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Tongan Community Action Programme – Phase 2 Tongan Community Action Programme Phase 2 Final Report 13 September 2008 Prepared for HealthPAC By Chris Mene, Project Facilitator and Principal Investigator With Bridget Chiwawa P.G.Dip Diet, BSc Nutrition Kirsty Donaldson MPH, BA, RN Anne Trappitt NZ Reg Dietitian, BHSc Page 1 of 87 Tongan Community Action Programme – Phase 2 Acknowledgements Malo e lelei, Talofa lava, Warm Pasifika Greetings, On behalf of the Heart Foundation of New Zealand we wish to sincerely thank the many people and organisations who participated and supported this Tongan Community Action Project. Malo aupito to the participating families and the Christchurch Tongan Community Association. Thank you for placing your trust in this partnership and taking a proactive leadership role on behalf of yourselves and community. You have served your community as champions of health and we wish you the very best on your individual and collective journeys from here. Fa’afetai lava to the Canterbury Pacific Community Reference Group (CRG) for providing valuable counsel and direction for this project. Thank you also to the Christchurch office of the Ministry of Pacific Island Affairs for the administrative support you provided to the CPCRG and the ongoing advisory support to the project management team. We want to acknowledge the following people and organisations that have made this project the dynamic community action project that it became. Cancer Society Canterbury Community Trust Canterbury District Health Board Christchurch City Council Ministry of Health Heart Foundation Committee (Christchurch) Partnership Health Canterbury Pacific Trust Canterbury and Pacific Health Clinic Rowley Community House Sport Canterbury Special thanks to: Dr Alistair Humphrey Professor Ann Richardson Dr Api Talemaitonga Catherine Robinson Duncan Edwards Lily White Manu Sione Marcelino Taulango Martin Witt Michael O’Dea Tokanga Vehikite Vivienne Daley Community and Public Health Otago School of Medicine Pacific Health Clinic Canterbury District Health Board (Previously at Sports Canterbury) Student, Otago School of Medicine ‘Gardening Guru’ Previously at Pacific Trust Canterbury Group fitness instructor Cancer Society Partnership Health Canterbury Project facilitator & co-ordinator Pegasus Health Group Malo aupito, Fa’afetai lava, Thank you _______________ Chris Mene ________________ ________________ _______________ Anne Trappitt Bridget Chiwawa Kirsty Donaldson Page 2 of 87 Tongan Community Action Programme – Phase 2 Table of Contents Acknowledgements .................................................................................................................2 Abbreviations ..........................................................................................................................4 Executive Summary ................................................................................................................5 Recommendations ..................................................................................................................7 Part One – Context and structure ............................................................................................9 1.1 1.2 1.3 1.4 1.5 1.6 Introduction..................................................................................................................9 Purpose .....................................................................................................................10 Objectives..................................................................................................................11 Methodology ..............................................................................................................11 Tongan Community Action Project Logic Model.........................................................14 Current situation ........................................................................................................15 Part Two – Activities and Outcomes ......................................................................................16 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 Knowledge and awareness of smoking on health ......................................................16 Physical activity sessions ..........................................................................................20 Awareness of Key Messages in HEHA ......................................................................26 Healthy Shared Breakfasts ........................................................................................34 Commitment to Healthy Lifestyles .............................................................................37 School Holiday Programmes .....................................................................................45 Edible Gardens..........................................................................................................47 Tongan Community Workforce Development ............................................................50 Feedback from Tongan Families ...............................................................................54 Part Three – Sustainability ....................................................................................................55 3.1 3.1.1 3.1.2 3.1.3 3.2 3.2.1 3.2.2 3.2.3 Long term outcomes (3-5years) – Sustaining change ................................................55 Sustaining change through Leadership ..................................................................55 Sustaining change through learning .......................................................................57 Sustaining change through communicating............................................................57 Increased Community Connectedness ......................................................................59 High level of community support ............................................................................59 Partnership Health Canterbury...............................................................................60 Professional Relationships .....................................................................................61 Part Four – Discussion, Conclusions and Recommendations ................................................62 4.1 4.2 Discussion - Process Success Factors ......................................................................62 Recommendations .....................................................................................................74 Part Five – Bibliography ........................................................................................................76 Part Six – Appendices ...........................................................................................................77 Page 3 of 87 Tongan Community Action Programme – Phase 2 Abbreviations BMI BP CATINC CCC CPCRG CPN CTCA CV HDL HeLP HEHA LDL MoH NHF PHC PHO PMR PTC SIA TC TCAP2 Body Mass Index Blood Pressure Community Action To Improve Nutrition Capacity Christchurch City Council Christchurch Pacific Community Reference Group Certificate in Pacific Nutrition Christchurch Tongan Community Association Cardiovascular High Density Lipoprotein cholesterol Healthy Lifestyle Pasifika Project (Wellington) Healthy Eating Healthy Action Low Density Lipoprotein cholesterol Ministry of Health National Heart Foundation of New Zealand Partnership Health Canterbury Primary Health Care Organisation Performance Monitoring Report Pacific Trust Canterbury Services to Improve Access Total Cholesterol Tongan Community Action Project Phase 2 Page 4 of 87 Tongan Community Action Programme – Phase 2 Executive Summary This is a summary of the Tongan Community Action Programme – Phase 2 (TCAP2) intervention. The duration of this project was for 18 months and covered the period from September 2006 to April 2008. This report incorporates information on: Current status at final data collection, Data analysis in progress, Short and medium term outcomes, Sustainability streams (leadership, learning and communications) The long term outcomes for the TCAP2 (see logic model 3-5years) are to: Increase health of Tongan community in Christchurch Reduce Health inequalities Sustain change Increase community connectedness This will be achieved by: Improving nutrition Reducing obesity Increasing levels of activity Notable features of this project include: ● Collaborative ‘Community Action’ approach ● Early, meaningful and ongoing engagement with Tongan community leadership and diverse stakeholder advisory groups ● Nutrition and Physical Activity focus for intervention to improve the health of the Tongan community in Christchurch ● Achieving ethics approval status for two years - obtained September 2006 ● 12 month (October 2007) data collected from 35/40 consented participants. At that time one participant had died, two had moved from Christchurch and two chose to exit the project. A second participant died earlier this year. ● 18 month data collected over April and May 2008. This data will be further analysed and will be compared to the baseline data to be reported in the Ethics report and MoH evaluation final report due September 2008. This report provides information on the current situation for participants of the TCAP2 and extension of the programme that has developed through the Free Church of Tonga and the Tongan Wesleyan Church. Along with the primary TCAP community participants both church groups continue to gather for shared meals, breakfasts, nutritional instruction and exercise sessions. Page 5 of 87 Tongan Community Action Programme – Phase 2 Current status at 18 months Current status at final data collection (18 months) have been identified through interim information derived from the five data collection periods. Total Cholesterol/High Density Lipoprotein cholesterol (TC/HDL) ratios 13 out of 25 participants had TC/HDL ratios <4.5 at baseline and at 18 months 6 participants improved their TC/HDL ratios at 18 months. 5 participants had TC/HDL ratios that went from within the normal range at baseline to being elevated at 18 months. The proportion of the 26 participants with a BMI higher than 40kg/m2 fell from 30% to 15% by 18 months 19 out of 29 participants had TC/HDL ratios <4.5 at 18 months 14 out of 28 participants had glycated haemoglobin <6% (non-diabetic) 17 out of 26 participants had triglyceride levels <1.7mmol/l 21 out of 25 participants had HDL levels >1mmol/l 7 of the 26 participants had normal LDL levels <2.5mmol/l Identification of high risk participants: 14 out of 28 had glycated haemoglobin >8% indicating an increased risk of diabetes 17 out of 29 had serum glucose > 6mmol/l indicating an increased risk of diabetes 21 out of 25 had elevated total cholesterols (>8mmol/l) indicating an increased risk of heart disease 19 out of 26 had LDL >2.5mmol/l, indicating an increased risk of heart disease 21 out of 26 participants were obese (BMI >30kg/m2) Awareness of the importance of Healthy Food: Increase intake of fruit and vegetables Healthier meals made at home Reduction in households consuming high fat and/or salt specialty breads Most households reported having cooked porridge and breakfast cereals 1-4 times per week Most households have basic equipment and appliances for preparation of healthy meals Food purchasing patterns were good with most families buying food once a week Frying as a cooking method has decreased Page 6 of 87 Tongan Community Action Programme – Phase 2 Recommendations The following recommendations are made for community and government health organisations working with the Tongan community. These recommendations may also have relevance to working with other Pacific nations groups. The following recommendations are encouraged for future projects that have a focus on: increasing health in Tongan communities, Reducing Tongan health inequalities, Increasing Community Connectedness, and Research and development pertaining to Tongan communities in Aotearoa New Zealand. Increased Health in the Tongan Community (Primary focus: 40 consented participants) Community Development and Support Continue development and support for community workforce as it enhances local leadership. SIA worker provides capacity for sustained long term outcomes and is a priority being met by Partnership Health Canterbury (PHO) Continue developing and supporting local leadership for ownership, motivation and mentoring. Support and utilise facilitators with bi-lingual capabilities and development of bilingual resources recognising learning preferences of that community of interest. Supporting the brokering of linkages to develop community capacity. Access Support awareness raising and community engagement through local leaders communicating in their own language and community channels. This is enhanced by utilising simple, visual & culturally appropriate resources. Continue resourcing areas that enhance access to health including availability, time, costs, lack of transport, childcare, knowledge and skills Community Action approach encourages and provides for flexibility, innovation and responsiveness. Encourage initiatives supporting participation in the process of preparing healthy food Engagement with Primary Care is an important part of future planning for PHO’s Reduced Health Inequalities (Secondary focus: Christchurch Tongan Community) Tongan Community Engagement / Participation Best practice consultation is extremely important for Pasifika focused initiatives. For effective Guided Decision Making it is critical to engage Pasifika stakeholders early, meaningfully and ongoing through project. For effective consultation allow flexibility in timeframes. Consider community cultural frame and appropriateness when menu planning. Supporting Community Action by developing a commitment to role modeling healthy food at every opportunity. A Community Development approach will strengthen linkages and relationships for sustainable change. Page 7 of 87 Tongan Community Action Programme – Phase 2 Increased Community Connectedness (Tertiary focus: Community Stakeholders) Partnerships / Connectedness Pasifika community stakeholders benefit from developing organisational capability. Edible gardens and related key messages are effective components of nutrition focussed initiatives. Synergies are achieved by organisations taking a strategic approach to funding. Continue interagency collaboration for connecting, leading and communicating initiatives. Strengthen leadership coordination in order to facilitate whole community approach. Target funding support and resources to support high needs communities and organisations take a strategic approach to apply for funding to support these groups. Resource co-ordination between partner organisations. Resource networking opportunities for Pasifika community stakeholders. Research and Development Evidence recorded so no similar projects may not need to replicate with ethics research component. Link future projects to General Practices for sustainability. Future projects consider ethics process with respect to end outcomes desired for the community of interest of each project. Page 8 of 87 Tongan Community Action Programme – Phase 2 Part One – Context and structure 1.1 Introduction This is a summary of the Performance Monitoring Return (PMR) for the Tongan Community Action Programme – Phase 2 (TCAP2) intervention. It is intended to be read in conjunction with the previous PMR reports covering the period from 1 October 2007 to 13 April 2008. Some sections from the previous report have been retained where relevant to the ongoing intervention and evaluation. This PMR includes a progress report incorporating information on: Current status at final data collection, Data analysis in progress, Short and medium term outcomes, Sustainability streams (leadership, learning and communications) 12 month data - Short term Outcomes 12 month data provided information towards the effectiveness of the intervention towards short term outcomes. This information is summarised below. According to respondents some positive changes have been made towards healthier food choices. The respondents demonstrated an awareness of the importance of physical activity. However, there is a need for continued health education and support. The results for breakfast consumption were inconclusive so it's not clear what changes have been made to date. All respondents reported eating fruit and vegetables though the variety for both was limited. Respondents were generally citing healthier food preparation and cooking methods such as steaming and raw vegetable consumption though continued education is still required. There is a need for continued education and support regarding edible gardens as none of the respondents cited their own production as a source of fruit and vegetables at 12 months. Analysis of the blood results is inconclusive and needs to be considered in the separate categories that are reported on. However, results do indicate that a number of individuals in this community are at very high health risk. Thirteen participants lost weight over the twelve month period. Despite these reductions, three participants remained in the overweight range and fifteen in the obese range. Page 9 of 87 Tongan Community Action Programme – Phase 2 1.2 Purpose The purpose of the programme is to reduce health inequalities of Tongan people living in Christchurch. The objectives are to reduce obesity and associated long-term health problems by: improving nutrition, increasing physical activity levels and reducing the levels of smoking among the participants As the TCAP2 has progressed it has become apparent that significant impact is occurring as a result of the intervention. The PAG have identified three clear and intersecting areas where this impact is occurring. They are illustrated in Figure 1 below. Figure 1.2 TCAP Impact Community Development Physiological changes Lifestyle modification The project is community-based and also aims to develop capacity within the community to ensure sustainability and less reliance on external support. A community workforce development focus continues. The TCAP2 programme intervention is being coordinated and facilitated by two members of the Christchurch Tongan Community Association. Havili Fifita and Tokanga Vehikite are both graduates of the Certificate in Pacific Nutrition (CPN) programme (2006). Havili and Tokanga are fluent speakers of English and Tongan and were contracted to the National Heart Foundation during 2007. Tokanga continues her role as a Community Health worker along with Ifalame Teisi. Ifalame graduated from the CPN programme in 2007. They have been joined recently by Marcellino Taulango who is a qualified personal trainer. Chris Mene has retained the role of Principal investigator for the research component of the project and plays a mentoring role for Tokanga, Ifalame and Marcellino. Page 10 of 87 Tongan Community Action Programme – Phase 2 1.3 Objectives The objectives for the TCAP2 were initially identified through research and consultative means. The research component identified previous projects that had attempted to engage with Pacific peoples in New Zealand and selected the Healthy Lifestyle Pasifika (HeLP) promotion to model the TCAP2 intervention on. The HeLP activity was run in the Wellington region for Pacific people during 2002-2004. An evaluation of this Wellington programme found it to be successful in increasing knowledge and awareness of the participants about healthy nutrition and physical activity. Reasons for this success were in part attributed to the community-based setting, Pacific ethnic specific resources and Pacific Health workers with ethnic-specific language skills. One recommendation was that programmes should be delivered within the context of the Pacific family group. The development of the TCAP programme and the underlying health promotion theories are comprehensively outlined by Duncan Edwards (Pacific Community Action Project: Formative and Process Evaluation. February 2006 unpublished) Consultation with mandated Pasifika and Tongan representation endorsed the development of the TCAP2 objectives including the Christchurch Tongan Community Association executive and Christchurch Pacific Community Reference Group. This consultative process was identified as critical in order for the Tongan community to take ownership of the project and improve the level of sustainability that could be achieved once the intervention ceased. Ethics approval for the evaluation of the programme was sought and obtained by the Southern Regional Ethics Committee prior to commencement. A range of objectives were eventually identified and these appear in the TCAP2 Project Logic Model (over page). 1.4 Methodology The TCAP2 is a community action intervention supported by a process evaluation. The TCAP2 logic model (page 8) illustrates how the Research and development, programme activities and outcomes relate to each other. The development of the TCAP concept and consultation with stakeholders occurred first. Through this consultation process programme activities were identified by the project management team as was the value of a robust evaluation process. Intervention The Community Action Intervention (Second column on Project Logic) consisted of a series of nine types of activities. The activities were: 1. 