Long Term Conditions and their

Impacts in Counties Manukau Prepared for: Counties Manukau Health and East Heath Trust PHO

August 2015

introduction

The insights in this document were produced as part of a project to design a social marketing

programme that will support people with long term conditions to positively manage their health.

The project was led by innovate change for Counties Manukau Health and East Health Trust.

This document is an updated version of Insights on Long Term Conditions in Counties Manukau,

incorporating the findings from field research along with the initial information review.

innovate change is a social innovation agency that uses creative and participatory approaches to

improve health, wellbeing and social outcomes. We recognise the complexity of the social challenges

we face and the urgency of finding effective responses to them. For more information about this

project or other services and projects undertaken by innovate change, please visit

www.innovatechange.co.nz.

Counties Manukau Health (CMH) is a district health board that funds and delivers health services to

approximately 400,000 people in Manukau City, Franklin and Papakura Districts. As part of its

significant systems change work, CMH is developing a more equitable and flexible system that focuses

on activating patients to manage their health. This social marketing project connects with Manaaki

Hauora, the self-management support campaign being developed through Ko Awatea:

http://koawatea.co.nz/campaigns/self-management-support/.

East Health Trust is a primary health organisation (PHO) that provides services to approximately

100,000 people in the Howick, Pakuranga, Beachlands, Maraetai and Clevedon regions. East Health

Trust PHO aims to empower personal and community health and wellbeing by promoting quality

information, facilitating innovative programmes and endorsing healthy lifestyle choices. For more

information about East Health Trust, see www.easthealth.co.nz.

process and method

The project followed our innovative action model, focusing on the first four stages, as pictured.

This document summarises research from the questioning and understanding phases of the social

innovation process undertaken in 2015 by innovate change for Counties Manukau Health and East

Health Trust. One of two key outputs for the project, this document should be considered alongside

the Long Term Conditions Social Marketing Plan, which presents the full programme design, including

information about the process, target audience, ‘journey to wellness’ and proposed activities.

The first version of this document, Insights on Long Term Conditions in Counties Manukau,

summarised existing knowledge about long term conditions, population health, self-management,

social marketing and behaviour change. Synthesising information from a number of local, national and

international sources, it presented key insights that were used as background reading for the co-design

group in the ‘understanding’ phase. See Appendix 1 for some notes on research methodology.

The document you are reading brings together those insights with key findings from field research

with people with long term conditions in Counties Manukau. Once the first co-design workshop had

identified the group with the greatest opportunity for change, innovate change conducted qualitative

research with people from the potential target audience. Insights from the audience research informed

the subsequent development of the social marketing plan. Unless another source is cited, the quotes

throughout this document are from research participants. For more information about research

methodology and limitations, see Appendix 1.

summary of insights

1. Long term conditions are a major cause of death and disease in Counties Manukau (page 7)

2. Long term conditions are increasing and are felt most by Māori, Pacific and older people (page 9)

3. People often experience multiple conditions and mental health challenges (page 12)

4. The impacts of long term conditions are felt by individuals, whānau and the wider community (page 14)

5. There are lots of things individuals can do to manage their health (page 17)

6. Taking control and changing health behaviours can be challenging (page 19)

7. Family or whānau support inspires and motivates people with long term conditions (page 21)

8. Focus on people’s strengths, not what they are doing ‘wrong’ (page 23)

Insights - Part One: What are long term conditions and who has them?

A definition: long term condition

A long term condition is an illness that progresses slowly, limits activities of

daily living, requires some form of ongoing medical attention, lasts longer than

a year, and is rarely cured (Wilkinson 2013).

Long term conditions have become the most significant cause of death and

disease in the world (WHO 2014a). Not only are they becoming more

common, but they are associated with increasing rates of potentially avoidable

hospital admissions and premature death (Eaton, Roberts, and Turner 2015;

Winnard and Chan 2012). They pose significant challenges for healthcare

systems globally.

1. Long term conditions are a major cause of death and disease in Counties Manukau

“My husband died of obesity. My son was obese. I knew in my heart I needed to change our environment, change our pantry…. I had to change everything.” “I had one heart attack too many. It kind of woke me up...”

