Process, pitfalls and profits: lessons from interviewing New Zealand policy-makers.

Little has been written about interviewing policy-makers in health promotion and public health research. This article explores the process, pitfalls and profits of semi-structured interviews with policy-makers in 10 research projects conducted in New Zealand. Key members of each research team were surveyed about their research and findings verified against research publications. Key aspects of the process of policy-maker interviews include gaining ethical approval, navigating gatekeepers, using personal contacts and multiple research dissemination methods. Pitfalls of interviewing policy-makers include interviewers not having enough knowledge of the topic so efforts were made to use knowledgeable researchers or up-skill others. Interviews provide access to specialist knowledge of the policy process which cannot be obtained by other methods. While this study was conducted in one jurisdiction, it has implications for other countries. Effective policy-maker interviews in health promotion policy research could contribute to improvements in the quality of data collected and uptake of research by policy-makers.

Tackling 'wicked' health promotion problems: a New Zealand case study.

This paper reports on a complex environmental approach to addressing 'wicked' health promotion problems devised to inform policy for enhancing food security and physical activity among Maori, Pacific and low-income people in New Zealand. This multi-phase research utilized literature reviews, focus groups, stakeholder workshops and key informant interviews. Participants included members of affected communities, policy-makers and academics. Results suggest that food security and physical activity 'emerge' from complex systems. Key areas for intervention include availability of money within households; the cost of food; improvements in urban design and culturally specific physical activity programmes. Seventeen prioritized intervention areas were explored in-depth and recommendations for action identified. These include healthy food subsidies, increasing the statutory minimum wage rate and enhancing open space and connectivity in communities. This approach has moved away from seeking individual solutions to complex social problems. In doing so, it has enabled the mapping of the relevant systems and the identification of a range of interventions while taking account of the views of affected communities and the concerns of policy-makers. The complex environmental approach used in this research provides a method to identify how to intervene in complex systems that may be relevant to other 'wicked' health promotion problems.

Front-of-pack nutrition labelling in New Zealand: an exploration of stakeholder views about research and implementation.

ISSUE ADDRESSED: Front-of-pack (FOP) labels are identified as a way to encourage healthy food choices and good nutrition, factors critical in promoting health. New Zealand and Australia are currently considering policy on front-of-pack labels. This research aimed to identify the challenges associated with implementing a front-of-pack nutrition labelling policy in New Zealand and with designing research to determine its likely effect. METHODS: A strategic sample of key stakeholders with knowledge of food labelling from New Zealand and Australia participated in the research. The 17 participants included five food industry representatives, six policy makers, and six representatives of non-governmental organisations. RESULTS: Several key themes emerged including support for front-of-pack labels from key food industry, policy and NGO stakeholders because of potential for better informed consumers, changes in consumer behaviour and reduction in chronic disease. Barriers to front-of-pack labelling included limited evidence upon which to make decisions, lack of agreement on the label format, and the clash of values between 'profit driven' industry and public health. There is a high level of agreement about the need for real-life research on the effectiveness of FOP labelling. CONCLUSIONS: The introduction of consistent, comprehensive front-of-pack nutrition labelling in New Zealand has the potential to assist in the effort to promote healthy eating. This research suggests agreement on front-of-pack labels may not be easy to achieve.

Punching loan sharks on the nose: effective interventions to reduce financial hardship in New Zealand.

ISSUES ADDRESSED: Growth in the high-cost, unregulated fringe lender market (with these lenders commonly referred to as loan sharks) has occurred both internationally and in New Zealand in recent years. The credit practices of loan sharks create financial hardship for many people including Maori, Pacific and low-income New Zealanders. This paper reports on research that explored strategies for reducing the impact of the fringe lender market on Maori, Pacific and low-income New Zealanders. METHODS: A narrative literature review and 10 key informant interviews were conducted to provide information on how best to intervene to reduce the impact of the fringe lender market for these people. RESULTS: The main interventions identified were: two regulatory approaches, one for capping interest rates and another to create codes of responsible lending; access to safe affordable micro-finance options; financial literacy education; and Pacific cultural change around fa'alavelave, which are the 'obligations' of giving. CONCLUSIONS: Protecting consumers from the unsafe practices of fringe lenders requires a combined approach of discouraging the undesirable practices of fringe lenders through regulation and encouraging the growth of safe, affordable micro-finance options. Financial literacy education is a valuable activity for directing consumer attention to the safest options, but in isolation will have limited effect if options are limited. Health promoters have a valuable role to play in implementing these interventions.

