HiAP in action

Canterbury DHB
Health in all Policies

November 2014
Health in All Policies is an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts, in order to improve population health and health equity. (Helsinki Statement 2013)

What is this newsletter on about?

Kia ora Allison, and welcome to our second  issue of the Canterbury Health in All Policies (HiAP) newsletter.

This newsletter highlights where good policy making is occurring, where potential population health outcomes are explicitly considered in the process with as much weight as other outcomes, and what barriers there might be to this happening. We hope to share case studies highlighting lessons learned and celebrating successes.

It's important because organisations such as local and regional councils, and those working in transport and education, all contribute far more to health and wellbeing outcomes of a population than district health boards - who's primary work programme is to treat disease and manage injuries. 

If any of this hits the mark for you, have a look at this issue and consider whether any of the information might be of use to you now, or in the future.  Maybe save it for a coffee break.  It’s meant to be a reference, and to lead you to interesting resources, practical tools and case studies.  To plant the seed, so to say.  And nurture the plant to full growth.
We would very much like to hear back from you, and invite you to contribute to future issues. Questions and comments are welcome. Thanks for your interest.

Kind regards,

Anna Stevenson and Allison Nichols-Dunsmuir 

PS - If you missed the first issue of our newsletter, you can read it here.

In this issue:

  • Submissions
  • Housing
  • Sustainability
  • All Right? Campaign
  • Healthy Families
  • Wayfinding
  • Mobility parking
  • Introducing Jane Murray, Health in All Policies Advisor

Submissions – one way to have an influence...

Canterbury is presently submissions nirvana.  

The Christchurch City Council, CERA , Environment Canterbury and adjoining district councils are in full rebuild mode.  This means they are consulting on a regular basis, on plans big and small, and often with short response time-frames. Our submissions preparation machine has to be finely tuned and efficient.  We say, keep ‘m coming! We will take every opportunity to put forward population health perspectives, focusing on social determinants and equity. 

Making submissions is an important part of our democratic process in New Zealand and a way for communities to participate in decisions that are made about where they live and work, learn and play. So much so, that we want to encourage others to also make submissions.  To help this happen, we are promoting a resource developed by another public health unit, Regional Public Health in greater Wellington - A guide for health promoters: Working with communities to participate in the submission process.

This will provide anyone who wants to work with community or other groups to navigate the sometimes murky world of submissions.  Highly recommended.  

The Public Health Association also has a range of resources relevant to submission-making.  

Of course submissions are made for plans and proposals that have reached the stage of public consultation. In an ideal Health in All Policies world, social determinants of health and wellbeing are integral to policy development ‘upstream’ of this stage. Click here for more on tools and concepts.

An appetite for submissions – Jane Murray

Feeding solids to a baby and the feeding of ideas to government agencies are not completely disparate concepts. As a new mum, I am now trying to apply the lessons of tempting the appetites of my daughter to tempting the appetites of Councils for concepts of Health in All Policies. 

Lessons that I have learnt:

  1. Preparation doesn’t necessarily whet the appetite. A perfectly balanced meal may not tantalise the taste buds just as a well researched submission may not find the right audience. My daughter may not be hungry; she could be preoccupied, just as councils could also be preoccupied with other concerns. 
  2. Force feeding just doesn’t work. Ramming a spoon into a clenched mouth is no way to serve food. Bombarding people with ideas and expecting acceptance is unrealistic.
  3. Don’t make assumptions. My daughter assumed she could eat a mandarin whole. I need to give guidance on how different foods are eaten. New staff may not be familiar with HIAP concepts, don’t assume those receiving submissions know all the background information. 
  4. Offer bite sized pieces. I offer small pieces of food that are easily digestible, and in submissions, I try to offer suggestions which are manageable.
  5. Let them play with new food. My daughter wants to carefully examine food before she puts it in her month. Whilst this can be frustrating waiting, acceptance of new ideas takes time.
  6. Offer the dish again. What may be spat out may be accepted in good grace the next day. Being gently persistent can help alter people’s thinking. People may come back to ideas at a later date, be available to discuss ideas if it is more convenient.
  7. Change the recipe. Repackage the food and offer it again and it may be happily accepted. It may not have been the idea that was the problem but the delivery.
  8. Share the meal. Feeding can be difficult and repetitive work so I enlist trusted people to help me. Build relationships and networks with like-minded organisations to strengthen each other’s submissions.
  9. Engage and enjoy. Singing and dancing routines make dinner times more fun. Engaging organisations early and building relationships makes the submission process easier and more streamlined.
  10. Baby steps. Acceptance of new food takes time, and change is incremental but it does happen. 

Why high performing housing matters

Ask people about housing and health and the response can range from a quizzical ‘what does health have to do with housing?’ through to ‘what health outcomes are not affected by housing’?  

The first thought when considering health and housing is to connect issues about cold damp housing with respiratory and other health outcomes, but this is just the tip of the iceberg.  If you want to know more then visit He Kainga Oranga, the Housing and Health Research Programme for a wealth of research information. Another resource is the summary paper on the Healthy Christchurch website concerned with fuel poverty and housing.

