Empowering a community to care for itself: through strong community involvement. Otara Health Incorporated is delivering health promotion programmes to populations considered "unreachable".

Creating good health for Otara people through community voices and community action is the aim and philosophy of Otara Health Inc (OHI) in Manukau City.

The not-for-profit organisation, founded ten years ago in response to the unique needs of the Otara community, delivers grassroots health promotion, community development and health education programmes, based on a range of funding contracts. These aim to improve health outcomes for target populations. Around 70 percent of the Otara population identifies as Pacific, leading to its description as the Polynesian capital of Aotearoa. Described as reaching those populations often regarded as "unreachable", including Maori, Pacific peoples and low income New Zealanders, OHI is seen as a possible model for other communities in New Zealand.

From its beginnings, OHI involved the community in governance and other processes, and created a model that has proved successful at improving community participation to define and prioritise health and social needs, and strategies to improve health outcomes. Through community participation at multiple levels, OHI has made the term "hard to reach" redundant. Rather than approaching people with the "you should do it this way" manner of experts, OHI has adopted a face-to-face approach based on the notion "we will help you to find a way".

Manager Louise McCarthy describes the person-to-person approach as one of the points of real difference between OHI and other health services. "When people are referred to us, we visit them in their homes or invite them to visit us in our offices. In this way, we can identify the barriers they face in accessing services and help to overcome them. This is very intensive work but it is one of the keys to our success and increases people's participation enormously."

Otara Health Inc's origins date back to 1994 when a group of community leaders and health professionals came together out of growing concerns for the worsening health status of the local population and the lack of effective arid co-ordinated services to meet health needs. A needs analysis was undertaken, resulting in a report to the funding authority of the day using quantitative and qualitative information to highlight demographic data, the significant gaps between needs and service provision, and to recommend a range of developments that would have the most positive effect on health outcomes.

There was unanimous agreement that community and health providers must work hand in hand because active community involvement was essential to providing local solutions to local issues. "The Otara community is a dynamic and very active community, with strong leadership," said McCarthy. "These leaders understood that only local solutions, developed collaboratively, would be successful They could see that lack of co-ordination between health services was preventing access. The first project was a care co-ordination service agreement to assist local health services work together better."

Groundbreaking governance model

The rules of OHI state that board membership must include mandated representatives from the key ethnic groups in Otara. These include Maori, Cook Island, Samoan, Tongan, and Niuean representatives. Health, education and social service representatives, eg doctors and pharmacists, are also included. Ten years ago, this model of governance was very much ahead of its time. Governance policies state the role of community representatives is to contribute to the strategic direction of the organisation, as well as providing a direct line between community needs and service design/delivery.

From its very beginnings, new concepts were developed for pilot programmes to address housing, social economic, environmental and cultural factors affecting families' health and well-being. These included partnerships in housing and health projects, "ambassadors" projects that employed local people who could speak the languages to deliver projects around a range of health issues; a strong advocacy role with local and central government; and a well-child project, bringing local well-child providers together to co-ordinate data.

Healthy housing project

Between 1998 and 2001, 90 percent of homes in Otara were visited by mature Otara residents of mixed ethnic backgrounds, known as "ambassadors" Their role was to assess whether homes needed improvements to prevent occupants getting sick. Ambassadors were trained to provide advice on such matters as controlling insects, disposal of rubbish, combating moisture and mould, fire safety, benefit entitlements and tenancy matters. Families needing ongoing assistance were referred to government agencies such as Housing New Zealand, Work and Income New Zealand and Manukau City Council

An additional benefit of the housing project was providing employment and work skills to a group of people who had been unemployed for some time. Of the nine people who worked in the 2000 housing campaign, many went on to remain in full employment. The project showed that training people from the community can sometimes be more effective than using professionals from outside. Following on from this project, Manukau City Council funded a three-year project employing two environmental community health workers (CHWs) to continue work with Otara residents.

A range of community projects provide formal mechanisms for broad community input. The Otara Maori Forum, held the first Friday of every month, is facilitated by OHI and aims to increase the participation of Otara Maori in discussions and actions to improve health status of local Maori.

Otara Hearth's injury prevention projects include a number of initiatives run in collaboration with Manukau City Council, with Accident Compensation Corporation support. One is an affordable child restraint scheme aimed at increasing the number of babies and children in child restraints. The scheme includes a comprehensive education programme, along with work with police to check that restraints are fitted and being used. Families who are fined for not having child restraints will have these waived if they hire or purchase, through the rent-to-own scheme, a car seat from OHI. "This is a good outcome for everyone," said McCarthy.

