AWA: Academic Writing at Auckland

Sudden Infant Death Syndrome (SIDS), was originally defined as the sudden and unexpected death of an infant through which post mortem examination failed to explain an adequate cause of death (Beckwith, 2003). In 2008 New Zealand embraced the international reclassification of Sudden Unexpected Death of an Infant (SUDI), however, this report will continue to use the commonly known term Sudden Infant Death Syndrome (Māori SIDS, 2010). SIDS will first be outlined in a New Zealand context, followed by a description of ethnicity/culture and education as two of the underlying determinants affecting SIDS. These determinants will be addressed by the Ottawa Charter and will be discussed as to how they incorporate the values of health promotion; equity, social justice, and empowerment.  

The high prevalence and non random distribution of SIDS throughout New Zealand proves that SIDS is a significant health issue in this country. The most recent SIDS data in New Zealand comes from 2005 in which the total overall SIDS rate was 0.8 per 1000 live births, the highest rates rate out of 17 other western countries including the United States of America and Japan (Hauck & Tanabe, 2008).  Differences in the distribution of SIDS across New Zealand show that it is three times more prevalent in deprived population compared with their wealthier counterparts (Shaw, Blakely, Crampton & Atkinson, 2000). Incidentally, and of extreme importance, the Indigenous Māori population of New Zealand occupy a large proportion of these disadvantaged neighbourhoods, with the burden of SIDS in the Māori population being five times the rate in Non Māori populations (Māori SIDS, 2010). Further, common SIDS trends throughout New Zealand have been distinguished; with an increased prevalence of SIDS in male infants, in areas of higher latitudes, and a peak in SIDS between the ages of two to four month old infants (Mitchell, 2009). Evidence also suggests an association between SIDS and cooler temperatures; with higher SIDS rates in winter and in the cooler temperature of the south island compared with the subtropical temperatures of the North Island (Mitchell & Scragg, 1994). Thus, the issue of SIDS is of high relevance to New Zealand.  

Culture is defined as the accepted patterns and norms of behaviour within specific societies. The most obvious cultural groups are those based on ethnicity; characterised by a distinctive socio-cultural tradition, common history and genetic heritage (MOH, 1998). In New Zealand, the differences in SIDS mortality rates amongst Māori and Non Māori appear to be ethnically and culturally determined; simply being Māori increased the risk of SIDS by 1.4 (Mitchell & Scragg, 1994).

Māori culture impacts various risk factors for SIDS such as bed sharing, high smoking rates, and the lack of breastfeeding (Mitchell & Scragg, 1994). Although Māori appear to have a cultural preference for bed sharing, it is in fact their lack of material resources that makes bed sharing inevitable (McIntosh, Tonkin & Gunn, 2009). Smoking as a coping mechanism for financial stress, coupled with deprived areas being targeted more by cigarette companies, provide an explanation for the higher smoking rates seen in Māori (MOH, 2002). Furthermore, there has been a decline in breast feeding amongst Māori post colonisation to accommodate western models of care (Māori SIDS, 2010). Infants being accidently smothered by bed sharing, the effect on nicotine on infants respiratory rates and their weights, and the loss of essential nutrients due to the lack of breast milk all pose to be threats for increased SIDS mortality Māori (Mitchell, 2009).

Education is deemed to be the strongest individual determinant of health (Lou, Wilkins, Kramer, 2006). Education provides increased employment opportunities, thereby potentially increasing income rates and consequently allowing for a greater control over the factors that play on an individual’s wellbeing. An inverse relationship exists between education and SIDS (Lou et al., 2006).  

Lowered education is associated with financial and social disadvantage, and being a young and solo mother (Lou et al., 2006). Younger mothers are more likely to withdraw out of educational institutions during and after pregnancy, and the amount of mothers return to schooling is minimal. This decreases their chance at attaining a decent level of education and gaining adequate health literacy. Young mothers are also less likely to be accessing pre natal and post natal support; with the consequence being that these mothers will lack sufficient knowledge surrounding a healthy pregnancy for example, information on diet or appropriate maternal weight gain. Further, all the mentioned factors lead to the risk of low birth weight (weighing less than 2500 grams) and pre term babies (Lou et al., 2006) which once again increase the risk of SIDS.

