Public and private sector initiative to prevent health problems in a country is very important because the cost for treating ill health conditions can cost more than prevention. It will be identifying, analysing and evaluating here Breastscreening Aotearoa Program, Hand Hygeine program, HIV/Aids Prevention Program and Tobacco Control Program and outcomes and strategies in those programs in New Zealand.
1.Executive Summery 2 2.Abbriviation 4 3. BreastScreening New Zealand Program 5 Outcome analyse 8 Evaluate Health Enhancement Strategies 9 4. Hand hygiene New Zealand Program 13 Outcome analyse 15 Evaluate Health Enhancement Strategies 16 5. HIV/AIDS prevention Program 17 Outcome analyse 19 Evaluate Health Enhancement Strategies 20 6. Tobacco Control New Zealand Program 23 Outcome analyse 26 Evaluate Health Enhancement Strategies 27 Reference 31
BSA Breastscreen Aotearoa LP Lead Provider NMNP Non Maori-Nan Pacific HHNZ Hand Hygiene New Zealand WHO World Health Organisation NZAF New Zealand Aids Foundation DHBs District Health Boards GDP Gross Domestic Production TCP Tobacco Control Program Programme Aim: To reduce the breast cancer associated unhealthy situation and deaths of women through early diagnosis and treatment. Established Date: December 1998 Target population: Before 2004, women age between 50-64 After 2004, women age between 45-69 Key Priority for Maori and Pacific women Administered By: Until December 2000, Health Funding Authority (HFA) and then incorporated with the Ministry Of Health. Statistical Method: Statistics NZ Census provides details on the eligible number of women for breast screening in the middle two-year screening period. women who are screened included in the coverage list based on the age they done the screening test. Program Implement through: 8 Lead Provider regions(LP) : Responsible to provide mammography breast screening and service assessment in their areas National Screening Unit(NSU): Provide support for women in high vulnerable groups to screening and assessment District Health Boards(DHBs): Provide treatment after diagnosis All the information above reference to (BreastScreen Aotearoa, 03 December 2014) Used approaches in the intervention Medical approach The program used the medical approach because the knowledge of medical professionals to detect the breast cancer was vital. Approach was implemented through different medical professional by dividing the key roles. Assigned key roles to each professional party are: BSA breastcare nurse The breastcare nurse plays a major role in providing details, education and guidance for women attending in screening. BSA medical physicist Medical physicists are responsible of Mammographic Quality Assurance (MQA), all the imaging and ancillary equipments are in place and function properly according to the standards, and review the result and program. Medical Radiation Technologist Radiation Technologist main role is to provide best quality medical images to diagnose breast cancer in a very early stage and to interact with women in an acceptable way to reduce the psychological issues such as anxiety during the screening. BSA Pathologist Pathologist role is to examine the specimen of screened women in a microscopic level and present the particular changes. BSA Quality Co-ordinator Quality Co-ordinator has the responsibility to assure if program comply with national policy and quality standards, organizational quality and make decision and implement them in order to improve the quality. BSA Radiologist Radiologist involve in interpreting the screening mammogram and clinic assessment. Recruitment and Retention Stuff They are responsible to promote the understanding of screening for everyone at every level. BSA Surgeon Perform surgeries in detected breast cancer patients in correct time and appropriate way. Medical Approach has been used not only to provide cancer detection and treating for cancer but also to promote awareness of psychological issues regarding the participation in screening. Beside that they provide knowledge, information, education, counselling service on why having breast screening is important and about the treatments for population specially for the targeted women group. All the information above reference to (BreastScreen Aotearoa, 03 December 2014) Outcome of the program: →The program has given prority for Maori and Pasific women because the mortality from breast canser is considerably higher among them than other ethnicities.
|Target rate : Over 70%||65%||75%||73%|
Table 1: Breast screen coverage women aged 50-69, July 2013 to June 2015 Brest screening for Maori women was 5% lower than the target rate, but the target rate has met for Pacific and other women. →The annual number of women screen in 2006-07 was around 27000. This proportion has doubled with in close to a decade. Between 2013 and 2015, screened number of women was 505936.
