National Health Promotion Framework and …...NATIONAL HEALTH PROMOTION FRAMEWORK AND IMPLEMENTATION...

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National Health Promotion Framework and Implementation Planning Guide for Screening Programmes

Transcript of National Health Promotion Framework and …...NATIONAL HEALTH PROMOTION FRAMEWORK AND IMPLEMENTATION...

National Health PromotionFramework and Implementation Planning Guide

for Screening Programmes

iNATIONAL HEALTH PROMOTION FRAMEWORK AND IMPLEMENTATION PLANNING GUIDE FOR SCREENING PROGRAMMES NOVEMBER 2004

Foreword

The information in this folder aims to help users to understand the National Screening Unit’s(NSU) intent and direction for health promotion in screening. The following documents providea nationally consistent framework, to help health promotion practitioners to develop regionalhealth promotion strategies

Each section of the guide has a different purpose:

National Health Promotion Framework

This section describes the NSU’s position on health promotion. It provides guidance for managers andhealth promotion staff on the strategic direction the NSU defines as important for health promotionplanning and implementation. It also provides definitions for terms and concepts commonly used inhealth promotion and screening.

National Health Promotion Framework: Implementation Planning Guide

This section is intended for screening service managers and health promotion practitioners. It is intendedto help users to understand the National Health Promotion Framework and how it can relate to theirservice. The questions can be used as a resource by individuals or groups to further assist thisunderstanding. The ideas developed as a result of working through this document can be used todevelop health promotion plans.

Ottawa Charter: Toolkit and Implementation Planning Guide

This section is intended for health promotion practitioners in the screening service who are responsiblefor writing and implementing health promotion plans. The toolkit asks questions that will assistpractitioners to consider the region concerned and develop appropriate health promotion strategies tomeet the needs of priority group women.

Te Pae Mahutonga: Implementation Planning Guide

This section provides an alternative planning framework for developing a health promotion plan. It isintended primarily for kaupapa Ma–ori health promotion planning and implementation.

Other useful documents to be read in conjunction with the National Health PromotionFramework and Implementation Planning Guide:

• Achieving Health for all People: A framework for public health action for the New Zealand Health Strategy.(Ministry of Health 2003)

• Nga– Tikanga Manaaki – Values and Ethics in Nga– Kai Katanga Hauora mo Aotearoa: Health PromotionCompetencies for Aotearoa New Zealand (Health Promotion Forum of New Zealand 2000)

• TUHA-NZ: A Treaty Understanding of Hauora in Aotearoa New Zealand (Health Promotion Forum of NewZealand 2002)

• Programme Evaluation: An Introductory Guide for Health Promotion (Waa et al 1998)

• He Korowai Oranga – Ma–ori Health Strategy Minister of Health and Associate Minister of Health 2002)

• Reducing Inequalities in Health (Ministry of Health 2002).

iiNATIONAL HEALTH PROMOTION FRAMEWORK AND IMPLEMENTATION PLANNING GUIDE FOR SCREENING PROGRAMMES NOVEMBER 2004

Foreword i

SECTION ONE1 Introduction 1

1.1 Definitions 11.1.1 Health promotion 11.1.2 Screening 21.1.3 Health promotion within screening 3

1.2 Purpose of the screening programmes health promotion framework 4

2 Strategic Context 52.1 Treaty of Waitangi and health promotion 52.2 Public health and primary health care 6

2.2.1 Public health 62.2.2 Primary health care 62.2.3 Primary and public health: the relationship with screening and health promotion 7

2.3 Consistency and links with other strategies 82.3.1 The New Zealand Health Strategy 82.3.2 He Korowai Oranga Ma–ori Health Strategy 82.3.3 Pacific Health and Disability Action Plan 8

3 Key Challenges for Health Promotion in Screening 93.1 Achieving high levels of programme participation 93.2 Developing an adequately trained health promotion workforce 93.3 Focusing on priority groups to reduce inequalities 103.4 Monitoring and evaluation to measure the outcomes of health promotion 103.5 Enabling informed consent 11

4 Health Promotion Models 124.1 Ottawa Charter 124.2 Te Pae Mahutonga 134.3 Pacific 13

5 Health Promotion Strategies 145.1 Community development 145.2 Communications 145.3 Health education 15

6 Conclusion 16

Appendix 1: Methods of Communication 17

Appendix 2: How to Develop a Health Promotion Plan 19

Appendix 3: A Health Equity Assessment Tool (Equity Lens) for Tackling Inequalities in Health 21

References 23

National Health Promotion Framework Implementation Planning Guide 24–45

SECTION TWOOttawa Charter Toolkit and Implementation Planning Guide 1–26

SECTION THREETe Pae Mahutonga Implementation Planning Guide 1–6

Contents

1NATIONAL HEALTH PROMOTION FRAMEWORK AND IMPLEMENTATION PLANNING GUIDE FOR SCREENING PROGRAMMES NOVEMBER 2004

1.1 Definitions

1.1.1 HEALTH PROMOTION

The World Health Organization (WHO) defines health promotion as (WHO 1986):

‘Health promotion is the process of enabling people to increase control over and to improve, their health.To reach a state of complete physical, mental and social well-being, an individual or group must be ableto identify and to realise aspirations, to satisfy needs, and to change or cope with the environment.Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasising social and personal resources, as well as physical capacities. Therefore,health promotion is not just the responsibility of the health sector, but goes beyond healthy lifestyles to well-being.’

Health promotion planning and strategy development requires consideration of the wider determinantsof health. In the context of screening these include social and community influences, gender and culture,socioeconomic and environmental conditions, and lifestyle and behavioural factors. Addressing thefundamental determinants of health ensures activities to promote health are concerned with equity ofaccess to services, including screening programmes, and equity of outcomes.

1 Introduction

The National Screening Unit (NSU) is responsible for two organised cancer screeningprogrammes, the National Cervical Screening Programme (NCSP) and BreastScreen Aotearoa(BSA). The NSU contributes towards reducing the burden of cancer through screeningprogrammes that aim to achieve two strategic outcomes: Reducing Inequalities and ImprovingHealth Outcomes (Ministry of Health 2003c). Health promotion is an essential part of achievingthese outcomes.

This framework and the implementation plans will support effective health promotionactivities within the NCSP and BSA by:

• raising awareness and understanding of screening among the eligible population

• raising awareness and understanding of how health promotion works in a screening contextamong the wider health sector

• providing information about how to encourage informed participation in the screeningprogrammes.

This framework and the implementation planning guide will underpin national and regionalhealth promotion strategies and initiatives.

2NATIONAL HEALTH PROMOTION FRAMEWORK AND IMPLEMENTATION PLANNING GUIDE FOR SCREENING PROGRAMMES NOVEMBER 2004

1.1.2 SCREENING

The NSU has adopted a definition of screening based on that of the National Screening Committee of theUnited Kingdom as adapted by the National Health Committee in New Zealand (National HealthCommittee 2003):

‘Screening is a health service in which members of a defined population, who either do not necessarilyperceive they are at risk of, or are already affected by a disease or its complications, are asked a questionor offered a test, to identify those individuals who are more likely to be helped than harmed by futuretests or treatment to reduce the risk of a disease or its complications.’

Screening refers not just to a screening test, but to a series of steps comprising the screening pathway.Health promotion initiatives form an integral part of the pathway (Figure 1).

F I G U R E 1 . T H E S C R E E N I N G PAT H WAY A N D R O L E S O F D I F F E R E N T S E RV I C E S

Source: Ministry of Health (2003c).

Screening occurs in two ways: as part of screening programmes and opportunistically. Quality assuranceand improvement processes distinguish organised screening programmes from opportunistic screening,and are essential for balancing the achievable benefits of screening with the potential harms. Organisedscreening is usually delivered through a screening programme with planning, co-ordination, monitoringand evaluation of all activities along the screening pathway. (Ministry of Health 2003c)

Population screening programmes involve screening entire populations or a large and easily identifiablegroup within a population. Often, members of this population are not aware that the disease which theyare being screened for could affect them. This in itself can be one of the barriers to screening, as thepopulation perceive themselves as well, and are being invited to participate in a programme that mayidentify them as unwell.

1 Introduction

Public HealthPrimary Care &

Referred Services

Ministry of Health

Minister of Health

Secondary &Tertiary Care

S E R V I C E S

S C R E E N I N G P A T H W A Y

Recall

Health Promotion Initiatives Invitation Screening Procedure Diagnosis Treatment

(negative) (positive)

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1.1.3 HEALTH PROMOTION WITHIN SCREENING

Health promotion within screening programmes aims to create an environment that is conducive to, andsupportive of, informed participation in screening. This helps ensure people who can benefit fromscreening are informed and empowered to take advantage of the potential benefits.

The health promotion component of screening programmes in New Zealand has evolved over the pastdecade. During the early years of the NCSP health promotion efforts focused on enrolling women in theprogramme therefore, measures of success were strongly linked to reaching coverage and participationtargets. To achieve this, health education was the main health promotion activity because populationhealth initiatives succeed only if sufficient numbers of the eligible population participate. A range ofstrategies was used, including health education sessions, health day expos, pamphlet distribution andadvertising. Such strategies proved effective in achieving high levels of coverage and participation forsome groups.

Many similar health education strategies were implemented during the initial phases of BSA. Whilecoverage and participation rates increased across both national screening programmes, the disparities ingroups participating in the screening pathway became apparent.

Reducing inequalities is a government priority area and the NSU has adopted a strong focus on prioritygroup women. The health promotion strategies adopted and implemented to date have been successfulin raising awareness of the screening programme. To be more effective in increasing coverage andparticipation rates for priority women, an approach needs to consider the wider determinants of health,strategies that focus on developing communities to encourage and engage long-term behaviouralchange, and the interface between personal and public health needs to be implemented. Participating inscreening is no longer enough. Increased awareness and a priority on informed consent highlights theneed for health promotion strategies that engage communities.

