Promoting Health in Aotearoa NZ

easier.

MIHI

Ko tō manawa, ko taku manawa

Tēnei hoki tō manawa ka tina

Tēnei hoki tō manawa ka toka

Tēnei hoki tō manawa ka poutāiki

Tina noho tō manawa ora, hei ora

Nau mai e te rau, hou mai e te tini ki tēnei papanga kōrero

Rauhītia mai he maimai aroha ki mata pūkenga, ki mata wānanga, whāiti atu ki te pō

Tēnā ko tēnei, ko mata rauora, ko mata raunui horapa te whenua, horapa te ao

Ko ngā tohu o te ora i matapakihia ai i ngā wā o te urutā, o te pōauau, o te aupēhi roa

He ohaohanga tērā nō ngā rautau, e kore e whakahua i a wai i tōna huhua

He ohaohanga tēnei nō nākua tata me te whakahuahua i tōna rārangi ingoa mai

Ko te kupu kua whāiti mai, engari anō te tirohanga he whāroa

Whakatau mai e aku piringa ki tēnei papanga aronui o ngāi ihiihi, o ngāi wanawana

Ngā māia e tohe tonu rā ki te ora, he oranga pūmau i roto i te ao nei, he ao whaimana

E kore rā e oti i te rārangi tuhituhi, kāhore, kei a koutou te pūtake o te pukapuka nei

Ka oti i runga i te pokohiwi o te hāpai ō, i te pane o te amorangi, o te amokapua

Ka oti i roto i ngā whakatupuranga e tupu ora mai ai, he oranga tonutanga

Nau mai e te manawa ora, e rarau e

Chapter 1

Introduction

LOUISE SIGNAL & MIHI RATIMA

Health promotion is an internationally accepted public health approach both within the health sector and across other sectors of society. Texts on health promotion in Aotearoa New Zealand are very limited, so overseas texts are frequently used in teaching and supporting public health practice. Often they are not appropriate to Māori, other New Zealanders, and the New Zealand context. This issue has been of concern to health promotion academics and practitioners for a number of years. This book aims to make a significant contribution to addressing this lack of relevant material. In particular, it provides an opportunity for key areas of health promotion competence to be explored and promoted to the public health workforce and those engaged in health promotion initiatives across all sectors. In doing so, it supports the Health Promotion Competencies (Health Promotion Forum of New Zealand 2012), the Generic Public Health Competencies (Public Health Association of New Zealand 2007) and the Public Health Workforce Development Plan (Ministry of Health 2007).

This book is written for everyone interested in promoting health, including students, practitioners and policy-makers in health and other sectors. It will be of interest to those promoting health across the health sector, in Māori and other NGOs (e.g. Tipu Ora, the Cancer Society, the Heart Foundation, and the AIDS Foundation) and to government agencies such as Accident Compensation Corporation (in accident prevention) and the New Zealand Transport Agency (in road safety). This book will also have wider relevance to an international audience with an interest in health promotion, for example to those concerned with promoting the health of indigenous peoples.

It is anticipated that the book will contribute to the improved quality of health promotion and public health process and outcomes, including reducing inequities, by:

• more clearly defining and articulating health promotion in the New Zealand context, including Māori health promotion

• enhancing the quality of health promotion knowledge, theory and practice

• informing Treaty of Waitangi-based practice

• promoting health equity

• contributing to enhancing community readiness to lead and/or benefit from health promotion initiatives, and

• supporting a better prepared and more effective workforce.

The book focuses on key aspects of health promotion thinking and practice, and not on specific health issues, risk factors or health determinants. This has been a deliberate strategy. We have concentrated on identifying the basic tenets of health promotion in New Zealand no matter what the issue being addressed. Issue-specific content is woven throughout the book as the various contributors illustrate their particular stories.

The book was conceptualised as a text that equally integrates Māori and Pākehā analysis, consistent with an approach that emphasises the Treaty partnership and indigenous rights. We have endeavoured to achieve this by the structure of the book, by the key themes that run through it, and by collaboration between Māori and Pākehā as editors, advisors and contributors. It is signalled by the use of the phrase ‘Aotearoa New Zealand’ in the title and in each chapter.

