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North Health Northern Regional Health Authority MOH Library
II IIII Ill Health of our People
098933
Measures and Targets for Public Health in the Northern Region
Dr Patricia Priest Public Health Medicine Specialist
December 1996 ISBN 1-877172-00-6
Information Centre Ministry of Health W1i r oton ACKNOWLEDGEMENTS
A number of health service providers and community groups commented on an early draft of these measures of public health. Their comments played an important role in the development of this document and North Health thanks them for giving their time and expertise.
Health of our People / CONTENTS
LIST OF TABLES V
LIST OF FIGURES vi
1. INTRODUCTION I
2. THE PEOPLE OF THE NORTHERN REGION 4
3. MEASURES AND TARGETS FOR PUBLIC HEALTH IN THE NORTHERN REGION 5
3.1 TARGETS 7
4. MEASURES OF GENERAL HEALTH 8
4.1 UNDER-FIVE MORTALITY 8
4.2 LIFE EXPECTANCY 9
5. DETERMINANTS OF HEALTH 10
5.1 SOCIOECONOMIC 10 Unemployment 10 Housing 13 Income 14 Transport 15 5.2 HAUORA MAORI 16 Iwi/hapu affiliation 16 Kohanga reo 16 5.3 PHYSICAL ENVIRONMENT 17 Hazardous substances 17 Drinking water 19 Sewerage 20 Air quality 21 5.4 FOOD AND NUTRITION 22 Breast feeding 22 Food safety 23 \ Healthy diet 24
Health of our People /
5.5 TOBACCO AND ALCOHOL 25 Tobacco use 25 Heavy drinking 28
5.6 VIOLENCE 31 Assault 31 Child abuse 32
5.7 EXERCISE I OBESITY 33 Physical activity 33 Obesity 35
6. SPECIFIC HEALTH OUTCOMES 36
6.1 COMMUNICABLE DISEASE 36 Immunisation 36 Vaccine preventable diseases 38 Campylobacteriosis 39 Rheumatic fever 41 HIV infection 42 Tuberculosis 44 Hepatitis B 45
6.2 NON COMMUNICABLE DISEASE 46 Asthma 46 Diabetes 48
Sudden Infant Death Syndrome (SIDS) mortality 49 Cardiovascular disease 50 Child hearing loss 51 Breast cancer 53 Colon cancer 55 Cervical cancer 56 Melanoma 57
6.3 NON-INTENTIONAL INJURY 58 Traffic injury 58 Falls 59
6.4 MENTAL HEALTH 60 Attempted suicide 60 Suicide 61
6.5 ORAL HEALTH 62 Decayed, missing and filled teeth 62
7. FUTURE DIRECTIONS 64
7.1 ADEQUACY OF INFORMATION 64
7.2 FREQUENCY OF MEASUREMENT 64
8. REFERENCES 65
Health of our People / APPENDIX I PUBLIC HEALTH COMMISSION PUBLICATIONS 67
APPENDIX 2 INFORMATION SOURCES FOR MEASURES 68
APPENDIX 3 PUBLIC HEALTH MEASURES, SERVICE OBLIGATION AREAS AND HEALTH GAIN PRIORITY AREAS 73
Health of our People / LIST OF TABLES Table I Targets for public health...... 7 Table 2 Under-five mortality; 1988-1992...... 8 Table 3 Life expectancy at birth in 1992 (years)...... 9 Table 4 Unemployment: percentage of labour force unemployed; September quarter 1995...... 11 Table 5 Income: percentage of households with incomes of less than $20,000 and more than$50,000; 1991 ...... 14 Table 6 Transport: percentage of households with access to at least one car; 1991 ....15 Table 7 Iwi/hapu affiliation (%); 1991 ...... 16 Table 8 Unintentional poisoning: hospitalisations for children aged 010 5 (per 100,000); 1989-1993 ...... 17 Table 9 Drinking water quality: compliance of water supplies with the 1984 drinking water standards for New Zealand: proportion of population served by type of supply (%); 1994...... 20 Table 10 Sewerage: percentage of households connected to reticulated sewerage; 1996...... 20 Table 11 Breast feeding: percentage of three-month-old children fully breast fed; 1994/95...... 22 Table 12 Smoking: proportion of group (all over 15 years) who describe themselves as current smokers (%); 1992/93 ...... 26 Table 13 Heavy drinking: percentage of people who drink heavily; 1990-1994...... 28 Table 14 Injury intentionally caused by others: hospitalisations (per 100,000); 1989-1993 ...... 31 Table 15 Child abuse or neglect: notifications and family group conferences, Children and Young Persons Service; 1994/95...... 32 Table 16 Physical activity: estimates of the proportion participating frequently (%); 1993/94...... 33 Table 17 Obesity: estimates of prevalence in adults and older people (%); 1993/94 ...... 35 Table 18 Immunisation: percentage of children fully immunised by two years old; 199237 Table 19 Vaccine-preventable diseases: hospitalisations for children under 15 (per 100,000); 1989-1993...... 38 Table 20 Campylobacteriosis: notifications (per 100,000); 1995...... 39 Table 21 Acute rheumatic fever: incidence (per 100,000 5 to 14 year olds); 1991-1995 (Northland), 1990-1994 (Auckland), 1991-1994 (Northern region) ...... 41 Table 22 Tuberculosis: notifications (per 100,000); 1995...... 44 Table 23 Hepatitis B: notifications (per 100,000); 1995...... 45 Table 24 Asthma: hospitalisations with more than three days stay (per 100,000); 1989-1993...... 46 Table 25 Sudden infant death syndrome: mortality per 1,000 live births; 1988-1992 ...... 49 Table 26 lschaemic heart disease and stroke: mortality (age standardised per 100,000); 1988-1992...... 50 Table 27 Hearing loss: percentage of new school entrants referred; 1993-1994 ...... 51 Table 28 Breast cancer: in (1989-1993) and mortality (1988-1992) per 100,000 53 Table 29 Colon cancer: incidence (1989-1993) and mortality (1988-1992) per 100,000.55 Table 30 Cervical cancer: incidence (per 100,000) and cases detected at stage I (%); 1989-1994 ...... 56 Table 31 Invasive malignant melanoma in non-Maori, non-Pacific Islands people: incidence (per 100,000); 1989-1993 ...... 57 Table 32 Targets for road safety for the Auckland region...... 58 Table 33 Targets for road safety for Northland ...... 58 Table 34 Falls: hospitalisations (per 100,000); 1989-1993 ...... 59
Health of our People / Table 35 Attempted suicide: hospitalisations (per 100,000): 1989-1993 ...... 60 Table 36 Suicide: mortality (per 100,000); 1988-1992 ...... 61 Table 37 Dental health: mean number of missing/filled teeth at school entry and Form II, 1994/95...... 62
LIST OF FIGURES
Figure 1 National and regional health service monitoring...... 2 Figure 2 Unemployment: young people (national), Northland, Auckland (all ages); 1993- 1995...... 12 Figure 3 Unemployment: ethnic groups (national); 1993-1995 ...... 12 Figure 4 Unintentional poisoning: hospitalisations for children aged 0 to 5; 1989-1993...... 18 Figure 5 Smoking: age/gender standardised percentages of ethnic groups who describe themselves as current smokers ; 1992/93 ...... 26 Figure 6 Parental smoking: percentages by district of mothers and fathers who smoke; 1994/95 ...... 26 Figure 7 Heavy drinking: proportion of women drinking more than four units of alcohol weekly, monthly and annually; 1990-1994...... 29 Figure 8 Heavy drinking: proportion of men drinking more than six units of alcohol weekly, monthly and annually; 1990-1994 ...... 29 Figure 9 Vaccine-preventable diseases: hospitalisations for children under 15 for measles, mumps and pertussis; 1989-1993 ...... 38 Figure 10 Campylobacteriosis: notifications; 1990-1995 ...... 40 Figure 11 HIV positivity: number of women and men found to be HIV positive; 1985-199443 Figure 12 Tuberculosis: notifications; 1990-1995 ...... 44 Figure 13 Hepatitis B: notifications; 1990-1995...... 45 Figure 14 Asthma: hospitalisations with longer than three days stay; 1989-93...... 47 Figure 15 Hearing loss: referral rates 1991/92 to 1993/94 ...... 51 Figure 16 Falls: hospitalisations by age and ethnic group; 1989-1993 ...... 59 Figure 17 Dental health: mean ME score for five-year-old children in central Auckland, 1991-1994...... 62 Figure 18 Dental health: mean ME score for Form II children in central Auckland; 1991- 1994...... 63
Health of our People / vi 1. Introduction
North Health is the Northern Regional Health Authority, responsible for purchasing health and disability support services for the people of the region between Mercer and Cape Reinga. This is the report of a project by the public health team of North Health to define a set of measures which reflect the health status of the Northern Region population and which can be monitored overtime.
Public health The term public health is used in two different ways in this report. The public health means the health status of the population, and it is the public health that the measures in this report are intended to reflect. Public health services are services which aim to protect and improve the health of the population through interventions that focus on preventive or health- promoting action at a population level, rather than through diagnosis and treatment of individuals who have become ill. North Health purchases a wide range of public health services from both Crown Health Enterprises (CHEs) and community-based organisations.
Monitoring in the health service Three aspects of health service activity are monitored to ensure that high quality services are delivered appropriately to improve people s health - process, outputs and outcomes. Organisational processes are monitored internally by providers and regional health authorities (RHAs), and the Ministry of Health monitors the RHAs performance in purchasing health services. Outputs are measures of what providers do, for example how many people they see, and RHAs monitor provider outputs as part of contract monitoring. Health outcomes are measures of how healthy people are. They are a result of health service activity and also other influences, such as people s environment and behaviour.
The measures in this report are intended to provide a baseline for monitoring health outcomes - the public health - for the Northern region. North Health, as purchaser of health services for the Northern region, is co-responsible for the state of the public health in the region. Other influences on public health are individual, family, cultural and societal. Monitoring the measures herein will give an indication of North Health s progress in improving the health of its population. It is intended that the results of the monitoring will contribute to determining North Health s purchasing policy.
The relationships between North Health purchasing policy, the process of purchasing services and the different types of monitoring, are shown in Figure 1.
Health of our People / 1 North Health priorities M0H monitors RHA Qualitative indicators performance against Strategic, targeted funding agreement Government North Health priorities (eg Purchasing Plan Health Gain Priority Areas)
Contracts between Funding North Health and agreement providers
RHA monitors provider 1 Qualitative and quantitative performance against I indicators contracts Provider Broader, more comprehensive outputs
measures and targets - Health monitoring outcomes
Figure 1 National and regional health service monitoring
Health outcome monitoring in New Zealand Previous goal and target setting exercises for public health in New Zealand include the New Zealand Health Charter and associated targets for reductions in the rate of diseases and risk factors . The Public Health Commission initially set targets based on these but subsequently, in a number of papers giving policy advice to the Minister of Health, has suggested a total of 58 numeric targets for health outcomes covering a range of areas of public health interest. The second of the Public Health Commission s reports on the state of the New Zealand public health, Our Health Our Future (1994), described progress towards some of these targets. In 1995 the Public Health Commission was disestablished, but published a report on progress towards the health outcome targets which had been set. The Public Health Commission s reports and policy advice papers are listed in Appendix 1.
Preparation of this report The health outcome measures and targets defined by the Public Health Commission were used as the starting point for this report and areas where measures had not been defined were identified. Other New Zealand and international reports about monitoring and target setting for public health were reviewed and measures which were potentially useful for North Health were noted2 3 4 5. Other teams within North Health, public health providers and other groups and individuals in the community were invited to comment on the resulting list of possible measures which covered the main areas of public health concern.
The group of measures shown in this report was decided upon following these comments, while balancing the importance of monitoring certain specific issues, maintaining fairly broad coverage and limiting the overall number of measures. Not all measures are direct measures of health outcome because this information is not available for many health issues. However, the measures chosen are either measures of health outcome or measures which have a close relationship to health outcomes.
Health of our People / 2 These measures are not intended to be comprehensive, that is they are not intended to cover all possible public health issues. Instead they aim to give an indication of whether or not the population s health is improving and, if not, in which groups of people or areas of health the main problems lie. Nor are the measures intended to give complete information about the issues they address. They are markers of health status in different areas: for any measure that was found to change for the worse during monitoring, more detailed investigation would be necessary to define the cause of such change and identify likely remedies.
Targets were set for 17 measures, particularly where the measure addressed a priority issue for North Health. Targets are quantified: time limited objectives which show the direction and amount of change which North Health is seeking in aspects of public health. In order to set a target, good baseline information on the current level of the measure, and preferably information about trends in the measure over the last few years, was necessary.
Structure of this report The remainder of this report consists of some basic demographic information about the people in the Northern region, a brief discussion of the main issues relating to the measures and targets, a table showing the targets for public health and a discussion of each measure and associated targets where relevant. Finally, some measurement and monitoring -related issues for the future are noted.