There are a number of emerging issues that have influenced the development of this framework.

• Health promotion delivered within personal health settings to ensure primary care is an essential partof the screening pathway.

• A wider acknowledgement of the determinants of health.

• The inclusion of community development initiatives that encourage and support long-term behaviourchange, particularly among under-screened and unscreened populations.

These emerging issues require consideration as part of health promotion planning and strategy development.

1 Introduction

4NATIONAL HEALTH PROMOTION FRAMEWORK AND IMPLEMENTATION PLANNING GUIDE FOR SCREENING PROGRAMMES NOVEMBER 2004

1.2 Purpose of the screening programmes health promotion frameworkThe purpose of the framework is to:

• ensure a consistent approach to health promotion as part of screening programmes

• build understanding and knowledge of health promotion and its role in screening programmes

• facilitate health promotion strategies that create opportunities for informed consent and supportiveenvironments and enable priority groups to participate in screening.

There is considerable evidence within New Zealand and internationally of significant ethnic,socioeconomic, geographical and gender inequalities in health. Success in reducing inequalities in healthwill bring positive results for the individual, the economy and society. The New Zealand Health Strategyseeks to improve the health of New Zealanders and to reduce inequalities amongst New Zealanders,with a focus on Ma–ori, Pacific peoples and low-income New Zealanders. The NSU is committed toachieving its two strategic outcomes of improved health outcomes and reduction in inequalities. A keyaim of the framework is to help ensure that screening programmes are contributing to reducinginequalities by focusing health promotion initiatives on priority group women.

The Ministry of Health’s Intervention Framework (Ministry of Health 2002b) provides a guide fordeveloping and implementing strategies to improve health and reduce inequalities. The Equity Lensprovides a set of questions to identify effective intervention points. The Equity Lens and the InterventionFramework are to be used together (Appendix 3). To assist this process, further information about howthis tool can be applied to health promotion and screening is in the implementation planning guide.

The model for health promotion in screening programmes summarises the direction of health promotionactivity and demonstrates the interdependence and necessity of integrating the determinants of health,the Treaty of Waitangi principles of Partnership, Protection and Participation and Health PromotionModels to effectively meet the needs of the under-screened and unscreened populations.

F I G U R E 2 . M O D E L F O R H E A LT H P R O M O T I O N I N S C R E E N I N G P R O G R A M M E S

1 Introduction

T R E A T Y O F W A I T A N G I

D E T E R M I N A N T S O F H E A L T H

Mo

nit

ori

ng

HEALTH

PROMOTION

INITIATIVES

• Consistent approach

• Build understanding andknowledge

• Create opportunities forinformed consent andsupportive environments P

op

ula

tio

nsPurpose

• Health Improvement

• Reducing inequalities

OutcomesModels•Ottawa Charter

•Te Pae Mahutonga

Evaluation

Set t ings

5NATIONAL HEALTH PROMOTION FRAMEWORK AND IMPLEMENTATION PLANNING GUIDE FOR SCREENING PROGRAMMES NOVEMBER 2004

2.1 Treaty of Waitangi and health promotionThe Government is committed to fulfilling the special relationship between iwi and the Crown under theTreaty of Waitangi.

The relationship between Ma–ori and the Crown in the health and disability sector has been based onthree key principles: (Minister of Health and Associate Minister of Health 2002)

Partnership – Working together with iwi, hap–u, wha–nau and Ma–ori communities to developstrategies for Ma–ori health gain and appropriate health and disability services.

Participation – Involving Ma–ori at all levels of the sector, in decision-making, planning, developmentand delivery of health and disability services.

Protection – Working to ensure Ma–ori have at least the same level of health as non-Ma–ori, andsafeguarding Ma–ori cultural concepts, values and practices.

Ma–ori have a long history of maintaining and improving their health situation. He Korowai Oranga, theMa–ori Health Strategy, sets out the Government’s direction for Ma–ori health development over 10 years.The overall aim of He Korowai Oranga is wha–nau ora: Ma–ori families supported to achieve theirmaximum health and wellbeing. The kaupapa behind He Korowai Oranga is twofold: affirm Ma–ori approaches and improve Ma–ori outcomes. Ma–ori models of health are essential tools to guide andimplement specific ways or paths to achieve wha–nau ora.

Ma–ori health perspectives recognise that good health is dependent on a balance of factors affectingwellbeing. A number of models have been developed, each translate health into terms which areculturally significant and include aspects of Ma–ori identity, knowledge, customs and beliefs. Some of theMa–ori health models utilised in the health and disability sector include Durie’s Te Whare Tapa Wha(1983), Pere’s Te Wheke (1984) and the Royal Commission on Social Policy Nga Pou Mana (1988) and TePae Mahutonga (Durie, 1999).

2 Strategic Context

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2 Strategic Context

2.2 Public health and primary health care

2.2.1 PUBLIC HEALTH

Health promotion is a core public health activity. Public health is defined as ‘the science and art ofpreventing disease, prolonging life and promoting health through the organised efforts of society’(Acheson 1998).

Public health is about the health of populations rather than the health of individuals. Populations maybe defined by locality, biological criteria such as age and gender, social criteria such as socioeconomicstatus, cultural criteria, or by those sharing a common interest.

Public health services are delivered to whole populations or sub-groups of the population at national,regional and local levels. They fall into two broad categories: health protection and health promotion.Public health services are often delivered as programmes combining several mechanisms or approachesfor action to tackle a health issue.

In the New Zealand health sector an increasing emphasis is on population health approaches. A population health approach takes account of all the determinants of health and how they can betackled, incorporating intersectoral involvement at all levels. It integrates the activities of the health anddisability sector (public health, mental health, personal health and disability support) and beyond.Personal health and public health can contribute to a population health approach (Ministry of Health2003c).

2.2.2 PRIMARY HEALTH CARE

The NSU’s Strategic Plan 2003–2008 identifies the need for increased involvement with the primary caresector to advance the NSU’s vision and achievement of the strategic outcomes. This will be achievedthrough a focus on the six key areas for action: service development, workforce development, overallmanagement, quality improvement, research and development, and partnership and understanding.

Primary health care services are delivered in community settings. Primary health care in New Zealandis mainly associated with general practice or primary medical care, but also includes other healthproviders, individuals, families and communities.

As defined in the Primary Health Care Strategy (Minister of Health 2001):

‘Quality primary health care means essential health care based on practical, scientifically sound,culturally appropriate and socially acceptable methods that:

• are universally acceptable to people in their communities

• involve community participation

• are integral to and a central function of New Zealand’s health system

• are the first level of contact with our health system.’

These concepts were first described in the Alma Ata Declaration of 1978 (International Conference ofPrimary Health Care 1978).

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2.2.3 PRIMARY AND PUBLIC HEALTH: THE RELATIONSHIP WITH SCREENING AND HEALTH PROMOTION

While screening programmes are public health activities, most screening procedures are delivered inprimary care settings. Screening lies at the interface of public and personal health and draws on bothapproaches. Effective screening programmes require a good understanding of the roles of public healthand primary health care and the need to work together to maintain and increase screening programmeparticipation rates, particularly among priority group women.

Health promotion is an important component of the Primary Health Care Strategy, which providesdirection for the future of primary health care and aims to re-orient the primary care sector towards apopulation health approach. Giving greater emphasis to comprehensive disease prevention and healthpromotion alongside treatment services brings a stronger population health focus to primary care, thatcan contribute to reducing inequalities and improving health outcomes (Ministry of Health 2003d). Thus,in addition to delivering screening procedures, primary care practitioners also have a role in healthpromotion as it relates to screening.

It will be essential to work with the primary health care sector to improve understanding and awarenessof health promotion and work towards increasing participation and coverage. The new structure forprimary health care, incorporating Primary Health Organisations with an emphasis on preventativeservices, will help to achieve this.

Figure 3 illustrates a range of activities used to improve individual and public health and shows howthis links with the Ottawa Charter. These activities can be combined as elements of a whole programme,including a screening programme, but may be delivered by different providers in a range of settings. All are needed to achieve improved health outcomes, but not all are necessarily relevant to an individualscreening programme (Ministry of Health 2003c).

F I G U R E 3 . S O M E A C T I V I T I E S U S E D T O I M P R O V E I N D I V I D U A L A N D P O P U L AT I O N H E A LT H

2 Strategic Context

I N D I V I D U A L F O C U S

Ottawa Charter for Health Promotion

P O P U L AT I O N F O C U S

Primary Care Health promotion

• Screening, individual risk assessment, immunisation • Health information • Health education counselling & skill development

• Social marketing• Organisational development• Community action• Economic and regulatory activities

• Developing personal skills • Strengthening community action• Healthy public policy• Re-orienting health services• Creating supportive environments

Te Pae Mahutonga

• Nga Manakura • Mauri Ora• Waiora• Te Oranga• Te Mana Whakahaere

• Toiora

8NATIONAL HEALTH PROMOTION FRAMEWORK AND IMPLEMENTATION PLANNING GUIDE FOR SCREENING PROGRAMMES NOVEMBER 2004

2.3 Consistency and links with other strategiesSeveral important strategic documents informed the development of this plan.

2.3.1 THE NEW ZEALAND HEALTH STRATEGY

Improving health and reducing inequalities in health are the two major goals of the New Zealand HealthStrategy. Significant inequalities in health exist among different groups of New Zealanders. For exampleMa–ori, Pacific peoples and people from lower socioeconomic groups have worse health and die youngerthan other New Zealanders. The reasons for health inequalities are complex and generally beyond thecontrol of the groups most affected. Addressing the social, cultural and environmental determinants ofhealth is as important as the biological and medical factors (Ministry of Health 2003c).

2.3.2 HE KOROWAI ORANGA MA–

ORI HEALTH STRATEGY

He Korowai Oranga, the Ma–ori Health Strategy has as its overall aim, wha–nau ora: Ma–ori familiessupported to achieve their maximum health and wellbeing (Minister of Health and Associate Ministerof Health 2002).