The contributors come from a wide range of backgrounds and experience, both in health promotion and in their lives, as can be seen from their biographies. This means that topics have been written about from different perspectives using a range of theories and approaches. While this diversity provides richness to the text, in some instances it has resulted in the same issue being discussed in different ways. We see this as a strength of the book as it illustrates the diversity that is health promotion, emphasises that health promotion is a living concept that continues to evolve, and provides further points for debate.

What is health promotion?

In 1986 the World Health Organization (WHO) joined with the Canadian Federal Government and the Canadian Public Health Association to hold the first international health promotion conference in Ottawa. The main output of the meeting was the Ottawa Charter (World Health Organization, Health and Welfare Canada, & Canadian Public Health Association 1986), a brief document that has come to define health promotion internationally. It is this document that we use to define generic health promotion in this book.

The Ottawa Charter defines health promotion as ‘the process of enabling people to increase control over, and to improve, their health’ (World Health Organization et al. 1986, 2). It is defined as a method to enable or facilitate people and therefore aspires to be empowering rather than dictatorial, patronising or disabling. Whether it always succeeds in this ideal is another matter, and one we explore in this book.

The Ottawa Charter defines health broadly as ‘a state of complete physical, mental and social well-being’(World Health Organization et al. 1986, 2). This is the definition of health contained in the 1946 constitution of the WHO (World Health Organization 1946). The definition has been criticised for having no boundaries to what is encompassed by health – that is, for being so broad as to be meaningless – and for requiring health to be complete when many people live full and active lives with health problems (Rootman & Raeburn 1994). It has also been criticised for omitting spirituality as an aspect of health (Khayat nd), an issue of particular relevance in the New Zealand context due to its inclusion in Māori models of health (Durie 1998). Despite these valid concerns, this definition provides an aspirational goal for health promotion that clearly sets a broad agenda.

Next, the Charter identifies a wide range of prerequisites, or determinants, of health including peace, shelter, income, a stable ecosystem, equity and social justice. It foreshadows the wide range of potential areas of health promotion activity and highlights the emphasis health promotion places on addressing inequity. Some of the roles that health promoters can play are then identified. Included here are advocate, enabler and mediator, although there are others such as community leader, policy analyst, educator and social marketer.

A comprehensive range of health promotion strategies is also highlighted. First, at the policy level, the strategy of building healthy public policy is identified as a process that ‘puts health on the agenda of policy makers in all sectors and at all levels, directing them to be aware of the health consequences of their decisions and to accept their responsibilities for health’(World Health Organization et al. 1986, 3). Hancock (1985) clearly defines this concept and distinguishes it from health care policy. Second, is creating supportive environments. This includes the ‘protection of the natural and built environments and the conservation of natural resources’ and ‘living and working conditions that are safe, stimulating, satisfying and enjoyable’. (World Health Organization et al. 1986, 3, 4). While this is presented as an action, and is crucial to health, it is an outcome that uses actions such as healthy public policy, community action and personal skills development to achieve it. It is useful to recognise that creating supportive environments is an outcome, otherwise it can be confusing to consider how best to act in this domain. Third, is strengthening community actions through empowerment and self-determination. Fourth, is developing personal skills through ‘providing information, education for health, and enhancing life skills’ (World Health Organization et al. 1986, 4). Fifth, is reorienting health services beyond clinical and curative services towards health promotion and to a focus on the whole person. Finally, the document calls for international action to advocate for the promotion of health, a call that has been picked up to some extent by nations throughout the world.

In summary, health promotion acknowledges that health is a complex concept determined by a wide range of factors. Therefore, health promotion identifies a complex set of solutions at multiple levels: at the individual, community and societal levels and through the health sector. It is not looking for single solutions to complex problems. It is this fundamental component that we believe makes health promotion so attractive.