Our health system is full of people affected by their poor performing housing, our schools are missing children due to poor performing housing, workers are missing from workplaces due to poor performing housing – the impact of improving housing is far reaching and critical. And housing policy underlines the outcomes.

What is high performing housing?  Warm, dry, energy efficient, affordable, accessible, toxin-free. Its size is adequate for the number of residents.  

How do we achieve high performing housing given our current housing stock?  Newer buildings are better overall, but even within existing building standards there is more that can be done when planning homes such as orientation to the sun to ensure passive heating.  

The real challenge though is the older housing stock. Improvements to make a home higher performing will have a flow on affect to those living in the home.  This might include underfloor and ceiling insulation, thermal backed curtains, plenty of ventilation and airing of homes on dry days, dehumidifiers or cheap window scoopers or plastic coverings to reduce condensation. All of these combined will make a significant difference to the occupants of a home and many of these can be done very reasonably especially for low income homes who can access most of this at little or no cost through agencies like, in Canterbury, Community Energy Action. Think of it like keeping yourself warm a good pair of socks and hat (insulation) a light coat (curtains and window film insulation) and staying dry (ventilation) are what works for us – and works just as well for our homes. You can read a really good summary of what matters when building or renovating a home here.

The next issue of this newsletter will discuss strategies to influence the improvement of our housing stock. 

Sustainability and public health

Environmental sustainability is often considered to be something completely separate from public health. Some of the misunderstanding may arise from the language we use. If we consider that sustainability is really about the health of the environment the strong link to human health may be easier to see. When the environment is healthy we have clean air, our rivers are pollution free, our land is toxin free. Animals and fish are healthy and plants grow easily. Without a healthy environment humans cannot flourish as they should. For example when air is thick with smoke and fumes from motor vehicles asthma attacks are far more frequent. The human health costs in New Zealand, of poor air quality have been costed in the HAPiNZ study.

In the worst cases such as London in the late 1940s children needed regular exposure to Ultraviolet light because there was not enough sunshine getting through the smog. This is a direct link between environmental health and human health. A current example in Canterbury relates to urban planning decisions that led to homes being built on areas prone to liquefaction – Although the ultimate decision may not have been different a HiAP approach could have enabled the possible outcomes to be more transparently part of the decision making process and the risks may have been weighted differently.  Similarly design modifications to waterways some decades ago which combined with earthquake issues have led to the recent flooding in Flockton basin.  Allowing homes to be built in flood prone areas has obvious health and wellbeing implications but it appears these potential  long term possibilities were not fully considered when the decisions were made.

Indirect links are known as ‘co-benefits’. A good example of this is when more people take buses or walk or cycle to get around instead of using cars. There is an environmental benefit because there is reduced pollution entering the air and greenhouse gas emissions are reduced. There are also benefits to human health from the freeing up of household income to spend on e.g. more nutritious food rather than petrol, benefits resulting from reduced injury risk from car crashes, benefits from reduced congestion on the roads and ultimately less need to spend billions of our tax dollars on roads. The co-benefits to human health from using alternatives to cars also include getting more exercise from walking and cycling – the health benefits here are a large part of the business case for cycle path infrastructure. Click here to read about the economic benefits of provision of such infrastructure. The well know cartoon above makes the health co-benefits of environmental sustainability very clear. 

Population health outcomes are dependent on getting environmental health right.

Strong allies key to All Right? success

Since its launch in February 2013 Healthy Christchurch’s the All Right? wellbeing campaign has spread its wellbeing messages throughout Canterbury, gaining national and international attention in the process.
One of the key reasons All Right? has been successful is that it has been able to tap into the established networks of Community and Public Health and the Mental Health Foundation, such as schools and its Healthy Christchurch partners. In the context of recovery it has also been able to explore territory not traditionally the domain of health promotion, including corporates and a mainstream media prepared to be a voice to the recovery.
The campaign itself is run by a very small group located within Community and Public Health and the Mental Health Foundation. Supporting them is a team of advisors from a variety of government and non-government organisations, including the Red Cross, He Oranga Pounamu and SKIP.
Promoting wellbeing to an entire population requires a large number of allies and partners, and All Right? works closely with a wide range of other organisations, ranging from the engineering multinational BECA to Christchurch’s very own volunteer baking army.
Having such a broad and diverse range of advisors, partners and stakeholders has enabled All Right? to effectively facilitate wellbeing and mental health conversations. It has opened doors and minds, and has provided a tremendous platform for continued engagement on health issues.  

Healthy Christchurch & Healthy Families

An alliance for a new delivery model

A Healthy Christchurch backed proposal has been selected to by the Ministry of Health to deliver a new model for a health promotion initiative in the Spreydon Heathcote ward of Christchurch. We are excited to see how this initiative reflects a Health in All Policies approach to collaboration across sectors to improve health outcomes.

Under the successful tender, Pacific Trust Canterbury will spearhead the delivery of the health promotion activities within this community. Pacific Trust will be supported by nine strategic partners, all of whom, like Pacific Trust, are members of Healthy Christchurch. The partners are the Cancer Society, Christchurch Methodist Mission, the Heart Foundation, He Oranga Pounamu, Sport Canterbury, the South West Baptist Church, Pegasus Health, and Healthy Christchurch itself.