He Korowai Oranga sets a new direction for Ma–ori health development over a 10 year period, and buildson the gains made over the last decade.

Ma–ori have lower participation rates in cancer screening programmes than non-Ma–ori (Ministry ofHealth 2003c). It is imperative that this knowledge informs the development of health promotionstrategies which aim to improve the health outcomes of priority groups (Ministry of Health 2003c).

Ma–ori holistic models and wellness approaches to health and wellbeing are strongly supported in thisframework and Implementation Planning Guide.

2.3.3 PACIFIC HEALTH AND DISABILITY ACTION PLAN

The Pacific Health and Disability Action Plan details key activities to improve overall health outcomesfor Pacific peoples and reduce inequalities between Pacific and non-Pacific peoples (Ministry of Health2003c).

2 Strategic Context

9NATIONAL HEALTH PROMOTION FRAMEWORK AND IMPLEMENTATION PLANNING GUIDE FOR SCREENING PROGRAMMES NOVEMBER 2004

3.1 Achieving high levels of programme participation‘Recruitment’ is a term that has been used traditionally to describe the process by which women areactively encouraged to participate in the programme. This may be the result of a personal discussion orthrough a group, meeting or hui. Providers have varying responsibility for recruitment.

Within screening, recruitment is one of the critical outcomes of health promotion activity because thesuccess of population-based screening programmes relies in part on high levels of programme participation.

More recently, the term ‘participation’ within screening has replaced recruitment. This more accuratelydescribes the way in which women are actively involved in deciding whether or not to be part of theprogramme.

Many overseas screening programmes do not include health promotion activities in the screeningpathway and focus strongly on recruitment and retention activities to achieve coverage andparticipation. This is made possible by the availability of population registers that enable theprogrammes to invite women directly for screening.

3.2 Developing an adequately trained health promotion workforceCurrently within screening people working in health promotion enter the workforce with variedexperience and backgrounds: this results in a workforce with a wide range of skills. Due to the NSU’sfocus on priority women and community involvement, it is imperative that health promoters establishcommunity networks and have experience in community development, as well as a theoreticalknowledge of health promotion practice.

The NSU has a commitment to workforce development for health promotion practitioners. However,previous and future investment in health promotion workforce development will not see benefits untilthe issues of workforce recruitment and retention are addressed.

The NSU is developing generic competencies for the screening workforce. This means health promoterswill be required to have a broad understanding of the screening pathway and specialised knowledge ofhealth promotion.

3 Key Challenges for Health Promotion in Screening

The New Zealand approach to health promotion and screening differs in some aspects fromthe approach adopted internationally. The reasons include: the lack of a population healthregister in New Zealand, the relationship with Tangata Whenua, and the uneven serviceprovision and coverage due to New Zealand’s geography.

The approach to generic health promotion in New Zealand also differs from the approach toscreening health promotion. Screening health promotion is positioned at the interfacebetween public and personal health. Screening relies on clinical and personal health careservices for the effective delivery of the screening procedure, including informed consent,subsequent treatment and appropriate follow-up.

10NATIONAL HEALTH PROMOTION FRAMEWORK AND IMPLEMENTATION PLANNING GUIDE FOR SCREENING PROGRAMMES NOVEMBER 2004

Development of the health promotion workforce will help ensure:

• national consistency of health promotion messages

• sharing of knowledge and expertise among providers

• strengthening of national co-ordination

• maximising of health promotion opportunities.

It is therefore important that all people working in and delivering the health promotion components ofa screening programme have a good understanding of public health and health promotion. This willinvolve participating in continuing education, including nationally certified courses, training providedby the NSU and regional training opportunities.

3.3 Focusing on priority groups to reduce inequalitiesHealth promoters working in screening have historically focused their energies on women who areundergoing regular screening. This ensures good coverage and participation rates for that group. Whilewomen who have been previously screened are highly likely to return for screening, disadvantagedgroups, including those who have low income, are geographically isolated, or are disabled, oftenexperience a number of barriers that hinder their access to screening services (Jepson et al 2000). In NewZealand this includes Ma–ori women and Pacific women.

Thus, the focus of health promotion initiatives should be on women in the priority groups, particularlyMa–ori women and Pacific women, who are currently under-screened. Raising Ma–ori and Pacificcoverage and participation rates will increase the programmes’ effectiveness. It is a strategic priority forhealth promotion providers to identify and work in partnership with priority groups, but it is alsoimportant to the overall goals and success of the programmes that health promotion activity ismaintained with other groups.

The Screening Health Promotion Framework identifies priority groups for the programmes. For thehealth promotion activity undertaken with priority groups to be effective, key relationships withprimary health care providers need to be developed and maintained to maximise informedopportunities for coverage and participation.

3.4 Monitoring and evaluation to measure the outcomes of health promotionMonitoring and evaluation are central to screening programme planning and implementation, includinghealth promotion activities. Evaluation must be undertaken at all levels to determine overall effective-ness and ensure high quality.

Reducing inequalities for Ma–ori and Pacific women needs to be explored. Qualitative and quantitativeresearch methods should be used to identify factors that influence the participation of under-screenedand unscreened groups. The development and impact of new health promotion strategies includingthose developed for priority group women will be evaluated.

3 Key Challenges for Health Promotion in Screening

11NATIONAL HEALTH PROMOTION FRAMEWORK AND IMPLEMENTATION PLANNING GUIDE FOR SCREENING PROGRAMMES NOVEMBER 2004

3.5 Enabling informed consentConsumers value information and the provision of information increases satisfaction levels. Consumersgenerally want more information about screening than they receive, especially on potential harms andthe implications of positive and negative results. Potential programme participants should have accessto the information they need to make an informed decision about whether or not to participate. Theyneed to decide the appropriateness of screening for themselves based on accurate, relevant and easilyunderstood information about the benefits and limitations of the screening process.

The overall benefits of screening programmes depend on a high level of participation by the eligiblepopulation. Information about screening has tended to omit the negative aspects so as to not raiseanxiety and potentially reduce participation. It has been suggested that providing full information aboutthe benefits and harms of a screening programme may result in reduced participation for disadvantagedgroups. However, participation by individuals in disadvantaged groups should be addressed byimproving service accessibility, including acceptability, rather than by selective use of information(National Health Committee 2003).

In practice it is not easy to achieve individual informed consent for screening. Good information isneeded to achieve informed consent and to support health promotion programmes.

3 Key Challenges for Health Promotion in Screening

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4.1 Ottawa CharterThe Ottawa Charter is used in New Zealand and internationally as a framework for planning publichealth and health promotion strategies. Action across the strands of the charter maximises the likelihoodof achieving the desired outcomes.

‘Health promotion’ as defined by the Ottawa Charter (1986) is the process of enabling people to increasecontrol over and to improve their health (WHO 1986). The Ottawa Charter identifies three basicstrategies for health promotion: advocacy for health to create the essential conditions for health, enablingall people to achieve their full health potential, and mediating between the different interests in societyin the pursuit of health.

Health promotion represents a comprehensive social and political process; it not only embraces actionsdirected at strengthening the skills and capabilities of individuals but action directed towards changingsocial, environmental and economic conditions to alleviate their affect on public and individual health(WHO 1986). Five strands support these actions. All areas have significant relevance to health promotionwithin screening programmes and opportunities are maximised when all five strands are implementedtogether.

• Building healthy public policy – Putting health on the agenda of policy makers and at all levels withinsociety.

• Creating supportive environments – Creating living and working environments that promote health.

• Strengthening community action – Making it easier for concrete and effective community action totake place as part of a health promotion process.

• Developing personal skills – Providing information and education for health and enhancing lifeskills.

• Re-orienting health services – Moving the health sector towards health promotion beyond itsresponsibility for providing clinical and curative services (Duignan 1992).

For screening, this means health promoters extending their scope of work beyond health education andrecruitment into strategies that will encompass a broad range of short-term and long-term initiatives tohelp women integrate screening into the complexity of their lives.

4 Health Promotion Models

13NATIONAL HEALTH PROMOTION FRAMEWORK AND IMPLEMENTATION PLANNING GUIDE FOR SCREENING PROGRAMMES NOVEMBER 2004

4.2 Te Pae MahutongaTe Pae Mahutonga is one of several Ma–ori models of health. This model has been developed specificallyfor Ma–ori health promotion and is based on the Southern Cross. The four stars represent the key tasks ofhealth promotion as it relates to Ma–ori health (Durie 1999):

• Access to te ao Ma–ori – Mauriora (promotes secure cultural identity)

• Environmental protection – Waiora

• Healthy lifestyles – Toiora

• Participation in society – Te Oranga.

The two pointers represent:

• Nga Manukura (leadership)

• Te Mana Whakahaere (autonomy).

This framework provides the ability for health promotion practitioners to support Ma–ori-led initiatives.It supports the desires of wha–nau, hap–u, iwi and Ma–ori to manage and initiate self-identified solutionsin manners best suited to Ma–ori. It also encompasses cultural values and practices, specifically te reo,tikanga and kawa.

For screening, this means health promoters develop and support health promotion initiatives thatintegrate screening into the broader aspirations of Ma–ori.

4.3 PacificA nationally consistent approach to health promotion work in Pacific communities is being developed.

4 Health Promotion Models

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5.1 Community developmentCommunity development is an effective strategy for building relationships and developing the long-term ownership of initiatives with priority groups of the population, so it should be incorporated as amajor component of a health promotion plan.

Community development has been defined as (Ministry of Health 2003b):

‘The process of organising and/or supporting community groups in identifying their health issues,planning and acting upon their strategies for social action/social change and gaining increased self-reliance and decision-making power as a result of their activities.’