The Ottawa Charter integrates working at an individual lifestyle level and structural policy-based approaches. Baum (2002, 34) notes that this integration is ‘perhaps the genius of the Ottawa Charter’. Certainly, our experience has been that those with conservative agendas can use the Ottawa Charter to focus on individual responsibility for health and the promotion of healthy lifestyles. Equally, those with more radical agendas can use it to promote community development and structural change at the policy level. Stone (1988) argues that the most powerful concepts are those that are ambiguous, ones that everyone can see their face in and therefore ones that everyone can agree with. It is this ambiguity, this genius of those who wrote the Charter, which means that policy-makers and practitioners support this framework and use it to emphasise individual, community or structural approaches according to their politics.

A further level of integration that the Charter achieves is to combine ‘the distinction between health promotion as a bureaucratic entity or formal domain of study and practice, as opposed to health promotion as a process concerned with empowering people to take control of their own health’ (Pedersen, Rootman & O’Neill 2005, 255). It is our aim, in this book, to take a similarly integrated approach.

What is Māori health promotion?

The concept of Māori health promotion draws on both Māori and Western traditions and aspirations (Ratima 2001). It is grounded in Māori worldviews and realities, and therefore Māori beliefs, values and aspirations are at the core. Māori health promotion is identity-centred and seeks to improve Māori health as a foundation for the achievement of individual and collective potential. At the same time, Māori health promotion draws on the best of wider local and global health promotion knowledge and experience that is relevant to Māori contexts. Māori health promotion therefore recognises or incorporates many of the determinants, values, principles, processes and strategies outlined in the Ottawa Charter. As well, it shares a fundamental goal of enabling people to increase control over, and improve, their health – though health is more broadly defined to explicitly include spiritual and other dimensions. Māori health promotion is discussed in detail in Chapter 3.

Why undertake health promotion in New Zealand?

Health promotion in New Zealand is critical given the instrumental value of health. That is, that good health is a foundation for the achievement of potential for individuals, groups of people (including families, whānau, hapū and iwi) and society as a whole.

There is seemingly much to celebrate about health in New Zealand. Life expectancy continues to increase and is well above the Organisation for Economic Co-operation and Development (OECD) average, and we have one of the highest OECD rates of adults reporting to be in good health (89 per cent) (OECD 2013). However, these averages obscure important health issues and inequities in health that demand attention. Paramount among these is that Māori life expectancy at birth is at least eight years less than that for non-Māori (Blakely, Tobias, Atkinson, Yeh & Huang 2007). Further, findings from the 2011/12 Health Survey show that ‘Māori and Pacific adults generally experience disadvantage across all indicators of health status and access to health service … [and] many health conditions are more common in people living in more socioeconomically deprived areas’ (Ministry of Health 2012, ix).

While the daily smoking rate continues to fall, with less than one in five adults now smoking (17%), there are substantial inequities with two in five Māori (41%) current smokers. Our obesity rate continues to climb from 19% for adults in 1997 to 30% in 2013/14, and is much higher in Māori and Pacific adults (46% and 67% respectively) and for people living in more deprived areas. Obesity is a major risk factor for heart disease, type 2 diabetes and some types of cancer. The rate of diabetes is higher among Māori (7%) and Pacific (9%) adults than the national average (6%) (Ministry of Health 2014), and there are much wider disparities in terms of complications which are likely due to differential access to, and quality of, diabetes care (Harwood & Tipene-Leach 2007). Further, more adults have been diagnosed with a mood and/or anxiety disorder at some time in their life (13% in 2006/07 compared to 18% in 2013/14). Overall, 6% of adults had experienced high or very high levels of psychological distress in the last four weeks, and there are wide ethnic inequities with Pacific and Māori adults more likely to have experienced psychological distress (13% and 9% respectively). There has been a decrease in the percentage of adults who are hazardous alcohol drinkers from 18% in 2006/07 to 16% in 2013/14, but Māori rates are higher at 30% (Ministry of Health 2014).