2. 3. 4. Knowledge and awareness of smoking on health*, Physical activity sessions* Delivery of Key Health messages* Healthy shared breakfasts* Page 11 of 87 Tongan Community Action Programme – Phase 2 5. 6. 7. 8. 9. Healthy food demonstrations* School holiday programmes Establishment of edible gardens in homes and community venues Workforce development Research feedback to individual participants by their General Practitioners. The first five activities (*) were implemented during the first three months of the intervention. The last four activities were implemented over a longer period and developed in a process of ongoing consultation with the Tongan participants and their community association. The initial community action approach described the responsive approach that the project would take. The intervention has adapted to respond best to this particular community. For example, participation at certain events has been impacted due to: Bereavements, Church, sporting and cultural commitments, Financial difficulties within the host community group The initial three month intervention (October to December 2006) of the TCAP2 programme consisted of 30 planned sessions: ● ● ● 14 Physical Activity sessions, 9 Shared Breakfast gatherings and 7 lunch food demonstrations. More detail on these 30 sessions, the venues used and participant withdrawals are contained in the previous PMR. Over the three month period another participant died as a result of cancer. This reduced the number of participants expected for the fifth and final testing in April 2008 to 34. All four individuals living in Christchurch who had withdrawn from TCAP continue to be invited to programme initiatives. After the 18 month data and information is collected, collated and analysed a request will be made to these four participants for an interview to explore further what barriers continue to prevent them from participating (ie motivation, transportation, lifestyle choices) and what support the project could provide to assist them. Intervention Evaluation Members of the Christchurch Tongan Community were informed of the project and invited to participate. The evaluation component consisted of collecting clinical and action research data. In addition observations and narratives were recorded. Detail on the consent, clinical data, action research data and the documenting of activities can be found in the previous PMR. Documentation of the activities of the TCAP2 continues to be a dynamic and ongoing process. The process evaluation included documenting activities allowing for a more robust outcome evaluation that documents the characteristics of the project so that, if it is successful, it can be replicated elsewhere. Page 12 of 87 Tongan Community Action Programme – Phase 2 There is potential significance of this project for the advancement of knowledge as Pacific people living in New Zealand are at higher risk of cardiovascular disease and diabetes than the total New Zealand population. Programmes to promote lifestyle interventions such as smoking cessation, healthy eating and physical activity in New Zealand are rare. They have been shown to reduce obesity and other cardiovascular risk factors in other populations. This is the first time such a programme has been used for a specific Pacific population in New Zealand. It is hoped that the positive outcomes and learnings for the Christchurch Tongan community will benefit other Pacific populations in Aotearoa New Zealand. Figure X (over page) provides a visual representation of the evaluation component of the TCAP2 and has the three impact areas relate to each other. Figure 1.4 TCAP Impact evaluation through clinical and action research Action Research Data Community Development Physiological changes Lifestyle modification Clinical Research Data Ethics approval for the evaluation of the programme was obtained from the Southern Regional Ethics Committee prior to commencement of TCAP2. This approval extends for the period 20 September 2006 to 30 September 2008. Page 13 of 87 Tongan Community Action Programme – Phase 2 1.5 Tongan Community Action Project Logic Model Research & Development Activities Development of TCAP concept / consultation with stakeholders Programme Activities Knowledge and awareness of smoking on health Short Term Outcomes (Up to 1 year) Improved blood pressure / bloods Intermediate Term Outcomes (1-3 years) Long Term Outcomes (3-5 years) Health of Tongan community in Christchurch Rates smoking cessation Weight reduction Formative evaluation Baseline, 3, 6, 12, 18 month data outcomes & sustainability evaluations Biomedical measurements N&PA data questionnaire Lifestyle activity survey TCAP Qualitative survey Physical activity sessions Awareness of key messages in HEHA Key health messages Participation in physical activities Healthy shared breakfasts Awareness of the importance of breakfast Healthy food demonstrations Intake milk, fruit & vegetables School holiday programmes Knowledge of food preparation and cooking skills Edible gardens Workforce development Research feedback Key: Contact with General Practices Levels regular physical activity Accessibility to and affordability of low FSS food Healthy meals made at home Sustained change Commitment to Healthy lifestyles by Tongan families Capability to grow vegetables & fruit in own garden Commitment to healthy lifestyles by Tongan community leadership Capacity Tongan community workforce Capacity Tongan community workforce Biomedical outcomes Reduced health inequalities Lifestyle intervention outcomes Community connectedness Community development outcomes Page 14 of 87 Tongan Community Action Programme – Phase 2 1.6 Current situation The previous Project Monitoring report (PMR) contained an outline of the current situation for Pacific peoples including the Tongan community. Information provided included a breakdown of socio-economic and demographic data by Pacific ethnic group, age and location. Information highlighting the Tongan peoples place in New Zealand is provided by Statistics New Zealand. In 2006 Tongan people in New Zealand: Were the third largest Pacific ethnic group living in New Zealand, comprising 50,481 or 19 percent of New Zealand’s Pacific population (265,974) Had a population increase by 9,762 or 24 percent between 2001 and 2006. Had a median age of 19 years compared to 35 years for the total New Zealand population 41 percent of the total Tongan population in New Zealand is New Zealand born. 40 percent of the total Tongan population was born in Tonga. In Christchurch, the Tongan community represents approximately 11 percent of the total Christchurch Pacific population (9,465) with 1,071 occupants in the city. The Tongan population has a young demographic which reinforces the importance of proactive health responsiveness. The Tongan population has a low median income which highlights a significant financial barrier and some of the challenges this community has in maintaining and changing their lifestyles. The Ministry of Health (2008) reports Pacific people are more likely to be in lower income bands and less likely to be in higher income bands. Pacific people are over represented in the most deprived areas; 42% of Pacific people live in NZ Deprivation 10 areas (would expect 10%) (MoH 2005). The age distribution of people living in the households of participants in the TCAP indicates that some families had extended family members living with them. This was confirmed by the project facilitator and is consistent with evidence indicating that Pacific people are much more likely to be living as part of an extended family, eg grandparents, parents and children or siblings living together than the total New Zealand population (Koloto 2007; MoH 2008). High needs communities on low incomes have less access to healthy food. Every opportunity should be made for appropriate messages regarding cheap, healthy food options. These health messages were provided at the beginning of the programme followed by cooking demonstration sessions at Rowley community House in April 2008. Budgeting needs to be an integral part of menu planning. Page 15 of 87 Tongan Community Action Programme – Phase 2 Part Two – Activities and Outcomes 2.1 Knowledge and awareness of smoking on health Knowledge and awareness of smoking on health was identified as a programme activity as smoking is a well known contributor to elevated blood pressure and cardiovascular disease. Two programme participants admit to smoking cigarettes regularly. Blood Results The participants’ lipid profiles were recorded and some also had their glycated haemoglobin and serum glucose recorded. All results were forwarded to the participants’ doctors and were interpreted in strict accordance with the prescribed limits. Thirty three individuals had blood sampled at one or more of the five waves of data collection. However, only seventeen had blood sampled four or five times resulting in an incomplete data set. This means it is not possible to accurately identify trends across this group or to use percentages. Therefore, the number of participants for whom data was collected is stated for each test. Thirty two individuals participated in the 18 month wave of data collection. Of these thirty two, one had blood sampling only, that is, no blood pressure and weight were recorded, while four individuals had only their blood pressure and weight recorded but did not have blood sampled. Glycated haemoglobin Glycated haemoglobin (Gly Hae%) is formed when excess blood sugar binds to haemoglobin. It gives an indication of blood sugar control over the previous weeks. Glycated haemoglobin was not recorded for all participants, or at each point of data collection. 28 participants had their glycated haemoglobin recorded at one or more points of data collection. Of these 14 were within the normal range and 14 were elevated The highest glycated haemoglobin (13.5) was recorded at baseline and was taken from a woman who was known to be a diabetic. Since the baseline wave of data collection her glycated haemoglobin has been lower each time it was recorded. Although still high at the 18 month wave of data collection it had reduced to 9.1. SerumGlucose The normal range for serum (blood) glucose is 3.5-5.5. Serum glucose was not recorded for all participants or at each point of data collection. Fasting blood glucose is the recommended test to determine if an individual has diabetes and a fasting blood glucose equal to or over 7mmol/L indicates that an individual has diabetes (Diabetes New Zealand; WHO 1999). A fasting blood glucose level between 6.1mmol/L and 6.9mmol/L is diagnostic of impaired fasting glycaemia (IFG) or pre-diabetes. Page 16 of 87 Tongan Community Action Programme – Phase 2 29 participants had their serum glucose recorded at 18 months; of these 13 were within the normal range and 17 were elevated Of these 17 participants, ten* had fasting blood glucose levels above 7mmol/L indicating they may be diabetic. Eight of these recorded fasting blood glucose levels above 7mmol/L on two or more points of data collection. Another two had fasting blood glucose levels between 6.1mmol/L and 6.9mmol/L indicating IGF. * One of the ten is a known diabetic. The continued elevated glycated haemoglobin and serum glucose levels reported in this group of people is consistent with a MoHa (2008) report that 33 percent of the Tongan participants in a study had exceptionally poor control of their diabetes compared to 6 percent of the European participants. The study found differences in the perceptions of diabetes between Tongan and European participants. The Tongan participants tended to view their diabetes as a cyclical, acute illness and were characterised by lower adherence to dietary and medication recommendations. This contrasted with European participants who considered it to be a long term condition. Tongan participants were more likely to attribute their illness to external factors, were more emotionally distressed by their diabetes had less confidence in their ability to control their and saw less necessity for diabetes medication. Lipid Profile According to the National Heart Foundation (2005) the normal range for a lipid profile is: Total cholesterol (TC) <4 mmol/L Triglycerides <1.7 High density lipoprotein (HDL) >1 mmol/L Low density lipoprotein (LDL) <2.5 mmol/L TC/HDL ratio <4.5 One participant had a normal lipid screen at both baseline and the 18 wave of data collection, while one was abnormal at baseline and came into the normal range at 18 months and conversely one participant had a normal lipid screen at baseline that was abnormal a 18 months. Total Cholesterol (<4mmol/L) The following results relate to 25 participants. Twenty-seven participants had their lipids screened at baseline and 18 months, however, the results of two participants are not included as they were pregnant which may have altered their lipid profile. At baseline the median total cholesterol was 5.0 (range 3.5 to 6.9). The mean was 5.1 At 18 months the median total cholesterol was 5.0 (range 2.7 to 7.3). The median was 4.9 2 participants had total cholesterol levels within the normal range at baseline 4 participants had total cholesterol levels within the normal range at 18 months Page 17 of 87 Tongan Community Action Programme – Phase 2 Triglycerides (<1.7) At baseline the median triglyceride was 1.5 (range 0.5 to 3.2). The mean was 1.5 At 18 months the median triglyceride was 1.3 (range 0.6 to 2.6). The median was 1.5 17 participants had triglyceride levels that were within the normal range at baseline 14 participants had triglyceride levels that were within the normal range at 18 months High density lipoprotein (HDL) At baseline the median HDL was 1.3 (range 1.0 to 2.1). The mean was 1.4 At 18 months the median HDL was 1.2 (range 0.9 to 1.7). The mean was 1.2 24 of the 25 participants had HDL levels within the normal range at baseline 21 of the 25 participants had HDL levels within the normal range at 18 months Low density lipoprotein (LDL) (<2.5mmol/L) The laboratory analysing the blood samples gives <3.4 as the preferred value compared with the Heart Foundation’s value of <2.5. A laboratory technologist was not sure why the values differ. For this report the Heart Foundation limit was applied, therefore <2.5 mmol/L is considered to be the normal limit for a low density lipoprotein. At baseline the median LDL was 3.2 (range 1.4 to 4.9). The mean was 3.0 At 18 months the median LDL was 3.0 (range 0.9 to 4.8). The mean was 3.0 7 participants had LDL levels within the normal range at baseline 7 participants had LDL levels within the normal range at 18 months (four participants had normal LDLs at both data collection points). 19 (of 26) participants had elevated LDL levels at 18 months TC/HDL ratio (<4.5) At baseline the median TC/HDL ratio was 3.6 (range 1.8 to 4.9). The mean was 4.0 At 18 months the median TC/HDL ratio was 3.8 (range 2.1 to 5.3). The mean was 4.0 13 participants had normal TC/HDL ratios recorded at both baseline and 18 months 3 participants had TC/HDL ratios that went from being elevated at baseline to within the normal range to at 18 months. 5 participants had TC/HDL ratios that went from within the normal range at baseline to being elevated at 18 months. Page 18 of 87 Tongan Community Action Programme – Phase 2 Total Cholesterol/High Density Lipoprotein cholesterol (TC/HDL) ratios 13 out of 25 participants had TC/HDL ratios at baseline and at 18 months 3 had improved TC/HDL ratios showing lowered CV risk 3 participants had TC/HDL ratios that went from being elevated at baseline to within the normal range to at 18 months. 5 participants had TC/HDL ratios that went from within the normal range at baseline to being elevated at 18 months. The MoH (2005 pg.26) reported that 48% of households with dependant Pacific children can afford to eat properly only sometimes compared with the national average of 20 %. These results show some improved blood results and identify some high risk participants. It is useful to consider that for some participants their cultural views, language and history may lead them to a different worldview of health which may influence the way “they perceive, access and use health service and (sic) can influence the outcomes of interventions” (MoH a2008 pg.17). The MoH a (2008 pg.17) quotes Tukitonga stating that “in general, Pacific culture and beliefs about health and illness are different from those of mainstream New Zealand; as health is considered to be a holistic notion and a family concern rather than an individual matter”. Many of the participants remain at high risk for CV disease and other obesity related conditions. The proportion of the 26 participants with a BMI higher than 40kg/m2 fell from 30% to 15% by 18 months 19 out of 29 participants had TC/HDL ratios <4.5 at 18 months 14 out of 28 participants had glycated haemoglobin <6% (non-diabetic) 17 out of 26 participants had triglyceride levels <1.7mmol/l 21 out of 25 participants had HDL levels >1mmol/l 7 of the 26 participants had normal LDL levels <2.5mmol/l Identification of high risk participants: 14 out of 28 had glycated haemoglobin >8% indicating an increased risk of diabetes 17 out of 29 had serum glucose (>6mmol/l) indicating an increased risk of diabetes 21 out of 25 had elevated total cholesterols (>8mmol/l) indicating an increased risk of heart disease 19 out of 26 had LDL >2.5mmol/l, indicating an increased risk of heart disease 21 out of 26 participants were obese (BMI >30kg/m2) Intermediate term outcomes (1-3 years) Increased rates of smoking cessation There were two questions related to intention to stop smoking. These questions were intended to be completed only by participants who smoke. Page 19 of 87 Tongan Community Action Programme – Phase 2 The first question asked individuals to respond to one of three options about their intention (or not) to quit. Participants were then asked to respond to a ‘stages of change’ question, again regarding their intention to quit. These questions are designed to be completed by participants who smoke and to be passed over by non-smokers. Therefore, as there were only two participants identified as smokers there should have been only two responses, however, the first question was completed by 14 participants and the second question by 12. The numbers answering this question varied at each wave of data collection and was reduced to four at 18 months. As there was not a question regarding participants’ current smoking status it is not possible to accurately identify the number of smokers. However, according to the project facilitator two participants (5%) identified as smokers at the initial wave of data collection. This low number of reported smokers is in contrast with the MoH (2005) that reports that 34.6 % of Pacific males aged over 15 years smoke and 28.5% of Pacific females aged over 15 years smoke. The MoHb (2008) reports the prevalence of smoking in Pacific people aged over 15 years as 26.9%. Three possible interpretations of this are; that participants did not understand the question and replied that they had ‘no intention of quitting smoking’ because they do not smoke and therefore had no thought of quitting, secondly, they gave a socially acceptable answer due to the publicity of smokefree messages and thirdly, there were actually more smokers than were identified. ● Blood Pressure According to the National Heart Foundation (2005) an ideal blood pressure (BP) is less than 130/80. The data was analysed according to these limits. High blood pressure (hypertension) is defined as the systolic (top) number being greater than 140mm Hg and the diastolic (lower) number being greater than 95 mm Hg on repeated readings (National Heart Foundation). The systolic, diastolic or both may be high. Twenty seven participants had their blood pressure recorded at baseline and 18 months. At baseline the median systolic blood pressures of these 27 participants was 130 mm Hg (range 104 mm Hg to 180 mm Hg). The mean was 130 mm Hg. At 18 months the median systolic blood pressure was 130 mm Hg (range 100 mm Hg to 198 mm Hg. The mean was137 mm Hg. At baseline the median diastolic blood pressure of these 27 participants was 81 mm Hg (range 65 mm Hg to 100 mm Hg). The mean was 80 mm Hg. At 18 months the median diastolic blood pressure was 80mm Hg (range 60 mm Hg to 115 mm Hg). The mean was 85 mm Hg. The median blood pressure at baseline was 130/81 and 130/80 at 18 months. 