|Target rate: Over 85%||81%||79%||88%|
Table 2: Timely rescanning after a subsequent screen, July 2013- June 2015 →There is lower risk from dying breast cancer if women follow rescanning after a subsequent scan within 20 to 27 months than women who scan less regular basic. The rescanning target is met only for other women but the both priority groups Maori and Pacific aren’t met the target rescanning rate. →According to the given information none of the LPs have met the rescanning target. →First surgical treatment receive within 20 days after the final diagnosis, wasn’t met the target. Outcomes of the program reference to (Bridget Robson, 8 December 2016) Analyse outcomes: According to my assumption the program is almost success in its aims though there are some exceptions. Considering the outcomes of the program, coverage couldn’t achieve only for Maori women but it’s just a 5% lower than the target rate. Also in the timely rescanning target rate for Maori and Pacific couldn’t achieve but there is no big difference between the target rate and achieved rate. 60% of Maori women have invasive breast cancer compare the European women in New Zealand (Sanjeewa Seneviratne, April 7, 2015). Estimated five year relative survival from breast cancer is 0.74 Maori, 0.72 for Pacific and 0.83 for non-Maori Non-Pacific women. (Mckenzie, 2010). It’s clear according to the statistics, Maori and Pacific women are in high risk of breast cancer survival. But the breast screening coverage and the timely rescanning after a subsequent screen target rates haven’t met for them where as both target rates have met for the non Maori-non Pacific women. According to the 2004-2006 statistics, women in aged 50-64, within two-year period, 42% of Maori and 62% of non Maori women has preceded the screening. (Shirley Simmonds, october 2008) . Comparing those statistics with the 2013-2015 statistics, The achievement of the program is quite high. But there are considerable disparities within the ethnicities in achievement of breast screening process. As program was implementing close to a decade, there was enough time to reduce the disparity between ethnicities in the process of breast screening. It’s a question of investigate the reasons why Breastscreening program couldn’t achieve the ethnic targets although all the resources are in place. It shows that the program was not running effectively and efficiently in the point of view addressing the people who at most risk. Although the program aim to reduce morbidity and mortality connected to breast cancer, they couldn’t treat women within the target period. Which means cancer eradication in early stage might fail and possibility to spread the cancer within the body is increase. It shows that there is a problem in the program or healthcare system as most of the women couldn’t get the first surgical treatment within 20 days after diagnose with breast cancer. Although there is a considerable success of the screening program, there were failures in the system. For example, In 1998, The Cytopathology was working alone without providing enough information about the seriousness of cervical intra-epithelial for a considerable period which increased the chance to spread the cancer and brought death for some women. The second failure in 2000 was a problem of clerical information flow in Otago and Southland Breastscreening program. Women weren’t referred to immediate rescanning or treatments even they were detected with abnormalities instead they had to wait 2 years for the next check up. It’s a positive aspect of the program that they identify the problems and found solutions for that. In the same time I’m very optimistic about the program as it’s running by overcoming its failures by becoming more organized and well administered than before. Breast Screening programs are implementing in many countries. Because most diagnose cancer among women throughout the world is the breast cancer. Breast Screening for Ontario Women is another program running in Canada. In that program, they could cover 65% of Ontario women (age 50-74) in 2008-2009. But they couldn’t achieve the target rate of 70%. But in 2014-2015 they could cover 82% of Ontario women where as New Zealand overall overage was close to 71% in 2015. There is 11% difference in the program outcomes of both countries. I think the reason is for that Ontario sends appointment invitations for women to attend in the breast screening. (Cancer Quality Council Of Ontario, 2017) Evaluation of the Health Enhancement Strategies used in BreastScreening program. The program needs to enhance its current strategies or develop new strategies to improve the effectiveness of program for a better outcome. I can’t criticise that the medical approach wasn’t effective at all. Because there are some considerable success in the program. And there are some weak points also to be addressed. One of the major weak point is women couldn’t get the first surgical treatment after detected with abnormalities in the breast. Investigation is needed to find out the reasons why women couldn’t access to the treatments within the targeted period. As I assume, may be the facilities can be insufficient to accommodate many women at once soon after their scanning. If the problem is so, it will be a good idea to expand the facilities. The program has used the medical professionals not only to provide medical assistance but also to provide education for women who participate in the program. It’s a good idea that medical professional provide the appropriate knowledge for women. But in the same time this intervention could seek the help of other professionals in social care sector to provide community base education for women who are at most risk. Another weakness I see in the program is the medical professionals have giver education mostly women who participate in the program but not the whole women as a nation. It’s clear as they couldn’t achieve similar target coverage for every ethnicity because there were many women out of the scope who didn’t know the importance of screening the breast to identify cancer in the early stage. What I suggest is instead of focusing only on the medical approach, priority need to be given also to use the educational approach in a broad spread way. In order to educate the women population they could use media such as TV, newspapers and radio. Because almost everyone in a country uses media even if men get knowledge about the breastscreening from media they could refer their wife, mother, sisters or friends for the program. There was the behavioural change approach inside the medical approach as