In New Zealand, two in three adults (and one in three children) have a long term condition. These conditions , which can also be called ‘chronic illnesses’, account for 80 to 90% of all deaths in New Zealand (Ministry of Health 2009; WHO 2014b). People with long term conditions repeatedly use a wide range of health services. Long term conditions consume between 70% and 80% of all healthcare spending. In 2008, people with cardiovascular diseases and/or diabetes accounted for 13% of the adult population in Counties Manukau, but contributed to 46% ($101 million) of the total inpatient hospitalisation costs. The long term conditions with the most significant impact on the Counties Manukau population and the greatest potential for a population-level approach to their management are:* • cardiovascular disease • chronic respiratory diseases, including chronic obstructive pulmonary

disease and asthma • diabetes • arthritis, including gout • congestive heart failure Cardiovascular diseases, type 2 diabetes, chronic respiratory diseases and some types of cancer can be considered a ‘package’ of conditions. They are linked because they are largely preventable and they share common risk factors, including smoking, unhealthy diet, lack of physical activity and harmful use of alcohol. These conditions and risk factors are responsible for the majority of avoidable deaths and reduced quality of life in Counties Manukau communities. Mismanagement of long term conditions is the leading cause of hospitalisations (National Health Committee 2007). Healthcare costs four times more for a person with a cardiovascular disease or diabetes than a person without either condition (Ministry of Health 2009). * There are a number of other significant long term conditions. See Appendix 1 for more information about why they were not included in the primary focus of the project and how we selected and calculated the prevalence of the conditions.

8

2. Long term conditions are increasing and are felt most by Māori, Pacific and older people

10

Long term conditions are the major cause of the 10 year difference in life expectancy between Māori and non-Māori. In Counties Manukau, half of all Indian and Pacific people aged 65-74 years have diabetes.

Long term conditions are not randomly distributed across society. Māori, Pacific and older New Zealanders are disproportionately affected. These groups tend to have lower incomes, greater exposure to health risks and lower access to health services. These factors result in poorer health, especially due to long term conditions. The number of people experiencing long term conditions is increasing. This is due to our ageing population, growing rates of obesity, an increase in sedentary lifestyle, and advancements in our ability to treat previously fatal conditions. This adds to the significant pressure that Counties Manukau is already experiencing on its health services. People from lower socio-economic groups develop multiple conditions 10 to 15 years earlier than their peers and are at a higher risk of avoidable hospitalisation (Eaton et al. 2015; Winnard and Chan 2012). Māori are less likely to seek and follow medical treatment and do not receive comparable health management for a range of conditions (EWG 2010). Pacific people experience higher levels of long term conditions and at younger ages. Older people in Counties Manukau Counties Manukau has the highest growth rate in the population aged over 64 years old in the country. Older people are more likely to have multiple long term conditions. People over 64 account for: • 15% of the adult population • nearly 40% of the group with a common long term condition • about two thirds of people identified in 2013 with chronic obstructive

pulmonary disease (COPD) and congestive heart failure (CHF) • over 80% of the people in the East Health PHO population with COPD,

CHF and osteoporosis (Goh 2015). Older people from certain ethnic groups have extraordinarily high rates of specific conditions in Counties Manukau. Nearly one in two Indian and Pacific people aged 65-74 years have been identified as having diabetes, and approximately one in three Māori and Pacific men in this age group are being treated for gout (MacLeod et al. 2014)

Insights - Part Two: What are the impacts of long term conditions?

3. People often experience multiple conditions and mental health challenges

“Wellness is a state of being mentally, as well as physically...if you have non-negative thoughts, then you are well.” “Never think about the pain in my body, [I] like to keep on doing my exercise. I am still strong to keep on doing these things.” “I wake up and I play Beyoncé.”

13

It is common for individuals to be affected by two or more long term conditions. This is a significant challenge for the New Zealand health system. In Counties Manukau, at least a quarter of the people identified with a common long term condition have more than one condition, and many of them also face mental health challenges. Management of conditions becomes more complex for people with more than one long term condition. These people typically see a range of health professionals and take differing medication for different conditions. This can result in reduced consistency of care and conflicting advice, which may mean conditions are missed or mistreated, and medications that are ill-advised to be taken together could be prescribed by various medical professionals. People who live with a long term physical condition are also more likely to experience mental health conditions like depression and anxiety (Naylor et al. 2012; Winnard et al. 2014). Over half of the people interviewed as part of the audience research mentioned a suicide attempt. Some had attempted suicide more than once, and cited the management of depression as a central part of the journey to wellness. Depression not only develops as a result of having physical long term conditions, but it can contribute to their development (NHC 2007). Emotional and mental health problems play a key role in reducing people’s ability to manage their health on an ongoing basis. To combat negative thoughts and achieve an active and positive mind, participants in our research emphasised the importance of: • keeping an active mind and body to distract from feelings of pain or