The aim is to improve peoples’ health; where they live, learn, work and play, in order to prevent obesity. As part of the programme a new health promotion workforce will work with schools, early childhood education centres, workplaces and sports clubs to encourage and support healthy lifestyle choices. The programme will start later this year.

Healthy Christchurch Manager Tanya McCall says the initiative has already succeeded in bringing together many of the services already working with the Spreydon Heathcote community.

“Bringing a range of providers and expertise together under one umbrella, combined with specific central government funding, will help this consortium deliver some innovative public health programmes that will meet the health needs of the Spreydon-Heathcote ward.”

The initiative is built on one of the main HiAP approaches “seeking synergies” – the alliance can achieve better health outcomes than any of these organisations can achieve on their own.

Wayfinding is a public health issue

thanks to Christchurch Daily Photo
There are not many areas that couldn't benefit from some public health specialist input.  Such specialists should be considered as advisors on projects, either at the initial concept stages, as part of a steering group and/or involved in the peer review process. For example advice in the area of wayfinding may be provided with the understanding of disease states that cause perceptual issues –such as dementia
Dementia, increasing with the aging population, is a health condition that includes confusion, perceptual and memory problems. Over time, these make it more and more difficult for people to continue their usual activities.
But there is evidence that certain environmental features enable people with dementia to cope better, thereby extending the time they have to engage with their families and communities.  Independence, wellbeing and contentment can be enhanced.
Wayfinding is one of those environmental features that make a real difference.  Wikipedia defines wayfinding as all of the ways in which people orient themselves in physical space and navigate from place to place.  Dementia-friendly wayfinding includes:
  • Grid designs for streets
  • Easy to locate building entrances and reception counters
  • Consistent signage, contrasting with background, low mounted
  • Well positioned lighting
  • Easy to identify doorways that contrast with wall and floor tones
  • Public toilets and water fountains that are well located and signed
Anyone involved in designing facilities would learn a lot from this research, as it is easy to make choices that promote wellbeing.  As a start, the University of Stirling in Scotland has a Dementia Services Development Centre with excellent publications.

The Podcast 99% Invisible is a radio show about design, architecture & the 99% invisible activity that shapes our world. They have a great wayfinding podcast which is available here.

(Thanks to Christchurch Daily Photo for the above photo)

A human rights perspective on car parking for all

Car parking for people who hold mobility parking permits can be a contentious issue. It’s a major topic on disability advocacy websites and blogs across the world.  Why the fuss? Consider how often in our daily lives we make our way from one place to another.  We want these journeys to be unimpeded.  

In 2005 the Human Rights Commission released 'The Accessible Journey: Report of the Inquiry into Accessible Public Land Transport'.

‘The accessible journey’ is a powerful concept to understanding the importance of environments being built with actual people in mind.  

"All steps in the accessible journey are interlinked and are of equal importance. If one link is inadequate, the whole journey may be impossible". 

The Commission explains:

"Providing adequate access to the built environment allows disabled people to be included in the economic and social life of the community, to participate in education and employment and to contribute to their society. For Tangata Whenua and people from culturally and linguistically diverse communities, the right and ability to access cultural spaces such as marae and Pacific churches is integrally tied to rights to cultural participation and identity."
One example of barriers to the accessible journey is a lack of mobility car parks. The photo above depicts a Lisbon, Portugal protest by disability advocates.  The wheelchairs blocked ordinary car parks, and each chair had a label with a typical excuse given by people who park illegally in mobility car parks, such as:
  • I’m just going to be five minutes
  • Didn’t want to get a scratch on my car
  • There were lots of available spaces
This graphic is a move towards changing attitudes about people with disabilities. In New York State, the new law on accessibility signage and terminology has incorporated a symbol that is more active and positive.  Designated car parks are now called ‘accessible’ rather than ‘handicapped’. 

Introducing Health in All Policies Advisor Jane Murray

So what does a Health in All Policies Advisor do?  Well, my job has many aspects to it.  Currently I am focusing on coordinating the joint work plan between the Christchurch City Council and the Canterbury District Health Board.  So this part of my role is about bringing people together to help ensure that health of the people of Christchurch is considered as various stakeholders plan their projects. 
The best part of my job is working ‘upstream’, as it were.  Working with council officers on health impact assessments and early drafts of policies and plans means we get our Health in All Policies message embedded at an early stage.  It has a real flow on effect where we all get to help shape the city at the planning stages to become an amazing, healthy place for everyone to live.
Another interesting feature of my role is sometimes stumbling across the interconnections between policy areas.  Recently after a Land Use Recovery workshop we retired to our ‘office’ at the Pegasus Arms for a debrief.  While talking with some of the Environment Canterbury representatives I discovered one of their consultants was someone I had been emailing with for the past two weeks on an entirely different submission...small world!
One challenging aspect is understanding the roles of all the different stakeholders.  Every stakeholder has their own emphasis so understanding what is important to each one and how that might relate to policy and planning is key. 
Right now Christchurch is a region that needs dynamic recovery policies.  This means there is always something new around the corner.  So watch this space…
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