medical professionals provided the counselling services for women who participate in the program to reduce their anxiety and follow up the subsequent screening in two-year basis. It’s a question how it was totally successful as on an average only 80% of women were participated in the rescanning process from the first total coverage. What I suggest is besides using the behavioural approach through medical professional, they could use social services. As social change approach makes easier to reach for the women who haven’t participated at all and have participated already in the program to bring them in to screening process for the first time or rescanning. Because social services are effective to reach the people and bring them back to the process rather than waiting inside premises until people reach by themselves. Social services such as campaigns, community gatherings, family support, etc., can be effective options. All what I mean here that the program should to reach for women than waiting women reach to the program. In order improve the women coverage in the program, it’s possible to send reminders for women through email, or post about when and what time is the appointment along with information book let. If I consider about my experience, the medical intervention used in Sri Lankan breast screening program doesn’t reach to most of the women at all. Although there were few campaigns organised to educate women in Sri Lanka, those campaigns were basically on few cities and the women who are living in rural areas were left without any knowledge about the breast cancer. Most of the women in Sri Lanka don’t diagnose the breast cancer in early stage. Two women died in my village because they diagnose cancer only after it reach to untreatable stage. Comparing my experience to New Zealand, here many women have the knowledge about breast cancer and importance of breast screening, means the interventions used in the New Zealand BreastSreening Program reached the women than in Sri Lanka. The way of using interventions in UK and New Zealand is different. Interventions used in the UK are -Person directed intervention (this intervention in created to bring invited and non-responders of invited women to participate in the screening process) -Systematic directed intervention (telephone reminders, letter reminders) -Multi strategy intervention (focus mainly in inner city area) UK intervention system is well addressing bringing women in to the scanning process. Specially they use the technology and other communication methods for that. Whereas New Zealand basically provides information through person to person interaction. My Idea about on which stages Health Enhancement Strategies need be implemented:
Ringa Hororia Aotearoa
Aim: to promote the hand hygiene in the in New Zealand health sector. Established through: National Quality Improvement and Infection Prevention and Control program Importance of the hand hygiene: Hands are the high risk factor for our health if don’t keep it clean. It can cause ill health by bringing infection to our body and also spread infections to others. Most of the infections out breaks in the health sector are transmitted by the hands. Therefore promoting hand hygiene is very important. Implemented thorough: District Health Boards “5 moments” of hand hygiene “1. Before come in to contact with patient for hand shaking or any other patient assistance 2. Before any procedures such as needle insertion, surgeries 3. After any procedure or risk of harmful body fluids such as blood, urine 4. After come in to contact with a patient 5. After come in to contact with a patient surrounding such as beds, linen, and table” WHO standards. “5 moments of the hand hygiene is design to protect the protect the health sector workers as well as patient and healthcare environment” Used Approach in the program New Zealand Hand Hygiene Program mainly uses the Behavioural Change Approach to promote the hand hygiene in health sector. The way they are promoting the hand hygiene is wash hands in the proper way, use alcohol-based hand sanitizers for hand washing, administer if health sector workers follow the hand hygiene process and view the results time to time, exchange ideas on problems or improvement of hand washing, provide knowledge and information on hand hygiene, keep displaying hand washing in all suitable places to remind it, promote feedback and feed forward by each person and institutional level, take support from high level leaders, train to follow up ‘ 5 moments. How hand hygiene is also promoted through Educational approach:
- Provide support for organisations to follow up hand hygiene program requirements such as information, technology, data management etc.
- Provide help through telephone, email, reports and let access to necessary information
- Provide up to date information
- Ensure continuous of the hand hygiene program through promotion and distribution of education material and information.
- Research and gather information on effective international hand hygiene programs and distribute it for wider use.
- Provide ongoing training programs and activities
|Current moments||Total moments||Aggregated National compliance rate||National average performance rate By DHBs|
Table 2: Aggregated hand hygiene compliance, 1 April 2017 to 30 June 2017 As data indicates, the national hand hygiene compliance rate was 83.7%. Although expected hand hygiene moments were 588222 but only 49222 moments complied with program. Data for following 5 steps of hand hygiene
|Before touching the patient||79.9%||55.5%|
|After procedure or body fluid exposure risk||90.3%||69.4%|
|After touching patient||88.5%||71.9%|
|After touching a patient’s surrounding||77.3%||54.9%|