Public, private and personal: qualitative research on policymakers' opinions on smokefree interventions to protect children in 'private' spaces.

BACKGROUND: Governments use law to constrain aspects of private activities for purposes of protecting health and social wellbeing. Policymakers have a range of perceptions and beliefs about what is public or private. An understanding of the possible drivers of policymaker decisions about where government can or should intervene for health is important, as one way to better guide appropriate policy formation. Our aim was to identify obstacles to, and opportunities for, government smokefree regulation of private and public spaces to protect children. In particular, to seek policymaker opinions on the regulation of smoking in homes, cars and public parks and playgrounds in a country with incomplete smokefree laws (New Zealand). METHODS: Case study, using structured interviews to ask policymakers (62 politicians and senior officials) about their opinions on new smokefree legislation for public and private places. Supplementary data was obtained from the Factiva media database, on the views of New Zealand local authority councillors about policies for smokefree outdoor public places. RESULTS: Overall, interviewees thought that government regulation of smoking in private places was impractical and unwise. However, there were some differences on what was defined as 'private', particularly for cars. Even in public parks, smoking was seen by some as a 'personal' decision, and unlikely to be amenable to regulation. Most participants believed that educative, supportive and community-based measures were better and more practical means of reducing smoking in private places, compared to regulation. CONCLUSIONS: The constrained view of the role of regulation of smoking in public and private domains may be in keeping with current political discourse in New Zealand and similar Anglo-American countries. Policy and advocacy options to promote additional smokefree measures include providing a better voice for childrens' views, increasing information to policymakers about the harms to children from secondhand smoke and the example of adult smoking, and changing the culture for smoking around children.

Predictors of intent to vaccinate against HPV/cervical cancer: a multi-ethnic survey of 769 parents in New Zealand.

AIM: To identify factors predictive of parents' intent to have their daughters' receive the HPV/cervical cancer vaccine. METHODS: 3123 questionnaires were distributed to parents recruited from 14 socioeconomically diverse schools in 2008. Survey questions were structured around the health beliefs model. The main outcome measure was intent to seek vaccination for daughter(s). RESULTS: A quarter of parents completed questionnaires (769/3123). Two-thirds of respondents (67%) indicated they would want their daughter(s) to receive the vaccine, with no significant differences by ethnicity. Intent to vaccinate was significantly associated with having fewer negative views on vaccination (OR 0.47, 95%CI 0.37-0.59), having adequate information about the vaccine, perceiving HPV infection and cervical cancer as serious and likely to occur (OR 1.2, 95%CI 1.05-1.36), and considering efficacy and safety of the vaccine important (OR 1.17, 95%CI 1.06-1.28) (p<0.01). Awareness of HPV-related facts was lowest among Maori and Pacific parents (p<0.001). Pacific parents were more likely to have concerns about vaccination impacting negatively on girls' sexual behaviour. IMPLICATIONS: Strategies will be needed to provide detailed information outlining HPV prevalence and consequences, vaccine safety and efficacy to ensure all parents and their daughters are adequately informed when deciding on vaccination.

Promoting uptake of the HPV vaccine: the knowledge and views of school staff.

BACKGROUND: School-based human papillomavirus (HPV)/cervical cancer vaccination programs have been implemented widely, but few studies have investigated the knowledge and views of school staff about this new vaccine. METHODS: Prior to the introduction of the HPV vaccine in 2009, we surveyed staff at 14 socioeconomically diverse schools to assess views toward this new program, including staff's information needs, ideas on promoting return of consent forms, and uptake of the vaccine among minority groups. RESULTS: Of 583 invited staff, 456 participated (78%). About 58% of the participants knew about the link between HPV and cervical cancer, and that HPV is passed on during sexual contact. When asked if vaccination would increase sexual activity at a younger age, 71% disagreed, 6% agreed, and 23% were unsure. The majority of staff agreed that vaccine uptake could be improved through provision of information and consent forms in indigenous and Pacific languages; ensuring parents are well informed and girls educated about the vaccine; involving community groups and by extending availability of the vaccine into community settings as well as school and primary care. Three fourths of the staff surveyed wanted more information about the program before and during its implementation. CONCLUSIONS: This important group of stakeholders requires appropriate information so that they can support girls and their parents in deciding whether to have the vaccine. School staff members are potential health advocates with whom consultation should occur before and during the implementation of such programs.