2.2 Physical activity sessions Physical Activity sessions were provided throughout the 18 month intervention. A more complete schedule of physical activity support is outlined in the methodology (page 9). Physical activity helps to improve blood pressure and weight reduction. Intermediate term (1-3 years) Page 20 of 87 Tongan Community Action Programme – Phase 2 Weight reduction at 18 months Body Mass Index The body mass index (BMI) calculates the ratio between an individual’s height and weight giving an indication of body fat and the associated risk of morbidity. It is not useful for some individuals as the BMI cannot distinguish between lean muscle mass and fat mass and therefore, may overestimate body fat in athletes, certain ethnicities and those with higher amounts of muscle. Conversely, BMIs may also underestimate body fat in the elderly population. However, the BMI is useful for estimating the proportion of a population who have an increased risk of health conditions associated with obesity (MoH b 2008). The World Health Organisation (WHO) lists 17 conditions associated with obesity. Twenty-nine participants had their height and weight recorded at 18 months and one or more other points of data collection (not necessarily baseline). However, only 26 are listed in the table below as two participants were pregnant and one had recently given birth at the time of the 18 month data collection. The individual body weights in the following table are consistent with the Ministry of Health (2005 pg.28) statement that “Pacific Peoples are not significantly more likely to be overweight than the national average but are approximately twice as likely to be obese despite using a higher cut off for the overweight and obesity categories”. The MoHa (2008 pg.18) also reports “that overweight and obesity were uncommon in traditional Pacific communities and up until the 1960s were rarely noted”. The MoHa (2008) reported on a study finding that Tongan men consistently chose larger body sizes for both females and males as being more attractive. The “attractive body size” for men corresponded approximately to a BMI of 30. The Ministry of Health (2005) classifies BMIs in the following way: For the total population: overweight = ≥ 25.0 - <30.0 obese = ≥30.0 For Pacific peoples: overweight = ≥26.0 - < 32.0 obese = ≥ 32.0 According to the MoH b (2008) the mean BMI for Pacific adults is 33.2, which is lower than the mean BMIs of participants at both baseline and 18 months. At baseline the median weight of the 26 participants was 104.5 kilograms (kg), (range 70 kg to 200 kg). The mean was 109 kg. At 18 months the median weight of the 26 participants was was 111 kg (range 78 kg to 205 kg). The mean 104.5 kg. At baseline the median BMI of the participants was 36 (range 24.2 to 66.8). The mean was 37.7 At 18 months the median BMI of the participants was 35.3 (range 27 to 68.5). The mean was 37.2 Page 21 of 87 Tongan Community Action Programme – Phase 2 Table 1. The Body Mass Index of Participants Height (m) 1.70 1.73 1.80 1.69 1.61 1.67 1.58 1.68 1.80 1.61 1.61 1.67 1.71 1.66 1.67 1.63 1.85 1.70 1.80 1.65 1.64 1.70 1.81 1.77 1.73 1.75 Baseline Weight (kg) 77 89 98 85 85 91 84 99 117 97 93 117 118 122 112 110 138 127 114 139 98 70 113 101 200 148 Baseline BMI 18 month weight 26.6 29.7 30.2 29.8 32.8 32.6 33.6 35.1 36.1 37.4 35.9 42 40.4 44.3 40.2 41.4 40.3 43.9 35.2 51.1 36.4 24.2 34.5 32.2 66.8 48.3 78 30 93 85 81 89 80 91 109 92 92 104 111 111 112 105 136 126 110 135 100 98 115 106 205 158 18 month BMI 27 29.1 28.7 29.8 31.2 31.9 32 32.2 33.6 35.5 35.5 37.3 38 40.3 40.2 39.5 39.7 43.6 34 49.6 37.2 33.9 35.1 33.8 68.5 51.6 At baseline (of the 26 participants listed): 1 participant had a BMI in the normal range 4 participants had BMIs in the overweight range 21 participants had BMIs in the obese range At 18 months (of the 26 participants listed): There were no BMIs in the normal range 5 participants had BMIs in the overweight range Page 22 of 87 Tongan Community Action Programme – Phase 2 21 participants had BMIs in the obese range 1 participant’s BMI had moved down from the obese range to the overweight range 1 participant gained 28 kg, raising her BMI from the normal range to obese. Figure 1: The BMIs of 26 participants at baseline and 18 months grouped into specific BMI ranges. Percentage of participants BMIs of 26 participants at baseline and 18 months 70 60 50 40 30 20 10 0 Baseline 18 Months 20 30 40 50 60 BMI y As the figure shows the proportion of participants with BMIs in the 20s, 50s and 60s remained the same at baseline and 18 months. However, the proportion of participants whose BMIs were in the 40s fell from 30% to 15% at 18 months. At 18 months, 18 participants had lost a total of 90 kgs. The median individual weight loss was four kilograms (range one to 13 kgs). The mean was five kilograms. Two individuals recorded the same weight at baseline and 18 months. Six participants gained a total of 52 kilograms. The median individual weight gain was five kgs (range two to 28 kgs). The mean was seven kilograms. ● Increased rates of smoking cessation Refer to page 20. ● Increased contact with General Practices Participants were asked the question “When was the last time family saw GP/Dr?” during the baseline and 18 month data collection. Thirteen participants completed the questionnaire at baseline and 18 months. Page 23 of 87 Tongan Community Action Programme – Phase 2 All thirteen participants who completed questionnaires at both baseline and the 18 month wave of data collection indicated that they had visited a doctor within the last year. Some listed specific dates. Two participants did not respond at baseline and one did not at 18 months. A survey was conducted in February and March 2008 with the GPs responsible for the 18 participants who had biological (Blood pressure, Fasting Glucose and/or Lipids) outside of the normal range. The survey sought evidence of sustainability by obtaining feedback on their perspective of whether the short and medium term objectives were being achieved by their clients as participants in the TCAP intervention. GPs responded that they had increased contact with 10 out of 16 participants in the TCAP intervention. GPs did not have increased contact with four of the 16. This was also considered to be a tool for gauging prospective levels of sustainability with respect to general practice in relation to the short and medium term objectives of the TCAP programme. Three GPs were identified for meeting to interview. Two of the three GPs agreed to meet and discuss the project and feedback through the survey with the Tongan community worker. The third was not accessed as the receptionist indicated he was very busy. This GP had two clients participating in the project who have been a challenge to keep engaged in the project. No data was received by the GP for these two participants leaving a total number of 16. The following are the short term (up to 1 year) and intermediate term (1-3 years) outcomes that we have aimed to achieve. GPs were asked to indicate beside each outcome their perspective of each outcome with respect to each client. The outcomes are numbered 1-11 and GPs indicated whether they agreed, were unsure or disagreed with the outcome. Note that some questions were not answered. The results are positive showing agreement by GPs that the project is having a positive effect on the majority of the participants considered ‘higher risk’ towards the short and medium term outcomes of the project. Table 2 (over page) provides the tabulated results from GPs for 16 of the 18 participants who have been identified as having blood results outside of the normal range. One of the more significant statistics is that GPs indicated 10/16 participants have had increased contact with their GPs as a result of the TCAP programme. GPs were unsure about 2/16 and disagreed about 4/16. Remedial action will be considered for the 6 participants where GPs were unsure and disagreed. Of the five short term outcomes GPs indicated disagreement on only two occasions across two of the five outcomes. There appears to be indicative agreement by GPs that participants were achieving the short and intermediate term outcomes of the TCAP project. Other comment from GPs included: Learned about food preparation and has increased physical activity Information about food and food preparation Short conversations only. He seemed quite motivated at the time Ongoing contact to help support and keep him motivated Page 24 of 87 Tongan Community Action Programme – Phase 2 Ongoing contact to motivate Nothing I can think of. We have a recall system in place Motivated Unsure 1 12 4 9 11 6 5 11 4 11 4 1 Intermediate term 6. Increased rate(s) of smoking cessation 1 7 2 7. Increased contact with General Practices 10 2 4 8. Increased levels of regular physical activity 9 6 1 8 7 10 9 5 6 Short term 1. Increased awareness of key messages in HEHA 2. Increased participation in physical activities 3. Increased awareness of the importance of breakfast 4. Increased intake milk, fruit & vegetables 5. Increased knowledge of food preparation and cooking skills 9. Increased accessibility to low fat, sugar and salty foods 10. Increase in healthy meals made at home 11. Increased commitment to Healthy lifestyles by Tongan families ● Comments Agree Table 2 - Collated results Disagree Needs encouragement from work colleagues to have healthy options Needs encouragement from work colleagues to have healthy options Wife prepares food Help keep family healthy Continues to smoke 20/week Stopped smoking in 2003 2x Not applicable 2x Assisted by Careplus Often limited by lack of an interpreter Last seen in 2006 2x Uses free diabetes review annually Very proactive with health Not seen for 12 months Depends on family Regular with medicines 2x Not seen since arriving to NZ from Australia Some lack of motivation although aware of benefits Aware although finding this difficult General Practitioners Survey follow up The second survey was conducted with the general practitioners of those participants who had one or more recorded blood and blood pressure results outside of the normal range. This was done face to face and by mail out. The results are positive showing agreement by GPs that the project is having a positive effect on the majority of the participants considered ‘higher risk’ towards the short and medium term outcomes of the project. (Refer to detailed results on pages 12-13) Page 25 of 87 Tongan Community Action Programme – Phase 2 2.3 Awareness of Key Messages in HEHA The consistently high cholesterol results of the participants indicated a closer look at the saturated fat foods influencing cholesterol levels. Short term (up to one year) ● Pantry Project The ‘Pantry Project’ assessed the extent to which high saturated fat foods are still a part of participants’ diets. This project relates to three short and intermediate term project outcomes which were: 1) Increased awareness of key messages in HEHA (0-12 months) 2) Increased knowledge of food preparation and cooking skills (0-12 months) 3) Increased healthy meals made at home (1-3 years) The results show that high saturated fat foods still form a significant part of the participants’ diet. Positive changes have occurred in the frequency of consumption of some foods however, a significant number of participants mentioned eating high saturated fatty foods once/twice or three to five times a week. Introduction Discussions regarding food and dietary practices that influence blood cholesterol were conducted with 15 participants over the phone. The following section is a summary report of food consumption and dietary practices as outlined below. Food consumption Participants were asked to discuss how often they eat certain foods and the following information was obtained. Food types: Cream/ coconut cream One third (5/15) of the participants have creams or coconut cream once or twice per week and the rest (10/15) less than once a week. Ice-cream About three quarters (11/15) of the participants ate ice-cream less than once a week while the rest had it once or twice a week (2/15) or three to five times a week (2/15.) Cheese Though three in every five (9/15) participants ate cheese less than once a week or never, one in five (3/15) still consumed it three to fives per week. Eggs All participants reported eating three eggs a week or less. Page 26 of 87 Tongan Community Action Programme – Phase 2 Milk type Three in every five (9/15) participants reported using trim (green top) or low fat (light blue top) milk. However, a significant two in five (6/15) use homogenised blue top milk. Skin on chicken Just under half (7/15) the participants reported eating some, most or all of the skin on chicken; the rest said they ate none of it. Fat on meat Two in every three (10/15) participants reported having some, most or all the fat on meat while the rest said none. Deep fried food in batter Four in every five participants (12/15) reported having deep fried food in batter less than once a week and the rest (3/15) had once or twice a week. Sausages, meat pies, sausage rolls, luncheon sausages, tinned corn beef, bacon or mutton flaps. Two in every three (10/15) participants had the above mentioned meat once/twice or three to five times a week. Only one in three (5/15) ate these less than once a week. Hot chips or fries The majority of participants (9/15) reported eating chips or fries less than once a week. Only one in five (3/15) had them once or twice a week. The remaining 3/15 said they never ate chips. Gravy, cream or cheese sauces All 15 participants said they ate the above foods once or twice a week or less. Sweet pies, pastries, cakes, muffins or croissants Four in every five (12/15) of the participants ate the above foods less than once a week or never. The rest (3/15) had them once or twice a week. Chocolate, chocolate bars and chocolate biscuits Almost all (13/15) participants said they ate the above foods less than once a week or never. Dietary Practices Addition of butter, margarine, oil or sour cream to vegetables, cooked rice, pasta or noodles Four in every five (12/15) participants reported adding the above fats/ oil to food three to five times a week or more. The rest (3/15) said less than once a week or never Spreading butter/margarine on bread All 15 participants reported using margarine instead of butter on bread. However, almost half (7/15) said they used medium to thick spread. Page 27 of 87 Tongan Community Action Programme – Phase 2 Discussion The above results show that high saturated fat foods still form a significant part of the participants’ diet. Positive changes have occurred in the frequency of consumption of ice-cream, deep fried food in batter, hot chips/ fries, gravy, cream or cheese sauces, chocolate, coconut cream, cheese, sweet pies, pastries, cakes, muffins or croissants. However, a significant number of participants mentioned eating sausages, meat pies, sausage rolls, luncheon sausages, tinned corn beef, bacon or mutton flaps once/twice or three to five times a week. Most also said they had some, most or all the fat on meat or skin on chicken. As meat plays an important role in the Tongan diet, there is a need to emphasize the importance of removing fat and skin off meat and chicken as well as suggesting less fatty options. Additionally, most participants still added oil, margarine or sour cream to food and also put medium to thick spread on bread. These practices increase the consumption of saturated fat, hence raising cholesterol levels. There is a need to review the abovementioned food choices and eating habits in order to make a significant reduction in cholesterol levels. An appropriate resource for the nutrition educator will be produced to address some of the above issues. ● Increased levels of regular physical activities Tongan Group Exercise Tongan Group Exercise was introduced during the initial TCAP2 intervention. Participants attended a local circuit gym up to three times a week over a ten week period (OctoberDecember 2006). Although this was proving to be an effective and highly attended sessions it was acknowledged that this would not be sustainable for many Tongan community members. Reasons given included: Cost (Even with a community services card) Childcare costs Access/Transport Self confidence Language barriers As a result of this the Tongan community were supported in 2007 to develop there own exercise circuit sessions. The NHF supplied a range of exercise equipment and provided support for a Tongan fitness instructor to take these classes. Exercises classes continue to attract small but consistent numbers of participants and have been delivered at a local community facility up to 30 June 2008. Tongan community and local community leaders have been connected with local government and health staff to identify ongoing funding and resource support for group exercise. Reasons given for attending include: No cost Page 28 of 87 Tongan Community Action Programme – Phase 2 Children can join in or play nearby with sports equipment Accessible location Its fun exercising with friends and family Happy to speak in English or Tongan Intermediate term (1-3 years) ● Increased levels of regular physical activity This section covers physical activity data collected from the sixteen participants who completed most of the questions in the questionnaire at baseline and 18 months. Not all questions were completed and where the number varies it is listed. The questions in this section related to family behaviours rather than individual behaviours. It is assumed that this was understood by the participants who then replied to questions on behalf of their family. Any percentages given relate to the number of stated participants not the total number of individuals in the project. Normal modes(s) of travel The question was “normal mode(s) of travel”. 16 participants completed this question at baseline and 18 months. All participants listed cars as a method of travel at baseline and 18 months. 50% (n=8) families indicated walking was a method of travel at baseline. 56% (n=9) families indicated walking was a method of travel at 18 months. This is an increase of one family at 18 months. Favourite Family Physical Activities The questions were “Family favourite physical activities” and “How often family do these activities”. 10 participants completed this question at baseline and 18 months The following activities were reported; playing the guitar, exercise, walking, rugby, touch rugby, cycling, gardening, tennis, church, swimming, netball and gym. 3 families reported an increase in the number of weekly physical activity sessions 3 families reported the same level of weekly physical activity sessions 4 families reported a decrease in the number of weekly physical activity sessions At baseline there were 35 sessions of participation in physical activity reported in a week. Averaged between the 10 households, this is 3.5 sessions of physical activity per week per household. At 18 months there were 31 sessions of participation in physical activity reported in a week, which averaged to 3 sessions per week per household. Overall this is a slight decrease in the reported frequency of physical activity at 18 months. Six of the 16 replies were invalid, for example, one participant listed a specific date rather than a frequency, one reported daily guitar playing and one participant reported ‘am/pm’, that is, the time of day they engaged in the activity rather than the frequency. Some participants answered at either baseline or 18 months but not both. This left 10 people who responded on behalf of their family at both baseline and 18 months to the question ‘family favourite physical activities’ and ‘how often the family engages in these activities’ (sic). Page 29 of 87 Tongan Community Action Programme – Phase 2 Family’s favourite sport or game The questions were “Family’s favourite sport or game” and “How often the family plays these”. Seven participants completed this question at baseline and 18 months The same activities as above were listed with inclusion of volleyball. 