The Ottawa Charter, made primarily in response to a growing need for worldwide action to promote equity in health, is distinguished by five strands which are discussed below in relation to improving culture/ethnicity and education as determinants of SIDS.

Building public health policy directs policy makers at all levels to take responsibility for health (WHO, 2010). Policies can be implemented to encourage Māori governance with the purpose of Māori  leaders using culturally appropriate methods and policies to reduce the health inequalities between Māori and Non Māori (MOH, 2002).  For example, the New Zealand Public Health and Disability Act 2000 requires that at least two Māori representatives be involved in each District Health Board (MOH, 2002). This encourages Māori to contribute to decision making and participate in the delivery of health services where they can address the SIDS inequality between Māori and Non Māori  in a culturally appropriate manner.

Healthy Public Policy assists in creating supportive environments; in which individuals encourage healthy behaviours and there is reciprocal reliance between community members (WHO, 2010). Supportive environments can be created amongst Māori where Māori traditions and values are tightly bound within the relationships of the people in the community. For example, during mothers birthing classes, the instructor could incorporate Māori cultural values and beliefs into the sessions, and explain the importance of adequate nurture and care for the infant right from pregnancy to the birth, and the following crucial months.

Strengthening community action uses the community’s existing resources to encourage empowerment and ownership within its members (WHO, 2010). Human and material resources within the Māori community can be used to promote the Māori values of whānau, hapū and iwi, for Māori health gain (MOH, 2002).  For example, a Māori community development programme could be implemented to enable Māori communities to define their own problems and device their own solutions with a cultural and spiritual value; which could then be extended to a SIDS intervention constituting Māori beliefs (MOH, 2002).  

Personal skills development is achieved by knowledge acquisition about health and life skills, in which individuals have greater ability to control the situations affecting their lives; it means providing information and supporting Māori in finding ways to reduce their ethnic inequalities themselves (Ward & Verrinder, 2008). For example, a Tohunga (Māori priest); of greatest respect in the community, could educate the Marae members on the importance engaging in healthy behaviours, and how this incorporates Māori traditional values. There could be an emphasis placed on adequate infant and child care, and the importance of passing these values onto the next generation.

Re-orientating health services moves beyond simply providing clinical care to providing culturally appropriate services tailored to the specific health needs of a community (Ward & Verrinder, 2008). Health services could incorporate Māori cultural values in their daily running of the services. This would provide a much more comfortable atmosphere for Māori, as they feel their values have been appreciated and are more likely to comply with any recommendations made; once again making a reduction in Māori health inequities. For example, this could mean training health professionals such as Plunket nurses and midwives on Māori traditions, values and beliefs which could be used in their recommendations to Māori mothers (Ward & Verrinder, 2008).

Building healthy public policy could be implemented in a way to encourage education advancements, especially in relation to tertiary education (WHO, 2010). For example, there could be a ‘Think Tertiary Earlier’ scheme implemented in which students over the age of 15 who start working can opt to set aside a certain sum of money a week only for tertiary educational purposes (McLaughlin, 2003). Those who can prove they are in a compromised financial position can be given subsidies for the rest of their fees (depending on the course) after saving a minimal amount of money. This would encourage students at an earlier age to think about tertiary education and make goals for their future earlier; thereby allowing them stay in school, be more educated, and develop greater life skills in which they would be better placed to care for their infant in an adequate manner. 

Supportive environments can be created to increase education by providing a permissive and non threatening environment that encourages the learning process (Ward & Verrinder, 2008). For example, as education rates are significantly lower in deprived areas, there could be more resources and time spent on improving the efficiency and effectiveness of educational institutions in this areas. This would increase the chances of students attaining a greater quality of education and increase their general life skills, as well as increasing their knowledge of safer health practices.  

