Ana Apatu: Aiming for a collective health focus

Ana Apatu

I attended a presentation by one of New Zealand's leading public health experts Massey University's Pro Vice-Chancellor of the College of Health Professor Paul McDonald. I arrived early hoping we could have time to discuss if he or his team could assist us with some formal evaluation of some of our U-Turn Trust programmes.

Core to his beliefs is the role society plays in our health. Professor McDonald said, "We tend to think of chronic diseases as medical problems with social consequences, but the time has come to think of chronic diseases as social problems with medical implications."

We assess population health through a series of measures of individuals, prevalence of smoking, obesity, poverty, average life expectancy at birth, etc. We then tend to choose interventions that are most effective with individuals and reach as many people "at risk" as possible through primary care, screening, etc.

I reflect on past work with smokefree. This ABC smokefree work involves a brief intervention, a health target set up "systematically" whereby we know that a brief intervention nudges people towards quitting. ABC asks A) are you smokefree B) suggests the best thing you can do for your health is to quit smoking and C) offer cessation support. This is routinely asked at any door you enter into our health system - whether hospital or general practice. Most of our work also had to be based on "evidence".

Professor McDonald likens this form of evidence gathering we generally rely on to driving by only looking in the rear view mirror and forgetting about the other traffic around you. Now I am really listening. "Systems ... a science for seeing wholes".

"It is a framework for seeing interrelationships rather than things, for seeing patterns rather than static snapshots." An interactive neighbourhood with a collective identify and purpose is a social system.

A famous Sufi parable says, "You think that because you understand 'one' that you must be able to understand 'two' because one and one makes two. But you forget that you must also understand 'and'."

We need to better understand why an individual's health will be influenced by their interactions with other people and contexts; why population health is more than the sum of the health of individuals within the population, or why population health cannot be substantially improved by focusing on individuals.

He goes on to discuss how we tend to focus on elements because they are the most tangible and visible aspects of a system, but interconnections between elements may be the most important - they allow one part to respond to what is happening in another part.

Interconnections are essential for adaptation, resilience, self- preservation, and evolution. To be truly effective we must consider various ways people are connected - socially, economically, politically, culturally, etc.

Various studies support this - a study of over 80,000 representative Canadian adults aged 25 to 64 found that men and women with strong social connections were 3 and 2.5 times, respectively, more likely to be very or moderately active compared to those with low social connections.

Another study found lower smoking rates among those that have a greater sense of belonging. Another study found children who received social skills training were half as likely to start smoking.

We need to consider interventions on the friend's friends of those who have made recent changes. Surround them with a large group of stable low risk people. Use Facebook and other virtual connections, aim the intervention at changing the dynamics of networks, not directly at individuals at risk. Focus on changing the behaviours and attitudes of key nodes/inferences within social networks, focus on building connection and trust. Focus on building connection and trust resonates with me.

Our programmes we oversee in response to community requests are based on just that.

-Ana Apatu is chief executive of the U-Turn Trust, based at Te Aranga Marae in Flaxmere.