Cancer Society of New Zealand

Health Promotion Action Plan 2009 - 2010

1. Introduction to the Cancer Society of New Zealand 2009-2010 Action Plan for Health Promotion

2. The Health Impact of Cancer in New Zealand

3. Cancer Related Inequalities in Health

4. The Challenge of Reducing the Incidence of Cancer

5. Focus Area 1: Primary Prevention

6. Focus Area 2: Screening and Early Detection

7. Health Promotion Philosophy

     7.1 The Treaty of Waitangi

     7.2 The Ottawa Charter for Health Promotion

8. The Challenges of Addressing the Determinants of Health

9. Cancer Society of New Zealand Health Promotion Principles

10. Criteria for Establishing Health Promotion Priorities

Since 1991 National Strategic Plans for Health Promotion have provided the framework and set the direction for health promotion activity at a national, and more recently divisional, level. With the development of the New Zealand Cancer Control Strategy (Minister of Health 2003),the New Zealand Cancer Control Action Plan 2005-2010 (Ministry of Health 2005) and the Cancer Society of New Zealand National Strategic Plan (CSNZ 2006) the health promotion strategic direction document has been renamed the Health Promotion Action Plan. The format has been informed by the Cancer Council Australia National Cancer Prevention Policy 2007-09 (The Cancer Council of Australia 2007).

The Health Promotion Action Plan incorporates the agreed objectives of the Cancer Society of New Zealand (CSNZ) Strategic plan and reflects alignment with the Cancer Control Strategy (CCS) and the Cancer Control Action Plan (CCAP). To ensure congruity with all documents, health promotion work has been incorporated into the two relevant CCAP /CSNZ Strategic plan goals of:

Goal 1: To reduce the incidence of cancer through  primary prevention, and

Goal 2: To ensure effective  screening and early detection  to reduce cancer incidence and mortality.

2. The Health Impact of Cancer in New Zealand

New Zealand has an increasing incidence of cancer mainly due to population growth, an ageing population, and lifestyle changes such as tobacco use, excessive Ultra Violet Radiation (UVR), exposure to toxins, infectious diseases (such as Human Papilloma Virus (HPV) and Hepatitis B) an increase in obesity, increasing physical inactivity and population dietary changes. The death rate from cancer has slowed and survival rates have improved over the last two decades due to advances in knowledge of risk factors and associated behavioural change, screening and early detection programmes, improved diagnosis and treatment. In 2005, cancer remained the leading cause of death in New Zealand accounting for 29.4 percent (7970) of deaths. In 2005 there were 18,610 new registrations for cancer with 9,647 male and 8,963 female registrations. In the same year 4,184 males and 3,786 females were recorded as having died from cancer (Ministry of Health 2008a).  

3. Cancer Related Inequalities in Health

Inequalities in health exist between different socioeconomic and ethnic groups, between males and females, and across geographical regions, and are reflected by the unequal distribution of the cancer burden across the different New Zealand population groups (Blakely et al 2007). 

Evidence shows that people's exposure to risk factors (e.g. tobacco use) is generally greatest among those who are least well off in society and that this is further compounded by differential access to health care - leading to poorer health outcomes.  Further, it is clear that addressing risk factors alone without consideration of the social and economic determinants of health is likely to lead to increasing inequalities in health outcomes (Ajwani et al 2003, World Health Organisation 2008). 

The role of the Cancer Society of New Zealand in addressing cancer related inequalities relates to:

• identification and prioritization of health promotion activities to reduce the incidence of cancer in Maori, Pacific and low socio-economic groups.
• the use of health equity assessment and intervention tools to guide the planning and implementation of health promotion activities, e.g. the Health Equity Assessment Tool (Te Ropu Rangahau a Eru Pomare 2003) identifying and addressing structural barriers that exist within the Society that minimise participation of Maori, Pacific and low socio-economic groups in health promotion activities
• identifying and addressing the possible unintended consequences of health promotion activities for Maori, Pacific and low socio-economic groups
• building strategic alliances with other organisations and groups to increase the reach of health promotion for Maori, Pacific and low socio-economic communities
• a continuous process of critical appraisal and reflection on how health promotion may be strengthened to meet the needs of Maori, Pacific and low socio-economic groups.