helplessness; • focusing on the strengths and resources they already have; • taking it ‘one day at a time’; • finding their own ‘thing’ – e.g. walking a grandchild to school,

keeping a food diary, doing crafts, meditation, prayer, reading a poem or listening to Beyoncé first thing in the morning;

• positive thinking; • having the support of family or whānau, friends and healthcare

professionals.

4. The impacts of long term conditions are felt by individuals, whānau and the wider community

15

“My sugar levels got really high again, and my doctor said, ‘We really want you to go to hospital.’ I said, ‘I just can’t I’m too busy, I don’t have time.’ And he said, ‘Well, if you don’t start managing, you’ll have time to do nothing’.”

Long term conditions have physical, mental, social and economic consequences. They are often associated with a loss of, or reduction in, income and lowered participation in work and society (MoH 2009). Absenteeism due to illness may be an issue, and getting time off for health care appointments can be challenging. People with long term conditions are more likely to be unemployed or work part-time (Holt 2010), and are also more likely to develop additional physical or mental conditions. They may also experience decreased social activity, loss of strength and fears about the effects of the disease (Woods, Yates, and Primomo 1989). The economic burden of long term conditions has a flow-on effect on people’s ability to effectively self-manage and reduce risk behaviours. Access to government support, health service flexibility and health literacy all exacerbate hardship. Those on multiple medications, from disadvantaged cultural groups and/or not in paid employment experience more hardship, which in turn compounds their ability to manage their condition (Jeon et al. 2009; Harris and Wallace 2012). Of course, different illnesses impact people in different ways. For instance, diabetes requires specific care and management, while conditions such as arthritis are more likely to affect mobility and employment. A person with arthritis, for example, may experience chronic pain and depression, resulting in an inability to work (Harris and Wallace 2012). Long term conditions put significant pressure on personal, economic and social resources and the overall wellbeing of family and whānau. The impact felt by family members can include emotional stress, frustration and worry. Employment and education arrangements of other family members, as well as relationships between family members, can also be affected (Woods, Yates, and Primomo 1989). This can lead to depression or other health problems for family members who are providing care (Golics et al. 2013; Whitehead 2009). Families of a child with a long term condition are also likely to suffer increased stress as they manage the demands of care, work and school activities (Brown et al. 2008).

Insights – Part 3: How can people with long term conditions manage their own health?

5. There are lots of things individuals can do to manage their health

18

“I made a list for myself that I carry around - small things, a poem, a walk, cultivating silence.” “I even started a food diary… I thought, don’t bullshit myself…. be honest.” “I have one thing. I get up every day.”

Most people with long term conditions spend only a few hours a year interacting with healthcare professionals and most of their lives managing their conditions themselves. Patients managing their conditions more effectively will reduce the burden of long term conditions on the health system and improve their quality of life. Effective self-management involves the person with the long term condition, with the support of their family or whānau, working in partnership with health professionals to:

• increase knowledge about the condition and treatment options; • share in decision making; • monitor and manage the symptoms and signs of the condition; • manage the emotional, physical and social impact of the condition; • negotiate, review and monitor a care plan; and • engage in activities that protect and promote health. Mental wellbeing is an important factor in the health of people with long term conditions. Participants in the audience research overwhelmingly talked about the journey to wellness in terms of the struggle of managing their emotions and connecting with themselves more than the effects of the conditions on their physical bodies. Achieving an active and positive mind can create space for taking other positive steps for change. In this way, writing a poem or learning a new skill such as raranga can be just as important as more typical health directives related to exercise or diet.

Activities that protect and promote health are diverse and vary from person to person. According to participants in this project, self-management may involve: • taking small, achievable steps towards wellness – slowly reducing the

size of meals, eating a piece of fruit, walking a short distance

• drawing on existing strengths – e.g. faith, education, family

• putting yourself and your health needs first

• being conscious and compassionate toward how you feel

• learning, asking health professionals questions about your condition

• celebrating successes – losing weight, smoking less

• finding motivation through people who you support – e.g. your

children, spouse, grandchildren, parents, a support group.

