for health promotion, which provides a framework for health promotion internationally, an effective health promotion initiative increases the people’s control over their health. The Te Kahui Whai Ora initiative primarily aimed at strengthening the collaboration between key local organizations including the NGOs such as Sport Whanganui and Heart foundation (Ministry of Justice, 2001, p. 10). It also involved primary healthcare organizations in the region and the local government. Thus, the approach of local health organizations involvement intended to arouse community action to bring about social and environmental change particularly with regard to nutrition.
The initiative comprised of a ten-week program during which healthy nutritional and physical activity information was provided weekly to the children and their families. Additionally, local resources including health facilities and local experts were involved in the provision of health information to the locals. This stated activity constituted health education and skill development, which is essential in increasing people’s control over their health as well as undertake to improve their health. In addition, it enables people to realize and identify the need to change their lifestyles in order to improve their health. According to Barnes, the TKW health promotion initiative was sensitive to the indigenous people’s cultural and social contexts (2004, p.215). In other words, it supported change to people’s health while respecting the indigenous people’s right to self-determination and cultural aspects or heritage.
Barnes identifies the fundamental principles of TKW health promotion initiative as socially and economically empowering, equitable, participatory and sustainable (2004, p. 217). The main goal of the Te Kahui Whai (TKW) program was to empower the Maori children (tamariki Maori) and their families (whanau) to change their lifestyles and adopt healthier lifestyles through improved physical activity and nutrition. By empowering the tamariki Maori, the program targeted the disadvantaged group i.e. children were at a high risk of becoming obese in adulthood. Additionally, the program provided an opportunity to whanau to display the skills gained during the workshops (Ministry of Justice, 1997, p.5) and develop groups to support their nutritional and physical activity requirements. The participation of Maori health workers in the initiative was crucial as it strengthens community ownership and sustainability of the intervention.
TKW Conceptual Framework
Te Puni highlights four aspects that underlie the TKW intervention with regard to changing the lifestyles of the tamariki and whanau (2001, p. 4). Firstly, the program primarily involved the provision of health information to the indigenous population to facilitate lifestyle change. In other words, the program created awareness and marketed the effective physical activities and nutritional practices that can facilitate lifestyle change. Secondly, they conducted health education with an aim of promoting indigenous skill development and enhancing sustainability of the program. The intervention also involved local health workers, and local health agencies to facilitate the lifestyle changes. The program created supportive settings characterized by referrals of tamariki to the intervention to facilitate the lifestyle changes across the community.
TKW: Ottawa Charter
The Ottawa charter describes a health promotion initiative as “an intervention that increases the indigenous people’s control over the determinants of their health” (Springett et al., 1995, p. 66) and thereby undertake to improve their health. An effective health policy should involve joint action by various stakeholders to ensure healthier goods and services. The TKW was a multi-sectoral program with a broad membership consisting of key local NGOs such as Sport Whanganui and the Heart Foundation, public health, primary healthcare and the local government. The joint action between the key agencies in the region ensured the success of the program. However, the program failed to incorporate other non-health sectors such as the education sector. Since the target population was primarily the children or the tamariki, the needs assessment is more effective when done in a school context approach.
The Ottawa charter recognizes the impact the changes in technology and work environment have on the health of a society and in creating a supportive environment for the target population. Accordingly, the TKW target population comprised of urban tamariki Maori of the Castlecliff community, whose health is prone to lifestyle changes. However, the assessment of the impact of technology and urbanization on the tamariki lifestyle was not conducted. Nevertheless, the TKW involved the Whanganui Wellbeing Forum; a partnership consisting of community health agencies. It also involved the local health experts and facilities in the exercise. It involved local “knowledge-building” programs that utilized local resources making it a community-controlled, culturally appropriate and self-determining initiative. Thus, it involved a model that recognizes indigenous resources and health needs of the target population. In this way, the TKW initiative was able to strengthen community action and enhance sustainability of its strategies.
The Ottawa Charter describes the promotion of people skills as central to an effective health promotion initiative. After the end of the ten weeks, the tamariki and whanganui participated in a holiday camp to foster the skills learnt during the workshops. Incorporating these skills in curriculum or learning is essential as the tamariki would facilitate learning of these skills and use them later in life. The Ottawa Charter also defines an effective health promotion initiative as being able to reorient the health services in pursuit of improved health. The TKW initiative organized workshops using the local resources and health experts who educated the children and their families on healthy living.
Strengths and Limitations of TKW
The immediate effect of the intervention during the period it was under implementation, (2002-2010), indicates that, the program had direct and indirect benefits to the families. Thomas contends that, the families gained skills and knowledge on physical activity and essential nutritional practices to achieve improved health (1997, p. 46). Additionally, the program influenced behaviour changes at a personal and community level in line with the goals of the intervention. The TKW’s success is attributable to the use of a perspective sensitive to the Maori cultural and social aspects (Gifford, 2010, p. 11). The Ottawa Charter describes an effective indigenous health promotion initiative as being community-controlled and culturally appropriate. Thus, the involvement of the population and their own perspectives on health promotion contributed to the success of the initiative.
