Infant care practices in New Zealand: a cross-cultural qualitative study.

This paper describes and compares the infant care practices and beliefs of Maori, Tongan, Samoan, Cook Islands, Niuean and Pakeha (European) caregivers residing in Auckland, New Zealand. Focusing on four areas--sources of support and advice; infant feeding; infant sleeping arrangements; and traditional practices and beliefs--it explores inter-ethnic similarities and differences and intra-ethnic tensions. The international literature indicates that there can be significant cultural variation in infant care practices and in the meanings attributed to them. There is, however, little New Zealand literature on this topic, despite its importance for effective health service and health message delivery. Participants were primary caregivers of infants under 12 months. An average of six focus groups were conducted within each ethnic group, resulting in a total of 37 groups comprising 150 participants. We found similarities across all ethnic groups in the perceived importance of breastfeeding and the difficulties experienced in establishing and maintaining this practice. The spectrum of behaviours ranged widely with differences most pronounced between Pacific caregivers, especially those Island-raised, and Pakeha caregivers, especially those in nuclear families. Amongst the former, norms included: the family as central in providing support and advice; infant bedsharing; abdominal rubbing during pregnancy; baby massage; and the importance of adhering to traditional protocols to ensure infant well-being. Amongst the latter, norms included: strong reliance on professional advice; looser family support networks; the infant sleeping in a cot; and adherence to Western biomedical understandings of health and illness. Maori caregivers bridged the spectrum created by these groups and exhibited a diverse range of practices. Intra-cultural differences were present in all groups indicating the dynamic nature of cultural practices. They were most evident between Pacific-raised and New Zealand-raised Pacific caregivers, with the latter attempting to marry traditional with Western beliefs and practices.

Cancer in Niue: analysis of a cancer register 1962-1985.

Cancer is becoming an important cause of morbidity and mortality in Niue. Analysis of a cancer register showed an overall age adjusted rated of 11.3 and 9.9 per 10000 among males and females, respectively. A significant increase in the trend of cancer during 1952 to 1985 cannot be explained by improved registration alone. This study when compared with other data sources on Niue indicated a gross under-reporting of cancer (over 70%). The establishment of national registers for chronic diseases like cancer is the most accurate, economic and technically achievable way to provide population-based information for the small Pacific Island states.

Sudden infant death syndrome among the Auckland Pacific communities 1988-1996: is it increasing?

AIMS: To define ethnic origin and verify the diagnosis of sudden infant deaths among Pacific peoples in Auckland 1988-1996, and to elicit soci-econonic and demographic characteristics. METHODS: Police (P47) and coroner reports were analysed for an ethnic classification and diagnosis. Postneonatal and sudden infant death syndrome (SIDS) register and New Zealand Information Services data were analysed for additional Pacific cases. Rates of Pacific SIDS in Auckland calculated. A Pacific SIDS database was developed and families were tracked. Face to face interviews covering the SIDS event were undertaken with selected families. Data were coded, stratified and a thematic approach to analysis was utilised. RESULTS: There were 52 cases of SIDS and the ethnic origins were: thirteen Samoans, nine Cook Islanders, seven Togans fifteen multiple ethnicity, and eight could not be verified. The annual rates of Pacific SIDS varied from less than one (in 1989) to 4.5 (in 1995) per 1000 Pacific live births. 34 cases (65%) couldd not be contacted and eighteen were traced. Nine in-epth interviews were conducted with caregivers of these cases. All babies had slept in the supine position, seven were breasted, and five of the mothers were non-smokers. Eight babies sept in the same room with their primary caregiver, with seven sleeping in their own bed. All of the mothers had had continuous access to childcare and support from their families, and seven had had previous children. Grief counselling for partners and children was identified as necessary by almost all the mothers. CNCLUSIONS: This preliminary study concludes that the rate of Pacific SIDS increased in 1995 and remains a serious problem. Ethnic misclassification and under reporting of SIDS cases is apparent among Pacific infants. There is a need to establish a national infant mortality database that collects accurate data incorporating standardised ethnic specific categories. Official routine and data sources also need to incorporate standardised ethnic specific categories. A national prospective study is required to study SIDS in Pacific communities as a basis for effective prevention strategies.

Ethnic differences in perceptions of body size in middle-aged European, Maori and Pacific people living in New Zealand.