Comments North Health welcomes comments from readers and these should be directed to:
Manager, Public Health North Health Private Bag 92 522 Wellesley St Auckland
Health of our People / 3 2. The People of the Northern Region
The Northern region includes the Auckland region (divided into north, west, central and south Auckland health districts) and Northland. At the 1991 Census there were approximately one million and eighty thousand people living in this region, 51% of whom were female and 49% male. 23.2% of the population was under 15 years old and 10.5% was over 65; with Northland and south Auckland having the highest proportions of children, and central and north Auckland the highest proportions of older people. For the Northern region as a whole, approximately 71% of the population were European, 13% Maori, 10% Pacific Islands people and 6% were of other ethnic groups. The proportion of Europeans varied from 61.5% in south Auckland to 88.7% in north Auckland; of Maori from 5.5% in north Auckland to 28.2% in Northland; and of Pacific Islands people from 0.3% in Northland to 15.6% in south Auckland. The highest proportion of others was 9.4% in central Auckland where the most common ethnicity among those in this group was Chinese. Further details of the demographic characteristics of people living in the Northern region are available in three booklets available from North Health6 7
Health of our People / 4 3. Measures and Targets for Public Health in the Northern Region
This section includes some general comments of relevance to all the measures which are defined and discussed in sections 4 to 6.
For each measure a brief comment is included which describes the measure, how it is derived and measured, what the baseline is and whether or not it has associated targets and, if so, what they are. In many cases fuller background information and references are available from one of the Public Health Commission publications listed in Appendix 1. Appendix 2 shows the information sources used for the measures shown in this report.
Most measures are shown for different age groups. The age groups were chosen to reflect the groupings used by the Minister of Health in the Service Obligations 9, which define the public health services which regional health authorities are to purchase. These are children (up to age 14), young people (aged 15 to 24 years), adults (aged 25 to 64 years) and older people (65 years and older). For some measures slightly different ranges of ages are used; this is noted where relevant.
In some cases, particularly where there are marked differences in the level of a measure in different geographic areas, ethnic groups or genders, the level of the measure in the relevant sub groups is also shown. The ethnic groups used for comparison are Maori, Pacific Islands people and others . The others category includes all other ethnic groups, but is predominantly New Zealand European / Pakeha.
Where relevant, where a measure is shown for different sub groups, the numbers shown are directly age standardised to the Segi world population structure so that the sub groups can be compared. This is consistent with the Public Health Commission reports, but it should be noted that the use of this population for standardisation gives less emphasis to disease occurring in older age groups.
Age specific and age standardised hospitalisation and mortality rates are calculated over a five year period, with mortality data being from 1988 to 1992 (calendar years) and hospitalisation data from 1989/90 to 1993/94 (financial years).
A number of the measures relating to specific health outcomes use the data routinely collected by the New Zealand Health Information Service about deaths and hospitalisations, which are known to have some drawbacks. One of the problems with using death and hospitalisation data is that they do not reflect the full range of health experiences, even for people who have particular diseases. Deaths from a disease are the severe end of the spectrum of disease experience, and rates may change for a variety of reasons. These include there being less disease in the community, better treatment availability, changes in the way that causes of death are assigned. Hospitalisations, as well as being only part of a person s disease experience, are affected by factors other than the amount of disease in the community. For example, an increase in hospitalisations for a certain condition may reflect a change in admission policy, a trend away from managing the condition at home by primary health care providers, or improved access to hospital care; or it may indicate an increase in the amount or severity of disease in the community.
Hospitalisation and death data are also affected by the way in which the data are coded. Some diseases such as diabetes may be the underlying cause of a person s health problems but the primary diagnosis which will be coded is the leg ulcer or heart attack which led to
Health of our People / 5 their admission to hospital. Therefore routine data will underestimate the real number of deaths and hospitalisations caused by diabetes.
Another important piece of information included in the hospitalisation and death data is ethnicity. It is known that because of the way in which ethnicity is collected for the death data, death rates for Maori are underestimated - in some cases by a substantial amount. Ethnic coding for hospitalisation data is probably more accurate but may still lead to miscounting of hospitalisation rates for some ethnic groups. Work is in progress to improve the specification and coding of ethnicity for both hospitalisation and death data. Traditionally, the denominators used for calculating ethnic-specific death and hospitalisation rates have been the sole ethnic origin definition of Maori for calculating mortality rates and the mixed definition for hospitalisation rates. These are the denominators used in this report.
Despite these problems with hospitalisation and death data, they are used in a number of the measures in this report because of the lack of other regularly collected population-based data. Better data for some measures may become available in the future if regular, consistent population-based surveys are carried out, such as the National Health Survey planned for 1996.
Only one ethnic-specific mortality target is set: for Maori sudden infant death syndrome (SIDS) mortality rates. This target has been set because the rate of SIDS is very high in Maori and has remained high during a time when the rate in other ethnic groups has declined. However, as ethnic coding for mortality data improves, measured Maori mortality rates will increase regardless of whether the true rates increase or decrease. When ethnic coding is satisfactory for mortality data, then more ethnic-specific targets could be set on the basis of the ethnic-specific rates.
North Health recognises that some of the measures used are not an ideal reflection of the public health issue which they are designed to monitor. However, better measures are not currently available, so it has been decided that it is better to monitor these imperfect measures and investigate any changes in their levels rather than not monitor those areas of public health at all. For some measures very little information for the Northern region is available, but they have been included because of their importance to public health. Identification of gaps in available information will contribute to the future development of information systems by North Health.
Health of our People / 6 3.1 Targets
Table 1 shows the targets set for public health measures in this report. Subsequent sections define and discuss all the measures and targets.
Table I Targets for public health
Measure Baseline Target Hospitalisation rate for childhood poisoning in the 0 124.3 (1989-91) 87.0 by year 2000 to 5 years age group (per 100,000) Full breastfeeding at three months (%) 49(1994/5) 57 by year 2000 Proportion of people eating at least five servings 32-57 (1990) 75 by year 2000 each day of vegetables and fruit (%) Proportion eating at least six servings each day of 45(1990) 75 by year 2000 breads and cereals (%) Proportion of people aged over 15 years who 23 (1992/93) 20.7 by year 2000 smoke cigarettes Proportion of Maori who smoke cigarettes (%) 44 (1992/93) 40 by year 2000 Proportion of women who smoke during pregnancy 23.3 (1994/95) 21 by year 2000
Proportion of young people who drink heavily at Women 19, Men 29 Women 17, Men 26 least once a week (%) (1990-94) by year 2000 Proportion of adults engaging in frequent exercise Women 54, Men 50 Women 59, Men 55 (%) (1993/94) by year 2000 Proportion of children with completed early 55.4 (1992) 70 by 1996, childhood immunisation by the time they are two 85 by year 2000 years old (%) Incidence rate of acute rheumatic fever in 5 to 14 21(1991-94) 15.8 by year 2002 year old children (per 100,000) SIDS mortality (per 1,000 live births) 1.99 (1988-92) 0.8 by year 2000 Maori SIDS mortality (per 1,000 live births) 5.57 (1988-92) 2.2 by year 2000 Age standardised death rate from ischaemic heart Women 83, Women 55, Men disease (per 100,000) Men 176 (1988-92) 117 by year 2000 Breast cancer mortality in 50 to 69 year old women 82.8 (1989-93) 58.0 by year 2002 (per 100,000) Proportion of invasive melanoma cases diagnosed 75 and treated at a thickness level of less than 0.76mm (%) Number of missing and filled teeth for Form Two 0.96-1.43 Less than I per children child
Health of our People / 7 4. Measures of General Health Two measures of general health give an overview of the health of different populations within the Northern region. These measures directly assess the quantity of life rather than its quality , although in general as social and economic conditions and health overall improve, so do these overall measures. In a developed country like New Zealand, where the social and economic conditions are quite high, health service interventions by themselves could probably make only a small impact on these measures.
4.1 Under-five mortality
Measure:
This is the overall measure of child health used by Unicef when comparing the state of the world s children in different countries5. The Unicef goals for the year 2000 include a one third reduction in 1990 under-five mortality (or to 70 per 1,000 live births, whichever is less).
This measure is the number of deaths in under-five year olds in a population for a given time period, divided by the number of live births in that population in the same time period. It is expressed as deaths per 1000 live births. Table 2 shows the average under-five mortality for the Northern region for 1988 to 1992. The Maori under-five mortality is 1.7 times that for non-Maori.
Table 2 Under-five mortality; 1988-1992 Number of deaths Rate per 1000 live births Total 1032 10.3 Maori 191 15.9 Pacific Islands 163 9.8 Other 678 9.5
Source: New Zealand Health Information Service
Health of our People / 8 4.2 Life expectancy
Measure:
Life expectancy reflects a population s overall level of health.
Life expectancy at birth in 1992 is the average number of years a group of people born in 1992 would live if they experienced the 1992 age-specific mortality rates through their lives (for example when they were 50 they experienced the mortality rate which 50-year -olds were experiencing in 1992). Table 3 shows the life expectancy in 1992 for Maori and non- Maori men and women in New Zealand and in the Northern region, adjusted (by Statistics New Zealand) for the estimated under-reporting of Maori deaths.
Maori men have the shortest life expectancy at about 68 years, while non-Maori women on average can expect to live until they are 80 years old.
Table 3 Life expectancy at birth in 1992 (years) Women Men New Zealand Maori 73.0 68.0 Non-Maori 80.0 73.2 Northern Region Maori 75.0 68.8 Non-Maori 80.2 73.3
Source: New Zealand Health Information Service
Health of our People / 9 5. Determinants of Health
5.1 Socioeconomic Health outcomes in New Zealand and other countries vary according to social and economic circumstances, with the worst off having poorer health. The nature and possible explanations for this variation are explored in Chapter 1 of the Public Health Commission publication Our Health Our Future 1994.
The four measures shown below are not independent, but all have known associations with health status. They should be monitored as an indication of trends in the social and economic conditions which will predispose populations to overall improvements or deteriorations in health. It is not appropriate for the Regional Health Authority to set targets for these measures since they are not amenable to change through health service interventions.
Unemployment
Measure:
This measure is the percentage of over-15-year-olds who want to work but who are not working. It includes people unsuccessfully seeking both part-time and full-time work. Some information is gained from the Household Labour Force Survey, which produces quarterly statistics on unemployment by age and ethnic group nationally, and a figure for regional unemployment. The Census can give ethnic and age-specific figures regionally, but is only available every five years.
Table 4 shows the percentage of the labour force unemployed for different age and ethnic groups nationally and for the regional council areas in the Northern region, for the September 1995 quarter of the Household Labour Force Survey. Figure 2 and Figure 3 show how some of these figures compare with those for the previous 8 quarters. Unemployment has been decreasing over this period in all groups except the other ethnic group.
Recent age- and ethnic-specific figures are not available regionally but, at the 1991 Census, 6% of the Northern region population were unemployed, with the highest unemployment in Northland and the lowest in North Harbour. Unemployment rates in the local authority areas within the Northern region ranged from 3.9% to 6.4% for Europeans, from 9.8% to 16.3% for Maori, and from 5.7% to 15.6% for Pacific Islands people, confirming that the pattern of ethnic group unemployment shown by the Household Labour Force Survey applies in the Northern region.
Health of our People / 10 Table 4 Unemployment: percentage of labour force unemployed; September quarter 1995 Unemployed All 6.1 Women 6.2 Men 6.0 Young people 11.2 Adults 4.5 Maori 15.1 Pacific Islands 14.1 Pakeha 4.3 Other 11.5 Northland 9.3 Auckland 5.3
seasonally adjusted Source: Household Labour Force Survey, Statistics NZ
Health of our People / Figure 2 Unemployment: young people (national), Northland, Auckland (all ages); 1993-1995
16
14
12 a, 10 • Young C. people a,E c 8 .Northland
£ Auckland
CL
2
0 1993 Sep 1994 Mar Sep 1995 Mar Sep Quarter
Source: Household Labour Force Survey, Statistics NZ
Figure 3 Unemployment: ethnic groups (national); 1993-1995
30
25
a, 20 C. E a) 15
C a, 10 a, 0 5
0
1993 Sep 1994 Mar Sep 1995 Mar Sep Quarter
Source: Household Labour Force Survey, Statistics NZ
Health of our People 12 Housing
Measure:
The main aspects of housing thought to affect health are the physical state of the housing and whether it is overcrowded . Neither of these characteristics is routinely reported nationally or regionally. The Social Policy Unit of the Family Centre, Anglican Social Services, Lower Hutt undertook surveys in 1992 and 1993 where serious housing need was defined in terms of affordability, housing conditions, overcrowding and associated problems10. The size of Housing Corporation waiting lists and estimates of the proportion of households in serious housing need who were on waiting lists were used to estimate the total number of households with serious housing need. Using the data and methodology described in the Family Centre report, estimates can be derived of the number of households with serious housing need for the Northern region. These estimates are 20,000 households in 1992 and 26,000 households in 1993.