To achieve effective community development, priority groups need to be able to identify health issuesand be empowered to understand the role of screening. The development of long-term strategiesencourages behavioural change and ongoing participation in the pathway. Effective communitydevelopment requires a partnership to be developed and maintained between the community andproviders. Community ownership of health promotion initiatives is imperative for long-term success.

5.2 CommunicationsThe NSU aims to provide and distribute accurate and appropriate information related to screening. It is important the information is evidence-informed, sensitive, available and conveyed appropriately tothe priority groups.

The NSU has developed key messages using a population-based approach.

All NSU information must address the concept of informed consent and include a clear representationof the benefits and limitations of screening. This enables the population and individuals to makeinformed decisions about participating in screening programmes.

Information about screening programmes is communicated using different methods to presentinformation. eg, media campaigns, regional community action, resources, promotional items, the healthywomen website http://www.healthywomen.org.nz/ and touch screen interactive kiosks. Allcommunication tools use the programmes’ visual identities (Appendix 1).

5 Health Promotion Strategies

Health promotion activities occur in different contexts and in many different settings.

Diverse health promotion strategies are implemented as part of public health programmes.Within screening, health promotion is an essential component of the screening pathway.

Intersectoral action, public policy, mass media campaigns, effective distribution ofprogramme-specific information, community action and appropriate public health strategiesdelivered by Ma–ori for Ma–ori are examples of health promotion strategies used withinscreening.

For the purposes of this document the NSU has concentrated on the following areas to reflectits commitment to informed consent and priority women.

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5.3 Health educationHealth education is often confused with health promotion or thought of as a separate entity. It is oneaspect of health promotion and falls within the developing personal skills strand of the Ottawa Charter.

‘Health education comprises consciously constructed opportunities for learning involving some form ofcommunication designed to improve health literacy, including improving knowledge and developinglife skills which are conducive to individual or community health.’

Health education has limitations: it is not a strategy that can be used to initiate and support long-termbehavioural change. It is most effective if part of a broader health promotion plan (WHO 1998).

5 Health Promotion Strategies

16NATIONAL HEALTH PROMOTION FRAMEWORK AND IMPLEMENTATION PLANNING GUIDE FOR SCREENING PROGRAMMES NOVEMBER 2004

The following guiding principles will form the basis of any health promotion strategy development,planning and implementation (Appendix 2):

• Health promotion strategies for screening programmes will be delivered in the wider context of publichealth.

• Informed consent must underpin all activities within the screening programmes.

• Health promotion strategies are evidence-informed, planned, implemented and evaluated with a focuson reaching under-screened and unscreened populations.

• Ma–ori perceptions and experiences of screening are acknowledged and valued. This requires Ma–oriparticipation at all levels.

• Regional and local initiatives will ensure Pacific peoples’ perceptions and experiences of screening areacknowledged and valued.

• Regional and local initiatives and strategies are consistent with the national framework.

6 Conclusion

The NSU endeavours to maintain a high level of health promotion service delivery through wellco-ordinated and evidence-informed health promotion strategies.

The NSU believes women should have access to information about and services to screening.Through the development and implementation of evidence-informed health promotionstrategies, the screening programmes will continue to reduce barriers to screening.

As a catalyst for community development priority women will be encouraged to attend forscreening. The NSU will encourage and strive to support sustainable initiatives to ensure thebenefits of screening are achieved.

17NATIONAL HEALTH PROMOTION FRAMEWORK AND IMPLEMENTATION PLANNING GUIDE FOR SCREENING PROGRAMMES NOVEMBER 2004

Media campaigns

Research supports national media campaigns as effective ways to raise awareness of screening as ahealth issue. Campaigns evaluated both in New Zealand and overseas have shown increases inparticipation in screening as a result of television advertising. Evidence-informed televisionadvertisements have effectively reached people from traditionally under-screened groups.

Most efforts to change public attitudes use the mass media. Studies of other health promotion campaignsaffirm its ability to create a climate of opinion that is supportive of healthy public policies. However, itis also generally accepted that the media is better at confirming attitudes and slow at changing them(Wyllie 1997).

Importance of community action and development as part of a media campaign

Other campaigns have demonstrated that, while mass media on its own is unlikely to be successful,campaigns that set realistic outcome criteria and are supported with community-based education andtraining are more effective. While media can be most effective at raising awareness and changing theclimate of opinion, changing behaviour requires more direct action. A community developmentapproach at the grassroots level provides opportunities to reach priority groups to adapt messages to thedifferent cultures that make up New Zealand society and to address barriers when they occur (Ministryof Health 2001).

A co-ordinated media strategy can greatly enhance the effectiveness of a screening programme. Womennot reached by other health promotion strategies can be informed about the programmes andencouraged to participate.

Visual identity

In response to requests from people working in screening programmes, a thorough process wasundertaken to develop a visual identity for the screening programmes.

The benefits of a co-ordinated visual identity for the screening programmes include:• a signal that this is a national public health programme• a recognisable link amongst screening providers• a means of conveying the messages and values of the programmes• an opportunity for brand recognition• a vehicle to link national and regional initiatives.

Promotional items

Promotional resources are used to increase public exposure to screening messages, using a variety ofappropriate strategies to reach priority groups within the population.

Promotional resources are an internationally recognised method of conveying information such as keymessages and information about access to screening programmes.

APPENDIX 1: Methods of Communication

18NATIONAL HEALTH PROMOTION FRAMEWORK AND IMPLEMENTATION PLANNING GUIDE FOR SCREENING PROGRAMMES NOVEMBER 2004

Website

The Internet is rapidly becoming an important way of accessing information and communicating withpeople including families and community groups.

The NSU has an online resource http://www.healthywomen.org.nz/. The site has specific informationand separate access points where information relating to Ma–ori, Pacific and Asian people can be found.

The website also provides health professionals with a point of access to programme-related informationand activity.

Kiosks

Following the success of the kiosk pilot project, touch-screen interactive kiosks have become an integralcomponent of the way in which health promoters deliver information.

Evidence strongly suggests that when people are empowered to access information individually,increased behavioural change that results in compliance occurs.

The kiosk project is parallel and complementary to the Healthy Women website and provides access toconsistent information to individuals who are not regular Internet users.

APPENDIX 1: Methods of Communication

19NATIONAL HEALTH PROMOTION FRAMEWORK AND IMPLEMENTATION PLANNING GUIDE FOR SCREENING PROGRAMMES NOVEMBER 2004

It should include (Ministry of Health 2003c):

Rationale

Why is this particular programme needed? Consider:

• special factors in the community or region that make particular problems or issues significant

• information and statistics specific to the region that support the emphasis on the issue

• the potential for health gain for each priority area

• how the programme will reduce inequalities.

Population Group

Who are the affected population and how will they be involved in the process?

Programme description

What will the programme do?

Goal

Describe the aim over a specific timeframe. Identify the consultation process followed in reaching thisaim.

Objectives

These should be specific, measurable, achievable, realistic and time-framed.

Strategies

Actions eg, plan (including consultation and joint planning), develop relationships, arrange andimplement, conduct, participate, assist, deliver, evaluate and complete.

The range of activities and resources to be used eg, policies, programmes, hui, meetings, submissions.

Setting or population group; settings include schools, kohanga reo and workplaces, while populationgroups include pre-school children, Ma–ori women, communities and neighbourhoods.

There may be a number of activities for each part of the programme or conversely activities willsometimes address components of other programmes.

Making a difference

Identify what you hope to influence from the programme.

There will be a variety of inputs, processes, outputs and outcomes.

These could include quantitative measures and milestones and qualitative measures such asparticipatory mechanisms for including communities and their feedback.

APPENDIX 2: How to Develop a Health Promotion Plan

20NATIONAL HEALTH PROMOTION FRAMEWORK AND IMPLEMENTATION PLANNING GUIDE FOR SCREENING PROGRAMMES NOVEMBER 2004

Linkages

Health promotion programmes are activities based on collaboration and co-operation with other sectorsand providers.

Review and evaluation

A process of reviewing and evaluating all aspects of the programme is needed.

Resources

Identify all resources required including subcontracting arrangements, workforce requirements andfunding.

APPENDIX 2: How to Develop a Health Promotion Plan

21NATIONAL HEALTH PROMOTION FRAMEWORK AND IMPLEMENTATION PLANNING GUIDE FOR SCREENING PROGRAMMES NOVEMBER 2004

There is considerable evidence, both internationally and in New Zealand, of significant inequalities inhealth between socioeconomic groups, ethnic groups, people living in different geographical regions andmales and females (Acheson 1998; Howden-Chapman and Tobias 2000). Research indicates that thepoorer you are, the worse your health. In some countries with a colonial history, indigenous people havepoorer health than others. Reducing inequalities is a priority for government. The New Zealand HealthStrategy acknowledges the need to address health inequalities as “a major priority requiring ongoingcommitment across the sector” (Minister of Health 2000).

Inequalities in health are unfair and unjust. They are also not natural; they are the result of social andeconomic policy and practices. Therefore, inequalities in health are avoidable (Woodward and Kawachi2000).

The following set of questions has been developed to assist you to consider how particular inequalitiesin health have come about, and where the effective intervention points are to tackle them. They shouldbe used in conjunction with the Ministry of Health’s Intervention Framework (Ministry of Health 2002b).

1. What health issue is the policy/programme trying to address?

2. What inequalities exist in this health area?

3. Who is most advantaged and how?

4. How did the inequality occur? (What are the mechanisms by which this inequality was created, is maintained or increased?)

5. What are the determinants of this inequality?

6. How will you address the Treaty of Waitangi on the context of the New Zealand Public Health andDisability Act 2000?

7. Where/how will you intervene to tackle this issue? Use the Ministry of Health InterventionFramework to guide your thinking.

8. How could this intervention affect health inequalities?

9. Who will benefit most?

10. What might the unintended consequences be?

11. What will you do to make sure it does reduce/eliminate inequalities?

Based on Bro Taf Authority, (2000). Amended by Ministry of Health May 2004. Source: Te Ropu Rangahau Hauora a E–ru Pomare, Ministry of Health and Public Health Consultancy (2003).