4. The Challenge of Reducing the Incidence of Cancer

The variations in incidence in different countries, and migrant studies, have led epidemiologists to conclude that the great majority of cancers are caused by factors in our lifestyle or environment. Hence the conclusion reached that reducing the exposure of populations to these factors has the potential to reduce the number of people developing many common types of cancer. Because of its strong evidence-based potential in controlling cancer, prevention or more exactly risk reduction has been identified as the focus of the Cancer Society's health promotion activities.  Although there are many agencies in New Zealand involved in disease prevention, the Cancer Society is the only organisation dedicated to reducing the incidence and impact of cancer.

Evidence suggests that one-third of all cancers may be prevented, and a further third may be effectively detected and treated depending on the availability of appropriate resources (Cancer Council of Australia 2007).

As identified in The New Zealand Cancer Control Strategy, the most significant and modifiable risk factors for cancer in New Zealand include tobacco smoking, exposure to ultraviolet radiation from the sun, infectious diseases, occupational exposures to hazardous substances, obesity, alcohol consumption, physical inactivity and diet (Minister of Health 2003). Because people's exposure to these factors are generally the result of a complex range of behavioural, social, economic and cultural factors that are not easy to change, efforts to reduce the incidence of these lifestyle-related cancers require a comprehensive health promotion approach.

As demonstrated overseas, the effectiveness of such approaches depends on their being implemented widely over substantial periods of time, with adequate resources, leadership and a sound research base.  Maximising the effectiveness of the Society's health promotion activities also requires working cooperatively, and establishing working relationships with other agencies and groups to address common objectives.

The following sections from the CSNZ Strategic Plan (Cancer Society of New Zealand 2006) include health promotion areas of focus and the national office staff responsible for leading the work on the objectives and strategic initiatives. Each focus area develops and reports against an annual operating plan.

5. Focus Area 1: Primary Prevention

6. Focus Area 2: Screening and Early Detection

7. Health Promotion Philosophy

"Health Promotion is a combination of educational, organisational, economic and political actions designed with consumer participation to enable individuals, groups and whole communities to increase control over, and to improve their health through knowledge, attitudinal, behavioural, social and environmental changes." (Howat et al 2003).

An important characteristic of health promotion is its focus on groups of people, either the whole population or specific sub-groups. It places emphasis on changing the environment to enable behaviour to change rather than expecting the individual to make behavioural changes after being given information (education) about health[1].

Health promotion draws upon principles of:

• Social change
• Physical change
• Policy development
• Empowerment
• Community participation
• Equity in health
• Accountability
• Building partnerships and healthy alliances between groups.

7.1 The Treaty of Waitangi

The Treaty of Waitangi is the founding document of Aotearoa and key to health promotion in this country.  The Treaty is a contract between two parties, Maori and the Crown. The Crown is represented by the New Zealand government and various government and non government organisations. The crown also represents all people of other than Maori ethnicity in New Zealand. The underlying aspirations of health promotion can be seen in the Treaty of Waitangi.  The Treaty is, therefore, a key document which provides a framework for Maori and non-Maori to exercise control over their health and well-being.

A key role that health promotion can play is in addressing the inequities in health status that have occurred in the past.  This can be achieved through formal recognition of the Treaty and application of it within health promotion.  This also serves to identify health promotion in the context of, and in a manner relevant to, Aotearoa.  Treaty principles and provisions of particular relevance to health are partnership, participation, and active protection (Health Promotion Forum 2002).

Partnership refers to ongoing relationships between the Crown and Maori.

Participation  emphasises Maori involvement in all aspects of society within Aotearoa. Within health promotion this includes involvement of Maori stakeholders in the planning, delivery and monitoring of programmes that are relevant to Maori.