Table 3: Compliance by moment Following hand hygiene moments very important to prevent the infection outbreak . But there is a left risk for that as program couldn’t achieve 100% compliance in the 5 moments. Outcomes reference to: (National hand hygiene compliance report:, June 2017) Analyse of the outcome: Considering outcome of the program I can say it has some great improvements. In 2012, National hand hygiene compliance rate was just 62.3% and it increases to 83.7% in 2017 is a positive aspect of the program. New Zealand Hand Hygiene Program 5 moment set target was 80% of the hand hygiene. In 2012, five moments was far lower that the targeted rate. The highest compliance with hand hygiene was after touching patient which was 71.9% but still around 9% lower than the target rate. But in 2017, target hand hygiene rate exceeded by the before procedure, after procedure or body fluid exposure risk and after touching patient. Only before touching patient and after touching patient surrounding moments couldn’t achieve the exact target rate but almost achieved. It’s very important in the health care sector to keep hand hygiene in optimal level as it’s high risk sector for infection outbreak. Most of the people who are working in the health sector are educated and they know infection can transfer one person to another. Even they can be get infected by patient. My concern is, although the people who work in health sector are acknowledged about the importance of hand hygiene and also the education approach is in place, number of activities don’t comply with the target rate. There are some problems to follow the moments of the program as medical professionals need to give priority for patient needs. For example if a patient is struggling with life and death professionals may not have enough time to pay attention in hand hygiene rather than bringing the patients alive. Beside that accesses to hand washing places are not always convenient when professionals are in a rush and also they have not get a separate time for hand washing in the duty roster. But after introducing the alcohol hand sanitizers to health sector, hand hygiene has improved considerably because it’s not time consuming and easy to use. That could be one of the reason for dramatically increase in the hand hygiene by 21.4% from 2012 to 2017. Therefore more focusing to improve the alcohol hand sanitizers would be a good idea. More over technical machines could be developed in the form of “air hand dryers”. Kind of machine can include sanitizing materials and dryer in the same time that will make faster and easier hand hygiene. Both Australian Hand Hygiene program and New Zealand Hand Hygiene Program have improvements over the years. But Australian Hand Hygiene Program is operating better than the New Zealand Program. In 2012, Australia had 68% before touching the patient and 79% after touching the patient and those are 55.5 and 71.9% in respectively for New Zealand. Australian program target rate has set for 70% but New Zealand program target is 80%.The overall Hand hygiene achievement for New Zealand was 64% in 2012 and 76% in 2014 but it was 75% and 80% for Australia in respectively. It shows Australian hand hygiene compliance is success than New Zealand. (I Wilkinson, 2014) Evaluation of Health Enhancement Strategies used in the program: The main approach of the program is Behavioural Change Approach means to change the behaviour of health sector workers for follow up hand hygiene. The Behavioural Change Approach has well designed to cover all the area and also take participant of workers top to bottom to ensure everyone comply with the program requirements. Not only that, the program collect worldwide data on hand hygiene and compare it with New Zealand hand hygiene system and add to the national system if they recognize any effective areas. It helps to keep the New Zealand Hand Hygiene Program up to date. The Hand Hygiene New Zealand program is running according to the international standards that WHO provide. The “5 moments” given by the WHO is implemented as it’s and it’s clear from the statistical data presentation. Spending lot of money to provide hand hygiene education again and again for health workers is not much cost effective (except providing updated information). Because the programme is running for some years and health sector workers are already acknowledged about the hand hygiene except the newly enrolled workers. Therefore program need to find out which information need to provide and which workers need to address more. The negative point of this program is not having a target group (for example new enrolled workers and cleaners). Investing lot of money and time for one approach can be less rational if some people don’t follow rules although they have knowledge about hand hygiene. Therefore I suggest policies and regulations should be implemented to take actions against who doesn’t comply with the hand hygiene process. It can be included disciplinary practice or penalties. I think producing new technological equipments would be a good idea to detect harmful germs in the hands. When someone detected with harmful germs, the machine should give immediate notice (like an alarm) to mention clean the hands well. In that way health care workers won’t forget to clean their hands. It’s also important to change the focus for somewhat. Instead of focusing only on the hand hygiene of the health sector workers , attention need to be given also to the hand hygiene and cleanliness of patient who are accessing to get the service. Although it’s not possible always prevent patients carrying germs, it will be helpful for somewhat to reduce the infection outbreak through interactions. That means Educational approach can use to educate patient and the population of country to participate in hand hygiene. Though the strategies used in the Australian and New Zealand hand hygiene program is quite similar, Australia is planning to add hand hygiene education in the under graduate and post graduate curriculum. (Australian Commission Of Safety And Quality in Health Care, 2017).That would be good idea if it can be included in New Zealand Primary, Secondary and Tertiary education because extra cost will not need to provide educational support in hand hygiene. It will also contribute to hand hygiene for whole nation not only in health care. In my experience most of the health workers throughout the world are more and more complying with hand hygiene process. Sri Lankan health workers were not following hand hygiene when I was a child. I almost haven’t seen a doctor wash their hands or use gloves before or after touching a patient in my childhood. But now I see health workers are in Sri Lanka Specially in private sector keep their hand hygiene mostly by using disposable hand gloves. I saw in Israeli health workers are very concern about the hand hygiene than Sri Lankan health workers. Israel health workers are mostly using alcohol hand sanitizers and hand gloves for the hand hygiene. In Israel hospitals hang a bottle of alcohol hand sanitizer in each bed. New Zealand hospital also very concern about the hand hygiene. It seems most of the countries are moving to achieve the hand hygiene in their countries. Therefore world Hand hygiene in health sector is not too far. HIV/Aids Prevention program Aim: To prevent the transmission of HIV virus and support people who are already infected. Implemented though: mainly New Zealand Aids Foundation Needle Exchange Service, Peer support