The Ministry of Housing also produced a report on this issue in 199411. Using a different methodology and defining serious housing need as the sum of inadequate housing and unaffordable housing , the Ministry report estimated the total number of households in serious housing need in the country as 20,000 to 30,000. If these households were distributed according to population numbers then North Health, with approximately. 32% of the country s population, would be expected to have 6,400 to 9,600 households in serious housing need, using the Ministry of Housing s definition. A second Ministry of Housing report, not including households in unaffordable housing , estimated a total of 15,700 homeless households in New Zealand12.
Better measures of the aspects of housing with impacts on health are required for ongoing monitoring.
Health of our People / 13 Income
Measure:
Income affects health through its effect on the standard of housing, food, education etc which can be purchased, and also through its effect on the use of health services.
Total household income is probably the most important indicator of income and is available from the five-yearly Census. In 1991, approximately 30% of the households in the Northern region who reported their income had an income of $20 000 or less. Approximately 30% of those reporting their income had an income of more than $50 000. 15% of the households in the region did not report their income.
Table 5 shows the proportion of households in the five health districts of North Health whose income was below $20,000 or above $50,000 in 1991. Northland had the highest proportion of low-income households and the lowest proportion of high-income households whereas the opposite was true for North Harbour.
Table 5 Income: percentage of households with incomes of less than $20,000 and more than $50,000; 1991 Households with income Households with income of less than $20,000 of more than $50,000 Northland 40.3 16.8 North Harbour 24.0 37.4 West Auckland 25.1 31.8 Central Auckland 29.7 33.2 South Auckland 25.5 34.0 North Health overall 28.3 32.0
Source: Statistics NZ
Health of our People / 14 Transport
Measure:
In the absence of widely-available, comprehensive public transport, access to a car affects access to opportunities for recreation and physical exercise, to a range of food, as well as to preventive health services and treatment services. Table 6 shows by district the proportion of households with access to a car at the 1991 Census. People living in central Auckland are least likely to have access to a car but they are perhaps more likely to have access to public transport. 12% of Northland households and 11% of south Auckland households do not have access to a car.
Table 6 Transport: percentage of households with access to at least one car; 1991 Access to at least one car Northland 88 North Harbour 91 West Auckland 91
Central Auckland 1 83
South Auckland 1 89
Source: Statistics NZ
Health of our People I 15 5.2 Hauora Maori
Both measures in this section are of cultural affiliation, a starting point for the holistic Maori view of health status.
Iwi/hapu affiliation
Measure:
While affiliation with a non-iwi/hapu Maori organisation may be as relevant to cultural affiliation and health status as iwi/hapu affiliation, no comparable measures of affiliation to such groups are available.
The 1991 Census asked people who had any New Zealand Maori ancestry to identify their main iwi, with the option of answering don t know my iwi and do not belong to an iwi . Table 7 shows the proportion of people who identified a main iwi or hapu for the health districts in the Northern region.
Table 7 Iwi/hapu affiliation (%); 1991 Proportion of people with Maori ancestry with iwi/hapu affiliation Northland 80.8 North Harbour 63.2 West Auckland 68.5 Central Auckland 70.6 South Auckland 76.4 North Health 74
Source: Statistics NZ
Kohanga reo
Measure:
Attendance at kohanga reo is an indication of Maori parents desire not only to use early childhood education but, more particularly, to involve their children and possibly themselves in learning te reo. It is an element of whanau health.
This measure is the proportion of Maori children under five who are enroled in kohanga reo. Information supplied by Te Kohanga Reo National Trust Boards Mokopuna Oranga Pumau statistics shows that in Tai Tokerau (Northland) 1628 children (32.6%) of Maori children under five attended Te Kohanga Reo in July 1995. In Tamaki Makaurau (Auckland region), 2500 children (16.5%) of Maori children under five attended.
Health of our People / 16 5.3 Physical environment
Hazardous substances
Measure:
Hospitalisation due to poisoning in the 0 to 5 year age group was recommended by the Public Health Commission as a measure of the health effects of hazardous substances. Information for this measure is available and the link to health status is clear. Poisoning is one of the two major causes of unintentional injury requiring hospitalisation among one to four year olds. For other aspects of hazardous substances control, either there are no clear links between the substance and specific health outcomes or data on the health aspects is not available.
This measure is the hospitalisation rate for all unintentional poisonings ( drugs, medicaments and biologicals and other solids, liquids, gases and vapours ) in the 0 to 5 year age group. Table 8 below shows rates of hospitalisation for poisoning for different ethnic groups in the Northern region, for 1989-1991 and for 1993/94 (the most recent available). Figure 4 shows trends in hospital discharges for poisoning over five years, indicating no clear trend in rates over that time.
Hospital admissions for childhood poisoning are known to underestimate the actual number of incidents of poisoning since many children receive treatment from a general practitioner or hospital emergency department without requiring admission to hospital. For example, analysis of cases of poisoning seen in the Auckland Hospital accident and emergency 13 department showed that 64% were recorded as being admitted to hospital.
Only cases admitted to hospital are represented in the available routine data . However, as long as admission policies are consistent over time, the routine data should be valid for demonstrating trends. Data illustrated in Table 8 and Figure 4 do not include children admitted but not kept overnight in hospital (day cases), since a change in admission policy at the Starship Children s Hospital between late 1992 and late 1994 caused an apparent sharp rise in day cases during that period. However, for the years from 1995 it would be useful to include the data for all hospitalisations for poisoning in both the measure and the target.
Table 8 Unintentional poisoning: hospitalisations for children aged 0 to 5 (per 100,000); 1989-1993 Average, 1989190 to 1991/92 1993/94 Total 124.3 135.3 Maori 120.6 213.1 Pacific Island 60.3 60.3 Other 142.8 127.2
Source: NZHIS
Health of our People / 17 Figure 4 Unintentional poisoning: hospitalisations for children aged 0 to 5; 1989-1993
250
200
0 150 I-overall ---Maori .--- Pacific Island CL o 100 Other
50
0 1989-90 1990-91 1991-92 1992-93 1993-94
Source: NZHIS
Target:
The PHC target for childhood poisoning was for a 30% reduction by the year 2000, using the average of 1989-1991 rates as the baseline. The overall baseline for the Northern region defined in this way is 124.3 per 100,000. Baseline rates for different ethnic groups are shown in Table 8.
Although the overall rate in 1993/4 is higher rather than lower than the baseline, figures from individual years are based on small numbers and should be treated with caution. The three- year average for 1991-1993 is 118.4, a slight reduction from baseline. Rates for Maori and Pacific Islands children from individual years are based on very small numbers and data from further years are required before concluding that there has been a large increase for Maori children from the baseline to 1993.
Health of our People / 18 Drinking water
Measure:
The Drinking Water Standards for New Zealand 1995 specify sampling regimes and the essential microbiological criteria which any water supply must meet to comply with the Standards. Supplies must also meet supply-specific criteria for other microbiological and chemical determinants to be classed as compliant. However, the latter criteria are set based on monitoring results from the first year of the specified sampling regime, so are not yet defined.
This measure is the proportion of households in the Health Districts in the Northern region which have access to water from a supply which meets the sampling and microbiological criteria of the Drinking Water Standards for New Zealand.
The most recent information about drinking water quality comes from a survey by the 14 Institute of Environmental Science and Research (ESR). This was a survey by health protection officers to obtain information about the adequacy and results of microbiological monitoring of water supplies by Crown health enterprises, territorial local authorities and other organisations responsible for water supply throughout the country. The 1994 results assess compliance with the 1984 drinking water standards, which define microbiological quality criteria and sampling frequency. A supply which is non compliant may be so because of inadequate sampling or because of microbiological contaminants.
In 1994, no supplies in the Northern region which were sampled adequately failed to comply because of microbiological contamination. However, supplies which failed to comply because of inadequate or no sampling cannot be assumed to be free of microbiological contamination simply because no contaminated samples were found.
Table 9 shows the proportion of the population served by complying, non-complying and unmonitored supplies and those whose status is unknown. The total populations used by ESR for these estimates is in most cases lower than that estimated from the 1991 Census, particularly in Northland and south Auckland. This probably reflects a number of people in these areas whose drinking water is from a supply not included in the health protection officers survey replies. Presumably many of these people s water is from very small supplies or from private collections such as bores or roof water. The quality of water from these supplies is unknown but a study is proposed to measure roof water collection.
If it is assumed that water from supplies which health protection officers did not identify does not comply with the drinking water standards, then the proportion of the population in Northland with access to water from a complying supply falls to 37.7%, in south Auckland to 83.1% and in North Health overall to 84.3%.
Health of our People / 19
Table 9 Drinking water quality: compliance of water supplies with the 1984 drinking water standards for New Zealand: percentage of population served by type of supply; 1994 Complying Non- Supply not Status of supply complying monitored supply supply unknown Northland 59.4 0.6 32.9 7.1 North Harbour 88.9 0 0.1 11.0 West Auckland 98.4 0.8 0.8 0 Central Auckland 100 0 0 0 South Auckland 96.1 0 3.9 0 North Health overall 93.3 0.2 4.0 2.6
Source: Water Group, ESR, Christchurch Science Centre
Sewerage
Measure:
Sewage treatment reduces the hazards of contamination of coasts and waterways, reducing the health risks of bathing and gathering food from the water, especially shellfish. This measure is derived by ascertaining the number of households served by reticulated sewerage systems and dividing that by the number of households in the region. This information is held by territorial local authorities and is not easily broken down by health district. Therefore Table 10 shows the proportion of households connected to reticulated sewerage for the district council areas of Auckland, while for Northland the figure is the proportion of people in the Northland Regional Council are who live in census area units with reticulated sewerage connections.
Table 10 Sewerage: percentage of households connected to reticulated sewerage; 1996 Connected to reticulated sewerage Northland Region 59 Rodney District 63 Waitakere City 90 North Shore City 99 Auckland City 100 Manukau City 95 Papakura District 87 Franklin District 39
Information supplied by relevant regional councils or local authorities
Health of our People / 20 Air quality
Measure:
Although air pollutants are known to cause health effects in high quantities and especially for the very young, older people and those with respiratory disease, at present there are no health outcomes which are solely caused by air pollution. Therefore direct monitoring of the health effects of air quality is not possible except where there are discrete episodes of heavy pollution. The air quality guidelines 15 define levels of air pollutants which are thought to provide for the protection of the health of the general population.
In Northland, monitoring of air pollution was carried out in Whangarei in June to August 1994 and in Kaitaia and Dargaville in June to August 1995. Only carbon monoxide was measured in the three Central Business District (CBD) sites, while Nitrogen Dioxide, Particulates and lead were also measured in another Whangarei site. The only pollutant which exceeded the Ministry for the Environment guidelines was carbon monoxide in the CBD site in Whangarei. The guideline for an eight-hour average was exceeded for about 5% of the monitoring period.
There are 10 sites in the Auckland region where ambient air quality is monitored by the Auckland Regional Council. The samples are tested for a range of pollutants. From 1991 to 1994 there were an average of 13 exceedances of the guideline for an eight-hour average of carbon monoxide per year at the Queen Street site. In 1995, to the end of July there were six exceedances of the eight-hour guideline and five of the one-hour guideline in Queen Street, and two exceedances of the eight-hour guideline in Dominion Road.
Current air quality monitoring is insufficient to give a good indication of likely health outcomes.
Health of our People / 21 5.4 Food and nutrition
Breast feeding
Measure:
Breast feeding, as well as providing a nutritionally balanced diet for young babies, is known to be protective against sudden infant death syndrome and some infectious diseases.
This measure is the proportion of three-month-old children who are being fully breast fed. Some information is currently collected by the Royal New Zealand Plunket Society, but in places where many women do not use Plunket services their data will not reflect breast feeding rates overall. Plunket estimates that in 1994/5 they saw 95% of new born babies and 82% of three-month-old babies in the Northern region. These figures can not be broken down by health district, but anecdotal evidence suggests that Plunket sees a lower proportion of babies in Northland than in Auckland.
Table 11 below is derived from the information collected by Plunket for the year 1 July 1994 to 30 June 1995. Plunket areas do not coincide exactly with the health districts, but have been grouped together for the purposes of this table to approximate the districts within North Health. For all districts and for North Health as a whole, Maori have the lowest rate of full breast feeding and Pakeha have the highest rate. Northland has the highest rate of breast feeding for all ethnic groups, while west Auckland has the lowest overall for both Maori and Pakeha. An alternative estimate of breast feeding rates in part of Northland is available from Hauora Hokianga, which reports that 94% of six-week-old babies in the Hokianga were breast fed in 1994/5. The comparable Plunket figure for the Northern region is 72.5% exclusively breast fed and 11.8% partially breast fed at the first Plunket visit (two to six weeks old).