Following the implementation of the TKW, the Whanau were able to make better food choices (Lodder, 2003, p.18). For instance, the whanau showed keen interest on nutritional content of a given food when shopping at a supermarket. Additionally, there is effective referral of the tamariki into the initiative due to efficient and sustainable partnerships established by the initiative. In this way, children at risk of becoming obese can learn the best nutritional and physical activity practices to improve their health. Thomas argues that, the participatory nature of the TKW program, which engaged many whanau and children, strong relationships were developed (1997, p. 48). This provided social support and ensured that the program remains sustainable. Additionally, the program’s use of tamariki as the primary target population nurtured leadership, collaboration and self-esteem among the young people.
However, the TKW program experienced challenges during its implementation. Durie (2001, p. 116) states that, the coordination of the program was initially a problem due to high turnover of the participants. The providers also had difficulties managing certain responsibilities of the program including assigning roles and recruiting staff and local health workers from the population. The problem of communication and alignment of the program’s priorities was also experienced during the implementation of this program (Durie, 2001, p. 120). In addition, collaboration between the whanau was a problem initially as they had a problem working together. The partners in the program including the local health agencies and providers experienced difficulties sourcing for funds to implement the program.
TKW: The Best Practice Principles
The principles of best practice with regard to health promotion rely on the Ottawa Charter approach. According to this framework, health promotion should allow the affected population to take control of the determinants of their health at their social and cultural contexts (Smith, 2004, p.34). The principles of health promotion initiative include empowering, participatory, inter-sectoral, sustainable and multiple strategic.
Empowering
The TKW initiative sought to empower the whanganui Maori of Castlecliff community by enabling them to control the determinants of their health. In other words, the whanganui Maori were able to assume more power over personal, environmental and social factors that directly or indirectly affect their health.
Participatory
The partners of TKW involved collaboration between indigenous primary care organizations such as the Te Orenganui Iwi Health Authority, the Heart foundation and Sport Whanganui that are sensitive to the cultural and social aspects of Maori lifestyles. A local partnership called the Whanganui Wellbeing forum was formed with a purpose of increasing community participation in physical activity and improving nutrition. Thus, by involving local health organizations, the TKW model was culturally appropriate and community-controlled.
Inter-sectoral
An effective health improvement intervention must utilize the local assets and be based on the health goals of the local community (McQueen, 2001, p. 267). The TKW involved of local health agencies as well as local government resources to facilitate the identification of the health aspirations and the social determinants of health among the Maori.
Multi-strategic
The TKW health promotion initiative involved a number of complementary approaches. Health education was carried out to sensitize the community the ways of achieving healthy lifestyles. Additionally, the TKW enhanced communication through a variety of partnerships that promoted health education as well as a lifestyle change among the tamariki and their whanau. This also ensured sustainability of the TKW program.
TKW and the Needs Assessment
The TKW health promotion initiative focused on “at risk children” identified as obese or overweight among the Maori population. The health promotion employed a family or whanau based strategy to identify the nutritional needs of the target population. Additionally, this helped to assess the priorities of the target population in relation to lifestyle changes. Statistics indicate a high prevalence of obesity among the Maori primarily due to nutritional behaviour patterns. Between 2006/2007, approximately 43% of all Maori adults were overweight or obese. In comparison, the cases of obesity in the rest of the population were low at 23% indicating a pattern of ethnic differences. The local health agencies that collaborated in the TKW initiative facilitated the identification of the target population as well as their needs. This ensured that the TKW was culturally appropriate and sensitive to the social and cultural aspects of the target Maori population.
TKW Planning and Implementation
The Whanganui Wellbeing forum, a local partnership organization, undertook the planning and implementation of the TKW. Green’s PRECEDE/PROCEED model emphasizes on the importance to identify the priorities, the goals, as well as the targets during project planning (De Leeuw, 2007, p.53). The PRECEDE phase encompasses project planning and identification of project goals. The project goals ultimately form the basis for evaluation of the program to determine its success. TKW planning involved the identification of partnership of local health agencies, the social and cultural circumstances unique to Maori, the community resources to be used and the specified target population group, i.e. the tamariki and their whanaui. The goal of TKW was to empower the Maori children (tamariki) and their families (whanau) to adopt healthier lifestyles such as better nutritional practices and increased activity.
Further, this model proposes that the planning phase include the identification of the epidemiological determinants of health (De Leeuw, 2007, p.64) such as the genetics, behavioural patterns and the environmental factors of the target population. However, the TKW initiative only focused on changing the behaviour patterns or lifestyles of the tamariki and their whanau. In particular, the genetic factors determine various illnesses or biological conditions that predispose individuals to obese condition (Slama et al., 2007, p. 159).