APPENDIX 3: A Health Equity Assessment Tool (Equity Lens)for Tackling Inequalities in Health (May 2004)

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Intervention framework to improve health and reduce inequalities

APPENDIX 3: A Health Equity Assessment Tool (Equity Lens)for Tackling Inequalities in Health (May 2004)

1. STRUCTURAL

3. HEALTH AND DISABILITYSERVICES

2. INTERMEDIARY PATHWAYS 4. IMPACT

Social, economic, cultural andhistorical factors fundamentallydetermine health. These include:

• economic and social policies inother sectors– macroeconomic policies (eg,

taxation)– education– labour market (eg, occupation,

income)

• power relationships (eg,stratification, discrimination,racism)

• Treaty of Waitangi – governance,M–aori as Crown partner

The impact of social, economic,cultural and historical factors onhealth status is mediated byvarious factors including:

• behaviour/lifestyle

• environmental – physical andpsychosocial

• access to material resources

• control – internal, empowerment

The impact of disability and illnesson socioeconomic position can beminimised through:

• income support, eg, sicknessbenefit, invalids benefit, ACC

• antidiscrimination legislation

• deinstitutionalisation/communitysupport

• respite care/carer support

Specifically, health and disabilityservices can:

• improve access-distribution,availability, acceptability,affordability

• improve pathways through care forall groups

• take a population health approachby:– identifying population health

needs– matching services to identified

population health needs– health education

Source: Ministry of Health ‘Reducing Inequalities in Health’. Wellington (2002).

23NATIONAL HEALTH PROMOTION FRAMEWORK AND IMPLEMENTATION PLANNING GUIDE FOR SCREENING PROGRAMMES NOVEMBER 2004

Acheson D. 1998. Independent Inquiry into Inequalities in Health: Report. London: Stationery Office.

Bro Taf Authority. 2000. Planning for Positive Impact: Health inequalities impact assessment tool. Cardiff: Bro Taf Authority.

Duignan P, Dehar MA, Caswell S. 1992. Planning Evaluation of Health Promotion Programmes: A framework for decision-making.Auckland: Alcohol and Public Health Research Unit, University of Auckland.

Durie M. 1994. Whaiora: M–aori health development. Wellington: Oxford University Press.

Durie M. 1999. Te Pae Mahutonga: A model for M–aori health promotion. Health Promotion Forum Newsletter 49.www.hpforum.org.nz (accessed October 2003).

Health Funding Authority, National Cervical Screening Programme. 2000. Interim Operational Policy and Quality Standards.Auckland: National Screening Team, Health Funding Authority.

Health Promotion Forum of New Zealand. 2002. TUHA-NZ: A Treaty understanding of hauora in Aotearoa/New Zealand.Place: Health Promotion Forum of New Zealand. www.hpforum.org.nz/tuha-nz.pdf (accessed October 2003).

Howden-Chapman P, Tobias M (eds). 2000. Social Inequalities in Health: New Zealand 1999. Wellington: Ministry of Health.

International Conference on Primary Health Care. 1978. Declaration of Alma-Ata. International Conference on PrimaryHealth Care, Alma-Ata, USSR, 6–12 September 1978. www.who.int/hpr/archive/docs/almaata.html (accessed June 2003).

Jepson R, Clegg AA, Forbes C, et al. 2000. The determinants of screening uptake and interventions for increasing uptake:A systematic review. Health Technology Assessment 4(14).

Minister of Health. 2000. The New Zealand Health Strategy. Wellington: Ministry of Health.

Minister of Health. 2001. The Primary Health Care Strategy. Wellington: Ministry of Health.

Minister of Health, Associate Minister of Health. 2002a. He Korowai Oranga: M–aori Health Strategy. Wellington: Ministry ofHealth.

Ministry of Health. 2001. Like Minds, Like Mine National Plan 2001–2003: Project to counter stigma and discrimination associatedwith mental illness. Wellington: Ministry of Health.

Ministry of Health. 2002b. Reducing Inequalities in Health. Wellington: Ministry of Health.

Ministry of Health. 2003a. Achieving Health for All People: A framework for public health action for the New Zealand HealthStrategy. Wellington: Ministry of Health.

Ministry of Health. 2003b. Community Project Indicators Framework: Its use in community projects. Wellington: Ministry ofHealth.

Ministry of Health. 2003c. National Screening Unit Strategic Plan 2003–2008. Wellington: National Screening Unit, Ministryof Health.

Ministry of Health. 2003a. Public Health in a Primary Health Care Setting. Wellington: Ministry of Health.

National Health Committee. 2003. Screening to Improve Health in New Zealand: Criteria to assess screening programmes.Wellington: National Health Committee.

Pere R. 1984. Te oranga o te wh–anau: The health of the family. In Hui Whakaoranga: M–aori Health Planning Workshop.Wellington: Department of Health.

Royal Commission on Social Policy. 1988. Report of the Royal Commission on Social Policy. Wellington: Royal Commission onSocial Policy.

Te R–op–u Rangahau Hauora a Eru P–omare, Ministry of Health, Public Health Consultancy. 2003. A Health Equity AssessmentTool. Wellington: Public Health Consultancy, Wellington School of Medicine and Health Sciences

Waa A, Holibar F, Spinola C. 1998. Programme Evaluation: An introductory guide for health promotion. Auckland: Alcohol andPublic Health Research Unit, University of Auckland.

WHO. 1986. Ottawa Charter for Health Promotion. Geneva: World Health Organization.

WHO. 1998. Health Promotion Glossary. WHO/HPR/HEP/98.1. Geneva: World Health Organization.

Woodward A, Kawach I. 2000. Why reduce health inequalities? Journal of Epidemiology and Community Health 54(12): 923.

Wyllie A. 1997. Evaluation of a New Zealand Campaign towards Reduction of Intoxification on Licensed Premises. HealthPromotion International 12(3): 197–207.

References

National Health Promotion Framework

Implementation Planning Guide

25NATIONAL HEALTH PROMOTION FRAMEWORK AND IMPLEMENTATION PLANNING GUIDE FOR SCREENING PROGRAMMES NOVEMBER 2004

1 IntroductionThe National Screening Unit (NSU) isresponsible for two organised cancerscreening programmes, the NationalCervical Screening Programme (NCSP) andBreastScreen Aotearoa (BSA). The NSUcontributes towards reducing the burden ofcancer through screening programmes thataim to achieve two strategic outcomes:Reducing Inequalities and Improving HealthOutcomes (Ministry of Health 2003c). Healthpromotion is an essential part of achievingthese outcomes.

This framework and the implementationplans will support effective health promotionactivities within the NCSP and BSA by:

• raising awareness and understanding ofscreening among the eligible population

• raising awareness and understanding ofhow health promotion works in a screeningcontext among the wider health sector

• providing information about how toencourage informed participation in thescreening programmes.

This framework and the implementationplanning guide will underpin national andregional health promotion strategies andinitiatives.

What is the aim of the organisation’s healthpromotion programme?

How has this aim been developed?

What health issue is this programme trying toaddress?

What research and documentation support the aim?

How is the aim demonstrated?

What effect will this programme have on healthinequalities?

Who will benefit most from this programme?

What might be the unintended consequences be?

Implementation Planning Guide

STRATEGY QUESTIONS

26NATIONAL HEALTH PROMOTION FRAMEWORK AND IMPLEMENTATION PLANNING GUIDE FOR SCREENING PROGRAMMES NOVEMBER 2004

STRATEGY QUESTIONS

1.1 DEFINITIONS

1.1.1 Health Promotion

The World Health Organization (WHO) defineshealth promotion as (WHO 1986):

‘Health promotion is the process of enablingpeople to increase control over and to improve,their health. To reach a state of complete physical,mental and social well-being, an individual orgroup must be able to identify and to realiseaspirations, to satisfy needs, and to change orcope with the environment. Health is, therefore,seen as a resource for everyday life, not theobjective of living. Health is a positive conceptemphasising social and personal resources, aswell as physical capacities. Therefore, healthpromotion is not just the responsibility of thehealth sector, but goes beyond healthy lifestyles towell-being.’

Health promotion planning and strategydevelopment requires consideration of the widerdeterminants of health. In the context of screeningthese include social and community influences,gender and culture, socioeconomic andenvironmental conditions, and lifestyle andbehavioural factors. Addressing the fundamentaldeterminants of health ensures activities topromote health are concerned with equity ofaccess to services, including screeningprogrammes, and equity of outcomes.

Do the health promoters employed by theorganisation have the skills and ability to plan,implement and evaluate health promotioninitiatives?

What does “health and well-being in communities”mean for the region?

What long-term impact on health and wellbeingdoes the health promotion programme intend toproduce?

What does your organisation identify as the specificdeterminants of health that affect the ability ofwomen in the region, to access screening?

What evidence is there of this?

Implementation Planning Guide

27NATIONAL HEALTH PROMOTION FRAMEWORK AND IMPLEMENTATION PLANNING GUIDE FOR SCREENING PROGRAMMES NOVEMBER 2004

1.1.2 Screening

The NSU has adopted a definition of screeningbased on that of the National ScreeningCommittee of the United Kingdom as adapted bythe National Health Committee in New Zealand(National Health Committee 2003):

‘Screening is a health service in which members ofa defined population, who either do notnecessarily perceive they are at risk of, or arealready affected by a disease or its complications,are asked a question or offered a test, to identifythose individuals who are more likely to behelped than harmed by future tests or treatmentto reduce the risk of a disease or itscomplications.’

Screening refers not just to a screening test, but toa series of steps comprising the screeningpathway. Health promotion initiatives form anintegral part of the pathway (Figure 1).