OBJECTIVES: The aim of this study was to compare perceptions of body size in European, Maori and Pacific Islands people with measured body mass index (BMI), waist-to-hip ratio and change in BMI since age 21 y. Socio-demographic factors that influenced perceptions of body size were also investigated. DESIGN: Cross-sectional survey. METHODS: Participants were 5554 workers, aged > or =40 y, recruited from companies in New Zealand during 1988-1990. RESULTS: Prevalences of BMI>25 kg/m2 were: Europeans, 64.7% men, 47.2% women; Maori, 93.2% men, 80.6% women; and Pacific Islanders, 94.1% men, 92.9% women. Similarly, prevalences of BMI >30 kg/m2 were: Europeans, 14.4% men, 14.6% women; Maori, 55.0% men, 41.9% women; and Pacific Islanders, 55.1% men, 71.7% women. At each perception of body size category, Maori and Pacific Islands men and women had a higher BMI than European men and women, respectively. BMI increased with increasing perception of body size in all gender and ethnic groups. Since age 21, increases in BMI were highest in Pacific Islands people and increased with increasing perceptions of body size category in all ethnic and gender groups. BMI adjusted odds (95% CI) of being in a lower perception category for body size were 1.70 (1.38-2.12) in Maori and 8.99 (7.30-11.09) in Pacific people compared to Europeans, 1.27 (1.13-1.42) times higher for people with no tertiary education, 1.41 (1.25-1.59) times higher in people with low socioeconomic status, and 0.94 (0.92- 0.95) for change in BMI since age 21. CONCLUSION: Nutritional programs aimed at reducing levels of obesity should be ethnic-specific, addressing food and health in the context of their culture, and also take into account the socioeconomic status of the group. On the population level, obesity reduction programs may be more beneficial if they are aimed at the maintenance of weight at age 21.

Maori infant care practices: implications for health messages, infant care services and SIDS prevention in Maori communities.

This paper uses findings from the Maori section of a multiethnic infant care practices (ICP) study undertaken in Auckland, New Zealand/Aotearoa, in 1998. It aims to increase understanding of present day Maori infant care practices in order, firstly, to inform infant health message and service delivery to Maori and, secondly, to understand the context of practices that comprise modifiable risk factors for SIDS. Publicity about modifiable SIDS risk factors since the early 1990s brought about a significant reduction in the national SIDS rate but the Maori rate reduced more slowly and in 1998 was still three times that of non-Maori. The ICP study was a qualitative study that, for the Maori section, involved seven focus groups and a one-on-one interview comprising 26 caregivers of under 12 month old infants. This paper focuses on five selected areas explored within the ICP study: sources of support, customary practices, infant feeding, infant sleeping arrangements and smoking. It discusses both valued infant care norms and factors that inhibit changes known to reduce SIDS risk. It argues that valued practices need recognition in order to make messages effective. It also challenges the emphasis on individual behaviour change as the primary means to reduce SIDS risk and argues that there is a need to extend prevention strategies beyond simple behaviour change messages to include structural change to reduce 'non modifiable' risk factors.

Research imperialism in Pacific health: the case of Tonga (1966-1997).

Researches of and among Pacificans have been largely externally initiated, funded and controlled. It has become an imperialist tool to colonize, oppress and control the aspirations of Pacificans. This case study shows that research imperialism thrives in Tonga. Economic and social efficiency can be achieved through local initiatives by native researchers. Such an alternative approach must replace foreign data prospectors, "mosquito scientists" and "parachute consultants". This study provides a rapid assessment methods for monitoring research performance among Pacificans.

Pacific Health Research Council: health research by and for Pacificans.

The inaugural meeting of the Pacific Health Research Council (PHRC) was held at Sonaisali, Fiji 12-14 Oct 1998. It was attended by representatives of eight Pacific Island countries and five Pacific Island institutions. The organisation is designed to provide three levels of membership: Pacific Island countries; Pacific Island institutions; and individual Pacific Island researchers. An executive committee was appointed and given the task with the special objectives: to promote and strengthen health research by Pacific people and; to develop Pacific people capacity to exert more control and ownership of data generated through research. In the past Pacific health research has often been driven by external agendas and there is a need to increase the capacity among Pacific Island people to conduct action oriented research. An initial collaborative project for the PHRC is in the area of injury prevention and control. Implementing tasks of the PHRC will require the use of distant consulting and co-ordination to provide ongoing technical assistance, to manage multi-centre activities, and to share ideas and concerns etc. Hence, PHCR will be interested in participating in evolving telehealth networks in order to adequately address these tasks. In the spirit of cooperation and co-ordination, the PHRC can be expected to become actively involved in these emerging developments.