We have unusually high rates of infectious diseases such as acute rheumatic fever (largely only a problem among Māori communities), meningitis and skin infections, and there are substantial ethnic and socioeconomic inequities in infectious disease incidence that are increasing (Baker et al. 2012). Further, New Zealand has one of the highest rates of melanoma in the world (Erdmann et al. 2013).

While New Zealand is often regarded as a ‘great place to bring up children’, New Zealand’s child health outcomes compare poorly internationally. In a 2009 OECD report, ‘Doing Better for Children’, New Zealand ranked 29th out of 30 countries for child health and safety (OECD 2009). In fact, some of New Zealand’s disease patterns among children are closer to those of developing countries (Public Health Advisory Committee 2010, vii).

There are important health issues and inequities in child health. For example, 10% of New Zealand children are obese. Obesity rates are higher among Māori (15%) and Pacific (25%) children, and children living in the most deprived areas (18%). Asthma is common in childhood with 15% of children taking asthma medication; the rate is higher in Māori children (21%) (Ministry of Health 2014). Māori children report more frequent and severe symptoms and have higher rates of hospitalisation for asthma. Poor access to preventative care and differences in asthma treatment by ethnicity contribute to inequities (TMG Associates 2009).

Comparatively, total life expectancy in New Zealand is above the OECD average but lower than a number of countries such as Spain, Italy and Australia. While we are one of the OECD leaders in reducing smoking for the total population, this is not true for Māori, as noted above, and we have one of the highest OECD obesity rates. New Zealand also has above the OECD average rates of mortality from heart disease, all cancer mortality and infant mortality. While we are below the OECD average for stroke, traffic accidents and suicide, this total population figure again masks considerable inequities. Further, we fare worse than Australia in many arenas, including heart disease, all cancer mortality, diabetes, suicide and infant mortality (OECD 2013).

There is much that health promotion has contributed to improving health in New Zealand. However, there is still much to do to impact on preventable health issues, address the determinants of health and eliminate inequities in health.

Challenges faced in writing this book

One of the challenges in writing this book is the difficulty in isolating the impact of health promotion initiatives on health outcomes given the complex array of influences that prevail. However, as we emphasise, it is critical that all efforts are made to evaluate the effectiveness of health promotion endeavours. Certainly, health promotion cannot take responsibility for all that has been achieved, nor for all failures, in improving health and tackling inequity. However, there is a growing body of evidence for the effectiveness of health promotion that we explore, and international acceptance that health promotion is an essential component of any health system.

Our approach to this text has been to include a Māori focus (e.g. Chapter 3) and integrate a Māori analysis throughout chapters as appropriate. However, much of the thinking that underpins Māori health promotion practice is implicit and has not yet been articulated in a comprehensive way in the literature. As well, there is a relative dearth of published evaluations of Māori health promotion programmes. While it is true that generic health promotion does not have a lengthy history of academic study and published work, compared to other more well-established disciplinary fields, like psychology, there is still a relatively substantial literature base. The challenge has therefore been to ensure the incorporation of robust Māori analysis through drawing on existing literature, and working with Māori contributors who have extensive experience and credibility in Māori health promotion and Māori development as academics and practitioners.

A further challenge in writing a text on health promotion is to distinguish health promotion from the broader field of public health. Using the Ottawa Charter definition, as we do, it is possible to fit many, if not all, public health initiatives under health promotion. Certainly, health promotion is consistent with Winslow’s definition of public health as ‘the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts’ (Winslow 1920, 30).

When considering the public health professions that are involved in public health for the majority, if not all, of their work, medical officers of health are involved in much that is health promotion, as are health protection officers and public health nurses. We do not find the professional divisions that can arise in public health to be particularly helpful as we often work together in multidisciplinary teams, on the same issue, using similar strategies. Certainly, the domains of health promotion and health protection are often distinguished by name, by training, and by the approach of those working in the two fields. Health protection tends to emphasise environmental issues and focus on enforcing legislation, while health promotion has been weak in the area of the environment and tends to emphasise social issues. Health promotion also has a stronger role in working with communities than does health protection. Nevertheless, we contend that all public health professions have much to learn from each other. No matter where people stand on this issue, ‘few would challenge the centrality of health promotion in public health practice or its contribution to the development of thought and theory in an evolving social model of health’ (Bunton & MacDonald 2002, 1). We believe this book has much to offer all public health professionals and those interested in promoting public health.