Screening occurs in two ways: as part of screeningprogrammes and opportunistically. Qualityassurance and improvement processes distinguishorganised screening programmes from opportunisticscreening, and are essential for balancing theachievable benefits of screening with the potentialharms. Organised screening is usually deliveredthrough a screening programme with planning,co-ordination, monitoring and evaluation of allactivities along the screening pathway. (Ministryof Health 2003c)

Population screening programmes involvescreening entire populations or a large and easilyidentifiable group within a population. Often,members of this population are not aware that thedisease which they are being screened for couldaffect them. This in itself can be one of the barriersto screening, as the population perceivethemselves as well, and are being invited toparticipate in a programme that may identifythem as unwell.

STRATEGY QUESTIONS

Implementation Planning Guide

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STRATEGY QUESTIONS

1.1.3 Health promotion within screening

Health promotion within screening programmesaims to create an environment that is conduciveto, and supportive of, informed participation inscreening. This helps ensure people who canbenefit from screening are informed andempowered to take advantage of the potentialbenefits.

Reducing inequalities is a government priorityarea and the NSU has adopted a strong focus onpriority group women. The health promotionstrategies adopted and implemented to date havebeen successful in raising awareness of thescreening programme. To be more effective inincreasing coverage and participation rates forpriority women, an approach needs to considerthe wider determinants of health, strategies thatfocus on developing communities to encourageand engage long-term behavioural change, andthe interface between personal and public healthneeds to be implemented. Participating inscreening is no longer enough. Increasedawareness and a priority on informed consenthighlights the need for health promotionstrategies that engage communities.

There are a number of emerging issues that haveinfluenced the development of this framework.

• Health promotion delivered within personalhealth settings to ensure primary care is anessential part of the screening pathway.

• A wider acknowledgement of the determinantsof health.

• The inclusion of community developmentinitiatives that encourage and support long-termbehaviour change, particularly among under-screened and unscreened populations.

These emerging issues require consideration as partof health promotion planning and strategydevelopment.

What is the organisational understanding of healthpromotion’s role in the screening pathway?

What health promotion strategies does theorganisation intend to use?

What is the rationale for using these strategies?

What understanding does the organisation have ofusing an inequalities approach to healthpromotion?

What plans does the organisation have to addressthe emerging issues identified? These are:• health promotion delivered within personal health

settings• a wider acknowledgement of the determinants of

health• the development of community development

initiatives to ensure long-term behaviouralchange, particularly among under-screened andunscreened populations.

How will the organisational health promotion plansreduce inequalities and improve health outcomes forthe priority groups of women?

How will you make sure your programme reducesand eliminates inequalities?

How will you know if inequalities have beenreduced or eliminated?

How will the organisational health promotionplans:• raise awareness and understanding of screening

among the eligible population• raise awareness and understanding of how health

promotion works in a screening context amongthe wider health sector

• provide information about how to encourageinformed participation in the screeningprogrammes

• identify and prioritise population groups toreduce inequalities in screening coverage andparticipation rates?

Implementation Planning Guide

1.2 THE PURPOSE OF THE FRAMEWORK IS:

• ensure a consistent approach to health promotionas part of screening programmes

• build understanding and knowledge of healthpromotion and its role in screening programmes

• facilitate health promotion strategies that createopportunities for informed consent andsupportive environments and enable prioritygroups to participate in screening.

There is considerable evidence within NewZealand and internationally of significant ethnic,socioeconomic, geographical and genderinequalities in health. Success in reducinginequalities in health will bring positive resultsfor the individual, the economy and society. TheNew Zealand Health Strategy seeks to improvethe health of New Zealanders and to reduceinequalities amongst New Zealanders, with afocus on Ma–ori, Pacific peoples and low-incomeNew Zealanders. The NSU is committed toachieving its two strategic outcomes of improvedhealth outcomes and reduction in inequalities. Akey aim of the framework is to help ensure thatscreening programmes are contributing toreducing inequalities by focusing healthpromotion initiatives on priority group women.

The Ministry of Health’s Intervention Framework(Ministry of Health 2002b) provides a guide fordeveloping and implementing strategies toimprove health and reduce inequalities. TheEquity Lens provides a set of questions to identifyeffective intervention points. The Equity Lens andthe Intervention Framework are to be usedtogether (Appendix 3). To assist this process,further information about how this tool can beapplied to health promotion and screening is inthe implementation planning guide.

The model for health promotion in screeningprogrammes summarises the direction of healthpromotion activity and demonstrates theinterdependence and necessity of integrating thedeterminants of health, the Treaty of Waitangiprinciples of Partnership, Protection andParticipation and Health Promotion Models toeffectively meet the needs of the under-screenedand unscreened populations.

How will the organisation’s health promotion plandemonstrate the integration of the determinants ofhealth, the Treaty of Waitangi and the OttawaCharter to effectively meet the needs of the under-screened and unscreened populations?

Has the organisation used the Equity Lens as a toolto examine and prioritise the health promotionservices being planned and delivered?

29NATIONAL HEALTH PROMOTION FRAMEWORK AND IMPLEMENTATION PLANNING GUIDE FOR SCREENING PROGRAMMES NOVEMBER 2004

STRATEGY QUESTIONS

Implementation Planning Guide

2 Strategic Context

2.1 TREATY OF WAITANGI AND HEALTH PROMOTION

The Government is committed to fulfilling thespecial relationship between iwi and the Crownunder the Treaty of Waitangi.

The relationship between Ma–ori and the Crown inthe health and disability sector has been based onthree key principles: (Minister of Health andAssociate Minister of Health 2002)

Partnership – Working together with iwi, hap–u,wha–nau and Ma–ori communities to developstrategies for Ma–ori health gain and appropriatehealth and disability services.

Participation – Involving Ma–ori at all levels ofthe sector, in decision-making, planning,development and delivery of health anddisability services.

Protection – Working to ensure Ma–ori have atleast the same level of health as non-Ma–ori, andsafeguarding Ma–ori cultural concepts, valuesand practices.

Ma–ori have a long history of maintaining andimproving their health situation. He KorowaiOranga, the Ma–ori Health Strategy, sets out theGovernment’s direction for Ma–ori healthdevelopment over 10 years. The overall aim of HeKorowai Oranga is wha–nau ora: Ma–ori familiessupported to achieve their maximum health andwellbeing. The kaupapa behind He KorowaiOranga is twofold: affirm Ma–ori approaches andimprove Ma–ori outcomes. Ma–ori models of healthare essential tools to guide and implement specificways or paths to achieve wha–nau ora.

Ma–ori health perspectives recognise that goodhealth is dependent on a balance of factorsaffecting wellbeing. A number of models havebeen developed, each translate health into termswhich are culturally significant and includeaspects of Ma–ori identity, knowledge, customsand beliefs. Some of the Ma–ori health modelsutilised in the health and disability sector includeDurie’s Te Whare Tapa Wha (1983), Pere’s TeWheke (1984) and the Royal Commission onSocial Policy Nga Pou Mana (1988) and Te PaeMahutonga (Durie, 1999).

How does the organisation integrate the principlesof the Treaty of Waitangi?

How will the organisation ensure governance by,self-determination by and equity for Ma–ori?

How will this be demonstrated within the healthpromotion plan?

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STRATEGY QUESTIONS

Implementation Planning Guide

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STRATEGY QUESTIONS

2.2 PUBLIC HEALTH AND PRIMARY HEALTH CARE

2.2.1 Public Health

Health promotion is a core public health activity.Public health is defined as ‘the science and art ofpreventing disease, prolonging life andpromoting health through the organised efforts ofsociety’ (Acheson 1998).

Public health is about the health of populationsrather than the health of individuals. Populationsmay be defined by locality, biological criteria suchas age and gender, social criteria such associoeconomic status, cultural criteria, or by thosesharing a common interest.

Public health services are delivered to wholepopulations or sub-groups of the population atnational, regional and local levels. They fall intotwo broad categories: health protection and healthpromotion. Public health services are oftendelivered as programmes combining severalmechanisms or approaches for action to tackle ahealth issue.

In the New Zealand health sector an increasingemphasis is on population health approaches. A population health approach takes account of allthe determinants of health and how they can betackled, incorporating intersectoral involvementat all levels. It integrates the activities of the healthand disability sector (public health, mental health,personal health and disability support) andbeyond. Personal health and public health cancontribute to a population health approach(Ministry of Health 2003c).

What populations in your region does theorganisation identify as priority groups for healthpromotion initiatives?

How have these populations been identified?

Will the women recognise themselves as anidentifiable population group?

How will these women be accessed initially?

Think about the organisation’s current healthpromotion programmes. Are they population orpersonal health initiatives?

What needs to happen to re-orient the healthpromotion initiatives towards population health?

Implementation Planning Guide

2.2.2 Primary Health Care

The NSU’s Strategic Plan 2003–2008 identifies theneed for increased involvement with the primarycare sector to advance the NSU’s vision andachievement of the strategic outcomes. This willbe achieved through a focus on the six key areasfor action: service development, workforcedevelopment, overall management, qualityimprovement, research and development, andpartnership and understanding.

Primary health care services are delivered incommunity settings. Primary health care in NewZealand is mainly associated with generalpractice or primary medical care, but alsoincludes other health providers, individuals,families and communities.

As defined in the Primary Health Care Strategy(Minister of Health 2001):

‘Quality primary health care means essentialhealth care based on practical, scientificallysound, culturally appropriate and sociallyacceptable methods that:

• are universally acceptable to people in theircommunities

• involve community participation

• are integral to and a central function of NewZealand’s health system

• are the first level of contact with our healthsystem.’

These concepts were first described in the AlmaAta Declaration of 1978 (International Conferenceof Primary Health Care 1978).

What strategies will your organisation develop tolink and develop joint initiatives between healthpromoters and primary care services?

How will this relationship be developed andstrengthened?

What will be the ongoing benefits to prioritywomen and their participation in the screeningpathway?