2 families reported an increase in the frequency that the sport or game was played 5 families reported the same frequency of participation For the following reasons it is not possible to accurately record the number of times families engaged in their favourite sport or game; missing data and the lack of accurate frequencies, for example, one participant reported playing rugby ‘very rarely’ at baseline and cycling daily at 18 months. This increase is not able to be quantified. Likewise, as mentioned previously one participant gave a non-specific (but equal) frequency at both points of data collection. Of the five participants who did list specific frequencies; 4.5 sessions of participation in sport or games were reported in a week at baseline and 5.5 sessions of participation in sport or games were reported in a week at 18 months. Other potential reasons for both these questions not accurately capturing the frequency that families engaged in physical activities, games or sports include seasonal variations, for example, walking may reduce in frequency in winter. Also, differences in the activities listed may have contributed to different frequencies being reported. For example, some families listed the frequency of playing rugby as weekly and later the frequency of walking as daily. This was recorded as an increase in frequency. However, when this data was reported in the opposite order it was recorded as a decrease in frequency. Team activities such as rugby and league are not accurately comparable with walking and cycling. It could be that families continued to walk or cycle to work or school, but listed a team sport at a different point of data collection because it coincided with enrolment or purchase of boots etc and was therefore foremost in their mind. Some further questioning would have been useful to clarify this. This question is reasonably similar to the previous one and it is suggested that some of the 16 participants who completed most of the questionnaire at baseline and 18 months were confused by this question. This is shown by both their replies and the fact that nine responses were invalid for reasons such as, listing rugby as the family’s favourite sport but reporting the frequency of participation as ‘watching’ and non responses at either baseline or 18 months. One of the 16 participants did not respond at all to this question. Another participant listed ‘once in a while’ and ‘not very often’ as the frequency which they engaged in the activity. This was considered to be valid and was recorded as the same frequency. This left seven participants who completed the question at both baseline and 18 months. Television viewing The question was “On average how many hours a day is your TV on?” 12 participants completed the questionnaire at baseline and 18 months 4 families reported a decrease in the length of time the television was on 3 families reported the television was on for the same number of hours 5 families reported an increase the length of time the television was on Page 30 of 87 Tongan Community Action Programme – Phase 2 At baseline the television was reported as being on for a total of 43.5 hours per day amongst 12 families, which is an average of 4 hours per day. At 18 months the television was reported as being on for a total of 49 hours per day amongst 12 families, which is also an average of 4 hours per day. The responses to this question may be unreliable due to several factors; (i) the number of hours the television was on does not necessarily correlate to hours actually watched (the television may have been going in the background and/or the total viewing time may have been shared between family members), (ii) the response categories to this question were not mutually exclusive, for example, does having the television on for two hours a day fit in 1-2 hours or 2-3 hours? (iii) the number of people living in some households was dynamic and these altered household structures mean comparisons may not be accurate. Number of people living in a house The question was “How many people live in your house?” Twelve participants completed this question at baseline and 18 months At baseline the number of people living together in a house ranged from three to nine (median 6) at 18 months the number of people living together in a house ranged from three to ten (median 6 ) Two of the 12 participants reported the same number of people living in their house at baseline and 18 months, seven reported fewer people living in their house and three reported more people living in their house at 18 months than at baseline. The age distribution of people living in the households indicates that some families had extended family members living with them. This was confirmed by the project facilitator and is consistent with evidence indicating that Pacific people are much more likely to be living as part of an extended family than the total New Zealand population (Koloto 2008, MoH a 2008). Stages of Change for physical activity levels This section relates to the participants’ individual beliefs regarding physical activity. The questions were framed using a ‘stages of change’ model. Stages of change questionnaires are designed to assess an individual’s motivation and readiness to either, adopt a health promoting behaviour, or change an addictive behaviour; however, they were used here in a collective manner. It should also be noted that a stated intention does not necessarily translate into behaviour change. Participants were asked whether they ‘strongly agreed’, ‘agreed’, (sic) were ‘undecided’, ‘disagreed’ or ‘strongly disagreed’ to twelve statements; some of which are ambiguous. For example, when participants disagree with the statement “I am satisfied being an inactive person”, do they mean they are inactive and would like to be more active, or, do they mean that they are already active and therefore this statement is not applicable to them? Twenty nine participants completed this part of the questionnaire at the 18 month wave of data collection. Participants indicated an awareness of the potential consequences to their health of not being physically active. In response to the statement, “I am afraid of the consequences to my health if I do not exercise” Page 31 of 87 Tongan Community Action Programme – Phase 2 o o at baseline 25 out of 31 participants either strongly agreed or agreed with the statement At 18 months 28 of 29 participants strongly agreed or agreed. Responses to the statement, “I have been thinking about whether I will be able to exercise regularly” indicated that more people were aware of the importance physical activity. o at baseline 19 out of 30 participants either strongly agreed or agreed with the statement o at 18 months 27 out of 29 participants either strongly agreed or agreed In response to the statement, “I don’t exercise and right now I don’t care” o at baseline 21 out of 32 participants strongly disagreed or disagreed with the statement. o at 18 months 23 out of 29 strongly disagreed or disagreed Participants were asked to score three statements indicating that they were already exercising or had begun to exercise: “I have been exercising regularly for a long time and I plan to continue”, “I am finally exercising now and I plan to continue” “I have started to exercise regularly and I plan to continue” o 16-20 (of 29) respondents strongly agreed or agreed with these statements at 18 months There is an identified need for continued health education and support. Free Physical Activity sessions From February to April 2008 the remaining 34 TCAP participants were invited to attend physical activity circuit training at a local fitness centre. Classes were set up and a Tongan group trainer contracted to instruct and guide members attending the free sessions. The sessions were spread out over different days and times of the week to give participants every opportunity to attend. These sessions were established in response to a request from some of the TCAP participants at in June 2007. This was done through a qualitative survey in Tongan language. The following narrative comments had been received in Tongan and then translated to English: Increase time spending on exercise each week Exercising, blood test Help me to move those pains that haven’t been moved by other exercises Learn about body and how to keep it well Exercise for better health, eat healthy and socialize people More frequent exercise classes / circuits at the Tongan centre Keep to Saturday mornings or afternoons (work around children’s sport) Greater co-ordination from within the Tongan Community to ensure better turnout Page 32 of 87 Tongan Community Action Programme – Phase 2 More exercise days in a week To let messages reach little children and teenagers Attendance at the free sessions over February and March 2008 ranged from 2-14 participants and the sessions continued through until the end of June. April to June 2008 For the ten week period from April to June the physical activity programme continued to provide a physical activity resource for the TCAP2 participants and well as the Hoon Hay Community. Both these groups are based from the Rowley Resource Centre in South Christchurch. All sessions were run by Marcellino Taulango, a qualified personal and group exercise trainer who was contracted by the Heart Foundation. The venues used for the Physical Activity sessions included: Rowley Resource Centre, Hoon Hay The Active Room – Fitness Centre, Tower Junction Hoon Hay Park, Hoon Hay Hoon Hay Environs There were 32 individuals who participated in the programme and between them attended 198 times over the duration of the programme. Daily attendances ranged from a low of zero to a high of twelve. Page 33 of 87 Tongan Community Action Programme – Phase 2 2.4 Healthy Shared Breakfasts Short term (up to one year) ● Increased awareness of the importance of breakfast Having breakfast is important to reduce weight and cholesterol. Participants may be aware of this but definitely breakfast was not adopted as a daily habit. While it seems porridge and breakfast cereal consumption has increased it appears that most participants are only having breakfast some mornings. Intermediate term (1-3 years) ● Increased accessibility to and affordability of low fat, sugar and salt foods According to respondents some positive changes have been made towards healthier food choices. Increased awareness about the importance reducing fat Participants indicated an increased awareness about the importance of reducing the fat content in food at the 18 month wave of data collection. In response to a question about intended changes to the consumption of corned beef cooked in cream, bananas cooked in coconut cream, lamb cooked in coconut cream and coconut dumpling, o o 17 out of 29 indicated they were trying to eat less of these foods at baseline 23 out of 29 indicated they were trying to eat less of these foods at 12 months Sweet Foods At least a third of the respondents were consuming one form of sweet food or other 1-4 times per week over the 5 data collection periods. Some of these e.g. muffins can be effectively incorporated into a healthy, varied diet. Others such as cream-filled biscuits, sweet pies and pasties, puddings and desserts are still being consumed 1-4 times per week by about a third of respondents. These would contribute significantly to the fat and sugar consumption of the participants. Ongoing education is required regarding these foods. This should include recipe modification, portion size, recommended number of servings and appropriate lower sugar and/ or fat alternatives. Most households should be able to bake as they reported having ovens in their homes. This would be especially appropriate to encourage home baking and recipe modification to make these foods healthier. Snacks Additionally, households choosing healthy snacks such as crackers, fruits and vegetables did not change much or remained relatively low over the 18 months period. At the same time, chips, chocolates, biscuits and cakes still featured as snacks of choice over the same period. Page 34 of 87 Tongan Community Action Programme – Phase 2 Though number of respondents citing these may be considerably low, its possible that actual numbers are higher but participants under-reported due to familiarity with ongoing nutrition education messages. This community could benefit from on-going support to allow gradual acceptance and adoption of healthier food choices. Respondents were asked how often they ate selected sweet foods and soups. Fifteen of the 31 respondents (48.4%) said they ate the following foods 1-4 times per week , with the rest having them less than once a month or never at 18 months: o o cakes, scones or pikelets muffins-all types An average of one in every three respondents reported consuming the following sweet foods 1-4 times per week while the rest had these less than once a month or never for the five data collection periods. o o o sweet pies or pasties cream-filled or chocolate biscuits other puddings or dessert (not including milk desserts) One respondent cited having sweet pies/ pasties and 2 ate sweet biscuits 5 times or more per week at 18 months. An average of 1 in every 2 respondents had sweet biscuits 1-4 times per week. At least one in 3 respondents ate canned/ packet soups 1-4 times per week and the rest less than once per month or never for the 5 data collection periods. The most commonly cited snacks were toast/sandwiches, crackers, fruit and vegetables. Table 3 below shows the snack types usually eaten for the 4 reporting periods. Table 3: Commonly Consumed Snacks Snack type % Respondents Baseline 3 months N=39 (%) N=18 (%) Sandwich/toast 7 (17.9) 6 (33.3) Biscuits/cakes 12 (30.8) 2 (11.1) Crackers 5 (12.8) 7 (38.9) Fruit/vegetable 12 (30.8) 7 ((38.9) Tea 2 (5.1) 4 (22.2) Chips 15 (38.5) 2 (11.1) *Other 4 (10.3) 3 (16.7) Other= fizzy drinks, twisties, snack bars, noodles, chocolate, tuna 6 months 12 months 18 months N=19 (%) N=14 (%) N=17 (%) 6 (31.6) 8 (57.1) 7 (41.2) 3 (15.8) 3 (21.4) 3 (17.6) 8 (42.1) 2 ((14.2) 5 (29.4) 12 (63.2) 7 (50) 9 (52.9) 1 (5.9) 4 (10.3) 1 (7.1) 3 (17.6) 5 (26.3) 2 (14.2) 7 (41.2) ricies / weetbix, peanuts, scones, leftovers, The results show that number of households choosing sandwich/toast and fruit/ vegetable snacks did not change much from 3 to 18 months. The numbers choosing crackers also remained low with only 5 of the 17 households citing them at 18 months data collection. Though the number of households citing snacks such as biscuits and chips was also small (1-4), these remained snacks of choice from baseline to 18 months Page 35 of 87 Tongan Community Action Programme – Phase 2 data collection. Additionally, other “unhealthy” options such as snack bars and chocolate were still mentioned at 18 months. The majority (at least 2 in every 3) of respondents said they ate snacks two to 4 times a day from 3 to 18 months data collection periods. One to 3 respondents said they had snacks four or more time per day during the same period. Most respondents reported having snacks between 1 and 4 pm. The second most popular times were 11-12am or 7-8pm in the evening. None ate snacks before 9am at 3, 6 and 12 months, with only 1 household reporting this at 18 months. There were 3-4 households that consumed snacks between 9 and 10 pm at 3, 6 and 18 months. Healthy meals made at home (refer to page 23, Pantry Project) Awareness of the importance of Healthy Food Increase intake of fruit and vegetables Healthier meals made at home Reduction in households consuming high fat and/or salt specialty breads Most households reported having cooked porridge and breakfast cereals 1-4 times per week Most households have basic equipment and appliances for preparation of healthy meals Food purchasing patterns were good with most families buying food once a week Frying as a cooking method has decreased Page 36 of 87 Tongan Community Action Programme – Phase 2 2.5 Commitment to Healthy Lifestyles This report is based on data collected over 5 reporting periods i.e. baseline, 3, 6, 12 and 18 months. The numbers of respondents were different for the 5 data collection periods. They were also different for the various categories covered in the report. For example, the number or respondents for fruit and vegetable consumption, food purchasing patterns, household appliances, and children’s bed times were 40, 20, 30, 24 and 17 at baseline, 3,6,12 and 18 months data collection periods respectively. At baseline, individual respondents were interviewed but these were later grouped into households, hence the lower numbers for subsequent data collections for the above categories. On the other hand, the number of respondents for meat and fish, breads, cereals and miscellaneous foods consumption were 29, 20, 30, 24 and 31 for the respective periods. All the total respondents from baseline to 18 months represent individual respondents, not households for these food categories. Any numbers or percentages cited are with reference to the total respondents/ households for the specified period, unless otherwise stated. Additionally, time frames will be specified for any trends cited in the report. Statistical significance of changes mentioned in the report was not determined and this should be taken into account when interpreting the findings. Data analysis was conducted using summary tables and percentages cited are based on the respondent numbers for each category and reporting period as mentioned previously. There were limitations in some of the data or in the way some questions were asked. As a result, some assumptions were used to assist with interpretation of the results (see assumptions section). The categories used for grouping food consumption frequencies in the report are different from those used in the questionnaire. This is due to combination of overlapping categories into mutually exclusive ones for ease in percentage calculations and data interpretation. The report shows group and not individual results and trends as it was difficult to track the changes for individuals due to an incomplete data set and coding at data entry. The way certain foods were grouped in the food frequency questionnaire, especially meat dishes combined lean and fatty meats or dishes using “healthy" and “non- healthy” cooking methods. As a result, it is difficult to comment on whether the respondents were choosing lower fat cuts of meat and cooking methods or not. What can be deduced is how often they ate certain types of meat e.g. chicken or lamb. Assumptions 1. Naming favourite fruits and vegetables does not indicate availability, affordability and usual consumption by the respondent. However, for the purpose of the study, favourite fruit/vegetable means what the respondents normally consume. 2. Though ownership of specified household appliances does not necessarily reflect working condition or frequency of use, this report assumes that the respondents regularly use them. 3. Waking and sleeping times for children were recorded but naps were not included. The report assumes there are no naps during the day. 4. Though food consumption data is subject to respondent bias, the report assumes the trends fairly reflect the dietary changes made by the respondents. Page 37 of 87 Tongan Community Action Programme – Phase 2 5. Though the food categories used in the questionnaire do not include fish meat alternatives, milk and milk products, takeaways, spreads, sauces and dressings, the report assumes the categories covered give a fair picture of respondents’ general food choices and consumption patterns. Short term (up to one year) ● Increased awareness of the importance of breakfast (Refer to page 30) ● Increased intake of milk, fruit and vegetables There were no questions relating to milk consumption over the five data collection periods. All respondents reported eating fruit and vegetables though the variety for both was limited Increased awareness of the importance of fruit and vegetables Participants indicated an increased awareness of the importance of fruit and vegetables at the 18 month wave of data collection. The response choices in this section were ‘eat more’, ‘eat less’ and ‘don’t know’. o o o o at baseline 22 out of 30 participants indicated they were trying to eat more vegetables at 18 months 25 out of 28 participants indicated they were trying to eat more vegetables at baseline 24 out of 30 participants indicated they were trying to eat more fruit . at 18 months 25 out of 28 participants indicated they were trying to eat more fruit Fruits Respondents were asked to name their favourite fruits. Oranges, apples and bananas were the top three fruits mentioned at baseline, 3, 6, 12 and 18 months of the study. Water / rock melons and mangoes were also popular at baseline but these were mentioned by five households or less in subsequent reporting periods. Despite pawpaws, pineapples, mangoes and water melons being part of the traditional Tongan diet, these were mentioned by less than 40% of the households at 3, 6, 12 and 18 months. Grapes, pears, peaches, persimmons, nectarines, apricots, tamarillos, plums and cherries were all mentioned by five households or less during the same period. This was regardless of plentiful availability of some of the above fruits during some of the data collection periods. Vegetables Respondents were asked to name their favourite vegetable/s. The most commonly cited vegetable for the five reporting periods was carrot. This was followed by tomato at baseline, 6, 12 and 18. Lettuce was second most popular vegetable at 3 months, with tomato being as popular as carrots in the same period. The third most popular vegetables were green leafy varieties (taro leaves, spinach or silver beet). Potato/ kumara, peas/ beans, capsicum, cauliflower, celery, cabbage, mushroom, onion, corn, cucumber and beetroot were mentioned by four or less households at 3, 6, 12 and 18 months. Page 38 of 87 Tongan Community Action Programme – Phase 2 Increased knowledge of food preparation and cooking skills When asked how fruit was normally eaten, at least three in every four respondents said they ate them raw or fresh at all the data collection points. Less than 30% (25% baseline, 3mths=11%; 6mths=21% and 12mths=28%; 18 mths=17.6%) reported cooking them. Some respondents also said they ate fruits as dessert but did not state whether they cooked them or not before consumption. Boiling/cooking was the most common (baseline=82.5%, 3mths=94.4%; 6mths= 63%; 12mths=85.7%) way of cooking vegetables. Steaming was the next preferred way of cooking vegetables during the same period. However, steaming was the most preferred method of cooking vegetables at 18 months, followed by boiling. Respondents citing raw vegetable consumption remained low, with less than 50% mentioning this at baseline, 6, 12 and 18 months. Despite one in every four respondents mentioning frying at baseline, only one respondent (7.1% or less) mentioned it at 3, 6 12 and 18 months. Roasting was also not very popular and was cited by four respondents or less (<21%) in the same period. Intermediate term (1-3 years) ● Increased healthy meals made at home Respondents were generally citing healthier food preparation and cooking methods such as steaming and raw vegetable consumption though continued education is still required. Breads and Cereals The consumption of fatty and or salty bread and cereal products was low over 18 months from baseline. However, low consumption of most specialty breads may not reflect better food choices but may simply reflect other constraints such as cost or unfamiliarity of these foods to the respondents. Furthermore, the