6. Taking control and changing health behaviours can be challenging

20

“Expectations and comments from staff that, ‘I should know better, as a health professional’ (were really damaging).” “I used to put everyone before myself, but… I realised that if something is wrong with me who is going to look after my mother?”

To take greater control of their health, people need self-care skills, knowledge and understanding. Although anyone with a long term condition can be encouraged and supported to manage aspects of their health more successfully, some people face significant barriers. The challenges depend on personal and family circumstances; the number, nature and stages of their conditions; the need for specialist interventions; and their capacity to self-manage (Eaton, Roberts, and Turner 2015). These barriers are enhanced for Māori and Pacific people (MoH 2010; EWG 2010). Many people with long term conditions are not confident about getting the help they require from others or about taking responsibility for their own wellbeing. Our audience reported struggling to put themselves first – to place their needs ahead of the needs of their family, friends and/or employer. This is especially challenging when their familial role is culturally defined. Those who manage their conditions well learnt they need to put themselves first in order to best support others in their life. Barriers to self-management identified in the audience research include: • feeling ashamed of being very overweight and exercising in public • feeling embarrassed or ashamed about seeking help • educating the family of a person with a long term condition • lack of motivation for ongoing physical activity and healthy eating • pressure from family / culture / society to fulfil familial roles • lack of appropriate education and promotional material • hesitancy to visit a health professional Additional and well-documented barriers that appeared in our literature review include: • the cost of health care • culturally inappropriate health care structures • lack of belief in ability to control health (self-efficacy) • poor quality communication between patients and providers • low health literacy (the ability to read, understand and effectively use

instructions and information related to your healthcare)

7. Family or whānau support inspires and motivates people with long term conditions

22

“I got up again at 6am… hopped on the treadmill. Did I want to? No. But I have a focus for my grandkids.” “My grandchildren say, ‘Stop smoking, Nanny,’ when I’m coughing... I know they’re right… What they say makes a big difference but it’s for me to take it in.”

Supportive environments are needed to encourage and assist people in changing their health and wellbeing behaviours. The decisions and choices people make are influenced by a range of biological, psychological, environmental and social factors. Some people are caught in a "try-fail-guilt" cycle in their efforts to adopt healthier lifestyles, where factors such as cost, time and lack of healthy food outlets discourage them from improving their diet (Waldron 2007). Families and whānau play a key role in supporting people with long term conditions, as they can provide various forms of support and help to ensure individuals understand and manage their condition. The audience research showed that: • People enjoy and are motivated by the feeling of family members

being ‘proud of’ their commitment and achievements “My son is doing me a favour. He asks how many cigarettes to leave me and I only want two now. When there are cigarettes left… He looks at me… and says, ‘you’re doing well, Mum. I’m proud of you’.”

• People are motivated to be healthy and mobile to care for others

“I wake up and I think about my two beautiful children, and that’s what keeps me going.”

• Family members can assist in adopting healthy behaviours and

maintaining healthy household habits “I am a sweet man, I like my sugar, but we don’t have butter or sugar in the house now. We decided to stop getting it in the shopping.”

Involving whānau in self-management increases the likelihood that healthy behaviours will be adopted. Since family and whānau members are likely to have similar risk factors to an individual with a long term condition, involving them is also a sound preventative approach. Currently the role of whānau may not be adequately taken into account in many approaches to managing long term conditions.

8. Focus on people’s strengths, not what they are doing ‘wrong’

24

Information has an important role to play in influencing healthy behaviours, but simply providing people with information will not automatically lead to behaviour change. Information-only approaches assume people behave rationally, and change their behaviour when given information about the negative effects of certain habits. Instead, people need the motivation or desire to change and the skills and opportunity to do so. Information campaigns must be combined with other services and interventions if they are to bring about significant changes in behaviours. Increasing evidence tells us programmes that apply effective social marketing can lead to real, measurable behaviour change. Social marketing is the use of commercial marketing theory and tools to achieve positive behaviour change for social benefit (Andreasen 1994). To be effective, social marketing programmes must: • come from a trusted source; • identify specific target audiences and behaviour change goals; • capture the target audience’s attention; • have messages that impact on motivation, e.g. tap into social

norms or identify clear and credible benefits that people are willing to exchange for the adoption of the behaviour that is being proposed.