A danger of writing about the broad concept of health promotion is that you run the risk of reframing activities as health promotion that were not conceptualised in this way. While we do not wish to be imperialist in our approach, there is much that occurs within other sectors that is consistent with the definition of health promotion outlined above. It is work that focuses on the determinants of health such as housing or income or a secure cultural identity, and that aims to prevent poor societal outcomes, including health outcomes. This book has a strong focus on health promotion in the health sector but is by no means restricted to health. We believe it has lessons, not only for those who call themselves health promoters, or who actively promote health, but for others interested in preventing death, disease and injury, and in promoting wellbeing and developing communities.

The structure of the book

In Chapter 2 Signal, Ratima and Raeburn outline the history of health promotion in New Zealand and analyse the influences on its development. In Chapter 3 Ratima, Durie and Hond build on a combination of two Māori health promotion models, Te Pae Mahutonga (Durie 1999; 2004) and Kia Uruuru Mai a Hauora (Ratima 2001), as a basis for broadening understandings and critiquing the meaning and practice of Māori health promotion. Next Tu`itahi and Lima (Chapter 4) explore the notion of Pacific health promotion in New Zealand and implications for practice. Chapter 5 examines health promotion with immigrant communities. Here Nayer draws on lessons from a case study of New Zealand Indian women and proposes a new theory for promoting health with immigrant communities, ‘Navigating Cultural Spaces’.

In Chapter 6 Waa critically examines how interventions are planned and evaluated in New Zealand and presents a framework of the influences on evaluation and design. The following chapter (Chapter 7), by Delany, Ratima and Morgaine, considers the ethics of health promotion addressing the fundamental question: What matters? The chapter demonstrates how the systematic application of ethical frameworks can be useful to, and enrich, health promotion practice – in particular when problems arise, and different values point in opposing directions. Reid makes the case for addressing equity in health promotion in Chapter 8, in particular the challenge of closing the gap in life expectancy between Māori and non-Māori. Health promotion action in New Zealand is then critiqued from an equity perspective. The chapter concludes with exploration of the practical steps the health promotion community can take to strengthen its ability to promote health equity. In Chapter 9 Signal, Jenkin, Fougere and Poata-Smith examine the politics of health promotion in New Zealand and consider ways of analysing political influences to strengthen health promotion action.

Blaiklock and Kiro make the case for promoting the health of children and young people in Chapter 10. They identify a rights-based approach and explore how this approach can be used by health promoters. They illustrate their chapter with case studies from New Zealand. Chapter 11, by Neuwelt and Harwood, presents a conceptual argument for the promotion of health through the delivery of health care, focusing on the primary care setting. The chapter identifies ways that health promoters and other health practitioners can advocate for, and strengthen, health promotion in this context. Chapter 12 provides a wider discussion of health promotion in settings. Here Stairmand focuses particularly on health promotion on marae, Tu`itahi on health promotion in Pacific churches and Walton and Neely on health promotion in schools. The chapter concludes with consideration of opportunities and challenges for settings-based health promotion practice in this country. In Chapter 13 Lovell, Tunks and Egan consider health promotion workforce development in New Zealand by profiling the workforce and current workforce development initiatives, including initiatives to enhance the Māori workforce. Further, they explore strategic issues for future health promotion workforce development. In the final chapter (Chapter 14) Signal and Ratima conclude the book with critical reflections on health promotion in Aotearoa New Zealand and an examination of the challenges that lie ahead for progress in this key area of health.

REFERENCES

Baker, M., Barnard, L.T., Kvalsvig, A., Verrall, A., Zhang, J., Keall, M., … Howden-Chapman, P. (2012), ‘Increasing incidence of serious infectious diseases and inequalities in New Zealand: A national epidemiological study’, The Lancet, 379 (9821), 1112–19. DOI: 10.1016/S0140-6736(11)61780-7

Baum, F. (2002), The New Public Health (2nd edn), Melbourne: Oxford University Press.