Active Protection recognises that the Crown needs to be pro-active in health promotion and the development of preventative strategies. This may mean putting in additional resources so that Maori are able to enjoy equitable health status with non-Maori.

Together these three principles have a role to play in our understanding of health and sickness; the development of health policy and the delivery of health services and programmes.

7.2 The Ottawa Charter for Health Promotion

Where the Treaty of Waitangi gives relevance to health promotion in the context of Aotearoa, the Ottawa Charter provides a common understanding of health promotion internationally.  The Ottawa Charter (World Health Organisation 1986) sets out five key strategies for promoting health:

1. Building healthy public policy:  policies have an important function in promoting health.  Legislation to restrict advertising of tobacco and indoor smoking are examples of the role policy can have.  Health promotion policy often incorporates sectors beyond healthcare, emphasising that the health consequences of all policies need to be considered.

2. Creating supportive environments:  for people to be healthy they must live in supportive physical and social environments.  Health promotion aims to make these environments safe and satisfying.  Healthy Cities programmes, which develop a sense of community within cities, can promote social support and mutual help in the social environment.  Smoke free playgrounds and provision of shade in schools are examples of improvements to the physical environment.

3. Strengthening community action:  communities acting to increase control over their health is an important part of health promotion.  Key factors in facilitating this process are availability of funding, institutional support for advocacy and community organisation work, access to information and actively seeking public participation in health issues.

4. Developing personal skills:  the development of personal skills is supported by health promotion.  It enables people to more effectively gain control of their health and environment.  For example, health education can involve teaching people how to speak up about health issues which affect them, such as problems caused by local licensed premises.

5. Re-orienting health services:  health services should look beyond curative and clinical services to the promotion of health.  Health services should incorporate broader social, economic and physical environmental factors, as well as being appropriate for a diverse range of cultures.  The training and ongoing education of health professionals is one avenue to pursue the re-orientation of health services.

Other World Health Organisation Health Promotion Charters

In the 1990's the settings approach was encapsulated in the Jakarta Declaration (World Health Organisation 1997) which encourages integration of the five strategies of the Ottawa Charter into all settings were health is to be promoted, including physical, political and social environments. The Jakarta Declaration supports: the promotion of social responsibility for health; increased investments for health development; consolidation and expansion of partnerships for health; increased community capacity; empowerment for the individual; and strengthened health promotion infrastructure. The Jakarta Declaration is seen as a synthesis of conceptual approaches that support people making healthful choices and building the communities capacity to make these choices. It is a culmination of a century of thinking about health promotion and is grounded in the principles of primary health care and social justice (McMurray 2003).

The Bangkok Charter for Health Promotion (World Health Organisation 2005) affirms that policies and partnerships to empower communities, and to improve health and health equity, should be at the centre of global and national development. The Bangkok Charter builds on the Ottawa Charter and suggests that to make further advances there is a need to: Advocate for health based on human rights and solidarity; Invest in sustainable policies, actions and infrastructure to address the determinants of health; Build capacity for policy development, leadership, health promotion practice, knowledge transfer and research and health literacy; Regulate and legislate to ensure a high level of protection from harm and enable equal opportunity for health and well-being for all people; and, Partner and build alliances with public, private, nongovernmental and international organisations and civil society to create sustainable actions.

The Treaty of Waitangi, the Ottawa Charter, the Jakarta Declaration and the Bangkok Charter promote an holistic approach to health. Effective health promotion strategies usually incorporate a number of the principles and strategies found in these defining documents. 

8. The Challenges of Addressing the Determinants of Health

Pre-requisites for health are peace, shelter, education, social security, social relations, food, income, empowerment of women, a stable eco-system, sustainable resource use, social justice, respect for human rights and equity.  Above all, poverty is the greatest threat to health.