Pacific solutions to reducing smoking around Pacific children in New Zealand: a qualitative study of Pacific policymaker views.

AIM: To explore the views of Pacific policymakers on solutions to reducing smoking around Pacific children in New Zealand (given smoking is a cause of health inequalities between Pacific peoples and other New Zealanders). METHODS: Documentary and media sources were searched for Pacific policymaker attitudes. Key informants (n=18) were recruited and interviewed by Pacific interviewers during May-October 2008, in person or by phone. RESULTS: There was a focus on the need to change attitudes (e.g. by education), rather than on government regulation for secondhand smoke protection (e.g. smokefree cars). Families and churches were seen as major avenues for the changes, with increased bottom-up, community-controlled activity. Specific interventions for each Pacific ethnic group were sought by these policymakers, along with better resourcing of Pacific tobacco control. There was considerable variance of opinion on the extent to which smokefree areas should be extended, with some informants reluctant to interfere with smokers' 'choices'. CONCLUSIONS: Research on Pacific involvement in health policy is feasible and practical, and could be extended. General Pacific policymaker reluctance to consider smokefree regulation extensions is at odds with surveyed attitudes of Pacific peoples in New Zealand.

What are the determinants of food insecurity in New Zealand and does this differ for males and females?

AIMS: Food insecurity is a lack of assured access to sufficient nutritious food. We aimed to investigate the demographic and socio-economic determinants of food insecurity in New Zealand and whether these determinants vary between males and females. METHODS: We used data from the longitudinal Survey of Families, Income and Employment (SoFIE) (n=18,950). Respondents were classified as food insecure if, in the past 12 months, they had to use special food grants or food banks, been forced to buy cheaper food to pay for other things, or had to go without fresh fruit and vegetables often. Logistic regression analyses were used to investigate the association of demographic and socio-economic factors on food insecurity. Models were repeated stratifying by males and females. RESULTS: More than 15% of the SoFIE population in NZ were food insecure in 2004/05. The prevalence of food insecurity was much greater in females (19%) than males (12%). The adjusted odds of food insecurity was significantly higher in females compared to males (OR 1.6, 95% CI 1.5-1.8). In univariate analyses, food insecurity was associated with sole parenthood, unmarried status, younger age groups, Maori and Pacific ethnicity, worse self-rated health status, renting, being unemployed and lower socioeconomic status. Income was the strongest predictor of food insecurity in multivariate modelling (OR 4.9, 95%CI 4.0-5.9 for lowest household income quintile versus highest). The associations of demographic and socioeconomic factors with food insecurity were similar in males and females. CONCLUSIONS: Food insecurity is a timely and relevant issue, as it affects a significant number of New Zealanders. Targeted policy interventions aimed at increasing money available in households are needed.

HPV/cervical cancer vaccination: parental preferences on age, place and information needs.

INTRODUCTION: A vaccine against cervical cancer is available in New Zealand through school and primary care for girls aged 12-18 years. Factors that might increase or hinder widespread uptake by the target population need to be identified. AIM: To describe parents' preferences on where their daughter(s) receive the human papillomavirus (HPV) vaccine, at what age, and their information needs. METHODS: 3123 questionnaires were distributed to parents recruited from 14 schools in 2008, prior to the start of the school-based vaccination programme. Outcome measures were: preferred age and place of vaccination, and information needs of parents and their daughters. Tests for significance were performed to determine whether parental preferences differed by ethnic group (Maori, Pacific, New Zealand European and 'Other'). RESULTS: A 25% response rate was achieved (769/3123). Receipt of the HPV vaccine in a clinic setting was preferred by 40% of parents; 25% preferred vaccination at school. Fifty percent preferred vaccination to occur at age 13 or older; 28% thought ages 10, 11 or 12 appropriate. One in three parents wanted more information and 65% said they would seek information from their family doctor before deciding on the vaccine for their daughter(s). DISCUSSION: We suggest that a programme delivered jointly in primary care and school settings, that is appropriately resourced for follow-up and information-sharing, would increase vaccine coverage. The rationale for vaccination at age 12 needs to be made clear to parents and evidence-based information needs to be delivered appropriately to parents and girls.