respondents may still be purchasing other low cost, high salt breads available on the market. At least 2 in every 3 households reported having cooked porridge or breakfast cereals 1-4 times per week. This could be attributed to the key messages provided during the shared breakfast sessions. However, these figures are inconsistent with the low numbers citing having a meal in the morning (refer to table 2). This could be due to misinterpretation of the questions involved by the respondents. Pasta consumption was low and rice was the preferred cereal by most respondents/ households. This could be due to participants’ taste preference and not cost as pasta is reasonably inexpensive. Respondents were asked how often they ate specified breads/ cereal foods. Responses were grouped into 3 food consumption frequency categories: Less than once per month or never 1-4 times per week Page 39 of 87 Tongan Community Action Programme – Phase 2 5 times or more per week. From 3 to 18 months data collection, the number of households citing they had eaten the following breads / cereals less than once a month or never remained high (at least 3 in every 4): Rewana bread Doughboys Maori bread Waffle/doughnut Fruit or iced buns Crumpet/croissant There was also a general increase in the number of households who were eating focaccia, bagel, pita, paraoa parai (fry bread) and other specialty breads less than once a month or never in the same period. The number of households consuming the above mentioned breads 1-4 times a week remained generally low (5 households or less). No households ate Maori bread, crumpets/croissants, waffle/doughnuts, fruit or iced buns five times or more from 3 to 18 months. There was an increase in the number of households (2 in every 3) consuming cooked porridge 1-4 times per week between 3 months to almost all (except 2 households) at 18 months. Only 4 households or less reported having porridge 5 times per week/ more or less than once per month/ never over the same period. There was no clear trend for breakfast cereal consumption. However, 3 in every 4 households said they ate breakfast cereal 1-4 times per week at 12 and 18 months data collection. Additional 4-6 households ate breakfast cereals 5 times per week or more in the same period. At least half the households ate savoury/ dry biscuits, crispbread and crackers 1-4 times per week over the 5 data collection periods. However, 3 households or less said they consumed the above foods 5 times per week or more in the same period. At least 2 in every 3 households ate rice 1-4 times a week across the reporting periods. The number of respondent who reported eating pasta less than once a month or never steadily increased from 1 in every three at 3 months to at least one in every 2 at 18 months. There was a corresponding decrease in households eating pasta 1-4 times per week and 3 or fewer households having it 5 times per week or more. Meat When consumption of meat dishes is considered, it appears most or all households eat one type of meat or another everyday of the week. Unfortunately, information about quantities consumed was not available. However, the apparent regular meat consumption significantly contributes to the intake of saturated fat and cholesterol. This is supported by at least half the respondents citing consumption of different beef, chicken, lamb/hogget dishes and saveloys 1-4 times per week at 18 months. These dishes include potentially high fat ones such as casseroles and chops, unless visible fat is trimmed or lean cuts are used. Additionally, close to 3 in every 4 respondents said they consumed lamb roast/ chops 1-4 times a week at 18 months data collection. Page 40 of 87 Tongan Community Action Programme – Phase 2 One to 2 households said they consumed some of the various meat dishes 5 times or more per week. This further confirms that meat is an important part of the Tongan diet. Ongoing education regarding appropriate portion sizes, frequency of consumption and healthy preparation methods to reduce fat intake should be provided. This should be combined with information on appropriate meat alternatives and budgeting. When all data was considered across the 5 reporting periods, no clear trends could be derived for most of the food categories as figures generally went up and down over time. However, the information provided below broadly summarises the main conclusions drawn from the available data. At least 1 in every 2 respondents said they ate the following meat dishes 1-4 times per week at 18 months: Beef mince dishes, rissoles, and meatloaf Lamb-roast/chop Lamb mixed dishes e.g. casserole, stir-fry Chicken mixed dishes (e.g. casserole, stir-fry) Chicken – roast, fried, steamed Hogget/ mutton roast, chops The majority of respondents (at least 3 in every four) had liver (including pate) and other offal e.g. kidneys once a month or never. The rest (7 households or less) consumed these 1-4 times per week for all data collection periods. Between 30 and 46% respondents ate bacon, ham, luncheon meats, salami and brawn 1-4 times a week with the rest having it less than once a month or never between 3 and 18 months. Approximately 1 in 2 respondents ate saveloys 1-4 times per week while the rest ate it less than once a month or never during the same period. Twenty-two of the 31 households (71%) said they ate lamb roast/chops 1-4 times a week at 18 months data collection. Less than one in 3 respondents ate pork mixed dishes such as casserole or stirfry 1-4 times per week while the rest had these less than once a month or never at 6, 12 and 18 months. About 10-13 households (38-53%) respondents ate pork boiled bones 1-4 times per week while the rest ate it less than once a month or never at baseline, 3, 6 and 18 months. One to 2 households or less reported eating some of the meat dishes mentioned above 5 times per week or more from baseline to 18 months data collection. Awareness of Fruit and Vegetable Consumption and Reduced Fat Intake The results show that participants have increased awareness of the importance of fruit and vegetable consumption. They also had increased awareness of the importance of reducing fat in their diet. This could be attributed to on-going nutrition education as well as shared breakfast sessions conducted for this population. Fruits and Vegetables The results show that the respondents’ fruit choices are limited mainly to oranges, bananas and apples, despite the availability of other fruit varieties through out the year. Additionally, fruits such as pineapples and mangoes, which are part of the Pacific Page 41 of 87 Tongan Community Action Programme – Phase 2 island diet, were not eaten by most respondents. Vegetable varieties most commonly consumed were also limited mainly to carrots, tomatoes, green leafy vegetables and lettuce. This was despite several nutrition education sessions citing the benefits of consuming a wide variety of vegetables and fruits. The high cost of other options and not seasonal variation is the most likely explanation for this. This is supported by the majority of respondents buying food from supermarkets where fruits and vegetables may be more expensive than fruit/ vegetable shops. Additionally, cultural food preferences could be part of the reason, especially where fruits and vegetables that are not typically part of the Tongan diet are concerned. This population may therefore not be getting the full benefits associated with eating a variety of coloured fruits and vegetables. They should be encouraged to compare prices in supermarkets and fruit and/or vegetable shops, using frozen or canned ones over fresh to increase variety at a reasonable cost. Additionally, future education sessions could cover supermarket tours, information on food prices and encouragement on how to experiment with culturally unfamiliar foods to increase variety. Since 70-80% respondents said they have a fridge or freezer, they could take advantage of fruits and vegetables on special offer and freeze them for future use. Meal Patterns Reported meal patterns generally showed that some respondents do not eat breakfast and or lunch but most eat the evening meal. Those who skipped meals probably resorted to snacks at various times of the day as supported by 2 in every 3 respondents saying they ate these 2-4 times per day. At least 2 in every 3 respondents said they had an evening meal between 5 and 7pm. Less than one in five reported having meals between 8 and 9 pm. (refer to table 2). Between 3 and 4 households reported having snacks between 9 and 10 pm. There is need to continue encouraging regular meals, appropriate timing and frequency of consumption. Education regarding healthy snacks is also required to reduce potential weight gain. There is a need to continue educating the Tongan population preparation of healthy, quick and easy packed lunches. Meal times The most commonly cited meal times were 8-9am, 12-1pm; 6-7pm.Table 4 shows the percentage of respondents per meal time for the 5 reporting periods. Table 4: Commonly cited meal times Meal time 8-9am 12-1pm 5-7pm 8-9pm Baseline (n=39) 48.7% 36% 92.3% 23% 3 months (n=18) 44.4% 38.8% 83.3% - 6 months (n=19) 26.3% 26.35% 100% 21% 12 months (n=14) 14.2% 7.1% 64.3% 7.1% 18 months (n= 17) 35.3% 35.3% 64.7% 17.6% The results show that less than half the respondents have breakfast, just over a third or less have lunch and the majority (64-100%) eat an evening meal between 5 and 7pm. The number of respondents having breakfast decreased from baseline (48.7%) Page 42 of 87 Tongan Community Action Programme – Phase 2 to 12 months follow-up (14.2%). Less that a quarter of the respondents reported having a meal between 8 and 9pm at baseline; 6, 12 and 18 months follow-up. ● Commitment to healthy lifestyles by Tongan families Lifestyle Modification This section is a summary of the 12 month data collected over 5 reporting periods i.e. baseline, 3, 6 12 and 18 months. The numbers of respondents were 40, 20, 30, 24 and 29 for each data collection period respectively. The results show that some positive changes have been made in terms of healthier food choices, food purchasing patterns and methods of cooking. However, on-going education is required to ensure these positive trends continue. Though there is a need for continued education across all components, special focus should be on eating regular meals, methods of cooking (especially for vegetables) and own food production as highlighted above. Food Purchasing Patterns Respondents were asked where they normally bought food. At least 7 in every 10 households mentioned supermarkets (Countdown, Pak n Save, Supervalue) as the main source of food across the data collection periods. Fruit and/ or vegetable shops (including Raeward and Funky Pumpkin) were mentioned by one in four respondents or less at baseline, 6, 12 and 18 months. Only one respondent mentioned the local dairy and/or Mad Butcher as a source of food at various reporting periods. Own production was not a common source of vegetables or fruits with no respondents citing it at 6 and 12 months and 3 or fewer at baseline, 3 and 18 months follow up. At least half the households said they bought food once a week. The rest bought food 2-3 times a week, with only one household reporting buying food daily at 6, 12 and 18 months. Vegetable markets are still an important source of food but not as popular as supermarkets. The Tongan community should still be encouraged to compare prices and take advantage of cheaper, fresh, seasonal foods from the different suppliers. Frequency of food purchasing and meal planning should also be discussed to help them make optimum savings. The low percentage of respondents (one household; 5.6%) buying vegetables from the local dairy is a positive result for this population. Though dairy shops can be a convenient source of basic food, they often do not have sufficient fresh fruit and vegetables varieties to choose from. They should not be encouraged as a regular source of fruit and vegetable supplies. Additionally, they may be more expensive compared to supermarkets and fruit/ vegetable markets. Page 43 of 87 Tongan Community Action Programme – Phase 2 Household Appliances Seventy to 100% respondents reported owning a stove, oven, microwave, fridge, freezer, electric jug/kettle or toaster at all data collection periods. Two in every 3 households or less also owned an electric frying pan, food processor, toastie maker or rice cooker. Only one respondent reported owning a blender at baseline. Working hours and Meeting Days Though most participants reported working during the day, there are a few who work mornings or afternoons only. These families are likely to have limited income to afford the required dietary changes. Though the percentage of respondents citing night shift is generally low (23.5% or less), it still has a significant impact for the households concerned as it strongly influences food consumption patterns. None of the respondents reported family members who worked during the weekends at 18 months, which is a positive change especially where time to buy food and family meals are concerned. The most preferred day and meeting times was reported to be Saturday between 9 and 11 am. This time should be considered when planning any projects or events for this population. Children’s Sleeping Patterns Respondents were asked what time children woke up and went to bed. Most of them reported children getting out of bed between 6 and 7am for all data collection periods except at 18 months where most children were getting up between 8 and 9 am. Most children went to bed between 8 and 9pm for all the reporting periods. Assuming no daytime naps, most children were awake for 11-15 hours per day. The number of households reporting children went to bed later than 9pm decreased from 6 at 3 months data collection to just one at 18 months. Only one respondent reported children going to bed after 10pm. Children’s sleeping patterns had generally improved with most getting out of bed between 7 and 8 in the morning and going to bed between 8 and 9 at night. Only one household had children sleeping after 10pm. On-going education should be provided to address further concerns with this. Page 44 of 87 Tongan Community Action Programme – Phase 2 2.6 School Holiday Programmes The Christchurch Tongan Community Association (CTCA) initiated children’s programmes in the January, April and July school holidays in 2007 and January 2008. These programmes ran for two weeks in each of the holidays and included a focus on healthy nutrition and physical activity. The Christchurch City Council, Sport Canterbury and the National Heart Foundation supported these programmes. Support included funding, loan of sports equipment and the provision of staff. The programmes included: Swimming, Hiking, Play activities (outdoor and indoor) and Healthy lunches Short term (up to one year) ● Increased intake of milk, fruit and vegetables All respondents reported eating fruit and vegetables though the variety for both was limited. ● Increased knowledge of food preparation and cooking skills Children prepared the healthy lunches under supervision by NHF staff and a Tongan community health worker. Relationships were developed and nurtured with local suppliers of fruits, veggies and other healthy food stuffs. The nutrition at the school holiday programmes is a significant contrast to two years ago when the holiday programme lunches were fish and chips with sugar laden fizzy drinks. Intermediate term (1-3 years) ● Increased accessibility to and affordability of low fat, sugar and salt foods According to respondents some positive changes have been made towards healthier food choices. ● Increased healthy meals made at home Respondents were generally citing healthier food preparation and cooking methods such as steaming and raw vegetable consumption though continued education is still required. ● Increased commitment to healthy lifestyles by Tongan families Page 45 of 87 Tongan Community Action Programme – Phase 2 Ownership and exchange are the two fundamental tenets of Community Development in the local environment (Shirley 2007). They are factors that govern access to resources and are determinants of income and wealth. Empowering the Tongan Community, through families, in Christchurch has been a priority for TCAP2. In order to achieve sustainable outcomes for the Tongan community, the NHF have endeavored to involve and support current and emerging Tongan leaders in the evolution of this Community Activity. Support options were discussed with the participants of the programme from the outset and on an ongoing basis. These options included: o o o Exercise sessions, Shared breakfasts/lunches, instructional sessions (in Tongan and English language). Food Preparation and Cooking Skills When participants were asked how they ate fruits most of them cited raw fruit consumption, which is in line with some of the nutrition education messages provided during group sessions. Most participants cited steaming as the preferred method of cooking vegetables at 18 months compared to boiling which was previously cited in previous data collection periods. This was a positive change as steaming preserves more nutrients compared with boiling. However, it should be noted that boiling was still popular as it was the second preferred method of vegetable preparation at 18 months. More education needs to be provided so that more people adopt preparation and cooking methods that optimise nutrient retention in vegetable and fruits. Less than half the households cited raw vegetable consumption over 18 months, indicating it could be due to a taste preference for cooked over raw vegetables. Roasting was also not popular and this could be due to the limited vegetable options and inappropriateness of this method for cooking some of them e.g. green leafy varieties. Though frying was mentioned by just one household at 6, 12 and 18 months, the household concerned should get ongoing support so that healthier cooking methods are adopted. Additionally, this should continue to be part of on-going group education session to reduce fat consumption. Page 46 of 87 Tongan Community Action Programme – Phase 2 2.7 Edible Gardens Edible gardens were established in 20 participating families’ houses have been growing and providing plenty of gardening exercise and healthy produce. Short term (up to one year) ● Increased capability to grow vegetables and fruit in own garden Anecdotes from participants suggest that the older and younger generations tend to be the gardeners in the families. Large colour photographs of the gardens adorn the walls of the Tongan Community centre and competitions held for various varieties of produce. This initiative ran parallel with a larger edible garden at the nearby Rowley Community Centre where children from Rowley Primary School have been learning about edible gardens from local gardening guru Lily White. By October 2007 50 Tongan families had edible gardens growing at there homes. 