organisation Family Planning Clinics Funding: Grants, Donations, Ministry Of Health →According to the New Zealand AIDS Foundation (NZAF) the main reason for HIV transmission was unprotected sex. Gay and Bisexual men are in high risk of getting HIV virus. →NZAF suggest that the best way to reduce HIV transmission is to use condoms. →There is not risk of transmission HIV virus if the both parties involve in sexual behaviours Negative+ negative or Positive+ positive. (Ministry Of Health, 2014) Strategies used in the program:: The program mainly use Behavioural change approach . “Love your condom” is a social marketing method used in the programme to prevent transmission of HIV. This method used to educate gay and bisexual men to use the protections in their sexual behaviours such as condoms and lubes. This method promotes the change of behaviour to have protected sexual relationships. The program provides meditation programs in order to help people to live with HIV. Because it’s hard for a person to accept that he or she is infected with HIV which can cause psychological problems. These meditation programs help them to stay mentally healthy and accept they have been infected. (Stewart, 2017) Another program is “Ending HIV” which is a campaign design to bring gay and bisexual men together to achieve the goal of ending HIV. The program target to end HIV with in gay and bisexual by 2025. The campaign would provide information and preventive methods for homosexual men as HIV is considerably high among them. It promotes use of condoms, knowledge about Pre-exposure prophylaxis and importance of being treated early stage and frequent testing. Education workshops are provided by Community Engagement Team to provide education on HIV and using protections. “Love cover protect” is also another strategy implemented through HIV prevention program to educate African population about HIV and prevention of HIV. (New Zealand Aids Foundation) HIV statistics Male
Table 4: HIV prevalence among men by ethnicity (Miller, 2010) Female
Table 5: HIV prevalence among women by ethnicity (Miller, 2010) Gay/bisexual
|Year||Number of people|
Table 6: Annual approximate number of people diagnoses with HIV in gay and bisexual men, having men to men sex from 2008 to 2016(Not included overseas diagnose numbers) (New Zealand AIDS Foundation, 2016) Analyse outcomes: According to the statistics HIV is most prevalence among the men. New Zealand European males were more risk to infect with the HIV virus. Although the HIV infected rate of Gay and bisexual decline over the years until 2011(except 2010), this number continued to increase again. In the HIV history, 2016 had the highest number of HIV infected Gay and bisexual. Total HIV diagnose in 2016 was 244, among then 164 men were gay and bisexual, 137 were in New Zealand diagnosed and 22 overseas diagnosed. Considering the female statistics African women were in more risk to be infected with HIV Followed by European and Asian women. According to the statistics, Although New Zealand HIV prevention program aim to reduce transmission of HIV by addressing the most risk groups, they have some failures in some point as the number of HIV infected among gay and bisexual is continuously increasing. As I think it’s not so hard to identify the most risk group to target. As HIV infected rate is high among the European men, and gay and bisexual, the first target group should be the European gay and bisexual men. The HIV high risk group for women is different than the men. Exception to 1996-2003 years, HIV infected number among European women were relatively low. High number of HIV infected people could recognize with in migrated women such as African and European. Priority should be given to educated African women in the prevention of HIV. Usually transmission of infection is high among the people who have low educational level. Because understanding on matters, knowledge and experiences can prevent the transmission of HIV infection. In New Zealand Educational achievements are high among the European compared to Maori and Pacific ethnicities. But it’s question when I see the statistics how education played a role in here as HIV infected rate among European men are disproportionately higher than Maori and Pacific people. I’m curious here if the Maori and Pacific cultures played a role to have relatively low HIV infected rates. I’m quite optimistic about the outcomes of the programme because New Zealand has low level of HIV transmission compared to other countries. In 2011 number of HIV infected people were only 2500 and the HIV prevalence rate (age 15-49) was just 0.1. HIV prevalence in United Kingdome 0.33, United State 0.6 and Argentina 0.47. (Wikipedia, 2017). Comparing with many developed countries, New Zealand HIV prevention program is operating well to prevent HIV transmission. Evaluation about used Health Enhancement Strategies in the HIV prevention program: The strategies used in the program are very positive. Because they target to educate population specially people who are at most risk and promote the use of protections in sexual activities. The programme mainly focus on the behaviour changes of people to have protected sex but it also combines with medical approach in for testing HIV and provides treatments for HIV patients. This combination plays a vital role in prevention of HIV. One of the issue of this program is they don’t provide the frequent testing for the population. As a solution to this problem WHO is promoting a self-testing policy (WHO, 2017). WHO emphasise Self-Testing kits should be available worldwide and throughout the countries in public and private sector. That means product should reach the population and they can check themselves to diagnose HIV in early stage. This can be a very effective option to reduce HIV transmission in New Zealand. But I haven’t seen many promotions in New Zealand to increase the use of self-testing kit. It would be a good idea to take media support for the promotion of this product. As I see, the program includes all the people who are at risk with in the country. But people who not living in the country (overseas New Zealanders) is not addressing well in the program. It can be some New Zealanders have gone to other countries for tourism, studies or jobs. It’s also important to address them with in HIV prevention program system because New Zealand people who are diagnosed with HIV in overseas are high. Number of overseas diagnosed is 29 in 2013, 27 in 2014, 27 in 2015, and 32 in 2016 (HIV in New Zealand, 2016). It can happen that some overseas undiagnosed New Zealanders coming