Table 11 Breast feeding: percentage of three-month-old children fully breast fed; 1994/95 Total in Maori Pakeha Pacific Other district Islands Northland 56.6 42.9 62.4 100 56.3 North Harbour 53.8 40.8 56.0 50.7 43.5 West Auckland 44.4 29.9 47.3 44.8 40.6 Central Auckland 52.2 37.5 61.7 44.3 39.5 South Auckland 45.0 34.0 51.2 46.4 38.5 North Health 49.2 35.9 55.3 45.6 40.3
(very small numbers) Source: Royal New Zealand Plunket Society
Health of our People I 22 Target:
The baseline level of full breast feeding used by the PHC is 60% in 1991, with a target of 70% six years later in 1997. North Health has a lower baseline, but using the same percentage increase gives a target of:
In the future it is anticipated that there will be a well child database, whereby some information will be provided by all well child care providers, and this should include the feeding method being used. This will provide more complete information to monitor progress towards this target for the Northern region.
Food safety
The microbiological quality of food is important for health. However there is no satisfactory measure of food safety for which information is available. There is no ongoing random or consistent food-testing programme, so an increase in samples exceeding microbiological guidelines might mean more contamination or better targeting of sampling regimes. A measure which may be useful is the proportion of food manufacturing premises which have food safety plans . This information is not currently available but may be in the future.
Better measures of the aspects of food safety with impacts on health are required for ongoing monitoring.
Health of our People / 23 Healthy diet
Measures:
Nutrition is an important risk factor for a number of diseases, such as ischaemic heart disease, stroke, diabetes and some cancers. Fat intake in particular is a risk factor for all these diseases. However, accurate estimates of measures of fat intake - such as the proportion of total energy provided by fat - require a very detailed dietary survey. Fruit and vegetables and many breads and cereals tend to be low in fat, high in complex carbohydrates and dietary fibre. Eating more fruit and vegetables may be protect against ischaemic heart disease and cancer. Fruit and vegetable and bread/cereal intake, in number of servings per day, can also be assessed more easily than the measures of fat intake. This is why the number of servings of fruit/vegetables and of bread/cereals have been chosen as the measures of a healthy diet.
The New Zealand Food and Nutrition Guidelines recommend at least five servings of fruit and vegetables and at least six servings of bread and cereals per day. This measure assesses by age group the proportion of people who eat these quantities.
The Life in New Zealand survey, conducted by the Hillary Commission in 1989-1990", found that 32-57 of the population ate at least five servings of fruit/vegetables daily and 45 ate at least six servings of bread/cereals daily.
Target:
North Health endorses the PHC targets for healthy diets, which are:
Adult men are the furthest from the target for fruit and vegetable consumption. The National Health Survey planned for 1996 should provide information to enable updated estimates of fruit/vegetable and bread/cereal intake in the Northern region. Future estimates will require repeated population-based surveys.
Health of our People / 24 5.5 Tobacco and alcohol
Tobacco use
Measures:
Smoking is an important risk factor for a number of diseases including lung cancer, bronchitis and emphysema, heart attack and stroke, arterial disease and sudden infant death syndrome. Maori have higher rates of smoking than non-Maori, and the highest recorded rates of lung cancer in the world.
This measure is the proportion of each group who describe themselves as current smokers . Rates of smoking among different groups were measured in the 1981 Census, the 1992/93 17 Household Health Survey and other smaller surveys. Information is available from the 1993/94 Auckland University Heart and Health Study for non-Maori and non-Pacific Islands People who smoke more than five cigarettes a day in the Auckland area. This showed among 35 to 64 year olds, 13.7% of women and 16.6% of men smoked; whereas among 65 to 84 year olds, 5.3% of women and 9.2% of men smoked.
National figures from the 1992/93 Household Health Survey are shown in Table 12 because the National Health Survey in 1996 is likely to use a similar methodology, enabling analysis of trends. Generally, men smoke more than women, except for young people. Figure 5 shows figures for different ethnic groups from the same source (age/gender standardised to the survey population), illustrating the higher rate of smoking amongst Maori.
Maternal smoking figures are available from the Plunket SIDS Risk Factor Survey for 1 July 1994 to 30 June 1995. Information is not available about smoking during pregnancy, but Plunket collects information on parental smoking at four to eight weeks of age. In New Zealand as a whole, 21 .6% of mothers and 29% of fathers smoked. For the Northern region, 23.3% of mothers and 28.1% of fathers smoked. Figure 6 shows the figures by area (approximately but not exactly the health districts). As would be expected given the ethnic differences between districts, Northland has the highest rate of parental smoking, followed by south Auckland.
Health of our People / 25 Table 12 Smoking: national percentages of people over 15 years who describe themselves as current smokers ; 1992/93 All Women Men All ages 23 22 24 Young people - 24 27 22 Adults 24-27 23-26 24-29 Older people 16 11% 19% range of values shown because the House Health Survey used ifferent age mthis report Source: 1992/93 Household Health Survey
Figure 5 Smoking: Age/gender standardised percentages of ethnic groups who describe themselves as current smokers ; 1992/93
45% -
40%
35%
30%
25%
20%
15%
10%
5%
0% Overall Maori Pacific Island Other
Figure 6 Parental smoking: percentages by district of mothers and fathers who smoke; 1994195
40% ] Smoking 35% mother
30% • Smoking E father 25% 0 20% 0 15%
10% IL 5%
0% Northland North West Central South Harbour Auckland Auckland Auckland
Health of out People / 26 Target:
The PHC targets for current smokers used higher baselines than the figures shown above, and aimed for a prevalence of smoking of 20% among young people and adults and 40% among Maori - a reduction of between one quarter and one third between 1993 and the year 2000. However, there has been little change in the last three or four years in the proportion of smokers in the population aged over 15 or in the rate of smoking of different ethnic or age groups18. It has been suggested that tobacco consumption will not reduce towards the levels suggested in the PHC targets without large increases in tobacco taxation19.
Since the National Health Survey in 1996 is likely to use a similar methodology to the 1992/3 Household Health Survey, it is appropriate to use the Household Health Survey figures above as a baseline. North Health s targets are for a 10% reduction between 1992/3 and the year 2000 - still a change from the current trend, but more achievable than the PHC s 25% to 35% reduction.
For maternal smoking, the PHC set targets for smoking in pregnancy of reductions to 20% overall and 50% for Maori women, by the year 2000. North Health targets use Plunket data which is for smoking in the first few weeks of the baby s life, and are not broken down by ethnicity. The target is for a one tenth decrease from 1994/5 to the year 2000.
age/gender standardised to the 1992/3 Household Health Survey population
The National Health Survey planned for 1996 should collect information to enable updated estimates of smoking prevalence in the Northern region. The planned well child database (see section 5.4: Breast feeding), and the similar planned perinatal database which will collect information from providers of maternity care, should enable ongoing monitoring of maternal smoking, including smoking during pregnancy and figures for different ethnic groups. It may become appropriate to alter these targets on the basis of this data when it becomes available.
Health of our People / 27 Heavy drinking of alcohol
Measure:
Although small amounts of alcohol appear to confer protection against coronary heart disease, alcohol consumption above light to moderate levels is associated with a range of mental and physical health problems. These include traffic accidents and other unintentional injury, domestic violence and other assaults, alcohol dependency disorders, unsafe sexual practices and cirrhosis of the liver. There is a strong correlation between the mean consumption of alcohol in a population and the prevalence of heavy drinking, and a population approach to reducing alcohol-related harm uses strategies to reduce the overall level of drinking alcohol. The relevant measure is the per capita consumption of alcohol. However, this measure can only be calculated nationally, so North Health has chosen instead to monitor the proportion of people who drink heavily.
There is a relationship between increased alcohol intake and negative health effects, so it is appropriate to monitor the proportion of people who drink heavily . However, it is not possible to identify a safe level of alcohol intake for individuals, and the levels noted in the measure should not be interpreted as recommended or safe levels of intake.
This measure is the proportion of drinkers in each age group who drink heavily at different frequencies. Baseline data shown in Table 13 is from telephone surveys undertaken by the Alcohol and Public Health Research Unit (APHRU) at the University of Auckland 20. The numbers shown are the average for the years 1990 to 1994, for people living in the Auckland toll free calling area. Because of the sampling frame (households with a telephone) and small numbers, no ethnic breakdown is possible with this data. No recent data are available for Northland.
Although self reporting of alcohol consumption may produce an under-estimate of actual consumption levels, use of the same methodology will enable comparison of consumption over time.
Figure 7 and Figure 8 show the trends in heavy drinking for women and men aged between 14 and 65 over the years 1990 to 1994. There has been little change over this period in the proportion of drinkers who drink heavily.
Table 13 Heavy drinking: percentage of people who drink heavily; 1990-1994 Drink heavily at Drink heavily at Drink heavily at least once a week least once a month least once a year Women 14-24yrs 19 43 76 25-65yrs 7 19 54 Overall 10 25 59 Men 14-24yrs 29 50 78 25-65yrs 14 30 64 Overall 18 35 68 Source: Alcohol and Public Health Research Unit
Health of our People / 28 Figure 7 Heavy drinking: proportion of women drinking more than four units of alcohol weekly, monthly and annually; 1990-1994
70%
60%
50% --- Weekly 40% _.-__Monthly Annually 30%
20%
10%
0% 1990 1991 1992 1993 1994 Frequency of drinking more than 4U of alcohol
Figure 8 Heavy drinking: proportion of men drinking more than six units of alcohol weekly, monthly and annually; 1990-1994
70%
60%
50% _WeekIyl 40% -u- Monthly Annually 30%
20%
10%
0% 1990 1991 1992 1993 1994 Frequency of drinking more than 6U alcohol
Health of our People / 29 Target:
The PHC set a target for a 10% decrease in per capita consumption of alcohol between 1992 and the year 2000. Since regional figures for consumption are not available, the North Health target is for a 10% decrease in the proportion of heavy drinkers. In each category of heavy drinking, the highest proportion is amongst young people. Therefore this target is directed at young people and, as a first step, the heaviest drinkers among that group are targeted.
The 1995 APHRU survey will include the whole Northern region, enabling estimates of heavy drinking rates to be made for Northland and well as Auckland. If the National Health Survey planned for 1996 asks questions consistent with past surveys, then its data will enable updated estimates of the prevalence of heavy drinking in the Northern region.
Health of our People / 30 5.6 Violence
Assault
Measure:
Violence is increasingly being recognised as a public health issue. Victims of violence may suffer not only physical injury but also mental health and social consequences. Violence, and particularly domestic violence, was identified as an important issue by the Public Health Commission public consultation in 1993.21
Intentional injury inflicted by others includes injury due to child, partner and elder abuse as well as other assault. There is no one measure which captures all the cases of assault. Police figures include only those where a complaint was made. Hospital admission figures include only those where the injury was severe enough to require hospitalisation and the cause of the injury was identified by hospital staff as assault. Both sets of figures are likely to under report assaults on women and children, where assault may not be reported for fear of reprisal. Assaults leading to minor or no physical injury, which may still be psychologically damaging, are likely to be under reported in the police statistics and will not appear at all in hospital admission statistics.
This measure is the rate of hospitalisation for injuries which are identified as being intentionally caused by others. Although it is not a complete measure of assault, it probably represents the serious end of the assault spectrum reasonably consistently over time.
Baseline measures for 1989-1994 are shown in Table 14. Young people are the age group with the highest rates of injury from assault and Maori are the ethnic group with the highest rates. The rate for Maori young people is 1.4 times that for the nearest other age/gender group, Pacific Islands young people.
Table 14 Injury intentionally caused by others: hospitalisations (per 100,000); 1989- 1993194 Overall Maori Pacific Islands Other Children 76.4 115.9 74.9 63.9 Young people 170.2 319.4 232.4 123.7 Adults 75.9 214.6 188.2 47.5 Older people 10.1 23.7 7.2 9.8 All (Segi age standardised) 151.8 290.2 228.7 112.4
Source: NZHIS
Health of our People / 31
Child abuse
Measure:
Child abuse includes physical, sexual and psychological abuse. Some of the physical injuries will be reflected in the figures in Table 14. However the other effects of child abuse are also, of public health concern. The Children and Young Persons Service of the Department of Social Welfare collects figures on the number of children notified to them as needing help for child abuse or neglect. The service tries to sort out unsatisfactory situations through informal resolution or family group conferences, resorting to court orders only where the other methods are unsuccessful.
This measure is the rate (per 1,000 under-17 year olds) of family group conferences where there is ongoing work for the service. Table 15 shows notification numbers and rates, and the number and rate of family group conferences resulting in ongoing work for the service, for the fiscal year 1994/95. These are not ideal measures of child abuse since they require that the abused child is notified to the service and that staff there consider their involvement appropriate. However, the seriousness of cases where a family group conference is held and it is decided that ongoing input from the service is required is probably consistent in different areas. At present the rate of family group conferences is the best available measure for monitoring purposes. Data from the year from 1 July 1995 suggest that this rate is probably increasing.