20 of these were the initial Rowley group and an additional 30 in the development at the Free Church of Tonga. In March 2008 Lily White did a follow up session with the TCAP intervention group as well as the Free Church of Tongan group. Ten repeat sessions will happen between 12th of April and 30th of June 2008. Vegetables (Brassica and Broad beans) were provided to all participating families as a way continuation of the focus on edible gardens. There are still 50 gardens in this off shoot of the project. There is a need for continued education and support regarding edible gardens as none of the respondents to a phone survey cited their own production as a source of fruit and vegetables at 12 months. Three or fewer respondents cited own production as a source of fruits or vegetables at 6, 12 and 18 months while none did at baseline and 3 months. Alternatively, it could reflect that the produce was not yet mature for consumption at the various data collection periods and could therefore not be cited as one of the sources. If there is apathy in taking up gardening as a way to increase fruit and vegetable availability while increasing the level of physical activity, the cause of the apathy should be further investigated. Alternatively, more innovative methods such as competitions, growing vegetables for a cause e.g. charity should be investigated to encourage uptake. Intermediate term (1-3 years) ● Increased accessibility to and affordability of low fat, sugar and salt foods According to respondents some positive changes have been made towards healthier food choices. Page 47 of 87 Tongan Community Action Programme – Phase 2 ● Increased commitment to healthy lifestyles by Tongan community leadership Tongan Leadership There have been significant events occurring in the wider Tongan context that have had an indirect impact on the implementation of this project. These events include constitutional unrest in Tonga and the death of the reigning Tongan monarch and his son who was considered ‘the peoples Prince’. In Christchurch the impact of these events has resulted in a particularly powerful development. This was the appearance of the Tongan Council. The Tongan Council is a leadership structure that brings together six leaders of the local churches and well as the Tongan Community Association. This Council informs the elected Tongan representative on the Christchurch Pacific Community Reference Group (PCRG). The PCRG is administered by the Ministry of Pacific Island Affairs (MPIA) and is the mandated consultative body on Pacific community issues in Christchurch. In 2004 the National Heart Foundation engaged with the PCRG to consult on the direction and process for implementing the TCAP. The Tongan Council and the contextual events that acted as a catalist it have provided an environment with the potential to have significant benefit for the wider Tongan community in Christchurch. In November 2007 the Principal Investigator received a verbal invitation to attend the Tongan Council in 2008. The purpose of this invitation is to speak with the Tongan Leadership about the TCAP and to explore what opportunities may exist for developing health programmes for the wider Tongan community. Strategic meeting with Free Church of Tonga On Wednesday the 2nd of April 2008 Heart Foundation representatives met with Reverend Semisi Fonua, President of the Free Tongan Church. Rev Fonua came to New Zealand to speak and liaise with social service interests with the Ministry of Social Developments department of Child Youth and Family and Family and Community Services. Ifalame Teisi was invited to Auckland to attend this forum and was proactive in brokering the meeting with the Heart Foundation. Ifalame has worked with his head Church Minister in Christchurch over the few months to encourage increased participation in nutrition and physical activity based activities. As a result of Ifalame’s advocacy the President of the Free Tongan Church wrote to the Heart Foundation for more information about its programmes. There are around 5000 Tongans nationally who belong to the Free Tongan church in New Zealand. The community based setting of the initial TCAP has allowed participants to work in their own environment and religious and cultural beliefs to be incorporated. Community approaches in health promotion empower individuals and communities to gain control over the determinants of their own health and without community participation, long term health gains in populations are unlikely to be achieved (Egger et al 2004). Page 48 of 87 Tongan Community Action Programme – Phase 2 In New Zealand, churches have become the centre of community life for many Pacific Islands people and they have been successfully used as a setting for weight loss and smoking cessation programs in Pacific Island communities (Bell et al 2001). From July to December the Free Church of Tonga and original Rowley based group were have been working collaboratively sharing knowledge and resources. Page 49 of 87 Tongan Community Action Programme – Phase 2 2.8 Tongan Community Workforce Development Developing technical and professional capabilities of the Pacific (Including Tongan) community workforce has been and will remain a significant focus for the Heart Foundation. Short term (up to one year) ● Increased knowledge of food preparation and cooking skills (Refer to page ) ● Increased capability to grow vegetables and fruit in own garden (Refer to page ) ● Increased capacity in the Tongan community workforce (Up to one year) Since the start of the programme in October 2006 the following training opportunities have been provided: Chip Frying Awareness SI Health Provider Fono Cert. Pacific Nutrition Smokefree Cessation Training Health Promotion Forum Pacific Fono Nutrition Advisory Group October 2006 November 2006 December 2006 – February 2007 January 2007 February 2007 September 2007 Certificate of Pacific Nutrition We now have five 1 from 2004, 2 from 2006, and 2 from 2007. Two of these five are currently in leadership roles; two more are in support roles. The fifth person is involved in mental health (problem gambling). Two members of the wider Tongan community completed this tertiary qualification in 2007 bringing the total number of Tongan graduates to five. This certificate is important within the Tongan community as tertiary education is closely correlated with upward social mobility, more effective use of health information and better adult health outcomes (Pacific Health Chart Book 2004). Currently the Pacific youth enrolment rate in tertiary study is only half the national average (Statistics New Zealand 2002). A further Certificate in Pacific Nutrition programme was scheduled to be run in September 2007. This course was cancelled due to an insufficient number of participants. This has highlighted that greater flexibility is required in order to support workforce development that meets the needs of the Pacific community in Christchurch and particularly the Tongan community. Further information on the certificate as well as education and employment statistics are available from the previous PMR as well as from Statistics New Zealand and the Ministry of Pacific Island Affairs. Page 50 of 87 Tongan Community Action Programme – Phase 2 The NHF supports the “for Pacific, by Pacific” approach to programme delivery and for this there needs to be workforce development. Funding individuals to attend courses assists communities to help themselves and also empowers individuals. There is opportunity here for skill transfer and information exchange, two of the acknowledged principles of capacity building. Free Church of Tonga In addition to previous activity the National Heart Foundation has continued to engage and work with the Free Church of Tonga in the following ways. Developing a community champion (Church based Case Study) Reverend Ifalame Teisi and six others from his church are a part of the Tongan Community Action Programme research component which began in October 2006 with ethics approval. They are 7 of the 40 consented participants. Reverend Teisi has become a champion for improving Tongan health in Christchurch. After achieving the PIHB nutrition certificate in 2007 Rev Teisi assisted with the Tongan School holiday programmes and from July to September 2007 ran his own Healthy Eating programme based on his PIHB training for his Church community and other Tongan and Samoan people from the local community. He presented on 12 Saturdays. The Heart Foundation paid for the food demonstrations, edible gardens, physical activity sessions and shared meals as part of the Tongan Community Action Programme. Currently 30 families are growing their edible gardens. A tutor is providing another tuition session on vegetable gardening soon and we are providing further seedings and broadbeans for the winter crop this month. Rev Teisi is planning further Saturday sessions from April to June 2008 which will receive funding support from the Heart Foundation. Rev Teisi and his wife have been regularly attending physical activity sessions in a local fitness centre that have been funding by the Heart Foundation. Rev Teisi has also facilitated a further ten shared meal sessions which ran between 18 April and 30 June 2008. Rev Teisi has now been transferred to Auckland by the Free Church of Tonga to establish a Tongan community health outreach project for the Free Church. This project is to be a pilot initiative with the potential to expand to other Free Churches of Tonga in Australia and the United States of America. This opportunity has happened as a direct result of advocacy by the NHF office in Christchurch to the president of the Free Church of Tonga based in Tonga. The next challenge for the Free Church in Christchurch is to groom a successor to continue the health promotion initiatives that Rev Teisi developed and progressed. Page 51 of 87 Tongan Community Action Programme – Phase 2 Intermediate term (1-3 years) ● Increased commitment to healthy lifestyles by Tongan families (Refer to pages 20-21) ● Increased commitment to healthy lifestyles by Tongan community leadership (Refer to pages 22-23) ● Increased capacity in the Tongan community workforce (One to three years) Pacific Fono Nutrition Advisory Group Nutrition and Physical Activity Forum* 28 September 2007 12 June 2008 (* This regional forum was held in Christchurch, co-ordinated by Agencies for Nutrition Action (www.ana.org.nz) and supported by Ministry of Health and Sport and Recreation New Zealand) Developing a community champion (Community based Case Study) Tokanga Vehikite has been facilitating the TCAP intervention since July 2007. Tokanga took over this role in order for her to lead, learn and grow as a community health worker in the Tongan Community in Christchurch. Tokanga has now been contracted as a Community Health worker with Partnership Health Canterbury (PHC) for three years from July 2008 – June 2011. PHC is a Primary Health Organisation (PHO). Tokanga has continued to take on leadership roles including a recent initiative called Feeding our Futures. Feeding our Futures is a national social marketing programme, delivered by the Health Sponsorship Council, which helps parents and caregivers to achieve healthy diets for kids. The programme prioritizes Maori, Pacific and low income communities. Tokanga and another TCAP participant have been attending an initiative based in the high Pacific demographic suburb of Rowley. It is a joint initiative between the Cancer Society and National Heart Foundation. The participants are learning more about healthy eating and cooking for their families. Tokanga has been facilitating and another is one of a group of 14 learning. Tokanga has been demonstrating healthy food preparation, with recipes and health messages being provided. Tokanga demonstrates one meal and the participants take home the ingredients that evening to make the recipe for their families. Recipes have included meals like: Beef stir fry Home made hamburgers Home made muesli Page 52 of 87 Tongan Community Action Programme – Phase 2 Tongan Wesleyan Church In February 2008 the Tongan Wesleyan Church expressed interest in developing their own programme to achieve health outcomes for church members. Rev Sioeli Ofa contacted the NHF when putting together their Easter Youth Programme. NHF contributed $400 in funding for bread products and fresh fruit and vegetables. The Heart Foundation has provided resources for shared breakfasts and instructional sessions. Food has included cereals, fish, fruit and vegetables. Support was also provided by Couplands bakeries in Christchurch who provided bread and buns. The activity with the Tongan Wesleyan Church is another example of Tongan community action evolving through the relationships that have been nurtured through the structure of the initial TCAP. Page 53 of 87 Tongan Community Action Programme – Phase 2 2.9 Feedback from Tongan Families This section covers data collected from individuals representing 11 families. Data was collected either by self completed questionnaires or for those who are not fluent in English by the facilitator. This section contains information from the baseline, three, six, 12 and 18 month data. This section is presented differently to the previous eight programme activity sections. This is because the research feedback applies across several activity and outcome areas. Short and intermediate term outcomes from the logic model can be referred to in previous sections. Short term (up to one year) ● Increased capacity in the Tongan community workforce up to one year (Refer pages 25-26) Intermediate term (1-3 years) ● Increased commitment to healthy lifestyles by Tongan families (Refer to pages 20-21) ● Increased commitment to healthy lifestyles by Tongan community leadership (Refer to pages 22-23) ● Increased capacity in the Tongan community workforce - One to three years (Refer to pages 25-26) Page 54 of 87 Tongan Community Action Programme – Phase 2 Part Three – Sustainability 3.1 Long term outcomes (3-5years) – Sustaining change Analysis of the 18 month data collection is expected to provide some evidence towards longer term outcomes. These outcomes are: ● ● ● ● Increased health of Tongan community in Christchurch Reduced Health Inequalities Sustained Change Increased Community Connectedness The first two sections have not been addressed at this stage however some information is provided below towards ‘Sustained Change’ and ‘Increased Community Connectedness’. 3.1.1 Sustaining change through Leadership Synergies with other programmes Partnering with other organizations and initiatives improves synergies and sustainability. Rowley Primary School is involved in the Fruit in Schools (FIS) programme for ten low decile schools in Christchurch and information sharing occurs frequently between staff and participants involved in both these programmes. Funding Support Initial funding for two years was provided for the TCAP project was from the Heart Foundation and Canterbury Community Trust in 2006. Support and funding also came from Partnership Health Canterbury. Funding support has subsequently come from: Partnership Health Canterbury Cancer Society for Edible gardens from 2006-2008 Ministry of Health funding through Canterbury District Health Board for the evaluation component for this financial year (October 2007 – September 2008) Next Steps As a result a programme of action is being considered with a strong focus on ongoing empowerment, collaborative initiatives and sustainable outcomes. NHF and the Cancer society were partners with the Feeding our Futures (FOF) campaign with Tokanga as the lead presenter. The Cancer Society has been supportive of the TCAP since its initial conception. Requests for supporting an ongoing intervention are strong from the participants and the Christchurch Tongan Community. Page 55 of 87 Tongan Community Action Programme – Phase 2 The information contained within this report contributes to our ongoing planning and decision making going forward. Other areas of well being have been identified in order to further strengthen the Tongan community in Christchurch. These areas of wellbeing include: Social wellbeing Housing - Link in with the CCC with the housing figures in relation to overcrowding looking at state rental, housing, insulation and other relevant health determinants Strategies for Kids, Information for Parents (SKIP) – SKIP is a parenting initiative that the Christchurch Tongan Community Association has entered into with Family and Community Services (Ministry of Social Development) Cultural wellbeing Issues of heritage and identity are also on the wider government agenda. Given the dynamic nature of this community action project in a cross cultural context there are likely to be opportunities to explore and identify cultural outcomes. Sustainability As the end of the TCAP initiative draws nearer, time and space will be made to reflect on the TCAP process and what features of sustainability exist or have been enhanced as a result of the project. Ayre, Clough and Norris (2002) identify three Sustainability Streams which are leadership, learning and communicating. Community engagement Community Engagement is a critical tenet of a participatory democracy. Twyford (2006) summarizes Community Engagement as any process that involves the community in problem-solving or decision-making and uses community input to make better decisions. The Christchurch Tongan Community has been engaged in the TCAP from the start and the extent and effectiveness of this engagement should be explored. This dialogue should include any one who has a stake in the Tongan community in Christchurch particularly with respect to health outcomes. Some starter concepts and questions could include: o o o o o o o o Increasing Tongan community connectedness A Partnerships continuum 20 year Future Visioning dialogue SWAT analysis Community Capacity Framework What is the value of inter sectoral partnerships? What are the characteristics of a healthy community? Generating leadership everywhere and shapes its own future Page 56 of 87 Tongan Community Action Programme – Phase 2 3.1.2 Sustaining change through learning Intercultural & Professional Development One area identified by the project advisory group was intercultural development for mainstream providers delivering to pacific communities. Inter-culturalism includes competencies, knowledge and skills that assist a practitioner in delivering services across two or more cultural perspectives. The NHF recognizes the prerogative of the Tongan community to deliver to their own community. NHF also recognize that their staff has technical knowledge and skills that does not currently reside with the Tongan community in Christchurch. In April 2008 Bridget Chiwawa, a dietician working for the NHF, delivered a Public Health Research presentation to the NHF South Island Regional Training day. Bridget, who is from Zimbabwe, delivered a clinical review of the TCAP research methodology. Bridget also discussed ethical, consultation and cultural considerations for projects like TCAP in the future. The presentation was an example of the dynamic area that is action research and the importance of pre and ongoing planning, execution, evaluation and review processes. Cultural Worldviews The principal investigator of the project continues to source best and innovative ‘next’ practice processes that could contribute to the TCAP and other similar action research projects going forward. While acknowledging there is immense diversity amongst Pacific people it is useful to note that for some participants their cultural views, language and history may lead them to a different worldview of health which may influence the way “they perceive, access and use health service and (sic) can influence the outcomes of interventions” (MoH 2008a pg. 17). The MoH (2008a pg.17) quotes Tukitonga stating that “in general, Pacific culture and beliefs about health and illness are different from those of mainstream New Zealand; as health is considered to be a holistic notion and a family concern rather than an individual matter”. The MoH (2008a pg 27) reports that advertising campaigns promoting messages such healthy eating have not been effectively reaching Pacific people, suggesting that the methods of information delivery or promotion are not always useful, because of the diversity of Pacific views and priorities. 3.1.3 Sustaining change through communicating Appropriate opportunities for communicating the TCAP intervention and outcomes are constantly being sought after. The project featured in the Ministry of Health’s HEHA Action Report in March 2008 (Issue number 8, Page 6). A copy of this article is shown to the right. Page 57 of 87 Tongan Community Action Programme – Phase 2 The article focused on the development process, implementation and some outcomes of the project so far. Some important factors included the youthful Tongan demography, barriers to changing lifestyle and the engagement process with Tongan community and stakeholders. . Page 58 of 87 Tongan Community Action Programme – Phase 2 3.2 Increased Community Connectedness 3.2.1 High level of community support The TCAP programme has had the support of a high number of community organisations. Below are a list of those organisations that have and continue to support the project to date and a description of their involvement. Representatives from these groups also attend an inter-organisational advisory group for the programme. Cancer Society - Support for Edible gardens including gardens in 20 households, gardening instruction and a community garden based at the Rowley Community House and 30 from the group at the Free Church of Tonga. Christchurch City Council - Support across Community Services including development, engagement, funding and recreation services. He Oranga Pounamu - Resource provision including pedometers Medlab South - Medical laboratory services in house and community based. Ministry of Pacific Island Affairs - Supporting Pacific Community consultation and engagement. Providing advice on Pacific relevant policies across government sector. Sport Canterbury - Providing staff for training Tongan Community leaders in Physical Activities appropriate for preschool, primary and secondary school aged children. Providing equipment and sporting resources for Tongan school holiday programmes. Pacific Trust Canterbury - Support from Dr Alistair Humphrey, Dr Api Talemaitonga, management and nursing staff from the trust. They have also provided measuring equipment and some administrative support. Christchurch School of Medicine and Health Sciences - Supporting Principal investigator with project evaluation Community and Public Health - Providing advice on Public Health issues Page 59 of 87 Tongan Community Action Programme – Phase 2 3.2.2 Partnership Health Canterbury Partnership Health Canterbury (PHC) is a Primary Healthcare Organisation (PHO) which is providing additional support services Services to Improve Access (SIA) SIA is a support programme funded by PHC. ‘Services to Improve Access’ is a programme about helping individuals receive appropriate health care resources so they can maintain or improve their health and independence. A number of barriers exist to access for the Tongan people in Christchurch and outskirts including Ashburton. SIA allows community workers to support people with high health risk factors to access general medical practitioners and other health services in Canterbury. The TCAP2 coordinator works 17 per week with the project and this is now complemented with nine hours per week SIA. In March 2007 the Christchurch Tongan Community Association (CTCA) was contracted to deliver SIA. CTCA and Pacific Trust Canterbury (PTC) are both