32NATIONAL HEALTH PROMOTION FRAMEWORK AND IMPLEMENTATION PLANNING GUIDE FOR SCREENING PROGRAMMES NOVEMBER 2004

Implementation Planning Guide

STRATEGY QUESTIONS

2.2.3 Primary and public health:The relationship with screening and health promotion

While screening programmes are public healthactivities, most screening procedures aredelivered in primary care settings. Screening liesat the interface of public and personal health anddraws on both approaches. Effective screeningprogrammes require a good understanding of theroles of public health and primary health care andthe need to work together to maintain andincrease screening programme participation rates,particularly among priority group women.

Health promotion is an important component ofthe Primary Health Care Strategy, which providesdirection for the future of primary health care andaims to re-orient the primary care sector towardsa population health approach. Giving greateremphasis to comprehensive disease preventionand health promotion alongside treatmentservices brings a stronger population health focusto primary care, that can contribute to reducinginequalities and improving health outcomes(Ministry of Health 2003d). Thus, in addition todelivering screening procedures, primary carepractitioners also have a role in health promotionas it relates to screening.

It will be essential to work with the primaryhealth care sector to improve understanding andawareness of health promotion and work towardsincreasing participation and coverage. The newstructure for primary health care, incorporatingPrimary Health Organisations with an emphasison preventative services, will help to achieve this.

Is the organisation’s health promotion team awareof the Primary Health Care strategy?

How will the strategy be used to inform thedevelopment of the health promotion plan?

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Implementation Planning Guide

STRATEGY QUESTIONS

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Implementation Planning Guide

STRATEGY QUESTIONS

2.3 CONSISTENCY AND LINKS WITH OTHERSTRATEGIES

Several important strategic documents informedthe development of this plan.

2.3.1 The New Zealand Health Strategy

Improving health and reducing inequalities inhealth are the two major goals of the NewZealand Health Strategy. Significant inequalitiesin health exist among different groups of NewZealanders. For example Ma–ori, Pacific peoplesand people from lower socioeconomic groupshave worse health and die younger than otherNew Zealanders. The reasons for healthinequalities are complex and generally beyondthe control of the groups most affected.Addressing the social, cultural and environmentaldeterminants of health is as important as thebiological and medical factors (Ministry of Health2003c).

Is the organisation’s health promotion team awareof the New Zealand Health Strategy?

How will the strategy be used to inform thedevelopment of the health promotion plan?

2.3.2 He Korowai Oranga Ma–ori HealthStrategy

He Korowai Oranga, the Ma–ori Health Strategyhas as its overall aim, wha–nau ora: Ma–ori familiessupported to achieve their maximum health andwellbeing (Minister of Health and AssociateMinister of Health 2002).

He Korowai Oranga sets a new direction for Ma–ori health development over a 10 year period,and builds on the gains made over the last decade.

Ma–ori have lower participation rates in cancerscreening programmes than non-Ma–ori (Ministryof Health 2003c). It is imperative that thisknowledge informs the development of healthpromotion strategies which aim to improve thehealth outcomes of priority groups (Ministry ofHealth 2003c).

Ma–ori holistic models and wellness approaches tohealth and wellbeing are strongly supported inthis framework and Implementation PlanningGuide.

Is the organisation’s health promotion team awareof He Korowai Oranga: Ma–ori Health Strategy?

How will the strategy be used to inform thedevelopment of the health promotion plan?

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2.3.3 Pacific Health and Disability ActionPlan

The Pacific Health and Disability Action Plandetails key activities to improve overall healthoutcomes for Pacific peoples and reduceinequalities between Pacific and non-Pacificpeoples (Ministry of Health 2003c).

Is the organisation’s health promotion team awareof the Pacific Health and Disability Action Plan?

How will the strategy be used to inform thedevelopment of the health promotion plan?

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3 Key challenges for healthpromotion in screening

3.1 ACHIEVING HIGH LEVELS OF PROGRAMMEPARTICIPATION

‘Recruitment’ is a term that has been usedtraditionally to describe the process by whichwomen are actively encouraged to participate inthe programme. This may be the result of apersonal discussion or through a group, meetingor hui. Providers have varying responsibility forrecruitment.

Within screening, recruitment is one of the criticaloutcomes of health promotion activity becausethe success of population-based screeningprogrammes relies in part on high levels ofprogramme participation.

More recently, the term ‘participation’ withinscreening has replaced recruitment. This moreaccurately describes the way in which women areactively involved in deciding whether or not to bepart of the programme.

Many overseas screening programmes do notinclude health promotion activities in thescreening pathway and focus strongly onrecruitment and retention activities to achievecoverage and participation. This is made possibleby the availability of population registers thatenable the programmes to invite women directlyfor screening.

What role does recruitment play in theorganisation’s health promotion strategy?

What priority is recruitment given in the overallhealth promotion plan and strategy?

Which staff are involved in recruitment?

Is this the best use of the health promoter’s time?

Are there other people that would be moreappropriate to involve?

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3.2 DEVELOPING AN ADEQUATELY TRAINEDHEALTH PROMOTION WORKFORCE

Currently within screening people working inhealth promotion enter the workforce with variedexperience and backgrounds: this results in aworkforce with a wide range of skills. Due to theNSU’s focus on priority women and communityinvolvement, it is imperative that healthpromoters establish community networks andhave experience in community development, aswell as a theoretical knowledge of healthpromotion practice.

The NSU has a commitment to workforcedevelopment for health promotion practitioners.However, previous and future investment inhealth promotion workforce development willnot see benefits until the issues of workforcerecruitment and retention are addressed.

The NSU is developing generic competencies forthe screening workforce. This means healthpromoters will be required to have a broadunderstanding of the screening pathway andspecialised knowledge of health promotion.

Development of the health promotion workforcewill help ensure:

• national consistency of health promotionmessages

• sharing of knowledge and expertise amongproviders

• strengthening of national co-ordination

• maximising of health promotion opportunities.

It is therefore important that all people working inand delivering the health promotion componentsof a screening programme have a goodunderstanding of public health and healthpromotion. This will involve participating incontinuing education, including nationallycertified courses, training provided by the NSUand regional training opportunities.

What competencies is the organisation currentlyusing to measure and enhance health promotercompetency?

Are these used to recruit and train healthpromoters?

Is the organisation aware of the health promotioncompetencies developed by the Health PromotionForum?

Are these used to recruit and train healthpromoters?

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3.3 FOCUSING ON PRIORITY GROUPS TOREDUCE INEQUALITIES

Health promoters working in screening havehistorically focused their energies on women whoare undergoing regular screening. This ensuresgood coverage and participation rates for thatgroup. While women who have been previouslyscreened are highly likely to return for screening,disadvantaged groups, including those who havelow income, are geographically isolated, or aredisabled, often experience a number of barriersthat hinder their access to screening services(Jepson et al 2000). In New Zealand this includesMa–ori women and Pacific women.

Thus, the focus of health promotion initiativesshould be on women in the priority groups,particularly Ma–ori women and Pacific women,who are currently under-screened. Raising Ma–oriand Pacific coverage and participation rates willincrease the programmes’ effectiveness. It is astrategic priority for health promotion providersto identify and work in partnership with prioritygroups, but it is also important to the overall goalsand success of the programmes that healthpromotion activity is maintained with othergroups.

The Screening Health Promotion Frameworkidentifies priority groups for the programmes. Forthe health promotion activity undertaken withpriority groups to be effective, key relationshipswith primary health care providers need to bedeveloped and maintained to maximise informedopportunities for coverage and participation.

What information does the organisation have aboutthe NSU priority groups in the region?

How was this information gathered?

How up to date is the information?

How is the information being used to target andprioritise the organisation’s health promotioninitiatives?

What successful, evaluated strategies will beretained to encourage all other women toparticipate in the screening programme?

When you evaluate the work being done in yourhealth promotion programme:

• Who is most advantaged and how?

• How did this inequity occur?

• What are the determinants of this inequity?

• How will you tackle this inequity?(You can use the Ministry of Health InterventionFramework to guide you in this process).

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3.4 MONITORING AND EVALUATION TO MEASURETHE OUTCOMES OF HEALTH PROMOTION

Monitoring and evaluation are central to screeningprogramme planning and implementation,including health promotion activities. Evaluationmust be undertaken at all levels to determineoverall effectiveness and ensure high quality.

Reducing inequalities for Ma–ori and Pacificwomen needs to be explored. Qualitative andquantitative research methods should be used toidentify factors that influence the participation ofunder-screened and unscreened groups. Thedevelopment and impact of new healthpromotion strategies including those developedfor priority group women will be evaluated.

What evaluation skills are available in yourorganisation?

How are these evaluation skills used to evaluate theeffectiveness of current health promotion strategies?

What evaluation processes will be built in to thenext planning round or annual health promotionplan to ensure ineffective strategies arediscontinued and effective strategies aredocumented and developed?

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3.5 ENABLING INFORMED CONSENT

Consumers value information and the provisionof information increases satisfaction levels.Consumers generally want more informationabout screening than they receive, especially onpotential harms and the implications of positiveand negative results. Potential programmeparticipants should have access to the informationthey need to make an informed decision aboutwhether or not to participate. They need to decidethe appropriateness of screening for themselvesbased on accurate, relevant and easily understoodinformation about the benefits and limitations ofthe screening process.

The overall benefits of screening programmesdepend on a high level of participation by theeligible population. Information about screeninghas tended to omit the negative aspects so as tonot raise anxiety and potentially reduceparticipation. It has been suggested thatproviding full information about the benefits andharms of a screening programme may result inreduced participation for disadvantaged groups.However, participation by individuals indisadvantaged groups should be addressed byimproving service accessibility, includingacceptability, rather than by selective use ofinformation (National Health Committee 2003).

In practice it is not easy to achieve individualinformed consent for screening. Goodinformation is needed to achieve informedconsent and to support health promotionprogrammes.

What is the process for women who accessinformation through your organisation to receivesufficient information to make an informed choiceto participate – or not – in screening?