Community action can be strengthened to encourage the completion of state education. Community empowerment is promoted when the problem of an inadequate number of adolescents attaining a decent level of education is identified and there is recognition for action in response to this (Ward & Verrinder, 2008; WHO, 2010).  For example, there could be meetings and seminars in the community where the importance of attaining proper qualifications is discussed; there could be speakers who talk about their hardships when not gaining adequate education.

Personal skills development can be used to enhance education opportunities by providing adolescents the ability to learn a varied range of skills. This in turn provides greater employment and income opportunities (WHO, 2010). For example, as part of the curriculum for high school students, there could be a child development curriculum in which where teenagers receive practical experience and education in infant development and care such as ‘the baby project’ where students are assigned to care for a pretend ‘baby’ for a specified period of time. This teaches them the responsibilities of caring for an infant.

Re-orientating Health services to meet the specific needs of a community also includes services that lie outside the health sector that impact an individual’s health; this includes educational services (Ward & Verrinder, 2008). Educational services could be tailored to meet the specific educational needs of a population; giving everyone the chance to attain a minimal level of equal educational opportunity. This in turn gives those with lower education a chance to move up the social gradient; and attain better health. For example, to increase education rates amongst the deprived, educational institutions could be paid more by the government if they enrol the targeted students and tailor their programmes to meet the educational needs of these students.

The responses to ethnicity/culture and education as determinants of SIDS incorporate the health promotion values of equity, social justice and empowerment. In health, equity refers to the absence of systematic disparities between different social groups; in which resources are distributed according to the needs of different groups (Bravemen & Gruskin, 2003). The systematic ethnic differences in SIDS rate between Māori and Non Māori are inequitable and can be prevented. The strategies mentioned above promote equity in health as they aim to reduce the ethnic disparities in Māori and bring their rate of SIDS (and other health outcomes) to a similar level as that of Non Māori. Further, material and social resources are targeted at vulnerable populations and those with higher needs; such as younger mothers with low education or deprived Māori. Social Justice refers to a vision of an egalitarian society whose underlying principles are of equality and solidarity (Gostin & Powers, 2006). The strategies above promote the sharing of resources and knowledge in an equal manner. They stress the importance of human rights; as Māori have the right to have equal lowered SIDS rates as non Māori, and all populations should be able to have access to equal opportunities in education and subsequently employment. Empowerment is the process where people gain control over the social, cultural, psychological or other factors that have an impact on their health (WHO, 2010). The strategies aimed at improving Māori culture promotes feelings of control and responsibility over health in Māori  populations. It allows Māori to take action to reduce SIDS rates amongst their population themselves. Further, vulnerable mothers are provided with knowledge and understanding of the factors that effect their newly born infant’s life, and allows the mothers take at least to some extent, control over these factors.

Despite New Zealand being a first world country, it is of true shame to admit that it has one of the highest rates of SIDS worldwide. No single explanation will suffice to account for these high rates, but rather it is a mixture of complex interactions amongst the determinants of health. An attempt has been made to discuss two of these determinants; ethnicity/culture and education, along with suggestions to improve the determinants using the Ottawa Charter. Without using the health promotion values of social justice, equity, and empowerment, it would be unwise and ineffective to implement interventions to reduce the high rates SIDS.

References

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Braveman, P., & Gruskin, S. (2003). Defining equity in health. Journal of Epidemiology Community Health, 57 (4). 254–258.

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McLaughlin, M. (2003). Tertiary education policy in New Zealand. Auckland: Ian Axford (New Zealand) Fellowships in Public Policy.

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Ministry of Health. (2002). He Korowai Oranga.  Maori Health Strategy. Wellington: Ministry of Health.

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Ward, Bernadette., & Verrinder, Glenda. (2008). Young people and alcohol misuse: how can nurses use the Ottawa Charter for Health Promotion? Australian Journal of Advanced Nursing, 25(4), 114 – 119.

World Health Organisation. The Ottawa Charter for Health Promotion. Retrieved from http://www.who.int/healthpromotion/conferences/previous/ottawa/en/index1.html