contracted to deliver SIA and the CTCA and PTC staff continue to work in collaboration to assist TCAP2 participants to access health services during the six month evaluation of the project. Copies of results go to participants GPsGPs. Recent discussions between PHC and Tongan Community leadership have focused on ongoing development and support for the Tongan communities in Christchurch. Care Plus Care Plus is a nationwide service run through PHOs for people with chronic diseases or other high health needs. Tongan participants with diabetes are receiving support through this service which aims to: Improve quality of life Reduce hospitalisations Improve management of chronic conditions Reduce inequalities Facilitate teamwork within PHOs Increase access for high-need primary health users Community Action To Improve Nutrition Capacity (CATINC) CATINC is a collaborative PHO initiative established to improve nutritional capacity in identified communities of interest in Christchurch. The initiative uses a community action approach which involves enabling and empowering communities to build their own responses to identified nutritional needs. The project is working in the Rowley Area where the TCAP programme is based and the Tongan project facilitator and principal investigator have provided community engagement and development advice to the CATINC project co-ordinator and nutritionist. The coPage 60 of 87 Tongan Community Action Programme – Phase 2 ordinator and nutritionists jobs are to work with communities most in need of nutrition education and enabling them to make healthy food choices. The initiatives with a focus on supporting Pacific communities of interest and include: Increasing knowledge in general practices on good nutrition Educating church and community groups on healthy foods Ensuring vending machines are sugar free Improving access to fresh fruit and vegetables Eliminating junk food advertising from communities 3.2.3 Professional Relationships The two TCAP2 intervention coordinators are developing and nurturing relationships with other related organisations in the area’s of health, local government and social services. In September 2007 one of the coordinators attended a national Pacific Nutrition Advisory Group. The purpose of this group is to connect practitioners and support the communication of good practice when working with Pasifika peoples in Aotearoa New Zealand. Although difficult to quantify, relationships with experienced practitioners and knowledgeable individuals can provide significant value to our coordinators. These professional relationships provide: mentoring opportunities peer support and supervision coaching opportunities Page 61 of 87 Tongan Community Action Programme – Phase 2 Part Four – Discussion, Conclusions and Recommendations 4.1 Discussion - Process Success Factors The approach taken in this section has been to discuss and identify Process Success Factors relating to the impact and outcomes of the project. The challenge was then to evaluate the extent to which each of these factors work. Figure 4.1 below illustrates the context and impact that the TCAP2 has had within the Tongan community in Christchurch. At the beginning of the project 40 people consented to participating in the project. Over the three month period of the initial intervention a further 81 individuals became engaged with the project by ‘organic referral’. These people were friends and family of the 40 participants. Over the following 15 months two significant Tongan groups became engaged and self initiated programmes for their own groups. These were the Free Church of Tonga and the Wesleyan church Youth group. In both cases the initiators were consented participants of the project. As conservative estimate, the TCAP2 project has engaged more than 200 (19% of population) and possibly as many as 380 Tongan community members (35% of population). Figure 4.1 TCAP2 Impact context Christchurch Tongan community population x 1,071 Community Stakeholder organisations: Government & Not for Profit ~60 Wesleyan Church Youth x40 Consented ~200 Free Church of Tonga x81 other participants In order to provide clarity of process during the analysis and evaluation of information a matrix was developed. This matrix provided a framework for discussing and considering outcome areas and reflecting back on process factors had a successful impact and/or outcome on the project. The matrix includes input from within the project team and from external stakeholders represented by the Project Advisory Group. It became clear that the discussion, conclusions and recommendations should focus on three areas of impact which were: 1. The 40 consented participants 2. The Christchurch Tongan Community 3. Community Stakeholder organisations, including local and central government agencies, not for profit organisations and community groups Page 62 of 87 Tongan Community Action Programme – Phase 2 Primary focus: 40 consented participants 1. Community Development and Support a. Workforce b. SIA worker c. Local leadership d. Bi-lingual capabilities and recognition of learning preferences e. Community Capacity 2. Access a. Resources b. Flexibility c. Primary Care Engagement Secondary focus: Christchurch Tongan Community 3. Tongan Community Engagement / Participation a. Consultation, b. Guided Decision Making, c. Timeframes d. Community focus e. Supporting Community Action f. Community Development Approach Tertiary focus: Community Stakeholder Organisations 4. Partnerships / Connectedness a. Internal Organisational Capability b. Partnerships (Edible Gardens) c. Funding support d. Collaboration e. Coordination f. Cooperation g. Networking 5. Research and Development a. Formation b. Process (data collection) Page 63 of 87 Tongan Community Action Programme – Phase 2 Primary group: The 40 participants Increased Health In the Tongan Community (1) Community Development and Support PSF Outcome areas Key: PSF = Process Success Factor Discussion Conclusion Recommendation a) Community Workforce development and support Worked well, Five 5 trained PIHB Nutrition Certificate. Internal community dynamics emerged after it was found that one PIHB trained Tongan person engaged to deliver was not accepted by some members of the participating group. Identifying & developing health leadership within community of interest works best. Replicate as important to find & support local leadership. Strong recommendation. b) SIA worker This role was identified as the project developed to meet community needs and was funded by Partnership Health Canterbury. As a high needs community the SIA worker role is very important. Positive outcome, reduces barrier to linking to GPs. Provides explanations for importance of linking to GP A follow up plan is required particularly for the high risk participants to improve health outcomes. Priority for sustained long term outcomes c) Local Leadership Building local leadership for ownership, motivation, connecting and mentoring. Needs leaders who show enthusiasm and commitment. Mentoring was effective for four local community and church leaders. This included brokering connections, coaching and mentoring. This approach was referred to as ‘Tongan for Tongan’. Development and support of local leadership worked well Strong Recommendation to support local leadership. d) Bi-lingual capabilities and recognition of learning preferences Very important for role modelling and so that community understands the health messages and values eg Havili translating for Lily at Edible gardens. Tokanga did all presentations in Tongan as well as English. Visual / Pictorial resources created and provided Repeat as high priority for education to improve access Strong recommendation Facilitator and resources e) Community Capacity Brokering linkages has been an important skill to nurture within the Tongan community leadership. A successful example of this is the connections made between the TCAP and CATINC projects. Consistent with Partnerships Continuum (VicHealth 2005). Partnerships provide a functional platform for building community capacity. Supporting the brokering of linkages is a strong recommendation. Page 64 of 87 Tongan Community Action Programme – Phase 2 (2) Access PSF Outcome areas Discussion Conclusion Recommendation a) Awareness raising Increased access to information, raising awareness. Bi-lingual communication and delivery of key health messages is critical. There is a need to ensure translation retains original meaning for message consistency. Messages should also be visual, simple and culturally appropriate. ‘Talanoa’ means dialogue in Tongan & Samoan Resources in Tongan and English, ‘Talanoa’ in Tongan. Use visual, simplified & culturally appropriate resources Strong recommendation to have leaders speaking own language. Utilise simple, visual & culturally appropriate resources. b) Resources Enhancing access to resources, that the community would not otherwise have access to, is a critical approach. Barriers identified included availability, time, cost, lack of transport, childcare, knowledge and skills. Resources focussed at a community level in order to facilitate whole community change. Need to resource. There was raised awareness of the importance of breakfast consumption though implementation was variable among the households at 18 months data collection. Need to resource areas that enhance access to health including availability, time, costs, lack of transport, childcare, knowledge and skills. Need to facilitate change for better outcomes, edible gardens provided materials and tuition, Food for shared breakfast sessions coupled with key health messages was provided and participants encouraged to make their own breakfast. Sessions timed (at 9am) to show the importance of breakfast. Participants were given opportunity to go to The Active Room (a local fitness centre) then physical activity sessions and equipment were provided at their own venue. Own photos of food preparation edible gardens, PA sessions etc Face to face (Known as Talanoa) very important. Equipment, group trainer provided. Explore opportunities to integrate nutritional (ie vegetable gardens) and physical activity focused initiatives with church activities. Lifestyle factors such as “the lack of time for recreation/shift work’ are barriers that must be responded to. Engagement with Church leadership is important eg Free Tongan Church and Reverend Teisi. Page 65 of 87 Tongan Community Action Programme – Phase 2 c) Flexibility A community Action approach was encouraged and provided for flexibility, innovation and responsiveness. Provided wok, plants, lemon tree, etc , recumbent bike and some equipment. Also required plates, pots and cutlery to enable the leaders to provide healthy food gatherings and for group participation in the preparation. Key Health messages were incorporated into incentive package eg ”Make water/milk beverages of choice” on children’s mugs/ plates. Healthy recipes form Heart Foundation books were provided with the woks. Introducing incentives at the beginning of the project and ensure incentives link well with key health messages & desired behaviour changes. High needs communities need to be resourced? If participants are part of the process to prepare healthy food it is an excellent teaching environment d) Primary Care Engagement Services to Improve Access (SIA) worker appointed and was a strong positive outcome after intervention. Tokanga started SIA work July 2008 on a three year part time contract. Tokanga working as an independent contractor and is receiving PHO support from Partnership Health Canterbury as well as volunteered mentoring support as a sole trader. Important part of future planning for PHO’s. Strong recommendation Page 66 of 87 Tongan Community Action Programme – Phase 2 Secondary group: Christchurch Tongan Community Reduced Health Inequalities PSF Outcome areas (3) Tongan Community Engagement / Participation a) Consultation Discussion Consultation to gain a shared understanding of the needs, aspirations & priorities for that community of interest was very important. Engagement approach worked well from the outset where support was offered to the Tongan community leadership. Setting a culturally appropriate frame from the outset was very important to the success of the project. This cultural frame includes a world view on health that is different to that promoted by health authorities in New Zealand. Education is also an important factor. Pasifika peoples need the right information about health in an appropriate way in order to shift a cultural mindset. This can be carried out through normal activities that Pacific peoples engage in, whether it be a church service, sports day, youth/womens’ group meetings. Conclusion Recommendation Consultation is very important prior to the project design. This buy in drives ownership of the project. Consultation that is well thought through, early, meaningful and ongoing provides a strong partnership platform for the project Needs to be taken into consideration. Repeat for further projects b) Guided Decision Making The purpose of engaging with the Tongan Community leadership was to make better decisions for the project. The focus was on sustainable development. Decisions made around the sustainability of the project included the areas of leadership, learning and communications. The implementation included input from community on what, when and how. Community Engagement is a process by which better decisions are the outcome. Critical to engage stakeholders early, meaningfully and ongoing through project. c) Timeframes The process allowed appropriate time frame expectations and consultation. Throughout the formation and process of this project the tendency was to be optimistic around the timeframes required. Slower time line was needed to allow time at each stage to get buy in from the community. Best practise engagement with Pasifika peoples is to have early, ongoing and meaningful consultation with respect to an initiative or project. Particular areas were with respect to Pacific community engagement, the Ethics approval process and data collections. The Community Action approach did not always align smoothly with ethics application process. Consultation extremely important. Provide sufficient time frames for similar projects and build in extra time for early and ongoing consultation, unexpected delays and for celebrating successes. Priority for any project like this to have good consultation Page 67 of 87 Tongan Community Action Programme – Phase 2 d) Community focus Project coordinators were mindful of the needs communities on low incomes have during the process development for this project. Opportunities were made for appropriate messages regarding cheap, healthy food options. These health messages were provided at the beginning of the programme followed by cooking demonstration sessions at Rowley community House in April 2008. Budgeting needs to be an integral part of menu planning. Tongan community participants have high numbers in families and households, less access to physical activity, clubs, gyms, less time for recreation, and many work shift work. Shift work is a complication for families sharing meals together. Concentrate on making access easier for healthy food and physical activity during the process development of future projects. Practical eg’s on affordable, healthier food choices can be achieved e.g. through cooking demonstrations. Strong priority. Ensure community development drives menu planning to be culturally appropriate. e) Supporting Community Action Developing a commitment to role modelling healthy food at social events. Healthy food provided at every event. Good education and role modelling. Participants were involved in food preparation so key messages were demonstrated and this strengthened community involvement e.g. a Christmas barbeque with whole fish, chicken and vegetable kebabs and salads was held. Children and teenagers were involved in the food preparation. This needed funding so the community is able to learn from healthy food provided and strengthen community action. Strong priority to provide healthy food and have it funded Page 68 of 87 Tongan Community Action Programme – Phase 2 f) Community Development approach Creating an environment that promotes healthy lifestyles in local communities. Linkages to the Early Childhood Centres (ECCs), local schools and other Tongan community groups. All organisations need to create healthy environment for the local community. Facilitate linkages: Free Tongan Church, Wesleyan Church and Holiday Programme all funded as part of project. Cooking demonstrations at Rowley House held in April 2008 were advertised through schools and ECCs in that community with a positive outcome. Inter-link with all community groups within the area Needs to be a priority Stronger the linkages and relationships the better. Positive outcomes eg funding Wesleyan Church An analogy has been used of ‘Seeds falling from the tree and growing themselves’ with respect to the TCAP project. A number of these extra measures happened as a direct result of having the TCAP project. Some of the seeds include: SIA worker position established Other HEHA programmes Diabetes breakfasts in Bromley Gardens in the community (cancer society) Elma Sturgess at Rowley Community House being on CATINC advisory and piloting Great little cook book Increased intersectoral relationships CATINC funding the pacific nutrition course PHO funding for TCAP project Project highlighted in Partnership Health Canterbury (PHC) annual report MOU to be signed between PHC and Tongan Association This is an indication that the community development approach within the TCAP was supported by the intersectoral agencies involved. This is a key outcome for the project and it is expected that the sustainability and growth of other community initiatives will lead to community change over time. Page 69 of 87 Tongan Community Action Programme – Phase 2 Tertiary Focus: Stakeholder Organisations Increased Community Connectedness (4) Organisational Capability and Partnerships CSF Outcome areas a) Internal Organisational Capability Discussion As most of the community attend mainstream providers it is important to increase the skill and knowledge of these organisations to ensure that services are organised and delivered in a culturally competent and effective way (MoH 2008). Conclusion Building Pasifika organisational capability provides more knowledgeable and responsive mainstream workforce Continue to build Pasifika organisational capability and support mainstream providers to increase their knowledge and awareness of culturally appropriate services. Edible gardens involved children, adults and grandparents. Benefits of gardening should continue to be highlighted in future and linked to desired health benefits. Cancer Society funded the edible gardens as a part of project collaboration. Included edible gardens component and related key messages Over the period of the project a significant number of stakeholders have developed relationships with Pacific community representatives. This has provided the platform for developing and nurturing individual knowledge and competencies and brokering partnerships. b) Partnerships (Edible gardens) Education given, rotational garden continues for 50 families Cancer Society 2 year funding for gardens. Households participated in the edible garden photo competitions and received prizes. Seeds and plants were provided three times over the 18 months including broad beans and cabbages for the winter crop. Grand parents and children enjoyed helping out in the gardens. Key messages should reinforce the link between gardening, increased physical activity, access to fresh vegetables and fruits to potential health benefits and improved access to food. Recommendation Page 70 of 87 Tongan Community Action Programme – Phase 2 c) Funding support Organisations facilitated funding and identified champions for workforce development Worked well – There was a strong level of co-operacy (interdependence) observed between stakeholders. These were central Government (MPIA), local Government (CCC), Partnership Health Canterbury (PHO), notfor-profits, community and funding organisations (including CDHB). Strong support by individuals also like Dr Anne Richardson (School of Med), Dr Api Talemaitonga, Dr Alistair Humphrey (C&PH) Organisations especially Government agencies have a community / social responsibility to support high needs communities Organisations take a strategic approach to apply for funding and support workforce development d) Cooperation Facilitate whole community approach (Co-operation / Interdependence). Surveys required finding most suitable times to hold gatherings. Project leaders need to be funded if possible. Provided breakfast at gatherings to provide education and also thru the food demonstrations. Education on the relationship between breakfast consumption and meal timing was provided. This continually needs to be re-enforced with a focus on blood glucose & cholesterol control. Strong leadership facilitates whole community approach. Gatherings provided an effective discussion forum for health messages. Target funding support and resources to groups. Priority that leadership be strengthened in order to facilitate whole community approach. Funding support and resources targeted towards groups. e) Collaboration Multi stakeholder collaboration with a focus on Guardianship The establishment of the initial inter-agency group and terms of reference was important. The groups’ role was one of guardianship and facilitation as opposed to governance. Working with Ministry of Pacific Island Affairs (MPIA) worked well to identify the group. 