Table 15 Child abuse or neglect: notifications and family group conferences, Children and Young Persons Service; 1994/95 Notifications Notifications Family group Family group (number) (per 1,000 conferences conferences children <17) (number) (per 1,000 children <17) Northland 1458 38.6 118 3.1
North Auckland 3066 20.3 302 2.0 (Rodney, Waitakere City, Auckland City) South Auckland 2408 25.3 190 2.0 (Manukau City, Papakura, Franklin)
Source: New Zealand Children and Young Persons Service
Health of our People / 32 5.7 Exercise/obesity
Physical activity
Measure:
Physical activity protects against cardiovascular disease and probably other diseases such as osteoporosis and diabetes, and has been reported to reduce mental illness and promote wellness .
Studies define the relevant level of physical activity differently. The Life in New Zealand Y16 stud found that the 48% of the population who performed high intensity activity at least once in any four weeks, averaged 1.9 hours per week of high intensity activity (work and leisure). The 1992/93 Household Health Survey found that 32% of over-15 year olds reported more than two hours vigorous exercise in the last week. Both surveys found that younger people exercised more than older people and men more than women.
The Public Health Commission s target for exercise used exercise more than twice a week for a total of one hour or more as the measure of frequent physical activity . Using this measure 51% of the population aged over 18 years were participating in frequent physical activity in 1989/90. The American Centers for Disease Control recommend that adults accumulate at least 30 minutes of moderate physical exercise on at least five days per week, or at least 20 minutes of vigorous exercise on at least three days per week.
Table 16 uses 1992/3 data from the Auckland Heart and Health Study. It shows the proportion of each age group which engaged in different levels of physical activity at least once a week in the previous three months, and the proportion meeting PHC and CDC criteria for physical exercise. These figures include only leisuretime activity so, for working age people, are likely to underestimate the total amount of physical activity performed. They confirm that men tend to participate in vigorous physical activity more than women, and younger people more than older. However, when moderate physical activity is included, adult women have higher participation rates than adult men and older men have higher rates than adult men.
Table 16 Physical activity: estimates of the percentages participating frequently; 1993/94
Vigorous activity at Moderate activity Proportion Proportion least once a week in at least once a week meeting PHC meeting CDC last three months in last three months criteria criteria Women 35-64 yrs 30 67 54 35 65-84 yrs 7 73 55 33 Men 35-64 yrs 38 57 50 34 65-84yrs 10 78 66 51 vigorous - physical activity which makes you breathe hard and sweat moderate - other Dhvsical activity Source: University of Auckland (Note: only adults over 35 years were covered in this study)
Health of our People / 33 Target:
The Public Health Commission s target was for a 10% increase in participation in frequent physical activity between 1989 and 1997. Prevention of diseases related to inactivity is maximised by long-term changes in behaviour beginning at least in early adult life. Therefore North Health s target for exercise concentrates on adults. It uses the PHC s definition of exercise.
If the National Health Survey planned for 1996 asks questions consistent with past surveys then its data will enable updated estimates of the proportion of people engaging in frequent exercise in the Northern region. It may become appropriate to alter these targets on the basis of this data when it becomes available.
Health of our People / 34 Obesity
Measure:
Being overweight is a risk factor for death from cardiovascular disease and may increase the risk of diabetes and hypertension, as well as increasing illness from musculoskeletal and respiratory diseases. The prevalence of obesity appears to be increasing amongst non- Maori, non-Pacific Islanders in Auckland.
The usual measure for overweight and obesity is body mass index (BMI), which is calculated /M2). as weight divided by height squared (kg In the 1992/3 Household Health Survey 17, 9% of the population over 15 years old were found to have a BMI over 30, the level usually considered obese . More men than women were obese and those aged 45 to 59 had the highest proportion of obese people amongst the age groups.
Non-European ethnic groups have different mean BMI measures from Europeans, with whom most of the research has been done on the link between BMI and mortality/morbidity. Y22 A recent stud suggests that Polynesians have less body fat at a given BMI than Caucasians. Therefore, it has been suggested that different thresholds for overweight and obesity should be used for different ethnic groups.
This measure is the proportion of different age/ethnic groups who are obese. In line with the South Pacific Commission s recommendations23 the definition of obese is BMI over 32 for Maori and Pacific Islanders and over 30 for other groups.
Table 17 shows the prevalence of obesity for men and women over the age of 35 years, from the Auckland University Heart and Health Study in 1993/4. This study drew its sample from the general electoral roll and included only small numbers of Maori and Pacific Island people. Numbers were too small to calculate the prevalence of obesity for these ethnic groups except in the age group 35 to 64 overall, and even these estimates should be treated with caution since they are based on fairly small samples.
Table 17 Obesity: estimates of prevalence in adults and older people (%); 1993/94 Adults (35-64 years) Older people (65-84 years) Non-Maori, Non-Pacific Island (BMI>30) Women 17.7 Men 13.6 12.5 13.2Overall 15.4 Maori (BMI>32) Pacific Island (BMI>32) 45.6
Source: University of Auckland, Department of Community Health
The National Health Survey planned for 1996 should collect information to enable updated estimates of the prevalence of obesity in the Northern region.
Health of our People / 35 6. Specific Health Outcomes
6.1 Communicable disease
Immunisation
Measure:
The immunisation schedule for children under two years includes immunisation against polio, diphtheria, tetanus, pertussis, Haemophilus influenzae (type b), Hepatitis B, measles, mumps, rubella and, in certain cases, tuberculosis. Most of these diseases were not notifiable until June 1996 so information about the effectiveness of the immunisation programme in preventing them is difficult to obtain. However it is known that high rates of immunisation are necessary to prevent epidemics of these infectious diseases. Prevention of measles epidemics, for example, is thought to require that more than 95% of all children have been immunised against measles. Therefore the proportion of children whose immunisations are complete at two years old is a measure of the success of prevention of the above diseases.
This measure is the proportion of children with completed early childhood immunisation by the time they are two years old, for different ethnic groups. Immunisations may not necessarily have been given on time, but all the relevant immunisations must have been received by the age of two for a child to be counted in this measure. The baseline measures shown in Table 18 are from the results of the 1992 immunisation coverage surveys 24 conducted by the Communicable Disease Centre (175 children in the Northern region) and 25 the Auckland Area Health Board (308 children). Both surveys included small numbers of Maori and Pacific Islands children so estimates for these groups should be treated with caution. However, Maori immunisation rates were estimated as being about half and Pacific Islands rates approximately three quarters those of European children.
An analysis of data from benefit claim forms for June to November 1994 estimated coverage rates for particular vaccination sessions , but could identify neither whether immunisations were given on time nor the proportion of children who were fully immunised 26. Coverage levels for most vaccine sessions ranged from 79% to 87% nationally and from 75% to 93% for the Northern region. The analysis suggested that coverage for the immunisations given in the second year of life has increased since 1992.
A second immunisation coverage survey is planned for 1997. This will enable the figures in Table 18 to be updated. Ongoing information about coverage will require either repeated surveys or may be available if the benefit claim forms are improved to facilitate identification of completeness of cover.
Health of our People I 36 Table 18 Immunisation: percentage of children fully immunised by two years old; 1992 Fully immunised by two years old Northern region 554 North Harbour 51.9 West Auckland" 51.9 Central Auckland" 47.8 South Auckland 55.4
175 children from Northern region; CDC immunisation coverage survey 308 children from the Auckland Area Health Board immunisation coverage survey
Target:
The PHC set a target for immunisation of 85% by 1997 and 95% by 2000. North Health also aims to increase immunisation levels to high levels, but given the low starting levels has set a more achievable target. It is:
Health of our People / 37
Vaccine-preventable diseases
Measure:
As noted earlier, most of the vaccine-preventable diseases were not notifiable until June 1996 so it has not been possible to monitor their incidence. However, the numbers of children who die or are ill enough to require admission to hospital because of these diseases are available from routine statistics and give a measure of the effectiveness of the immunisation programme in preventing disease (rather than solely in delivering vaccine).
This measure is the rate of hospitalisation from measles, mumps and pertussis for children under the age of 15 from different ethnic groups. These diseases have been chosen because they cause cyclical epidemics when immunisation levels are inadequate. Table 19 shows the rate of admission per 100,000 for these three diseases for children in the Northern region for 1993/94. Figure 9 shows trends in hospitalisation rates over the five year period from July 1989 to June 1994. There was only one death from any of these diseases in the Northern region in this five year period. In the future, when vaccine- preventable disease notifications are available, they should be used to monitor the incidence of these diseases.
Table 19 Vaccine-preventable diseases: hospitalisations for children under 15 (per 100,000); 1989-1993
Measles Mumr
Overall 15.8 12.7 24.8 Maori 20.4 11.6 36.2
Pacific Island 31.3 14.9 41.4
10.6 12.6 17.2
Figure 9 Vaccine-preventable diseases: hospitalisations for children under 15 for measles, mumps and pertussis; 1989-1993
70T 0 I- 60
I- C, 50
- . x--- Measles • Murrps JU £ Pertussis CL
1989-90 1990-91 1991-92 1992-93 1993-94
Health of our People I 38 Campylobacteriosis
Measure:
Campylobacteriosis is the most commonly notified food- and water-borne disease in New Zealand. Notification rates are highest for Pakeha/New Zealand Europeans and lowest for Maori and Pacific Islands people. It is not known whether the lower rates of notification are due to Maori and Pacific Islands people having lower rates of disease, being less likely to see a doctor when they get disease, or having doctors who are less likely to notify cases. Of the health districts in the Northern region, Northland has the lowest unadjusted rate while the Auckland areas have similar rates.
This measure is the notification rate for campylobacteriosis for different age groups in the Northern region. Notifications are known to underestimate the true rate of disease because not all people with the disease go to a doctor and not all cases seen by a doctor are notified. However, the proportion of people with the disease who go to a doctor can be assumed to be fairly stable over time, or at least to not cause major fluctuations in notification rate.
Table 20 shows the age-specific notification rate for campylobacteriosis for 1995 for the Northern Region. Rates are lowest among older people but similar for other age groups. Figure 10 shows how rates have changed over time. They have risen over the 1990s, although this trend appears to be reversing in 1995. These changes over time are similar for all ethnic groups and health districts.
Table 20 Campylobacteriosis: notifications (per 100,000); 1995 Children Young people Adults Older pei Northern region 1 229.1 279.3 283.4 131.2
Health of our People / 39 Figure 10 Campylobacteriosis: notifications; 1990-1995
350
300 [-.- Children
0 0 o 250 Young 0 0 people I- C, .-..-_Adults CL C,
.2S. 150 —u--Older (5 people 11::
0 1990 1991 1992 11993 1994 1995
Source: ESR Health
Health of our People / 40 Rheumatic fever
Measure:
Rheumatic fever is a rare complication of streptococcal infection, affecting joints and the heart, and it may cause damage to heart valves. Rheumatic fever is a notifiable disease and cases are also recorded on an area-based register. The incidence of rheumatic fever is highest in the 5 to 14 year age group. Among ethnic groups, rates are highest among Pacific Islands children, with rates in Maori being intermediate between Pacific Islands children and children of the other ethnic group. Nationally in 1993 Pacific Islands children had 28 times the risk and Maori children almost 15 times the risk of rheumatic fever compared with children in the other ethnic group. In 1995, 11 cases of acute rheumatic fever were registered in Northland and in 1994, 38 cases were registered in the Auckland subregion.
This measure is the incidence rate of acute rheumatic fever per 100 000, for 5 to 14 year old children in the Northern region, from the Northland and Auckland rheumatic fever registers. Table 21 shows these rates for five years combined for Northland and the Auckland subregion, and for four years for the North Health region. The five years used for Northland are 1991 to 1995 and for Auckland are 1990 to 1994.
Table 21 Acute rheumatic fever: incidence (per 100,000 5 to 14 year olds); 1991-1995 (Northland), 1990-1994 (Auckland), 1991-1994 (Northern region) Children 5 to 14 years Northland 25.7 Auckland 20.5 Northern region 21.0
Source: Auckland University Department of Paediatrics and Northland Health Ltd
Target:
Prevention and prompt, proper treatment of streptococcal throat infections prevents acute rheumatic fever. The pilot of a school-based project to reduce rheumatic fever by implementing early treatment of streptococcal throat infections estimated that rates of acute rheumatic fever can be reduced by 60%. A randomised trial of the school-based programme is to be implemented in South Auckland from 1996 and, if it is as successful as the pilot, the incidence of rheumatic fever overall in the North Health region would be reduced by 25%. The target uses a five-year average rate because of large annual fluctuations. The target is set for the five years with the year 2000 at its mid point.
Health of our People / 41 HIV infection.