Creation of Total Healthcare Otara PHO

In January 2003, OHI joined with East Tamaki Healthcare to create the primary health organisation (PHO) Total Healthcare Otara. The PHO has access to over 75,000 enrolled patients. OHI has funding agreements for CHW and health promotion services. Working closely with the PHO staff and board to build understanding and awareness of health promotion, and to support population health approaches and stronger community engagement, are priorities for OHI. According to a recent report on PHOs and community development initiatives, health services have been estimated to contribute only about a fifth of recent health improvements in New Zealand. Health improvement mainly occurs through changes in the social, economic and cultural impacts on the community's health problems. (1) The report advocates that PHOs take a balanced approach to their mission. They must improve health and disability services, and tackle the social and economic inequalities that are the root causes of poor health.

OHI has a team of 11 CHWs, from a range of cultural backgrounds, who work closely with patients and their families referred by GPs from Total Healthcare Otara. At the same time, the CHWs upskill, gain self-esteem and become role models, with a number of them furthering their education through diploma and certificate courses at Manukau Institute of Technology. Otara Health also has its own ongoing internal education programmes. "Our staff reflect and speak the languages of the population groups we serve," said McCarthy. "They can engage with high needs' patients to work holistically and address their social, health and cultural needs. These must be addressed together for any real gains to be made."

The CHWs work closely with patients and families to provide education, support and advocacy around many issues, including asthma, skin conditions, medications, breast screening, sexual and mental health, family violence, budgeting and income support. Two members of the team are diabetes specialist CHWs and a smoking cessation intensive support service is being developed. Evaluation shows that diabetic patients referred to the service have improved HbA1c levels and better access to social support agencies. Patients who use the CHW service have also been shown to increase primary health care consultations by 15.4 times in the first year after engagement with a CHW and 3.3 times in the second year.

The other 12 OHI staff include health promoters, injury prevention workers and administration staff, based in three different offices in Otara.

Through its health promotion funding agreement with the PHO, OHI runs a number of projects and initiatives, including two physical activity and healthy eating programmes. The Getting Started programme, funded by Sport and Recreation New Zealand (SPARC) and Total Healthcare Otara, targets adults, particularly those who have not been active in the recent or distant past. Since it began just over three years ago, GPs and practice nurses have referred over 1000 patients to the programme. In June 2007, there were 112 participants on the programme, which runs five days a week at the Otara leisure Centre. The programme delivers aqua aerobics, gentle aerobics, water walking and a two-and-a-half day healthy eating/healthy lifestyles course. Getting Started has strong input from a committee made up of programme participants from different ethnicities and who are regarded as the "voice" of the programme. The committee's role is to ensure all planning and development is done in collaboration with participants. Members also link people to other projects within OHI, like Otara Healthy Kai and Active Families. Active Families is a programme targeting children and their families in the Otara, Mangere and Manurewa areas. The programme is funded by PHOs, Ministry of Health (Healthy Eating Healthy Action Innovations Fund), Counties Manukau District Health Board (Let's Beat Diabetes fund) and SPARC through green prescriptions funding. Children between the ages of seven and 12 years are the target population and they must be joined on the programme by at least one adult family member. Sessions include activity developed to engage children and the healthy eating course "Wise Kai" developed to engage the adult family members. Key healthy eating messages are reinforced with the children in fun activity sessions.

Achieving longer-term gains

McCarthy, who first joined OHI in 2003 as health promotion manager, describes every day she comes to work as "a source of satisfaction and joy". However, like the rest of the staff, she has a good understanding that environmental change takes time and OHI is not going to see major gains in the short term. "Any public health/ health promotion approach needs a generation or two to achieve longer-term gains. But we can see services becoming more responsive to the populations they serve and we can see people accessing these services more easily. Participation builds empowerment and what we see in Otara is a community becoming more capable of looking after itself. The essence of Otara Health has always been about the community, rather than health care professionals, deciding what is needed."

Two senior nursing lecturers from Manukau Institute of Technology, Pat Walthew and Fay Cobden-Grainge, have recently completed a two-and-a-hail year research project looking at the impact Otara Health has had on the local community. The project documents the history of OHI as well as the benefits to the community through interviewing consumers, workers and key personnel In June, they presented their findings at an international conference on health promotion in Vancouver.

By co-editor Anne Manchester

Reference

(1) Caring with communities: A joint report on primary health organisations and community development initiatives. Auckland: AuckEand Regional Public Hearth Service. Available on www.arphs.co.nz.