TKW Evaluation Criteria
The evaluation of a health promotion initiative is essential in assessing the effectiveness of the strategies used in the intervention. Green and Kreuter argue that, the evaluation of health promotion initiatives helps to inform action and future decisions (2005, p. 132). He identifies three levels of evaluation of a health promotion initiative: process, impact and outcome (Kelleher, 2007, p. 115). For TKW, the process evaluation involved observation of the lifestyle changes caused by the intervention.
Impact and outcome evaluation only provide the results of the health promotion program (IUHPE, 2000, p. 8). The evaluation criteria adopted for TKW involved process evaluation i.e. the immediate results following the implementation of the program such as increased referrals into the program. It also involved impact and outcome evaluation, where the factors that contributed to the success of the intervention with regard to lifestyle changes were examined. As a result, the evaluation provided recommendations for future policy options.
A review of the evaluation results provides evidence of the health promotion intervention’s effectiveness with specified focus on its practical outcomes. This requires a multi-sectored approach involving local authorities and government agencies, local community partnerships and health experts (Green, & Kreuter, 2005, p. 128). The TKW primarily involved the local community and health agencies with less participation from the central government or nutrition experts. Partnership approach involving local communities, food manufacturers, as well as retailers will contribute towards creating a healthier environment. Nutbeam argues that the central government’s involvement in health promotion initiatives acts as a role-model leadership that has positive impacts on the food industry (1998, p.36). Thus, health promotion interventions targeting the indigenous people should involve the central government and all actors in the food industry to effect necessary lifestyle changes. Additionally, these partnerships will also contribute to the improvement of local infrastructure and the creating of healthier environment for indigenous populations. The TKW health promotion initiative shows that a collaboration involving many industry players, the local community and the government is crucial in addressing not only the health impacts of a health promotion program but also its economic and political impacts. This has potential implications on the sustainability of the intervention as well as on health policy targeting indigenous populations.
Conclusion
Health promotion initiatives are vital strategies of improving the health of indigenous people. The Ottawa charter describes the health promotion initiatives as interventions that allow the indigenous people to control the determinants of their health. Accordingly, TKW’s approach involves the partnerships between local community health agencies that effectively identify the needs and aspirations of the people and undertake to meet them from their social and cultural contexts. In particular, the TKW’s involvement of local resources and partnerships contributed to the success of the health promotion initiative.
Reference List
Barnes, A. (2004) Social Justice Theory and Practice: Pakeha Kaupapa Maori and Educational Leadership. NZ Journal of Educational Leadership, 19, 214-217.
De Leeuw, E. (2007). Policies for health: The effectiveness of their development, Adoption and implementation. New York: Springer Publishing.
Durie, M. (2001) Mauri Ora: The Dynamics of Maori Health. London: Oxford University Press.
Gifford, H. (2010). Success Story-Te Kahui Whai Ora. IUHPE World Conference on Health Promotion. Geneva: IUHPE.
Green, L., & Kreuter, M. (2005). A framework for planning. New York: McGraw-Hill. Pp. 128-132
IUHPE. (2000). The evidence of health promotion effectiveness: Shaping public health In a new Europe, Part One, Core Document. France: IUHPE.
Kelleher, H. (2007). Health promotion planning and the social determinants of health. Melbourne: Oxford Press.
Lodder, S. (2003) Working with Indigenous Communities. Stronger Families Learning Exchange, 4, 17-22.
McQueen, D. (2001). Strengthening the Evidence Base for Health Promotion. Health Promotion International, 16(3), 261-268.
Ministry of Justice. (1997). Consulting with Maori: Process, Reports. Wellington: Ministry of Justice.
Ministry of Justice. (2001). He Hinatore ki te Ao Maori: A Glimpse Into the Maori World. Wellington: Ministry of Justice.
Nutbeam, D. (1998). Evaluating health promotion – progress, problems and solutions. Health Promotion International, 13(1), 27-44.
Slama, K., Callard, C., Saloojee, Y., & Rithiphakdee, B. (2007). Effective health promotion against tobacco use. New York: Springer Publishing.
Smith, T. (2004). Activism, Leadership and the New Challenges for Indigenous Communities. Wellington: NPHP.
Springett, J., Castongs, C., & Dugdill, L. (1995). Towards a framework for evaluation in Health promotion: Methodology, Principles and Practice. The Journal of Contemporary Health, 8, 61-67.
Te Puni, K. (2001). Strengthening Families: collaborative case management – State Sector performance. Wellington: Govett-Brewster Art Gallery.
Thomas, B. (1997). The Role of Business in Community Capacity Building: An Alternative Approach. Wellington: NH Modernization Agency.