• take a long-term approach. People manage their conditions in diverse, highly-personal and sometimes unexpected ways. It is important that a social marketing programme to support people with long term conditions presents a range of options and emphasises that it is up to the individual to find their ‘thing’ (what works for them) – be it Beyoncé or bicycling. People living well with long term conditions draw on their strengths. Their religious faith, having the support of friends, family and others living with long term conditions, and having already made positive changes, can provide the foundation for individuals to take control of their health and make positive changes on their wellness journey.

“I remember my wife doing that with our son, setting short term goals for him to achieve, and I thought, I’ll try that.” “I draw on my knowledge as a teacher, to reframe how I think about food.”

Appendix 1: Notes on methodology

The primary focus for this project was the non-communicable long-term illnesses listed on page 8. These conditions were

identified, using a combination of data sources, as having the most significant impact on the Counties Manukau population and

the greatest potential for a population-level approach to their management. There are, of course, a number of other significant

long term conditions. They were deemed outside the scope of the social marketing programme, due to one or more of these

reasons:

a) A specific approach is needed to their care, reducing the relevance of generic self-management practices and principles;

b) Other programmes effectively target the specific condition; or

c) The condition has not been shown to significantly affect a large number of people in Counties Manukau.

Mental health conditions also affect a large proportion of the population. Because many people with long term physical

conditions also experience mental health challenges, they are a secondary focus of this project - see Insight 3.

Despite it affecting a large number of people (12.9% of the Counties Manukau population, Winnard 2015), we elected not to

include chronic pain in the list of most significant conditions, because it is hard to profile the population who experience it and

because it often occurs with other conditions.

Throughout this document, we have provided figures for Counties Manukau, or, if this was not possible, for New Zealand

populations. We received specialist advice and peer review on interpreting this data from Doone Winnard, Clinical Director

Population Health, CMH.

The numbers provided are indicative estimates. There are some challenges and inconsistencies in the data collected on

diseases, so it is not possible to accurately state how many people are affected by a particular disease in a particular area. If, for

instance, a person does not get a prescription, laboratory test or diagnosis in hospital, they are not recorded in secondary care

data as having a particular condition. Some conditions are less likely to be classified than others in primary care data, which

relies on GP input. In addition, some diseases are under-reported in the NZ Health Survey, possibly because individuals have not

been clearly diagnosed or because they experience some shame around the condition.

Audience research

In the ‘understanding’ phase of the project, innovate change undertook field research with people from the target

audience. We designed a semi-structured interview framework and visual tools to help us explore and understand

people’s experiences of living with long term conditions. We recruited interview participants through self-

management groups, Facebook advertising and our own networks.

In April, we conducted in-depth group and individual interviews with 11 people living with long term conditions in the

Counties Manukau district. The people we interviewed were aged between 45 to 65 years and included people

identifying as Māori, Pacific Island, Indian and Pākehā. Many of the interviewees had diabetes; most had more than

one condition; and more than half also had experience of mental health challenges.

The people we interviewed were generally at a stage where they were positively managing their condition. Although

these people all described a stage of being unwell, it is a limitation of this research that we did not speak to anyone

at a point of crisis or when they were not managing their health well.

We analysed and synthesised the key themes and quotes from these interviews, and presented them back to the co-

design group and to Counties Manukau Health staff in a walk-through. The key findings from the audience research

have been distilled and combined with the information review to produce the insights presented in this document.

Reference List

• Andreasen, Alan R. 1994. “Social Marketing: Its Definition and Domain.” Journal of Public Policy & Marketing 13 (1): 108–14. • Brown, Ronald T., Lori Wiener, Mary Jo Kupst, Tara Brennan, Richard Behrman, Bruce E. Compas, T. David Elkin, et al. 2008. “Single Parenting and

Children with Chronic Illness: An Understudied Phenomenon.” Journal of Pediatric Psychology 33 (4): 408–21. • Carins, Julia E, and Sharyn R Rundle-Thiele. 2013. “Eating for the Better: A Social Marketing Review (2000–2012).” Public Health Nutrition, May,