Monolingual monologue: regional issues of professional communication from Pacific Health Dialog.

The Pacific Health Dialog (PHD) is a Journal of Community Health and Clinical Medicine with a Pacific. focus. A analysis of all nine PHD issues from 1994 to 1998 was made for origin of author and content. Tally sheets were used to compile data from which the tables were constructed. The results showed that of the 15,000 journals printed 70% were distributed to Pacificans. There were 287 items published by 489 authors of which 37% were Pacificans who were also the first or only author in 37% (excluding the authors of book reviews, editorials reprints, letters and abstracts). The contents of PHD have all been written in English even though the policy allows for any major Pacific language. Therefore a monolingual journal has emerged in spite of a multilingual policy. There has been minimal dialogue or discussion in PHD and not much of the content has been challenged, so the papers have become monologues by the authors. Thus we have a monolingual monologue. PHD is donor dependent with a hand to mouth existence. Funding covers only part of the expenditure and the balance comes from a 'labour of love' from many people. Despite this, PHD continues to grow. The development of PHD has demonstrated that a participatory media can increase the Pacificans role in health information dissemination throughout the Pacific. Many of the Pacific authors (73.5%) have never published previously. Since 1994 PHD has come a long way and contributed much to pacific based research. It addresses a wide variety of topics and problems and not just the need for medical information. PHD has become the prototype for regional health communication in terms of participation, ownership, development, maintenance and its use of 'labour of love' resources.

Communicating health risks in the Pacific: scientific construct and cultural reality.

Health workers often communicate to people from a position of power rather than focusing on the needs of the receivers. This is usually clouded with jargon and the so-called principles of scientific accuracy. Often the use of science is to justify the health worker's position rather than to precipitate actions to promote health and achieve people's control over their lives. Communication involves a tripartite reciprocal interaction between the sender, receiver and the medium. This involves both science and art specific to the message, language, values and participants. If the ultimate purpose of communication is healthful action and community control, then scientificness of the explanations must be secondary. Therefore the art of getting the message across must be the priority rather than it being scientifically sound. This conflict is discussed in relation to experiences in the Pacific Islands. The communication of health risks in the Pacific involves the multi-tiered translation of scientific concepts and language into those of the target populations. The scientific concepts are usually occidental and need to be translated into vernacular worldviews and languages. Experiences in and examples from the Pacific have challenged the primacy of scientific explanations over the need to minimise health risks and increase of community control. For health promotion to succeed in multicultural and multilingual Pacific, New Zealand and Australia, the art and science of communicating health risks must be titrated against scientific explanations to appropriately and primarily promote health.

Oral health and personnel needs in the Pacific.

A regional review of oral health in the Pacific showed the major problems to be dental caries, periodontal diseases, poor dental health service management and lack of appropriate dental personnel. A strategy for training appropriate dentists to manage oral health services in the Pacific was suggested. Such a strategy must include training of ancillary and auxiliary dental health workers guided by dentists with clinical and managerial competencies. The training programme for dentists must be career-ladder, problem-based, and community-oriented with competency-based learning of a spiral of tasks with increasing sophistication. The curriculum content must contain about 50 percent on public health and clinical aspects, respectively.

National health information systems in the Pacific islands: in search of a future.

Health information is essential for proper management and deployment of limited resources in the health services of the Pacific Islands. There have been numerous efforts to establish and strengthen sustainable information systems but the common feature of these attempts has been the very limited achievement. Subsequently, the use of information as a management tool has been abandoned in favour of 'gut feeling', hearsay and adhocry. In the last decade health planning and primary health care activities have necessitated the re-emphasis of monitoring and surveillance of health and health service indicators. Therefore a revival of interest in health information systems is taking place. A review of national health information systems in the Pacific showed that routinely collected data remained largely untouched by human thought. The contributing factors to the current inertia are examined with suggestions on how to elevate health information from its current lowly status to its rightful place as an essential tool for management. The special problems of small island states, like limited resources, geographical isolation, natural barriers to technology, and diverse cultural milieu, will be examined in relation to an appropriate health information system for Pacific Island countries in the twenty-first century.

Development and health in the Pacific: which way to die?