Measure:
The Northern region has the highest regional rate of notification of AIDS; a cumulative rate of 25.9 per 100,000 at mid-1995 compared with the national cumulative rate of 14.8 per 100,000. HIV infection is not notifiable, but the AIDS Epidemiology Group at the University of Otago collates anonymous information about people testing positive for HIV antibodies from the testing laboratories. Although laboratory tests reflect only those who get tested, and there may be some duplicates amongst the samples, HIV positive tests are an important indicator of both unsafe behaviour (sexual and intravenous drug use) and of likely future trends in AIDS cases.
Between 1985 (when the HIV antibody test became available in New Zealand) and mid 1995, 579 people were found to be infected with HIV in the Northern region: 45 women, 531 men and three people whose gender was not stated. Some of these people may not have been residents of the Northern region, but because the information is anonymous it is not possible to estimate the number of residents of other regions included in the North Health numbers. Of those found to be HIV positive, 54% were likely to have been infected through homosexual sexual intercourse, for 34% no information is available about the likely means of infection and 8% were likely to have been infected through heterosexual sexual intercourse.
This measure is the annual number of HIV antibody positive tests for women and men in the Northern region. Figure 11 shows the trends in number of positive tests for women and men since 1985. The number of positive tests in men has decreased but is still much higher than the number in women, although the number in women appears to be increasing slightly. It is important to note that the year shown is the year in which the positive test was performed and is not necessarily the year in which the infection occurred.
Health of our People / 42 Figure 11 HIV positivity: number of women and men found to be HIV positive; 1985- 1994
80 70
60
L.. 50 C) Men E 40 r-.- —(3—Women Z 30
20 10 0 LO CO r- Co C) D ("I c) Co Co Co Co C) C) C) C) C) 0) C) ? Year found to be infected
Source: AIDS Epidemiology Group, University of Otago
Health of our People / 43 Tuberculosis
Measure:
Although the rate of tuberculosis (TB) has declined dramatically in developed countries during this century, progress towards eradication of this disease in New Zealand stopped in the mid-1980s. There were 187 cases of tuberculosis notified in 1995 in the Northern region. The incidence rate is lowest amongst those of Pakeha/New Zealand European ethnicity and highest amongst those of other ethnicity (this category includes immigrants from high risk countries). Of the health districts in the Northern region, central and south Auckland have the highest rates - probably because of their immigrant populations.
This measure is the notification rate of tuberculosis per 100,000, including all notified cases, for different age groups. Notification of tuberculosis is likely to be almost complete, so the notification rate is a good estimate of the incidence rate. Table 22 shows these rates for 1995 for the Northern region. The rate increases with increasing age. Figure 12 shows rates over time, with an increase in 1994 and 1995 for older people but little change since 1990 in other age groups.
Table 22 Tuberculosis: notifications (per 100,000); 1995
Children Young p dults Older pe
Northern region 1 5.6 10.7 21.24 35.5
Source: Communicable Disease Centre, ESR Health
Figure 12 Tuberculosis: notifications; 1990-1 995
40 -•-- Children 35
30 Young Ct people a0 F 25 I- Adults CL r-(A 20 2 Older (A 15 C., - people 0 z 10
5
0 1990 1991 1992 1993 1994 1995
Health of our People / 44 Hepatitis B
Measure:
Acute hepatitis B is a notifiable, vaccine-preventable disease which is transmitted by blood and body fluids. Infection in early childhood is more likely to result in carrier status, increasing the risk of infecting others and of future liver disease. There were 24 cases of hepatitis B notified in the Northern region in 1995. The rate of infection is highest in Maori, followed by Pacific Islanders and other ethnic groups.
This measure is the notification rate of acute hepatitis B in different age groups. Notified cases underestimate the total incidence rate, especially in children where disease is often asymptomatic, but are a reasonable indicator of trends in incidence of disease. Table 23 shows the age specific notification rates for acute hepatitis B for 1995 for the Northern region. The rate is highest amongst younger people, and no children or older people were notified with hepatitis B in that year. Figure 13 shows trends in notification rates which have been falling over the 1990s in all age groups.
Table 23 Hepatitis B: notifications (per 100,000); 1995 Children Young people Adults Older people Northern 0 7.3 2.1 0
Source: Communicable Disease Centre, ESR Health
Figure 13 Hepatitis B: notifications; 1990-1995
16
14 _-_—Children
CD 12 ct —C3.— Young CD people CD 10
C) -è--Adults Q. I) 8 0 —.—Older C)Q 6 people 0 z 4
2
0 1990 1991 1992 1993 1994 1995
Health of our People / 45 6.2 Non-communicable disease
Asthma
Measure:
Asthma mortality rates were high in New Zealand during two epidemics, the most recent of which abated by the mid-1980s, but now New Zealand s asthma mortality rate is low compared with other OECD countries. In the North Health region, 294 people aged between 5 and 64 years died from asthma in the five years from 1988 to 1992. Hospitalisation rates in New Zealand have decreased overall since the early 1980s, with Maori rates remaining at least twice non-Maori rates.
This measure is the hospitalisation rate for asthma, for different age and ethnic groups. Older people are not included since the diagnosis bf asthma is less reliable in that age group. Asthma hospitalisation rates are affected by changes in-the way in which acute, but less severe asthma attacks are dealt with by general practitioners and accident and emergency doctors - whether the patients are treated and monitored in the community or admitted to hospital. Treatment in the community may be more appropriate in many cases but an increase in this approach would lead to lower hospitalisation rates without any change in the actual rate of disease. Therefore this measure includes only cases of asthma who stayed in hospital for more than three days - to reflect the level of severe asthma in the community.
Table 24 and Figure 14 show the rates of hospitalisation for asthma in the Northern region, where length of stay was greater than three days. Except for young people, Maori have rates of severe asthma which are much higher than other ethnic groups.
Table 24 Asthma: hospitalisations with more than three days stay (per 100,000); 1989- 1993/94
Overall Maori Pacific Islands Other Children 86.0 176.0 103.1 52.8 Young people 44.1 52.7 42.8 42.2 Adults 68.8 195.9 118.3 48.1
Source: NZHIS
Health of our People / 46 Figure 14 Asthma: hospitalisations with longer than three days stay; 1989-93
200
180
160
140 0 0 Overall 0 120 0 0 Maori 100 a Pacific Island CL a 80 .Other a, 60
40
20
Children Young people Adults
Health of our People / 47 Diabetes
Measure:
Maori and Pacific Islands people have much higher rates of death and hospitalisation from diabetes than the non-Maori, non-Pacific Islands groups, except in children and young people. As noted in section 3, mortality statistics will underestimate the number of deaths where the underlying cause is diabetes. A better measure of diabetes for public health purposes would be the incidence of newly-diagnosed diabetes, but this is not available. Prevalence data is also not available for the whole Northern region, although some information is available for Auckland.
The South Auckland Diabetes Project27 carried out a household survey of Otara and Mangere from 1992 to 1993. Estimates of age-standardised diabetes prevalence calculated from the published data are 1.7% for Europeans, 4.3% for Maori and 3.2% for Pacific Islands people. For people aged over 60, 8.0% of Europeans, 15.5% of Maori and 12.1% of Pacific Island people had diabetes. The Auckland University Heart and Health Study data, collected during the same time period but from the whole Auckland area, give prevalence estimates for non-Maori, non-Pacific Islands older people of 5.2% for women and 6.1% for men.
If the National Health Survey planned for 1996 asks questions consistent with these surveys then its data will enable updated estimates of the prevalence of diabetes in the Northern region.
Health of our People / 48 Sudden infant death syndrome (SIDS) mortality
Measure:
New Zealand s high post-neonatal mortality rate (the highest in the OECD countries in 1990) is strongly influenced by deaths from sudden infant death syndrome (SIDS), Which comprise about 60% of the post-neonatal deaths. In the years 1988 to 1992, 199 infants died of SIDS in the Northern region.
The rate of SIDS in New Zealand has been decreasing since the mid-1980s, particularly since about 1989. The decline has been less consistent in Maori, whose rate nationally is more than three times higher than the non-Maori rate. The four main modifiable risk factors for SIDS are sleeping prone, lack of breast feeding, maternal smoking and smokers sharing a bed with the infant. Breast feeding and maternal smoking are included in this set of public health measures.
This measure is the mortality due to SIDS per 1,000 live births by ethnic group. Table 25 shows the levels for 1988-1992 for the Northern region. Consistent with national data, Maori rates are much higher than the rates for other ethnic groups - four times higher than non- Maori, non-Pacific Islands rates.
Table 25 Sudden Infant Death Syndrome: mortality per 1,000 live births; 1988-1992 Overall Maori Pacific Islands Othe Northern region 1 1.99 5.57 1.97 1.39
Source: NZHIS
Target:
The Public Health Commission set a target for a reduction in SIDS deaths between 1991 and 2000 of approximately 60%. North Health has set targets for overall SIDS mortality and for Maori SIDS mortality using a similar reduction:
Health of our People / 49 Cardiovascular disease
Measure:
Cardiovascular disease, including ischaemic heart disease (IHD) and stroke, is a major cause of death and disability in New Zealand. The rate of death from IHD has decreased over the last 30 years but it remains the leading cause of death for Maori and non-Maori men and is second only to all cancers for women. In comparison with the other OECD countries, New Zealand IHD mortality rates are high and stroke mortality rates about average.
This measure is the age-standardised mortality rate for IHD and for stroke, by gender and ethnic group and overall. Table 26 shows these data for the Northern region for 1988 to 1992. Maori men and women have higher mortality rates for IHD than non-Maori. For stroke, Maori women have the highest mortality rate, and the rate for non-Maori men is higher than for Maori men. Pacific Islands women and men have the lowest rates of mortality from IHD and stroke.
Table 26 lschaemic heart disease and stroke: mortality (age standardised per 100,000); 1988-1992 Ischaemic heart disease Stroke Women Men Women Men Overall 82.6 175.9 42.0 44.6 Maori 108.0 197.3 53.9 37.6 Pacific Island 41.5 76.9 20.9 30.3 Other 81.0 176.2 41.2 44.7
Source: NZHJS
Target:
The PHC set a target for IHD for a 4% annual decline in mortality rates, in contrast with the 3.5% annual decline which occurred between 1980 and 1990. For North Health, this percentage decrease gives the target shown below.
Health of our People / 50 Child hearing loss
Measure:
Between six and ten percent of New Zealand children are thought to be affected by hearing loss, although good data using consistent definitions of hearing loss are not available. Almost all children s hearing is tested at school entry, by both pure tone audiometry and tympanometry. Where a child fails these tests twice, they are referred for further investigation. The National Audiology Centre keeps records of the proportion of children referred.
This measure is the proportion of children referred for hearing test failure at school entry. Table 27 shows these proportions for the year 1 July 1993 to 30 June 1994 for the Northern region. Northland and south Auckland have the highest referral rates, and of the ethnic groups Pacific Islands children have the highest rates, followed by Maori. Figure 15 shows the trends in referral rates over the last three years by district. Referral rates appear to be decreasing.
Table 27 Hearing loss: percentage of new school entrants referred; 1993-1994 Overall Maori Pacific Islands Other ethnic groups Northland 12.7 15.6 n/a 11.0 North Harbour 5.0 7.7 26.3 4.5 West Auckland 8.8 9.7 14.4 7.8 Central ,Auckland 8.5 11.4 15.5 5.4 South Auckland 12.8 19.4 13.5 11.0
Source: National Audiology Centre
Figure 15 Hearing loss: referral rates 1991/92 to 1993194
20 18 16 14
a) 12 .1991/92 (a 10 Dl 992/93 (a 1993/94 a) 8 a) 6 4 2 0 Northland North West Central South Harbour Akd Akd Akd
Health of our People / 51 Target:
The PHC set national targets for child hearing loss of 8% hearing test failure rate by 1995 and 5% by the year 2000, from a level of 10.5% in 1991. The failure rates in districts in the Northern region vary, and some were much higher than 10.5% in 1991. North Health has set one target which is more conservative than the PHC one but applies to all districts in the Northern region.
Health of our People / 52 Cancer
Mortality rates for cancer are an important measure but are influenced by both changes in the incidence of cancer and changes in the effectiveness of treatment. The best measure of cancer for public health purposes is incidence, since most public health measures are directed towards prevention. However, incidence can only be calculated if all new cases of cancer are known about. The national cancer registry is known to have been incomplete until recently, so incidence data derived from the registry should be treated with caution. Therefore, both registry incidence data and mortality data are shown below. In July 1994, new legislation made it compulsory for laboratories to notify the registry of all cancer diagnoses. Once data from that time is available, incidence data will be a better measure for monitoring public health.
Breast cancer
Measure:
Breast cancer is the most common cause of cancer death for women overall, although for Maori women lung cancer is a more common cause of death. From 1988 to 1992, 902 women in the Northern region died of breast cancer. Registrations for breast cancer nationally have increased slightly since 1980, but this could be due to improvements in registration rather than a real increase in incidence.