back the country and have sexual relationship in a form of HIV transmission. Therefore educating overseas New Zealand people on HIV is very important. This can be done through transferring information through technology. If it’s also possible to provide a HIV testing in the air port. The annual cost for HIV prevention is $35 million. Over the last 5 years program cost has doubled. Although more funding allocated to the program, the number of HIV infected cases has risen over the last 5 years. Therefore, As I think the program was not cost effective for somewhat. Providing social acceptance for people with HIV can reduce the HIV transmission. Because HIV infected people will share their ideas with others (how they are infected) and they can increase awareness of people in HIV. Living life with hiding infection is more dangerous because people don’t know how to make a careful interaction with them. In my experience Sri Lankan society is not accepting yet the people with HIV. There was a well known incident in Sri Lanka that a child with HIV didn’t accept by any school and in the end the problem went until the minister and he put the child in to a school. First of all people with HIV are also human like us and accepting them in society will reduce the unknown HIV transmission. Comparing the USA HIV prevention program to New Zealand program, USA has given a new way of thinking to their program which is treating people who are already infected with HIV reduce the risk of HIV transmission than giving priority for the preventing transmission. The reason might be new HIV medicines reduce the strength of the HIV infection inside the body and it reduces the chances of transmission. (Centers for Disease Control and Prevention, 2015). I think it would be a good idea if New Zealand giving equal priority for transmission prevention and treating people with HIV. My structure to cover all the population through Health Enhancement Strategies in order to prevent HIV transmission.
National tobacco control
The annual tobacco associated deaths were between 4500-5000 in New Zealand. Tobacco is one of the main fatal factor and cause ill health. The harmfulness caused by tobacco is totally preventable if the population quit smoking. The Tobacco control Program was launched in 1985.Ministry of Health (MOH) emphasised the focus on tobacco control and developed a plan in 2011 reduce tobacco consumption and achieve tobacco free New Zealand in 2025. Tobacco control program interventions are design to aim people is at most risk and to achieve highest cost effectiveness. The target groups of the program are Maori, Pacific, Pregnant women, Youth, Low socio-economic people, people live with mental illness and prisoners. Services provided to target groups: Maori: MOH implement a program called “Aukati Kalpaipa(AKP)” to control the smoking among Maori people through 32 service providers. In 2013-2014, MOH paid $5.8 million for the AKP providers. The program mainly provides face to face services. Pacific: MOH cover pacific people through “Pacific services”. Pacific services provide through 4 service providers on contract basis and the contact cost $1.3 million. The program is active in Counties Manukau, Canterbury, Waitemata, Waikato, Auckland and Capital and Coast/Hutt Valley DHBs. Those are the DHBs where majority of Pacific population in living. Pregnant women: Smoking cessation services are provided to Pregnant women by MOH. This service provides through 6 providers. Providers are in contract basis and a whole contract cost $1.5 million. The program is implemented in Auckland, Counties Manukau, Canterbury, Hawke’s Bay, Southern and Waitemata DHBs. DHB services: MOH provides various smoke cessation activities through DHBs. Such as education, advice and cessation support. 18 DHBs provide training programs for health workers on tobacco control. DHBs also obligated to provide reports in half year basis. NGO services: MOH funds 4 Non Governmental Organisations to support in Smoking Control Program. Those NGOs are ASH service(Action for Smokefree 2025), National Maori Tobacco Control Leadership, Smoke Free Coalition leadership, The Heart Foundation. Interventions used in the program : BEHAVIOURAL CHANGE APPROACH: Tobacco control program is using the behavioural change approach to achieve the “smoking free New Zealand” goal. The program aim is to change the behaviours of people to quit smoking. Individual (face to face) counselling: Health workers provide face to face counselling on how to stop smoking. Counselling is kind of advices for smokers who are not participated in clinical care. Cognitive Behavioural therapy (CBT): CBT provides to help for associated psychological (anxiety and depression) issues with quit smoking. Motivational Interviewing: Motivational Interview was created by the Miller and Rollnick to provide support for people who are unwilling and uncertain to change. This is a “client-centred” program. Stage Based Behavioural Therapy: This is a very similar therapy as Motivational therapy but there they divide smokers according to their willingness to change. Brief Advice: This is a 30 second advice given by doctors, nurses, health visitors and dentist for smokers to quit smoking. Group Counselling: Group counselling provides support for group of smokers to stop smoking. This programme hope smokers will help each other to quit smoking and it’s cost effective as group of people can cover in one time. Nicotine Replacement Therapy: It provides alternative for cigarettes such as patches, chewing gum or spay which are low in nicotine. It reduces the withdrawal effects of cigarette. Financial Intensives: Financial intensives are given to smokers as a reward to quit smoking and reinforce positive behaviours such as exercises, eating healthy foods. This wasn’t effective in long term but was effective with adolescent in short term. Smoke Free Legislation: Legislations implemented and enforce people not to smoke in public places. Service Delivery for prevention: Service delivery prevention is implemented in different settings such as family, community, priority groups, and school based. This aim to build a better environment for children to grow up and to give positive behaviours on quit smoking. It mainly delivers educational support on in those setting. Mass Media/ Social Marketing: Media and Social marketing use to educate the population on harmfulness of smoking and impose laws on media against promoting smoking. All above information refers to: (Massey University, July, 2014) Outcomes of the program
- “Daily smoking declined from 18.3 in 2006-7 to 15% in 2014-15.