Demographic trends such as urbanisation, an increase in the number of older people and the prevalence of chronic diseases, increased sedentary behaviour, growing disparities in levels of deprivation, increased drug abuse and civil and domestic violence, threaten the health and wellbeing of hundreds of many people.

Trans-national factors have a significant impact on health.  These include the integration of the global economy, financial markets and trade, access to media and communication technology, as well as environmental degradation due to the irresponsible use of resources.

These changes shape values, lifestyles throughout the lifespan, and living conditions across the world.  Some have great potential for health, such as the development of communications technology, others, such as international trade in tobacco, have a major negative impact.

Research and case studies provide convincing evidence that health promotion works.  Health promotion strategies can develop and change lifestyles, and the social, economic and environmental conditions which determine health.  Health promotion is a practical approach to achieving greater equity in health and comprehensive approaches are essential as segmented approaches have little effect on the causes of poor health (McMurray 2003).

There is clear evidence that:

• Comprehensive approaches to health development are the most effective.  Those which use combinations of strategies and principles are more effective than single track approaches
• Settings offer practical opportunities for the implementation of comprehensive strategies.  These include cities, municipalities, and local communities, their markets, schools, workplaces, and health care facilities
• Participation is essential to sustain efforts.  People have to be at the centre of health promotion action and decision-making processes for it to be effective
• Health literacy fosters participation.  Access to education and information is essential to achieving effective participation and the empowerment of people and communities
• These strategies are core elements of health promotion and are relevant for all countries.

9. Cancer Society of New Zealand Health Promotion Principles

The following principles are based on those of The New Zealand Cancer Control Strategy (Minister of Health 2003) and have been adapted to reflect the roles and responsibilities of the Cancer Society in health promotion. 

All activities undertaken by the Cancer Society to achieve the objectives of the Action Plan for Health Promotion should:

• reflect an understanding of, and a commitment to, the Treaty of Waitangi as a framework for working with Maori
• reduce health inequalities among different population groups
• be of high quality including appropriate monitoring and evaluation
• be sustainable - having adequate resources, including human resources, over a period of time to ensure a high standard of performance
• use an evidence based approach - with actions based on best practice, supported, where possible, by scientific knowledge, ongoing research and development
• reflect a population-based approach
• ensure active participation of individuals and communities
• recognise and respect cultural diversity
• be undertaken within the context of a planned, intersectorally collaborative, coordinated and integrated approach.
• be suitably flexible to allow for local and regional responsiveness whilst promoting national consistency.

Workforce development is an overarching and fundamental component of ensuring the effective implementation of health promotion within the Cancer Society.  The Society will work towards the continuous improvement of the health promotion workforce and as such is looking to develop core competencies that will form the basis of future workforce development.

10. Criteria for Establishing Health Promotion Priorities

The following questions have been addressed when establishing priorities for the Cancer Society's health promotion work:

1. How many people develop cancer, and how many die from the disease?
2. Are the causes of cancer known?
3. Are there ways of preventing the cancer?
4. Which groups are most commonly affected?
5. What is the impact on inequalities for Maori and Pacific People?
6. Are people able, and supported, to make the lifestyle changes needed?
7. Can effective policy or environmental changes be made (e.g. by schools, local and central government etc)?
8. Are there evidence-based strategies for changing behaviour and the environment?
9. Will the changes impact favourably on the prevention of other chronic diseases?
10. Do we have the resources to implement effective strategies (e.g. staff, funds, facilities, equipment etc)?
11. Can we work cooperatively and form strategic alliances with other health and community organisations? (Cancer Society Three Year Strategic Plan for National Health Promotion 2005-2008, 2005).

Specific areas of Health Promotion activity set out in the following sections include: 11.1 Tobacco Control, 11.2 Skin Cancer Control, and 11.3 Physical Activity, Nutrition including Alcohol, 11.4 Screening and Early Detection.

These sections are currently in development.

[1] Health Education is giving information on health and facilitating changes in behaviour.  It is a subset of health promotion.