Unequal risks, unmet needs: the tobacco burden for Pacific peoples in New Zealand.

AIM: To review the available published literature and documentary material relevant to smoking by Pacific peoples in New Zealand. METHODS: Electronic databases and websites were searched using a range of search words. RESULTS: Over 30% of Pacific adults in New Zealand reporting being smokers in the 2006 Census, compared to 21% of the whole adult population. Smoking by Pacific women increased from 23% in 1996 to 27% in the 2006 census. Other survey data indicates some fall in the prevalence of daily smoking from 35% in 2002/3 to 26% in 2006/7. The prevalence of smoking by Pacific Year-10 students declined sharply during 1999-2007, from 29% to 16%. Smoking inside the homes of Pacific students has declined during 2001-7, from 35% to 26%. We found little government attention to smoking by Pacific peoples, and no specific central government plan for Pacific tobacco control. CONCLUSIONS: The threat to health from smoking and secondhand smoke exposure is higher for Pacific peoples and contributes to health inequalities in New Zealand. There is a need for tobacco control interventions specific to Pacific peoples, with some policy shortcomings needing to be urgently addressed. A central government plan for Pacific tobacco control is required. Some progress has occurred, particularly in the decrease of smoking by Pacific youth, and the increase in smokefree Pacific homes.

Developing nutrition education resources for a multi-ethnic population in New Zealand.

In New Zealand, the burden of nutrition-related disease is greatest among vulnerable and disadvantaged groups, including Maori and Pacific peoples. However, little research is currently available on effective ways to improve nutrition in these communities. This paper describes the development of six paper-based nutrition education resources for multi-ethnic participants in a large supermarket intervention trial. Six focus groups involving 15 Maori, 13 Pacific and 16 non-Maori, non-Pacific participants were held. A general inductive approach was applied to identify common themes around participants' understanding and thoughts on relevance and usefulness of the draft resources. Feedback from focus groups was used to modify resources accordingly. Five themes emerged across all focus groups and guided modification of the resources: (i) perceived higher cost of healthy food, (ii) difficulty in changing food-purchasing habits, (iii) lack of knowledge, understanding and information about healthy food, (iv) desire for personally relevant information that uses ethnically appropriate language and (v) other barriers to healthy eating, including limited availability of healthy food. Many issues affect the likelihood of purchase and consumption of healthy food. These issues should be taken into account when developing nutritional materials for New Zealanders and possibly other multi-ethnic populations worldwide.

Perceptions of New Zealand nutrition labels by Maori, Pacific and low-income shoppers.

BACKGROUND: In New Zealand the burden of nutrition-related disease is greatest among Maori, Pacific and low-income peoples. Nutrition labels have the potential to promote healthy food choices and eating behaviours. To date, there has been a noticeable lack of research among indigenous peoples, ethnic minorities and low-income populations regarding their perceptions, use and understanding of nutrition labels. Our aim was to evaluate perceptions of New Zealand nutrition labels by Maori, Pacific and low-income peoples and to explore improvements or alternatives to current labelling systems. METHODS: Maori, Samoan and Tongan researchers recruited participants who were regular food shoppers. Six focus groups were conducted which involved 158 people in total: one Maori group, one Samoan, one Tongan, and three low-income groups. RESULTS: Maori, Pacific and low-income New Zealanders rarely use nutrition labels to assist them with their food purchases for a number of reasons, including lack of time to read labels, lack of understanding, shopping habits and relative absence of simple nutrition labels on the low-cost foods they purchase. CONCLUSIONS: Current New Zealand nutrition labels are not meeting the needs of those who need them most. Possible improvements include targeted social marketing and education campaigns, increasing the number of low-cost foods with voluntary nutrition labels, a reduction in the price of 'healthy' food, and consideration of an alternative mandatory nutrition labelling system that uses simple imagery like traffic lights.