- Tobacco consumed by per Capita declined by 23% from 2010 to 2014.
- Cost for National Tobacco Control Program was $61.7 Million.”
(Ministry Of Health, 2016)
Table 7: Proportion of population aged 15 years and over who were current smokers by sex and ethnic group, 2006/2007–2013/2014 (Ministry Of Social Development, 2016) Analyze of the outcome: Considering the outcomes of the program there are both positive and negative points to be highlight. The positive effect of the program is, it reduced the daily consumption percentage of cigarette. There is close to 3% of decline in the daily consumption cigarette from 2006-7 to 2014-15. When the quantity reduces, the government expenditure for treating tobacco related disease also reduces simultaneously. Beside that tobacco consumption per capita has also declined considerably by 23%. But, In my opinion, as MOH funds $61.7% million (2014-15) in the program, with that much of investment, achievements could be greater than that. It seems that the outcomes were not much cost effective though program has an influence on the peoples’ smoking behavior. When I compare the table 7 data for smoking rate over age 15 by sex and ethnicity in different years, the change are not greater. Smoking prevalence among both men and women just reduced from 21 % (2006-7) to 17% (2015-15). It was just a 4% decline over a decade. It shows me that the program is not running in its maximum efficacy or efficiency. Although program success is somehow good in the aspect of reducing the number of cigarette smoke daily, I’m not very positive about reducing number of smokers as it’s a slow decline over 10 years of long period. In my experience, the law enforcement to prevent smoking is effective. Because I haven’t seen yet anyone smoking in public places New Zealand. So, Enforcing law strictly might reduce the smoking rate considerably. The main goal of program is smoking free New Zealand in 2025. But when I take in to account the reduction of smoking rate close to decade, it seems impossible to achieve the goal in 2025. Although program was operating since 1985, they amended the Program and took in to serious consideration in 2011 and more strategies have created to achieve the goal. But the total smoking reduction rate since 2011 to 2014 was just around 3%. It’s a reduction of 3 year period. It can calculate to a 1% reduction per year through the program. I order to achieve 0% smoking rate in 2025, smoking rate need to by reduce by 17% within with 11 years (2014-2025).It means an average 1.55% smoking reduction per year. As the current yearly smoking reduction rate is around 1% per year, program need to be implemented more effective and efficiently to increase 1.55% per year , if not the goal will not be achievable within the target period. The total income of 6 largest tobacco companies in the world was USD 81 Billion in 2013. (New York Times, 2017). But the New Zealand GDP was NZD 141.6 Billion in 2014. (Wikipedia, 2017). The total revenue of New Zealand was just slightly higher than the those tobacco companies. It emphasizes how much people not only in New Zealand but all across the world spend and consume tobacco. The tobacco taxation in New Zealand was 70% and 63% in Sri Lanka in 2010. . And New Zealand Tobacco control program was more active than the Sri Lankan tobacco program. For example there were not Tobacco prevention campaigns and WHO standardized packaging in Sri Lanka where as New Zealand emphasized in their program. But the smoking rate in Sri Lanka was 15.8% and around 20% in New Zealand in 2010. It’s interesting here that the quality of the Tobacco Control Prevention program didn’t play a role in the smoking rate. (New York Times, 2017), (Ministry Of Health, 2010). “Smoking rate in 2011 or nearest year in OECD countries, United State 14.8%, Australia 15.1, Canada 15.7% ,United Kingdom 19.6, Ireland 29.0% and New Zealand 16.5% ” (Ministry Of Social Development, 2016) Comparing the with other OECD countries, the severity of smoking in New Zealand is in the middle level. Countries such as Ireland and United Kingdom have high level of smoking rate. Although I believe myself that Tobacco Control Program could achieve more in their spending in the national level but it’s different when I compared cost effectiveness with other countries. New Zealand spend $1.1(Ministry Of Health, 2016) on the Tobacco control program where as some other countries and states spent more such as United Kingdom €2.28, New York €7.74, California €6.83 per capita. (Ian Baxter, 2016). It seems in the international perspective the New Zealand get a good out come from less spending. Evaluation of Health Enhancement Strategies used in the Tobacco Control Program: First of all to mention, this program has used mainly the behavioral change approach as a strategy and Education Approach has used to support main approach of changing peoples’ behaviors. One of the things that I’m very positive about the program is the plan and structure. The program has created a best plan to address well people who are at most risk and the methods they are using to educate people in to change their behavior of smoking is highly valuable. I will just make scenario here. Best outcome= best plan and structure+ well practice or Action We can’t get a good outcome if we plan well and don’t put in