Blakely, T., Tobias, M., Atkinson, J., Yeh, L.C. & Huang, K. (2007), Tracking Disparity: Trends in ethnic and socioeconomic inequalities in mortality, 1981–2004, Wellington: Ministry of Health.

Bunton, R. & MacDonald, G. (eds) (2002), Health Promotion: Disciplines, diversity and developments (2nd edn), London: Routledge.

Durie, M. (1998), Whaiora Maori Health Development (2nd edn), Auckland: Oxford University Press.

Durie, M. (1999), ‘Te Pae Mahutonga: A model for Māori health promotion’, Health Promotion Forum of New Zealand Newsletter, 49, 2–5.

Durie, M. (2004), ‘An indigenous model of health promotion’, Health Promotion Journal of Australia, 15, 181–85.

Erdmann, F., Lortet-Tieulent, J., Schūz, J., Zeeb, H., Greinert, R., Breitbart, E.W. & Bray, F. (2013). ‘International trends in the incidence of malignant melanoma 1953–2008: Are recent generations at higher or lower risk?’, International Journal of Cancer, 132 (2), 385–400.

Hancock, T. (1985), ‘Beyond health care: From public health policy to healthy public policy’, Canadian Journal of Public Health, 76, 9–11.

Harwood, M. & Tipene-Leach, T. (2007), ‘Diabetes’, in B. Robson & R. Harris (eds), Hauora: Māori standards of health IV. A study of the years 2000–2005, Wellington: Te Rōpū Rangahau Hauora a Eru Pōmare.

Health Promotion Forum of New Zealand (2012), ‘Ngā Kaiakatanga Hauora mo Aotearoa: Health promotion competencies for Aotearoa–New Zealand’, Auckland: Health Promotion Forum of New Zealand.

Khayat, M. (nd), ‘Spirituality in the definition of health: The World Health Organization’s point of view’: www.medizin-ethik.ch/publik/spirituality_definition_health.htm

Ministry of Health (2007), ‘Te Uru Kahikatea: The public health workforce development plan 2007–2016. Building a public health workforce for the 21st century’, Wellington: Ministry of Health.

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Pedersen, A., Rootman, I. & O’Neill, M. (2005), ‘Health promotion in Canada: Back to the past or towards a promising future?’, in A. Scriven & S. Garman (eds), Promoting Health: Global perspectives, New York: Palgrave Macmillan.

Public Health Advisory Committee (2010), ‘The best start in life: Achieving effective action on child health and wellbeing’, Wellington: Ministry of Health.

Public Health Association of New Zealand (2007), ‘Generic competencies for public health in Aotearoa-New Zealand’, Wellington: Public Health Association.

Ratima, M. (2001), ‘Kia Uruuru Mai a Hauora: Being healthy, being Māori. Conceptualising Māori health promotion’, PhD, University of Otago, Wellington.

Rootman, I. & Raeburn, J. (1994), ‘The concept of health’, in A. Pederson, M. O’Neill & I. Rootman (eds), Health Promotion in Canada: Provincial, national and international perspectives, Toronto: WB Saunders.

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World Health Organization, Health and Welfare Canada, & Canadian Public Health Association (1986), Ottawa Charter for Health Promotion, Ottawa: World Health Organization, Health and Welfare Canada, Canadian Public Health Association.

Chapter 2

The origins of health promotion

LOUISE SIGNAL, MIHI RATIMA & JOHN RAEBURN

This chapter explores the origins of health promotion in Aotearoa New Zealand and examines the foundations of how and why it is constructed and practised as it is. We have chosen to emphasise three themes that we feel drive a distinctively New Zealand health promotion approach, and illustrate these with examples of their application. These themes are Māori health development, government-led public health initiatives and community development. The chapter draws on both a literature review of health promotion in New Zealand and our own experience, and covers the period up to the early 1990s. For discussion up to 2000 see Wise & Signal (2000).