A national breast cancer screening programme for women aged 50 to 64 years has recently been announced, and it is expected to reduce mortality in this age group by 30% after five years.
This measure is the incidence and mortality rates for breast cancer. Table 28 shows age- specific rates for adult and older women in the Northern region and age-standardised rates for different ethnic groups and overall (standardised to Segi s world population). Mortality rates for women aged 50 to 64 years are also shown.
Older women have incidence and mortality rates 2.2 and 3.5 times those of adult women. Maori women have the highest age-standardised incidence of breast cancer while non- Maori, non-Pacific Islands women have the highest mortality rates of the ethnic groups. Even using five years of data, mortality numbers for Maori and Pacific Islands women are quite small (26 and 17 in total) so their mortality rates should be treated with caution.
Table 28 Breast cancer: incidence (1989-1993) and mortality (1988-1992) per 100,000 Incidence Mortality Adult women 99.6 35.4 Older women 278.5 128.2 Women aged 50 to 64 82.8 Maori, age standardised 97.0 14.9 Pacific Islands, age standardised 58.6 8.0 Other, age standardised 54.5 27.8 Northern region, age standardised 57.8 26.0
Source: NZHIS
Health of our People / 53 Target:
North Health s target for breast cancer mortality is that which the national screening programme is expected to achieve - a 30% reduction in mortality in the 50 to 64 year age group, five years after the programme begins.
Health of our People / 54 Colon cancer
Measure:
Colon cancer is the third most common cause of cancer death and the fourth most common for men. From 1988 to 1992, 993 people in the Northern region died of colon cancer. Registrations for colon cancer nationally have increased slightly since 1980 for men but remained stable for women.
This measure is the incidence and mortality rates for colon cancer. Table 29 shows age- specific rates for all adults and older people in the Northern region and age-standardised rates for different ethnic groups and overall (standardised to Segi s world population). Incidence and mortality rates for older people are nearly ten times those for adults, while non-Maori, non-Pacific Islands people have the highest incidence and mortality rates in each age group and overall.
Table 29 Colon cancer: incidence (1989-1993) and mortality (1988-1992) per 100,000 Incidence Mortality Adults 22.0 12.0 Older people 210.0 118.8 Maori, age standardised 16.7 5.5 Pacific Islands, age standardised 10.1 1.9 Other, age standardised 25.4 14.7 Northern region, age standardised 24.4 13.7
Source: NZHIS
Health of our People / 55 Cervical cancer
Measure:
Between 1988 and 1992, 160 women in the Northern region died of cervical cancer, with mortality rates being highest in Maori and in older women. However, mortality rates are based on fairly small numbers so can fluctuate significantly from year to year. Since public health measures focus on both primary prevention (through safe sex) and early detection and treatment (through cervical screening), better measures for cervical cancer are incidence and the proportion of cases detected early.
This measure is the incidence of invasive cervical cancer and the proportion of cases detected at stage 1. Both these measures are derived from the cancer registry, so the data up to 1994 must be treated with caution. Table 30 shows these measures for adult and older women, by ethnic group and overall. Ethnic group incidence rates are standardised to Segi s world population while the proportion of cases detected at stage I are not.
Incidence rates for adult women are similar to those for older women, but a greater proportion of cervical cancers are detected early in older women than in adult women. The proportion of cases detected early does not vary greatly by ethnic group - the Pacific Islands data is based on small numbers so may not be very reliable.
Table 30 Cervical cancer: incidence (per 100,000) and percentage of cases detected at stage 1; 1989-1994 Incidence Cases detected at stage I Adult women 53.2 22.2 Older women 65.0 49.4 Maori 96.2 26.3 Pacific Islands 53.2 42.8 Other 28.8 23.6 Northern region 36.0 25.2
Source: NZHIS
Health of our People / 56 Melanoma
Measure:
European New Zealanders have the highest mortality from malignant melanoma of all OECD countries. From 1988 to 1992, 293 people in the Northern region died of melanoma, of whom 289 were non-Maori, non-Pacific Islands people. Half were under 65 years old, although mortality rates are higher in older people than in adults. Melanoma in older people can be related to sun exposure in their youth, so incidence is expected to continue to rise for some time until the prevention strategies begun in the 1980s take effect. Prevention strategies for melanoma should lead to increased awareness and thus both an increase in the proportion of cases diagnosed early and, in the short term, an increase in apparent incidence. However, in the medium term both incidence and mortality should decrease - at least in younger age groups.
This measure is the incidence of invasive melanoma, and the proportion of cases diagnosed at a thickness of less than 0.76mm, for non-Maori, non-Pacific Islands people. Incidence information is derived from the cancer registry, so the data up to 1994 must be treated with caution. Information on the proportion of melanomas diagnosed early is not yet available from the cancer registry, but can be included once 1995 data are available.
Table 31 Invasive malignant melanoma in non-Maori, non-Pacific Islands people: incidence (per 100,000); 1989-1993 Incidence Adults 62.0 Older people 65.3
Source: NZHIS
Target:
The PHC targets for melanoma include an increase in the proportion of cases detected early, and North Health endorses this target. As baseline information from the cancer registry becomes available, the level of this target should be reviewed.
Health of our People / 57 6.3 Non-intentional injury
Traffic injury
Road traffic injury is an important cause of death, injury and disability which, to reduce the incidence, requires action by a number of sectors of society. Intersectoral road safety groups exist nationally and in both the Auckland and Northland regions. A National Road Safety Plan includes targets for road deaths, injury crashes, alcohol use, speed, the use of child restraints and pedestrian and cyclist safety. The Auckland Region Road Safety Working Group has targets for the Auckland region, which were reviewed in 1995 and some of which are shown in Table 32. Rather than set separate road safety targets itself, North Health endorses those set in the Auckland Road Safety Action Plan. In Northland, the Regional Land Transport Strategy does not include numeric targets. Table 33 shows targets set by North Health for Northland using the same proportional reductions as used by the Auckland Region Road Safety Working Group for Auckland, where baseline information was available.
Table 32 Targets for road safety for the Auckland region 28 1994 1996 2001 Actual Target Target Number of road deaths 105 96 74 Reported injury crashes 3,694 3,413 2,711 Percentage of fatal crashes with alcohol as a factor 47% 43% 32% Pedestrian fatalities 17 13 4 Pedestrians injured 438 423 384 Cyclist hospitalisations (public hospitals) 371 343 272 Children restrained, 0-14 years (any restraint) 56.5% 68.4% 98%
Table 33 Targets for road safety for Northland 1994 1996 2001 Actual29 Target Target Number of road deaths 36 33 25 Reported injury crashes 366 338 269 Pedestrian fatalities 1 0 0 0
Pedestrians injured 1 28 27 25
Health of our People / 58 Falls
Measure:
Accidental falls are the second most common cause of death from unintentional injury, and the most common cause of non-fatal injury. Injury from falls can lead to significant disability, particularly in older women where falls may result in fracture of the neck of the femur necessitating long periods of hospital stay and rehabilitation.
This measure is the rate of hospitalisation due to falls for different age and ethnic groups. Table 34 shows the overall age-specific rates for the Northern region and Figure 16 shows the age-specific rates by ethnic group. Rates are highest in children and older people, with the highest rate in non-Maori, non-Pacific Islands older people.
Table 34 Falls: hospitalisations (per 100,000); 1989-1993 Hospitalisations Children 800.2 Young people 303.3 Adults 236.1 Older people 1861.4
Source: NZHIS
Figure 16 Falls: hospitalisations by age and ethnic group; 1989-1993
2000
1800
1600 Ct Ig Overall CD 1400 I- DMaori 0 1200 CL Pacific Island (a, 0 1000 .Other 800
600 (j 0 400
200
0 Children Young people Adults Older people
Health of our People / 59 6.4 Mental health
There are no easily available measures which reflect the mental health of the population. Hospitalisation statistics are particularly unsatisfactory for mental health, not only because they reflect only the severe end of the spectrum of mental illness, but also because the trend towards community-based care has changed the pattern of hospitalisation independently of any changes in incidence or prevalence of psychiatric disorders. If the National Health Survey planned for 1996 includes questions on well-being then better measures of the public s mental health may become available, but at present North Health s measures of mental health are attempted suicide and suicide.
Attempted suicide
Measure:
Hospitalisation for attempted suicide, while representing only a small part of the range of mental ill health, is less likely to be affected by changes in policies on admission to psychiatric hospitals since patients are likely to present to a general hospital initially.
This measure is the rate of hospitalisation for attempted suicide by age and gender. Table 35 shows age-specific rates for the Northern region for 1989 to 1993. Hospitalisation for attempted suicide is more common amongst women than men. Within most age/gender groups, Pacific Islands people have lower rates than Maori and non-Maori, non-Pacific Islands groups which have similar rates. The exception is young men, where Maori have higher rates than both other ethnic groups.
Table 35 Attempted suicide: hospitalisations (per 100,000); 1989-1993
Source: NZHIS
Health of our People / 60 Suicide
Measure:
Suicide is a measure that reflects the severe extreme of mental distress. It is the second most common cause of death by injury after motor vehicle crashes.
This measure is the suicide mortality rate by gender and age group. Table 36 shows age specific rates for the Northern region for 1988 to 1992. Men have higher suicide mortality rates than women. Within each age group, non-Maori, non-Pacific Islands people have the highest rates followed by Maori and then Pacific Islands people. Non-Maori, non-Pacific Islands young men have the highest suicide mortality rate at 40.8 per 100,000. No Pacific Islands women in the young or older age groups and no Maori older people were recorded as dying from suicide during this time.
Table 36 Suicide: mortality (per 100,000); 1988-1992 Women Men Young people 8.8 36.0 Adults 8.5 29.1 Older people 9.8 25.4
Source: NZHIS
Health of our People / 61 6.5 Oral health
Decayed, missing and filled teeth
Measure:
The average number of decayed, missing and filled teeth per child (mean DMF score ) is a standard measure of oral health. Fluoride, diet and dental hygiene, as well as access to dental services, have an impact on the average score for a population group.
This measure is the mean missing/filled score at school entry and at Form Il. At these ages the school dental service assesses all children and records the number of children, the number of missing teeth, fills decayed teeth and then counts the number of filled teeth. Table 37 shows this score for the four Crown Health Enterprise areas for the year ending March 1995, derived from figures returned as part of contract monitoring by North Health. Generally scores are higher at school entry than at Form II, suggesting that overall dental care is better in older children. Scores at both ages are higher in Northland than in other CHE areas. Although Northland has a higher proportion of children who live in non- fluoridated areas than other CHEs, this does not explain the difference in scores since Northland children who live in fluoridated and non-fluoridated areas have similar scores.
Figure 17 and Figure 18 show missing/filled scores from central Auckland for 1991 to 1994, including two years here Maori and non-Maori figures were collected. There is no clear trend over this time Dut Maori children tend to have higher DMF scores than non-Maori children.
Table 37 Dental health: mean number of missing/filled teeth at school entry and Form II, 1994/95 School entry Form II Northland 2.87 1.43 Waitemata 1.25 1.27 Central Auckland 1.56 1.17 South Auckland 1.81 0.96 Source: School Dental Service, Auckland Healthcare
Health of our People / 62 Figure 17 Dental health: mean missing/filled score for five-year-old children in central Auckland, 1991-1 994
2.5
° 15 -All LL -.•.... Maori •1 non 1
0.5__
0 1991 1992 1993 1994
Figure 18 Dental health: mean missing/filled score for Form II children in central Auckland; 1991-1994
2.5
2
1.5 I-All LL _-_Maori
C -- non Maori , 1
0.5
0]
1991 1992 1993 1994
Target:
The PHC target for dental health is to reduce the number of decayed and missing teeth for Form II children to less than one per child by the year 2000. Since data is only available on missing and filled teeth, the North Health target uses the ME score. The target has been reached overall in south Auckland according to the above data, but data for Maori and non- Maori children should be monitored separately.
Health of our People / 63 7. Future Directions
7.1 Adequacy of information
Monitoring public health requires measures for which data is collected regularly, consistently and comprehensively. It should include measures which reflect not only incidence of diseases or hospitalisation for - and death from - diseases, but also health as a state of wellness , physically, mentally, socially and spiritually. Risk factors for disease in developed countries often relate to excess of, for example, smoking, alcohol use, fat, vehicle speed. However, the prerequisites for health such as food security, housing quality and income should also be part of measures of public health.
It is clear from this report that the information available falls short of that which would be necessary for an ideal set of public health measures. Some measures, for example incidence and prevalence of chronic diseases and some risk factors, could be gained from regular population-based health surveys such as the National Health Survey planned for 1996. Standard well-being questionnaires can also be included in health surveys. In order for the information from such surveys to be used for monitoring public health, the sampling methodology and questions must be consistent from survey to survey. Other measures, such as housing quality, food security and access to transport, may be available from time to time from Census data or from special studies. Anecdotal information from service providers and the community itself, given informally or in the context of consultation processes, can supplement the numerical information.