to practice in its optimal level. What I mean here is the program has created a best plan to address the most risk groups but hasn’t reached some of the target groups to change their smoking habits. For examples: only 4 DHBs provide smoke cessation support for Maori, only 3 DHBs provide smoke cessation for Pacific, only 4 DHBs provide smoke cessation support for pregnant women, only two DHBs provides smoke cessation support for youth and NO DHB provide support for people with mental illness. (Massey University, July, 2014). It was mentioned that those chosen DHBs are where Maori and Pacific people are mostly prevalence. But what about the Maori and Pacific people who are not living in those DHBs. It’s the similar with Pregnant women. Women are getting pregnant in throughout the country and support provide in only 3 DHBs. Changing pregnant women’s smoking habit is very important because they are the one giving a health generation for the country. Therefore the program needs to reach each smoking pregnant mothers in the whole country not in only 3 DHBs. What I suggest here that DHB can get data from Health Departments and Demographic departments to find the current locations of Maori, Pacific, Pregnant women, Youth, and mental ill health people and to reach them through social services to change their smoking habits. In Sri Lanka it is prohibited to promote alcohol and smoking in Medias. When there is a smoking scene during a drama or movie in the TV they shade the smoking part not to visible to children and adults. Therefore specially young children doesn’t exposure to smoking style through direct are indirect smoking persuasion in media. But it’s different in New Zealand. Although media doesn’t advertise on tobacco, children still see the way how people smoke in drama and movies. Therefore children learn from media smoking is a normal habit and part of life as they grow up. Therefore New Zealand Tobacco Control program should not only focus on direct advertising on tobacco but also the smoking scenes shows in the television. What I suggest here is the easiest way to do that just to shade the scenes during a program that children won’t see how people are smoking. The program could add “difficult access to tobacco” for its improvements. Nowadays people can easily access for tobacco productions such as cigarettes. Because cigarettes are everywhere from retail shops to supermarkets. Therefore people can access to cigarettes anytime and can buy how much quantity they want. What I suggest here that government can regulate laws to stop selling cigarettes in supermarkets and retail shops instead to establish one tobacco shop in each city and issue cigarette for each person for a limited quantity. For example only one cigarette packet need to sell per person and the data must be recorded according to their ID card numbers. Cigarette need to be issued always with the ID card and in that way people can’t cheat the system. “Affordability” of cigarette needs more attention in my eyes. Although around 70% of the cigarette price in New Zealand is the tax but still people can afford it. Let’s say a pack of cigarette is $20 and there are 10 cigarettes. Each cigarette cost only 2 dollars and it’s still cheaper than having a coffee or fresh juice. What I suggest is to bring the cigarette price higher than fresh juice price. It will give a healthy choice for people. In that way peoples’ buying ability on cigarette will be reduced and smoking rate will decline considerably. In the same time it will reduce the drawing out money from country for cigarette companies, reduce ill health associated with smoking and also the expenditure of the government to treat for smokers. Although people are not allowed to smoke in public places but smoking is allowed in indoors such houses. It creates more problems as non-smoker in the family specially children becomes the passive smokers. In order to prevent that government can build few places in town that people who need to smoke should come there for smoking. As people can’t easily smoke a cigarette, chances are higher to give up on that. The Tobacco Control Program in UK uses the Behavioral Change Approach as in New Zealand. They also provide educational support, medical support and social support for people to stop smoking. Comparison with United Kingdom Tobacco Control Program, They are addressing the people with mental health problems well than New Zealand program. It’s important to address the people with mental health problems because smoking is highly prevalence among them. UK Tobacco Control Program has created a separate guideline (Smoking cessation in secondary care: mental health services guideline) for people with severe mental conditions (Department Of Helath, 2017). I think New Zealand program also need to pay more focus for the people with mental problems as one of the smoking target group. In overall, I think New Zealand has a better Tobacco Control Program (TCP) than UK. Because New Zealand’s TCP provide support for smokers to quit smoking in every stage where as UK is not very emphasis. For example there are programs running in New Zealand under the TCP for most vulnerable ethnicities but UK program is not running in such comprehensive manner. My structure for “Smoke free” in 2025
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