What structures and strategies does theorganisation need to ensure fully informedconsent?

Do all health promoters understand the screeningprocess and pathway sufficiently to provideadequate information to women, so they can makean informed decision?

Do all health promotion staff understand theimportance of proactively using information inwomen’s first languages and/or interpreters?

Do all health promotion staff understand theimportance of proactively making informationaccessible – eg, lesbian-friendly and appropriateinformation, interpreters for deaf people, oralinformation for blind people, information aboutaccessible clinical services for women with physicaldisabilities?

Do all health promotion staff understand theimportance of using medically trained interpretersto ensure messages are competently transmitted?

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4 Health promotion models

4.1 OTTAWA CHARTER

The Ottawa Charter is used in New Zealand andinternationally as a framework for planning publichealth and health promotion strategies. Action across thestrands of the charter maximises the likelihood ofachieving the desired outcomes.

‘Health promotion’ as defined by the Ottawa Charter(1986) is the process of enabling people to increase controlover and to improve their health (WHO 1986). TheOttawa Charter identifies three basic strategies for healthpromotion: advocacy for health to create the essentialconditions for health, enabling all people to achieve theirfull health potential, and mediating between the differentinterests in society in the pursuit of health.

Health promotion represents a comprehensive social andpolitical process; it not only embraces actions directed atstrengthening the skills and capabilities of individualsbut action directed towards changing social, environmentaland economic conditions to alleviate their affect onpublic and individual health (WHO 1986). Five strandssupport these actions. All areas have significant relevanceto health promotion within screening programmes andopportunities are maximised when all five strands areimplemented together.

• Building healthy public policy – Putting health on theagenda of policy makers and at all levels within society.

• Creating supportive environments – Creating livingand working environments that promote health.

• Strengthening community action – Making it easierfor concrete and effective community action to takeplace as part of a health promotion process.

• Developing personal skills – Providing informationand education for health and enhancing life skills.

• Re-orienting health services – Moving the healthsector towards health promotion beyond itsresponsibility for providing clinical and curativeservices (Duignan 1992).

For screening, this means health promoters extendingtheir scope of work beyond health education andrecruitment into strategies that will encompass a broadrange of short-term and long-term initiatives to helpwomen integrate screening into the complexity of theirlives.

Do the people in the organisation,responsible for writing and implementinghealth promotion plans, understand theOttawa Charter strands and how they canbe used to develop an effective healthpromotion plan?

What extra training or information isrequired to fully understand the OttawaCharter and how to use it?

Has the organisation developed its ownunderstanding of the five strands of thecharter, and how these relate to the priorityaims of the screening programme?

See the attached Toolkit.

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4.2 TE PAE MAHUTONGA

Te Pae Mahutonga is one of several Ma–ori modelsof health. This model has been developedspecifically for Ma–ori health promotion and isbased on the Southern Cross. The four starsrepresent the key tasks of health promotion as itrelates to Ma–ori health (Durie 1999):

• Access to te ao Ma–ori – Mauriora (promotessecure cultural identity)

• Environmental protection – Waiora

• Healthy lifestyles – Toiora

• Participation in society – Te Oranga.

The two pointers represent:

• Nga Manukura (leadership)

• Te Mana Whakahaere (autonomy).

This framework provides the ability for healthpromotion practitioners to support Ma–ori-ledinitiatives. It supports the desires of wha–nau,hap–u, iwi and Ma–ori to manage and initiate self-identified solutions in manners best suited to Ma-–ori. It also encompasses cultural values andpractices, specifically te reo, tikanga and kawa.

For screening, this means health promotersdevelop and support health promotion initiativesthat integrate screening into the broaderaspirations of Ma–ori.

Do the people in the organisation responsible forwriting and implementing health promotion plansunderstand Te Pae Mahutonga and how this modelcan be used to develop an effective health promotionplan?

What extra training or information is required forpeople in the organisation to understand Te PaeMahutonga and how to use it?

Has the organisation developed its ownunderstanding of the four key areas and the twostrategies and how these relate to the priority aimsof the screening programme?

See the attached Toolkit.

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4.3 PACIFIC

A nationally consistent approach to healthpromotion work in Pacific communities is beingdeveloped.

Do the people in the organisation responsible forwriting and implementing health promotion plansunderstand Pacific health promotion models andhow these can be used to develop an effective healthpromotion plan?

What extra training or information is required forpeople in the organisation to understand Pacifichealth promotion models and how to use them?

Has the organisation developed its ownunderstanding of working from a Pacificperspective and how this relates to the priority aimsof the screening programme?

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5 Health Promotion Strategies

5.1 COMMUNITY DEVELOPMENT

Community development is an effective strategyfor building relationships and developing thelong-term ownership of initiatives with prioritygroups of the population, so it should beincorporated as a major component of a healthpromotion plan.

Community development has been defined as(Ministry of Health 2003b):

‘The process of organising and/or supportingcommunity groups in identifying their healthissues, planning and acting upon their strategiesfor social action/social change and gainingincreased self-reliance and decision-makingpower as a result of their activities.’

To achieve effective community development,priority groups need to be able to identify healthissues and be empowered to understand the roleof screening. The development of long-termstrategies encourages behavioural change andongoing participation in the pathway. Effectivecommunity development requires a partnershipto be developed and maintained between thecommunity and providers. Communityownership of health promotion initiatives isimperative for long-term success.

Does the organisation have a thoroughunderstanding of community developmentprinciples and processes?

Community development involves:• identifying a priority community• developing relationships with key community

leaders – who are not necessarily health or otherprofessionals

• helping these people identify priority women whoare willing to engage in a development process

• establishing trust• discovering what these people understand as

priorities for their wellbeing• helping develop skills and gather the resources

necessary to achieve their aims• continuing this process until the women are

ready to learn about and become involved in thescreening pathway

• encouraging women to recruit and support othermembers of the identified community.

Are health promoters in the organisation supportedto engage in this process with selected prioritycommunities?

When planning this process think about:

• What are the determinants of health that affectthis community?

• What effect will this intervention have on healthinequalities?

• Who will benefit most from this intervention?

• What might be the unintended consequences ofthis intervention?

• What will you do to reduce the possibility of harm?

• How will you ensure the initiative will reduceinequalities?

• How will you know the intervention has reducedinequalities?

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5.2 COMMUNICATIONS

The NSU aims to provide and distribute accurateand appropriate information related to screening. It is important the information is evidence-informed, sensitive, available and conveyedappropriately to the priority groups.

The NSU has developed key messages using apopulation-based approach.

All NSU information must address the concept ofinformed consent and include a clear representationof the benefits and limitations of screening. Thisenables the population and individuals to makeinformed decisions about participating inscreening programmes.

Information about screening programmes iscommunicated using different methods to presentinformation. eg, media campaigns, regionalcommunity action, resources, promotional items,the healthy women websitehttp://www.healthy women.org.nz/ and touchscreen interactive kiosks. All communication toolsuse the programmes’ visual identities (Appendix 1).

Do health promoters in the organisation have acomprehensive understanding of the NSU keymessages?

Are these messages consistently delivered?

Are all health promoters aware of the range ofresources available to disseminate informationabout the screening programme?

Are all health promoters trained and skilled inusing National resources?

If not, how will they gain these skills?

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5.3 HEALTH EDUCATION

Health education is often confused with healthpromotion or thought of as a separate entity. It isone aspect of health promotion and falls withinthe developing personal skills strand of theOttawa Charter.

‘Health education comprises consciouslyconstructed opportunities for learning involvingsome form of communication designed toimprove health literacy, including improvingknowledge and developing life skills which areconducive to individual or community health.’

Health education has limitations: it is not astrategy that can be used to initiate and supportlong-term behavioural change. It is most effectiveif part of a broader health promotion plan (WHO1998).

Does the organisation have a thoroughunderstanding of the difference between healthpromotion and health education, and the place ofhealth education within a health promotion plan?

Do the health promoters in the organisationunderstand this relationship?

Does the organisation ensure health education isused in an appropriate way in health promotionprogrammes?

How is health education monitored and evaluated?

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6 ConclusionThe NSU endeavours to maintain a high levelof health promotion service delivery throughwell co-ordinated and evidence-informedhealth promotion strategies.

The NSU believes women should have accessto information about and services toscreening. Through the development andimplementation of evidence-informed healthpromotion strategies, the screeningprogrammes will continue to reduce barriersto screening.

As a catalyst for community developmentpriority women will be encouraged to attendfor screening. The NSU will encourage andstrive to support sustainable initiatives toensure the benefits of screening areachieved.

The following guiding principles will form thebasis of any health promotion strategydevelopment, planning and implementation(Appendix 2):

• Health promotion strategies for screeningprogrammes will be delivered in the widercontext of public health.

• Informed consent must underpin all activitieswithin the screening programmes.

• Health promotion strategies are evidence-informed, planned, implemented and evaluatedwith a focus on reaching under-screened andunscreened populations.

• Ma–ori perceptions and experiences of screeningare acknowledged and valued. This requiresMa–ori participation at all levels.

• Regional and local initiatives will ensure Pacificpeoples’ perceptions and experiences ofscreening are acknowledged and valued.

• Regional and local initiatives and strategies areconsistent with the national framework.

Is the health promotion plan developed using thischecklist?

• Health promotion strategies for screeningprogrammes will be delivered in the widercontext of public health.

• Informed consent must underpin all activitieswithin the screening programmes

• Health promotion strategies are evidence-informed, planned and implemented, andevaluated with a focus on reaching under-screened and unscreened populations.

• Ma–ori perceptions and experiences of screeningare acknowledged and valued. This requiresMa–ori participation at all levels in accordancewith the Treaty of Waitangi.

• Regional and local initiatives ensure Pacificpeoples’ perceptions and experiences of screeningare acknowledged and valued.

• Regional and local initiatives and strategies areconsistent with the national framework.

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