2 presentations to Pacific Community Reference Group (CRG) stakeholders provide strategic support, face to face must be all provided by own community leaders Ongoing interagency collaboration plays an important structural and facilitative role for connecting, leadership and communicating. This differentiation is important as it strikes to the heart of project purpose and ownership. Throughout the project a conscious effort was made to empower the Tongan community and provide them with developmental and support opportunities. Funding from several groups. Need to provide ongoing communication. Initially set up the stakeholder group. Facilitating the community development behind the scenes Page 71 of 87 Tongan Community Action Programme – Phase 2 f) Coordination Co-ordinating linkages to GPs, PHOs, TLAs, Heart Foundation worked well as all aim for all to be linked to the GPs. PHO funded the SIA worker. Opportunities to link into the TLA. The Heart Foundation has the resources and information for heart health and nutrition. Need strong links with lead organisation role modelling strong leadership Organisations partner to coordinated leadership g) Networking Organisations were proactive in searching out opportunities for linkages Some participants went to Bromley Diabetes breakfast needs another sentence to explain what this is. PHO provided some funding and strong linkage. Important to have a collaborate approach overall. Page 72 of 87 Tongan Community Action Programme – Phase 2 Process Focus: Research and development Increased Community Connectedness CSF Outcome areas a) Formative Discussion Conclusion Recommendation Ethics for administering questionnaires and collection of biochemical and anthropometric measurements. Ethics provided the opportunity to record qualitative & quantitative metrics showing high risk indicators. Pacific rates for cardio vascular disease (CVD) are consistently and significantly higher than those in the total population as is mortality due to CVD (MoH 2005; NHF). Good baseline for health promotion and community development project. Evidence recorded so no need to replicate. May not need ethics research component but strong recommendation that they must be closely linked to GPs (4) Research Although there is only one participant in the TCAP who has been diagnosed as diabetic (prior to the programme beginning) the high glycated haemoglobins indicate that almost 50% of this group are at high risk of developing diabetes. In fact, at 18 months ten participants meet the WHO criteria for diagnosis of Diabetes. The MoH (2008a) reports that although Pacific people are enrolled in Get Checked at higher rates than other groups; Pacific 92% Maori 27% and European/Other 63%, they have poor rates of retinal screening and less than satisfactory diabetes control, suggesting barriers to care and that “Pacific people for various reasons may not understand the importance of diabetes management’” pg. 23. b) Process (data collection) The data collection process has been discussed and consideration given to the appropriateness of invasive data collection (volume & frequency) to this community of interest. The focus on ethics may have limited (real or perceived) community based evaluation for this project. Ethics approval would be needed for information gathering and analysis. If there was a programme without the research component and was just evaluated for effectiveness evaluated that would be different – eg using the Active Canterbury tool Volume and frequency of data collection for this project could have been clearer and more specific to outcomes sought. Consider ethics process with respect to end outcomes desired for each project community of interest. Initial data collection facilitated awareness that some participants did not have a GP and that it is important to strengthen these links with GP with regular follow up. This is particularly relevant for the identification of high risk participants. Page 73 of 87 Tongan Community Action Programme – Phase 2 4.2 Recommendations The following recommendations are encouraged for future projects that have a focus on: increasing health in Tongan communities, Reducing Tongan health inequalities, Increasing Community Connectedness, and Research and development pertaining to Tongan communities in Aotearoa New Zealand. These recommendations are likely to have some relevance to working with other Pasifika nations. Increased Health in the Tongan Community (Primary focus: 40 consented participants) Community Development and Support Continue development and support for community workforce as it enhances local leadership. SIA worker provides capacity for sustained long term outcomes and is a priority being met by Partnership Health Canterbury (PHO) Continue developing and supporting local leadership for ownership, motivation and mentoring. Support and utilise facilitators with bi-lingual capabilities and development of bilingual resources recognising learning preferences of that community of interest. Supporting the brokering of linkages to develop community capacity. Access Support awareness raising and community engagement through local leaders communicating in their own language and community channels. This is enhanced by utilising simple, visual & culturally appropriate resources. Continue resourcing areas that enhance access to health including availability, time, costs, lack of transport, childcare, knowledge and skills Community Action approach encourages and provides for flexibility, innovation and responsiveness. Encourage initiatives supporting participation in the process of preparing healthy food Engagement with Primary Care is an important part of future planning for PHO’s Reduced Health Inequalities (Secondary focus: Christchurch Tongan Community) Tongan Community Engagement / Participation Best practice consultation is extremely important for Pasifika focused initiatives. For effective Guided Decision Making it is critical to engage Pasifika stakeholders early, meaningfully and ongoing through project. For effective consultation allow flexibility in timeframes. Consider community cultural frame and appropriateness when menu planning. Supporting Community Action by developing a commitment to role modeling healthy food at every opportunity. A Community Development approach will strengthen linkages and relationships for sustainable change. Page 74 of 87 Tongan Community Action Programme – Phase 2 Increased Community Connectedness (Tertiary focus: Community Stakeholders) Partnerships / Connectedness Pasifika community stakeholders benefit from developing organisational capability. Edible gardens and related key messages are effective components of nutrition focused initiatives. Synergies are achieved by organisations taking a strategic approach to funding. Continue interagency collaboration for connecting, leading and communicating initiatives. Strengthen leadership coordination in order to facilitate whole community approach. Target funding support and resources to support high needs communities and organisations take a strategic approach to apply for funding to support these groups. Resource co-ordination between partner organisations. Resource networking opportunities for Pasifika community stakeholders. Research and Development Evidence recorded so no similar projects may not need to replicate with ethics research component. Link future projects to General Practices for sustainability. Future projects consider ethics process with respect to end outcomes desired for the community of interest of each project. Page 75 of 87 Tongan Community Action Programme – Phase 2 Part Five – Bibliography Bell et al 2004 Egger, G., Spark, R., & Donovan, R. (2004). Health Promotion Strategies and Methods (2 ed.). Australia: McGraw-Hill. Edwards D., 2006. Pacific Community Action Project Formative and Process Evaluation. Otago University Student Project. Facilitating Community Change, Community Initiatives Inc (2002) ISBN 1-879502-39-9 Health Research Council of New Zealand. Guidelines on Pacific Health Research Third edition, May 2005. http://www.hrc.govt.nz Health Research Council of New Zealand. Strategic Plan for Pacific Health research 2006 – 2010. February 2006. http://www.hrc.govt.nz http://www.stats.govt.nz http://www.minpac.govt.nz Koloto, A., 2007. Pacific Housing Experiences: Developing Trends and Issues. A report prepared for Centre for Housing Research Aotearoa New Zealand and the Ministry of Pacific Island Affairs. Ministry of Health (2005) The Health of Pacific Peoples - Wellington Ministry of Health.(a) 2008. Improving Quality of Care for Pacific Peoples. Wellington: Ministry of Health. Ministry of Health.(b) 2008. A Portrait of Health. Key Results of the 2006/2007 New Zealand Health Survey. Wellington: Ministry of Health. New Zealand Guidelines Group. 2003. The Assessment and Management of Cardiovascular Risk. Wellington. Shirley, I., 2007. Community Development Practice in New Zealand. New Zealand Institute of Public Policy Twyford, V. 2006. Beyond Public Meetings; Connecting Community engagement with DecisionMaking. ISBN-13:978-0-646-46720-7. Page 76 of 87 Tongan Community Action Programme – Phase 2 Part Six – Appendices TCAP Questionnaire Tongan Community Action Programme - Participant questionnaire Malo e lelei, We would like to know a little about you to make your programme work better. Please answer the following questions as best you can. What are your families’ favourite fruits? _________________________________________________________________________________ How does your family normally eat these? (raw, cooked, in a dessert, etc.) _________________________________________________________________________________ What are your families’ favourite vegetables? _________________________________________________________________________________ How does your family normally eat these? (raw, steamed, fried, roasted, boiled, etc) _________________________________________________________________________________ Where does your family normally buy their food from? _________________________________________________________________________________ How often does your family buy food from these places in a week? _________________________________________________________________________________ What types of meals are usually cooked at home? _________________________________________________________________________________ 8am What times do your family usually eat a meal? (Please circle the closest hours) 9am 10am 11am 12 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm What kind of snacks do your family members eat? _________________________________________________________________________________ How many snacks does your family normally eat in a day? _________________________________________________________________________________ 8am What times in the day do your family members usually eat a snack? 9am 11am 12 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm How do family members normally get around? (Please circle) Walk 10am Car Bus Cycle Other_____________________ What are your family members’ favourite physical activities? _________________________________________________________________________________ Page 77 of 87 Tongan Community Action Programme – Phase 2 How often do your family members do these activities? _________________________________________________________________________________ What are your families’ favourite sports/games? _________________________________________________________________________________ How often do your family members play these? _________________________________________________________________________________ How many people live in your house? _________________________________________________________________________________ What ages are the people in your house? (Please write the number of people in your house that are within each age bracket) 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 When do the people in your house normally work? (Please circle all that apply) Mornings During the day Afternoons Nights Weekends What of the following appliances do you have in your house? (Please circle all the appliances that you have in your house) Oven Stove Microwave Fridge Freezer Jug/Kettle Toaster Electric Fry pan Toastie-Maker Food Processor Rice cooker Other____________________________________________________________ Do you have a GP/Doctor? If YES, what is the name of your GP/doctor _____________________________________________ When was the last time someone from your family saw a GP / Doctor? ________________________ On average how many hours a day is your TV on? (Please tick one) 0 hours 70+ Up to 1 hour 1-2 hours YES / NO (Please circle one) 2-3 hours 3-4 hours 4-5 hours 5-6 hours 6-7 hours 7-8 hours More than 8 hours What are the best days and times for you to attend a regular gathering? (Please tick days and times) Monday 8-9am Tuesday 9-10am Wednesday 10-11am 11-12 noon Thursday 12noon1pm 1-2pm Friday 2-3pm What time do children in your house normally wake What time do children in your house normally go to bed. Saturday 3-4pm 4-5pm Sunday 5-6pm 6-7pm 7-8pm _____________________________________ ________________________________ Malo aupito – Thank you for taking the time to complete this questionnaire. Page 78 of 87 Tongan Community Action Programme – Phase 2 Appendix 2 - Survey Tongan Community Action Programme Participant Assessment Form (1 September 2006) Malo e lelei, we would like to know a little more about what you are thinking regarding nutrition and physical activity. Please answer the following questions as best you can. There are FIVE possible responses to each question: Strongly disagree, disagree, undecided, agree, and strongly agree. Fill in the circle that best describes how much you agree or disagree with each statement. For other questions there also five responses that describe how often the statement applies to you: Never, Seldom, Occasionally, Often or Repeatedly. First name: _______________________ Last name (Surname): ______________________________ Agree Undecided I have started to exercise regularly, and I plan to continue 1 (action) I have lined up with a friend to start exercising regularly within the next few weeks 1 (preparation) When I feel tired, I make myself exercise anyway because I know I will feel better afterwards 2 (maintenance) I could exercise regularly, but I don't plan to 1 I am satisfied with being an inactive person 1 M (precontemplation) I have been thinking about whether I will be able to exercise regularly 1 (contemplation) I am afraid of the consequences to my health if I do not exercise 2 (contemplation) I reward myself when I don't eat Lu-Pulu / Vai Siaine / Lu Sipi / To’okutu 4 M (action0 I have been exercising regularly for a long time and I plan to continue 1 (maintenance) I don't exercise and right now I don't care 1 (precontemplation) I am finally exercising regularly 1 (action) (precontemplation) I think regular exercise is good, but I can't figure it into my schedule right now 1 (precontemplation) Strongly Disagree Disagree Strongly Agree Date of birth: ___________________________ Page 79 of 87 Tongan Community Action Programme – Phase 2 Never Seldom Occasionally Often Repeatedly When I am tempted to eat Lu-Pulu / Vai Siaine / Lu Sipi / To’okutu, I eat something else 4 M (maintenance) About eating vegetables, in what way are you trying to change 5 About eating fruit, in what way are you trying to change 5 About eating Lu-Pulu / Vai Siaine / Lu Sipi / To’okutu, in what way are you trying to change 5 M Are you seriously thinking of quitting smoking? (Tick one) Yes, within the next 30 days * Yes, within the next 6 months * No, not thinking of quitting * Each rung of the ladder represents where various smokers are in their thinking about smoking. Circle the number that indicates where you are now. 6 10 Taking action to quit (e.g. cutting down, enrolling in a quit programme) 9 8 Starting to think about how to change my smoking patterns 7 6 5 Think I should quit but not quite ready 4 3 Don’t know Eat less Eat more I tell myself I can choose to eat Lu-Pulu / Vai Siaine / Lu Sipi / To’okutu or not 4 M (action) Page 80 of 87 Tongan Community Action Programme – Phase 2 2 Think I need to consider quitting some day 1 0 No thought about quitting Page 81 of 87 Tongan Community Action Programme – Phase 2 How often do you usually eat these foods? 5 Please fill one circle for each food. Miscellaneous Never Cakes, scones or pikelets Muffins – all types Sweet pies or sweet pastries Other puddings or desserts (not including milkbased puddings) Plain sweet biscuits Cream filled or chocolate biscuits Canned or packet soup (in winter) Less than once per month 1-3 times per week1 Once per week 2-4 times per week 5-6 times per week Once per day 2 or more times per day How often do you usually eat these foods? 5 Please fill one circle for each food. Never Less 1-3 Once 2-4 5-6 Once Bread and than times per times times per day Cereal Foods once per month Focaccia, bagel, pita, other specialty breads Paraoa Parai (frybread) Rewana bread Doughboys or Maori bread Crumpet or croissant Waffle or doughnut Fruit or iced buns Savoury / dry biscuits, crispbread, crackers per week1 week per week per week 2 or more times per day Page 82 of 87 Tongan Community Action Programme – Phase 2 Cooked porridge Breakfast cereal (including muesli) Rice (including white or brown) Pasta (e.g spaghetti, ravioli, macaroni, noodles) Page 83 of 87 Tongan Community Action Programme – Phase 2 How often do you usually eat these foods? 5 Please fill one circle for each food. Meat and Fish Beef mince dishes (e.g. rissoles, meatloaf) Beef or veal mixed dishes (e.g casserole, stirfry) Corned beef (including canned) or brisket Hogget or mutton – roast, chops Lamb mixed dishes (e.g. casserole, stirfry) Lamb – roast, chop Pork mixed dishes (e.g. casserole, stirfry) Pork – roast, chop, steak Pork –boiled bones Sausage, frankfurter or saveloy Bacon or ham Luncheon meats, salami or brawn Liver (including pate) Other offal (e,g, kidneys) Chicken mixed dishes (e.g. casserole, stirfry) Never Less than once per month 1-3 times per week1 Once per week 2-4 times per week 5-6 times per week Once per day 2 or more times per day Page 84 of 87 Tongan Community Action Programme – Phase 2 Chicken – roast, fried, steamed, BBQ Page 85 of 87 Tongan Community Action Programme – Phase 2 On average, how many servings of fruit (fresh, frozen, canned or stewed) do you eat per day? 5 Do not include fruit juice or dried fruit. (Please mark one only) (a ‘serving’ = 1 medium piece or 2 small pieces of fruit or 12 cup of stewed fruit) e.g. 1 apple + 2 small apricots = 2 servings Per Day I don’t eat fruit Less than 1 per day 1 serving 2 servings 3 or more servings On average, how many servings of vegetables (fresh, frozen, canned) do you eat a day? 5 Do not include vegetable juices. (Please mark one only) (a ‘serving’ = 1 medium potato/kumara or 12 cup cooked vegetables or 1 cup of salad vegetables) e.g. 2 medium potatoes + 12 cup of peas = 3 servings Per Day I don’t eat vegetables Less than 1 per day 1 serving 2 servings 3 servings 4 or more servings Are there any foods that have been left out that you think are important to add (i.e. taro). Malo aupito – Thank you for taking the time to complete this assessment form. Page 86 of 87 Tongan Community Action Programme – Phase 2 References 1. Marcus, B. H., Selby, V. C., Niaura, R. S., & Rossi, J. S. (1992). Self-efficacy and the stages of exercise behavior change. Research Quarterly for Exercise and Sport, 63, 60-66. 2. Nigg, C.R., Norman G.J., Rossi, J.S. & Benisovich, S.V. (March, 1999). Processes of exercise behavior change: Redeveloping the scale. Poster presented at SBM. San Diego, CA 3. McConnaughy, E. N., Prochaska, J. O., & Velicer, W. F. (1983). Stages of change in psychotherapy: Measurement and sample profiles. Psychotherapy: Theory, Research and Practice, 20, 368-375. 4. Prochaska, J. O., Velicer, W. F., DiClemente, C. C., & Fava, J. L. (1988). Measuring the processes of change: Applications to the cessation of smoking. Journal of Consulting and Clinical Psychology, 56, 520-528. 5. Russell, D., Parnell, W., & Wilson, N. (1999). NZ Food: NZ People: Key results of the 1997 National Nutrition Survey: Ministry of Health. 6. Biener, L., & Abrams, D. (1991). The Contemplation Ladder: Validation of a measure of readiness to consider smoking cessation. Health Psychology, 10(5), 360-365. * These questions were supplied by Mark Wallace-Bell and are from the Stages of Change literature, though I am not sure were. However, I assume they are validated otherwise they would not have been forwarded M Question has been modified slightly to suit the Pacific Community Project. These modifications are in italics. Note: Lu-Pulu, Vai Siaine , Lu Sipi and To’okutu are all traditional Tongan dishes that are high in fats. Lu-Pulu is corned beef cooked in cream. Vai Siaine is bananas cooked in coconut cream. Lu Sipi is lamb cooked in coconut cream. To’okutu is a coconut dumpling. Page 87 of 87