I have a confession. Some years ago, I loved watching The Biggest Loser.
From the show's cheesy opening music, to its emotional contestant stories, I indulged in two seasons of a pretty questionable guilty pleasure.
As devoted as I was, one of its "temptation" challenges always left me irate.
In front of tables laden with baked goods, contestants were told whoever consumed the most calories would have two pounds deducted from their weight at the next weigh-in. Weight reduction is important because the team or person who loses the most each week stays in the competition. All other contestants can be eliminated.
To up the ante, the lights were switched off. The effectively blindfolded contestants then decided whether to gorge on cakes and compete for the "two-pound advantage". Understandably, some refrained, while others bought in.
One of the show's fitness trainers summarised my annoyance. "I struggle to make sense of [it]", he said. "I understand that contestants will face temptation in real life after the show, but [it works] against everything we are trying to teach."
Yes, it is a hyped-up reality television show, but the trainer has a point. Linking excessive consumption to weight loss makes no sense. It is counterproductive, not to mention degrading. But, hey, it adds to the drama right.
So, what happens when that same type of behaviour gets pushed into real-life health initiatives?
The Counties Manukau District Health Board has started an incentive-based pilot programme aimed at increasing the number of Māori babies who are up to date with the National Immunisation Schedule.
As reported by media, Māori parents eligible for the programme would be offered $20 petrol or grocery vouchers and nappies to participate. Eligible parents are those whose babies have missed their six weeks, three months and five months vaccinations despite repeated recalls.
I am all for increasing immunisation rates and protection against vaccine-preventable disease. But linking infant immunisations to money at the supermarket and reward-diapers is not the right way forward.
Vaccinations and subsequent health benefits must be promoted and supported free from material incentives. While there is no harm in identifying Māori infants as more likely to miss timely vaccinations, doling out incentives to combat that risks skipping over the real issues.
Health bosses' beliefs that some infants will only be immunised if basics like nappies and fuel are offered raises valid questions.
First, how is the current system contributing to lower Māori infant immunisation rates? Second, if vaccination rates do improve because of incentives, what does that mean for those families?
Should we be dangling infant vaccination for $20 of groceries? Indeed, other forms of intervention and assistance may be more appropriate.
Notably, 2017 research on the effectiveness of outreach immunisation services (OIS) tackled the issue head-on. Families referred to outreach immunisation services had infants who missed immunisations and were not seen by a family doctor. The Counties Manukau pilot is aimed at these families.
According to the research, published in the Journal of Primary Health Care, OIS providers "felt that more intense effort was required to engage with some Māori families, with some expressing a higher level of suspicion of immunisation than other ethnicities".
"This appears to be related to engagement with services rather than anti-vaccination sentiment; many OIS staff reported that most Māori families accepted vaccination once they had visited the family home."
So, the catalyst for change was identified as home visits by frontline staff.
I am not minimising the complexities of families the pilot is targeting. They are often poor, transient and difficult to find. However, those descriptors should raise hackles over an incentive scheme based on free nappies and supermarket vouchers.
Certainly, my eyes narrowed at an information paper on the pilot, presented to the Counties Manukau DHB board. The paper suggested securing contact with families via text messages like: "Get back to me to claim your free pack of nappies".
It also said incentives would be "offered during the first appointment and follow up visits in the lead up to the eight-month immunisation milestone".
The eight month "milestone" refers to the Government's health target for immunising infants. It wants 95 percent of babies to have completed their six weeks, three months and five months vaccinations by eight months.
Counties Manukau data from December last year showed only 83 percent of Māori infants reached the milestone, compared with 94 percent of Pacific infants, and the area's overall total of 93 percent.
My question is what happens to those babies, and families, after the eight-month mark? Another set of vaccinations is due at 15 months. The need for nappies, fuel and groceries is also likely unchanged.
Interestingly, the DHB said the equity gap for Māori infants at eight months improved by 12 months.
"If we look at our eight-month coverage for Māori pēpē, there is about a seven percent equity gap which is then improved by 12 months," the DHB told Stuff last week.
I see. Achievement of health targets is at stake.
While that is important, I cannot reconcile how providing nappies and fuel vouchers during an infant's first eight months achieves health equity for Māori.
Resources would be better spent addressing problems preventing access to health services for families targeted by the pilot.
Moreover, are incentives for immunisations really a positive for our health system?
To quote another trainer from The Biggest Loser on self-defeating incentives: "There's no way that I can wrap my brain around them".