7.2 Frequency of measurement
The Public Health Intelligence Section of the Ministry of Health has published a discussion document, State of the Public Health Reporting 30 . Here, it is suggested that progress towards health outcome targets be reported annually, health status trends every two and a half years, and trends in health determinants every five years. Since a number of the measures of the determinants of health are based on Census data, a five-yearly report seems appropriate for those measures. However, since most health outcome targets are measures of health status it seems unnecessary to report on them at different intervals.
For the Northern region, many health status measures involve such small numbers that averages over about five years are necessary to make valid comparisons between population groups. Therefore, it is recommended that the whole of this report be updated every five years.
However, it would be preferable if the next report was written soon after the results of the 1996 Census and the 1996 National Health Survey are available (probably about 1998), so that from then on reports are drawing on recent data. As different and improved information is available from those and other sources, measures and targets can be changed and updated as appropriate.
Health of our People / 64 8. References
1 New Zealand Health Goals and Target for the Year 2000. Wellington; Department of Health: 1990
2 National Health Status Measures. Report of the Health Status Working Group of the Review Committee on New Zealand Health Statistics. Wellington; Department of Statistics: 1989
3 Goals and targets for Australia s health in the year 2000 and beyond. Canberra; Australian Government Publishing Services: 1993
4 Great Britain Secretary of State for Health. The Health of the Nation: A strategy for health in England. London; HMSO: 1992
5 Grant JP, Executive Director of the United Nations Children s Fund. The State of the World s Children 1995. Oxford; Oxford University Press for Unicef: 1995
6 Walker R. The people in the North Health region: A demographic profile. Auckland; North Health
7 Walker R. He tangata he tangata: A demographic profile of Maori living in the North Health region. Auckland; North Health
8 Walker R. Pacific Island People: A demographic profile of Pacific Island people living in the North Health region. Auckland; North Health
9 Shipley J. Policy Guidelines for Regional Health Authorities 1996/7. Wellington; Ministry of Health: 1995
10 Waldegrave C, Sawrey R. The extent of serious housing need in New Zealand 1992 and 1993. Lower Hutt; Social Policy Unit, The Family Centre: 1994
11 Laking R. Serious Housing Need. Paper for the Minister of Housing. Unpublished: March 1994
12 Christoffel P. Homelessness. A paper prepared for the 1994 Housing Research Conference. Ministry of Housing
13 Wong AGK. An analysis of a database of poisonings seen at the Auckland Hospital Accident. and Emergency Department. Report for Auckland Healthcare Services Ltd: 1993
14 Nokes CJ. Microbiological quality of drinking water in New Zealand 1994. Compiled by the ESR Water Group for the Ministry of Health: 1995
15 Ministry for the Environment. Ambient air quality guidelines. Wellington; Ministry for the Environment: 1994
16 LINZ Life in New Zealand Survey Commission report vols 1-VI. Dunedin; University of Otago: 1992
Health of our People / 65 17 Statistics New Zealand and Ministry of Health. A Picture of Health. Wellington; Statistics New Zealand: 1993
18 Public Health Commission. Progress on Health Outcome Targets. The state of the public health in New Zealand 1995. Wellington; Public Health Commission: 1995
19 Public Health Commission. Tobacco taxation as a health issue. Wellington; Public Health Commission: 1995
20 Wyllie A, Zhang JF, Casswell S. Drinking: Patterns and problems. Auckland survey data 1990-1992. Auckland; Alcohol and Public Health Research Unit: 1993.
21 Coggan CA, Fanslow JL, Norton RN. Intentional injury in New Zealand. Analysis and Monitoring Report 4. Wellington; Public Health Commission: 1995
22 Swinburn B, Craig P, Strass B, Daniel R. Body mass index: Is it an appropriate measure of obesity in Polynesians? Report to the Thrifty Genotype Conference, Auckland: 1994
23 Gillian Tustin, dietician at Auckland Healthcare - personal communication
24 Stehr-Green P, Baker M, Belton A et al. Immunisation coverage in New Zealand: Results of the regional immunisation coverage surveys. Communicable Diseases NZ; 92 Supplement 2: 1992
25 Solomon N. The Auckland Area Health Board immunisation coverage survey 1992. Auckland Area Health Board: June 1992
26 McNichol A, Baker M. Immunisation coverage in New Zealand: Ongoing surveillance using benefit claim data. NZ Public Health Report 1995; 2:1-3
27 Simmons D, Gatland BA, Leakehe L, Fleming C. Frequency of diabetes in family members of probands with non-insulin-dependent diabetes mellitus. Journal of Internal Medicine; 237: 315-321: 1995
28 Auckland Region Road Safety Working Group. Auckland region road safety action plan review. August 1995
29 Land Transport Safety Authority. Motor Accidents in New Zealand 1994. Wellington; Land Transport Safety Authority: 1995
30 Public Health Group, Public Health Intelligence Section. State of the Public Health reporting: A discussion document. Wellington; Ministry of Health: November 1995
Health of our People / 66 Appendix I Public Health Commission Publications (this list does not include all PHC publications)
Progress on Health Outcome Targets. The state of the public health in New Zealand 1995
Our Health, Our Future: The state of the public health in New Zealand. 1993 and 1994 editions.
Policy advice 1993/4 A strategic direction to improve and protect the public health Alcohol Cervical cancei Child hearing loss Food and nutrition Food safety Hazardous substances HIV/AIDS Immunisation Melanoma Road traffic injuries Sudden infant death syndrome (SIDS) Tobacco products Water quality Water safety
Policy advice 1994/5 Congenital and inherited conditions Fluoride and oral health He Matariki: A strategic plan for Maori public health National plan of action for nutrition Pacific Islands health information Parenting School health The local environment
Health of our People / 67 Appendix 2 Information Sources for Measures
This appendix lists the sources of information used for the measures in this report. As noted in the introduction, enquiries about these measures should be directed not to the people or organisations listed below but to North Health.
Under-five mortality New Zealand Health Information Service mortality data, as analysed at North Health, ref. Lisa Kelsall
Life expectancy New Zealand Health Information Service mortality data, as analysed at North Health, ref. Ratana Walker
Unemployment Household Labour Force Survey results are published quarterly by Statistics New Zealand. Census 1991 data from the Supermap software.
Housing Social Policy Research Unit The Family Centre P0 Box 31 050 Lower Hull
Ministry of Housing P0 Box 10 729 Wellington
Income Census 1991 data from the Supermap software.
Transport Census 1991 data from the Supermap software.
Unintentional poisoning for children aged 0 to 5 New Zealand Health Information Service hospital discharge data, as analysed at North Health, ref. Lisa Kelsall. lCD E850-869; by drugs, medicaments and biological substances and by other solids, liquids, gases and vapours .
Drinking water Water Group ESR: Christchurch Science Centre P0 Box 29 181 Christchurch
Health of our People / 68 Sewerage Northland: Monitoring Manager, Northland Regional Council Rodney: Engineer, Rodney District Council Waitakere: Engineer, Waitakere City Council North Shore City: Systems Engineer, North Shore City Council Auckland City: Manager Water Resources, Auckland City Council Manukau: Manukau City Council Papakura: Senior Engineer, Papakura District Council Franklin: Finance Section, Franklin District Council
Air quality Air Quality Officer Northland Regional Council Private Bag 9021 Whangarei
Air Quality Officer Auckland Regional Council Private Bag 68 912 Newton
Breast feeding and maternal smoking Royal New Zealand Plunket Society P0 Box 6042 Dunedin North
Healthy diet Auckland University Heart and Health data: Clinical Trials Research Unit Department of Medicine University of Auckland Private Bag 92 019 Auckland
Iwi/hapu affiliation Census 1991 data from the Supermap software.
Kohanga reo Te Kohariga Reo National Trust Boards Mokopuna Oranga Pumau statistics from: Te Tai Tokerau ki Tamaki Makaurau Te Kohanga Reo Regional Office 42 Coates Crescent Panmure Auckland
Tobacco use See references.
Heavy drinking Alcohol and Public Health Research Unit Department of Community Health University of Auckland Private Bag 92 019 Auckland
Health of our People / 69 Assault New Zealand Health Information Service hospital discharge data, as analysed at North Health, ref. Lisa Kelsall.
Child abuse National Manager, Family Resolution Services New Zealand Children and Young Persons Service Private Bag 21 Wellington
Physical activity, obesity Auckland University Heart and Health data: Department of Community Health University of Auckland Private Bag 92 019 Auckland
Immunisation See references.
Vaccine-preventable diseases New Zealand Health Information Service hospital discharge data, as analysed at North Health, ref. Lisa Kelsall. Mumps - lCD code 72; Measles - lCD code 55; Pertussis - lCD code 33
Campylobacteriosis, TB, hepatitis B Notification data from: Institute of Environmental Science and Research Ltd Communicable Disease Centre P0 Box 50-348 Porirua
Rheumatic fever Northland: Rheumatic Fever Coordinator Community Health Services Northland Health P0 Box 137 Whangarei
Auckland: Department of Paediatrics University of Auckland Private Bag 92 019 Auckland
HIV infection AIDS Epidemiology Group Department of Preventive and Social Medicine University of Otago P0 Box 913 Dunedin
Health of our People / 70 Asthma New Zealand Health Information Service hospital discharge data, as analysed at North Health, ref. Lisa Kelsall. lCD code 493
Diabetes New Zealand Health Information Service hospital discharge data, as analysed at North Health, ref. Lisa Kelsall.
Sudden infant death syndrome (SIDS) mortality rate New Zealand Health Information Service hospital discharge data, as analysed at North Health, ref. Lisa Kelsall. lCD code 7980
Cardiovascular disease New Zealand Health Information Service hospital discharge data, as analysed at North Health, ref. Lisa Kelsall.
Child hearing loss Manager, National Audiology Centre 98 Remuera Rd Auckland 5
Breast cancer New Zealand Health Information Service hospital discharge data, as analysed at North Health, ref. Lisa Kelsall.
New Zealand Cancer Registry data, as analysed at North Health, ref. Lisa Kelsall.
Large bowel cancer New Zealand Health Information Service hospital discharge data, as analysed at North Health, ref. Lisa Kelsall.
New Zealand Cancer Registry data, as analysed at North Health, ref. Lisa Kelsall.
Cervical cancer New Zealand Health Information Service hospital discharge data, as analysed at North Health, ref. Lisa Kelsall.
New Zealand Cancer Registry data, as analysed at North Health, ref. Lisa Kelsall.
Melanoma New Zealand Health Information Service hospital discharge data, as analysed at North Health, ref. Lisa Kelsall.
New Zealand Cancer Registry data, as analysed at North Health, ref. Lisa KelsaIl.
Falls New Zealand Health Information Service hospital discharge data, as analysed at North Health, ref. Lisa Kelsall. lCD codes E880-E888
Suicide, attempted suicide New Zealand Health Information Service mortality and hospital mortality data: lCD codes E950-E955
Health of our People / 71 Decayed, missing and filled teeth North Health contract monitoring information
Central Auckland figures from: Manager School Dental Service Community Health Services Auckland Healthcare Services Ltd P0 Box 27 343 Auckland
Health of our People / 72 Appendix 3 Public health measures, service obligation areas and health gain priority areas.
This section shows which of the Ministry of Health s service obligation and health gain priority areas (HGPA) are most relevant to each of the measures in this report, apart from the general health measures, socioeconomic determinants of health and hauora Maori.
Service obligation areas HOPA Physical Food Comm Maori Child Young Adults Older Mental environ (a /nutrition disease (also a (also a people people health HGPA) HGPA) HGPA) Hospitalisation for poisoning for children aged 0 to 5 Drinking water Sewerage Air quality Breast feeding at three months old Healthy diet Smoking Heavy drinking of alcohol Assault Child abuse
0 0
co-4 Service obligation areas HGPA Physical Food Comm Maori Child Young Adults Older Mental environ (a /nutrition disease (also a (also a people people health HGPA) HGPA) HGPA) Physical activity Obesity Early childhood immunisation Vaccine preventable diseases: measles, pertussis, rubella Campylobacteriosis Rheumatic fever HIV infection Tuberculosis Acute hepatitis B Asthma Diabetes Sudden infant death syndrome Cardiovascular disease Hearing loss in children at school entry
0)
0 0
-.1 Service obligation areas HGPA Physical Food Comm Maori Child Young Adults Older Mental environ (a /nutrition disease (also a (also a people people health HGPA) HGPA) HGPA) Breast cancer Colon cancer Cervical cancer Melanoma Traffic injury Hospital admissions due to falls Attempted suicide Suicide Decayed, missing and filled teeth at school entry and Form •
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