Before exploring the specific origins of New Zealand health promotion, some discussion is required of its international origins. Many authors have written about the emergence of health promotion internationally and there is further discussion throughout this book. Valuable historical accounts include Catford (2004), Green & Raeburn (1988), McQueen (2007) and, in the Australian context, Baum (2008). Key points are outlined below.

Health promotion as a formal concept is relatively new, its origins dating from the mid-1970s. It has many precursors, of course, starting from earliest times with people’s universal preoccupations with staying well and feeling good. Thus, ‘health promotion’ is built into every culture. In modern times, however, health promotion has become a formalised area in its own right. The most immediate precursor of health promotion in the twentieth century was the area of health education. Until the advent of health promotion, this was largely a didactic domain directed at passive audiences, such as school children. It was primarily based on the assumption ‘that if the relevant information was put before a person, that person would, almost unquestionably, adopt the appropriate knowledge, attitudes and behaviour to do as expected’ (Ritchie 1991, 158). Other notable threads of health promotion development include:

… the community development and mass communications movements and technology of the 1950s and 1960s, which converted the top-down cooperation of the public into enlightened self-interest initiatives rising from the grassroots [and] the self-care, civil rights and women’s movements and reforms of the 1960s, which demanded a transfer of authority and resources to people previously dependent on others (Green & Raeburn 1988, 155).

It is widely agreed that ‘A New Perspective on the Health of Canadians’ (the Lalonde Report, Lalonde (1974)) launched health promotion. In this document Federal Minister of Health Lalonde argued that a major reorientation of health funding was required to address the health of Canadians. To contextualise this, he outlined his famous ‘health field concept’, which identified the major determinants of health as human biology, environment, lifestyle and health care organisation. The Lalonde Report led directly to the establishment in Ottawa of the Health Promotion Directorate, which employed over 100 people from largely educational and social science backgrounds, and which was the first government agency in the world identified by the label ‘Health Promotion’. Americans largely followed the Canadian model, with the 1979 US surgeon general’s report ‘Healthy People’ (Surgeon General 1979) a document that proved critical in setting the scene for health promotion in the US.

Meanwhile, developments were also taking place in Europe, particularly under the auspices of the World Health Organization (WHO). The first was the 1978 Alma-Ata Declaration (World Health Organization & UNICEF 1978) (discussed in more detail in Chapter 11), which identified the concept of comprehensive primary health care and the strategy of ‘Health for all by the year 2000’. It contained a number of values and principles relevant to health promotion, including health as a human right and a strong emphasis on equity and community participation. Second, the European office of the WHO in Copenhagen was behind the conference that resulted in the landmark Ottawa Charter for Health Promotion in 1986 (World Health Organization, Health and Welfare Canada, & Canadian Public Health Association 1986). The WHO has been a key player in defining health promotion, in building global support for it and in identifying a strong base of evidence for the effectiveness of health promotion. The organisation has hosted seven global health promotion conferences since Ottawa, the most recent in Helsinki in 2013, attended by government representatives from throughout the world.

The three themes

Having provided some international context for the origins of health promotion, we turn now to the three themes from these early years that we identify as the main drivers of the distinctive style of health promotion that has developed in New Zealand.

Theme 1: Māori health development

CUSTOMARY MĀORI PUBLIC HEALTH SYSTEMS

At the time of colonisation, Māori public health systems were well established and worked reasonably well for the time. Indeed, early British explorers commented on the good health of Māori people. Māori life-expectancy was estimated at 28–30 years, similar to that of European populations (Pool 1991). The Māori systems were based on concern for the wellbeing of the collective, and particular attention was paid to supernatural, social and environmental determinants of health. Also important were concepts that delineated safe from unsafe practices within a framework of Māori beliefs and values, which thereby regulated behaviour (Durie 1998). For example, designation of some sites as tapu (sacred) provided protection from the spread of contamination and depletion of food sources. Burial sites are one such example (Barlow 1994; Durie 1998).

A closer look at pā (Māori fortified villages) and