Development in the Pacific has largely ignored the importance of health as a pathway and an outcome. This paper reviews the effects of development on health and health services in the region. It aims to highlight the plight of development that happens without considering the sociocultural and physical environments of the small island countries. The review shows that health and social conditions in the Pacific are deteriorating. The process of development has been externally controlled without community participation. Pacific leaders have been preoccupied with economic development and have not been cognisant of health and social consequences. During progress an enjoyable life can be achieved through sustainable development with community participation. However, indicators of economic growth in the Pacific do not correlate with those of health. The increase of rape, suicide, drug abuse, sexual promiscuity and crime suggests that Pacific islanders are increasingly disillusioned by the present developmental approach: they have ceased to enjoy life before death. It is suggested that decentralized development planning with community involvement, integrating health and social considerations, would be the way out of this dilemma.

Pacific health: an analysis for training new leaders.

History, economics, culture, and politics have created health systems that can no longer meet the health challenges in the Pacific. An analysis of the health situations in the region revealed health trends, health service deficiencies and the various issues that need to be addressed. The morbidity and mortality experience in the Pacific has been approaching that of the developed countries. The contributing factors to diseases and death have been changing but other health issues, such as matters pertaining to environmental sanitation, management, health information, food and nutrition, ethnic pluralism, colonialism, and technological arrogance, may exacerbate these experiences. To appropriately meet these constraints, the health services need reorientation. However, these need new types of health leadership. Doctors, being the most socially acceptable and politically powerful, should be trained for this new leadership role. This training must be guided by the biopsychosocial model to produce community health physicians. This is being undertaken at the Pacific Basin Medical officer Training Program, Pohnpei. It is characterized by an integrated, community-oriented, student-centered, career-ladder and competency-based approach. The graduates will then provide the leadership and catalyst for the needed health service reorientation.

Rheumatic heart disease and school screening: initiatives at an isolated hospital in Tonga.

A simple and inexpensive assessment of cardiac murmurs and school health problems was conducted in an isolated island in the kingdom of Tonga. The prevalence of rheumatic and congenital heart disease in the population of 'Eua was 0.5% and 0.15%, respectively. The incidence of rheumatic heart disease for 1985 was 0.8 per 1000 population. The screening of 1106 students, who were aged five to 12 years, showed skin disease to be the most important problem. All identified cases were treated and referred for follow-up. The total cost of this study was US $281.48. This exercise demonstrated an alternative approach to maximizing the use of health resources as well as maintaining the skill and morale of health workers in isolated areas.

Oral rehydration salts and diarrhoeal diseases: effects of changing inpatient management in Tonga.

Methods of inpatient management of children with diarrhoeal diseases (DD) in 1978 and in 1980 were compared to assess the use of oral rehydration salts (ORS) and a national antidiarrhoeal programme (NAP). Inpatient notes of 369 children admitted with DD were reviewed. The management of DD differed significantly but the clinical outcome was similar, with the exception of the case-fatality rate. All deaths occurred within the first 24 h of admission, indicating that this difference was attributable to improved management of DD in the community rather than changes in the inpatient treatment regime.

PIP: Researchers examined the clinical case notes of 224 and 145 children admitted for diarrheal disease in 1978 and in 1983 respectively to Vaiola Hospital near Nuku'alofa, Tonga to determine any effects of the national antidiarrheal program on inpatient management. Most of the children were 2 years old. 64.4% of the 2 year old children on admission ranked below the 50th weight percentile compared to 37.5% in 1978 (p.002). On discharge, however, there was no significant difference. 28.6% of cases received intravenous fluids (IVF) in 1978 while only 2.1% did in 1983 (p.001). Further only 40% of the oral rehydration therapy (ORT) cases in 1978 received oral rehydration solution (ORS). Most ORT cases (45%) received water and the remaining cases (15%) received fruit juice or milk. In 1983, all ORT cases received ORS in larger amounts than in 1978 (p.001). In 1978, health practitioners withheld a normal diet from 78.6% of the children for 1-4 days and reintroduced it slowly. On the other hand, in 1983, they permitted all children to have a normal diet on admission (p.001). They restricted the diet, however, for 27.1% because of suspected lactose intolerance. Even though health practitioners correctly did not prescribe antidiarrheals in 1983, they continued to prescribe antibiotics in the absence of other acute infections and at a higher rate than 1978 (9.5% va. 22.9%; p.001). The case fatality rate significantly fell between 1978-1983 from 6.3%-.7% (p.005). This study showed that the national campaign was effective in changing inpatient management in clinical outcome of the 2 treatments. This suggests that improvements in morbidity and mortality were attributable to diarrhea management in the community.