1–12. doi:10.1017/S1368980013001365. • Eaton, Simon, Sue Roberts, and Bridget Turner. 2015. “Delivering Person Centred Care in Long Term Conditions.” BMJ, no. 350:h181 (February).

http://dx.doi.org/10.1136/bmj.h181. • Flanagan, Pat, Jill Moffat, Kate Healey, and Allan Moffitt. 2014. “Learnings from a Project to Develop a Generic Self-Management Care Plan for

Long Term Conditions”. Alliance Health +. • Gestro, Lisa. 2014. “Counties Manukau Health System Integration Programme”. presented at the Self-Management Support Campaign

Engagement Session, Ko Awatea, September 24. http://koawatea.co.nz/wp-content/uploads/2014/10/System-Integration-Programme-Lisa-Gestro.pdf.

• Goh, Kwee. 2015. “Prevalence of Long Term Conditions, Primary Care – East Health Cohort”. East Health Trust PHO. • Golics, Catherine Jane, Mohammad Basra, Salek, and Finlay. 2013. “The Impact of Patients’ Chronic Disease on Family Quality of Life: An

Experience from 26 Specialties.” International Journal of General Medicine, September, 787. doi:10.2147/IJGM.S45156. • Harris, Anne. 2015. “Research Summary: Effective Community and School Based Road Safety for Young People”. NZ Transport Agency. • Harris, Jeffrey R., and Robert B. Wallace. 2012. “The Institute of Medicine’s New Report on Living Well With Chronic Illness.” Preventing Chronic

Disease 9. http://www.cdc.gov/pcd/issues/2012/12_0126.htm. • Health Navigator. 2014. “Self-Management.” Health Navigator NZ. http://www.healthnavigator.org.nz/self-management/. • Holt, Heather. 2010. Health and Labour Force Participation. Working Paper. Wellington: The Treasury.

http://www.treasury.govt.nz/publications/research-policy/wp/2010/10-03. • Expert Working Group. 2010. Improving Responsiveness to Maori with Chronic Conditions. Health Improvement and Innovation Resource Centre. • Jeon, Yun-Hee, Beverley Essue, Stephen Jan, Robert Wells, and Judith A. Whitworth. 2009. “Economic Hardship Associated with Managing

Chronic Illness: A Qualitative Inquiry.” BMC Health Services Research 9 (1): 182. doi:10.1186/1472-6963-9-182. • MacLeod, Garth, Wing Cheuk Chan, Doone Winnard, and Dean Papa. 2014. “People Identified with Selected Long Term Conditions in CM Health

in 2013”. Counties Manukau Health. • Mays, Nicholas. 2013. Reorienting the New Zealand Health Care System to Meet the Challenge of Long-Term Conditions in a Fiscally Constrained

Environment. NZ Treasury. Health Improvement and Innovation Resource Centre.. • McKenzie-Mohr, Doug. 2000. “New Ways to Promote Proenvironmental Behavior: Promoting Sustainable Behavior: An Introduction to

Community-Based Social Marketing.” Journal of Social Issues 56 (3): 543–54.

• Ministry of Health. 2009. Report on New Zealand Cost-of-Illness Studies on Long-Term Conditions. Wellington: Ministry of Health. http://www.health.govt.nz/publication/report-new-zealand-cost-illness-studies-long-term-conditions.

• ———. 2010. Korero Marama: Health Literacy and Maori Results from the 2006 Adult Literacy and Life Skills Survey. Wellington: Ministry of Health. http://www.moh.govt.nz/notebook/nbbooks.nsf/0/4559082D3B05C11FCC2576CE006835A1/$file/korero-marama.pdf.

• ———. 2013. Health Loss in New Zealand: A report from the New Zealand Burden of Diseases, Injuries and Risk Factors Study, 2006–2016. Wellington: Ministry of Health.

• Moffitt, Allan. 2007. “Chronic Care Management Overview”. Counties Manukau Health, November 6. • National Health Committee. 2007. Meeting the Needs of People with Chronic Conditions. Wellington: Ministry of Health.

http://www.health.govt.nz/publication/meeting-needs-people-chronic-conditions. • National Social Marketing Centre. 2006. It’s Our Health! Realising the Potential of Effective Social Marketing. Summary - Independent review,

findings and recommendations. London: National Consumer Council. • Naylor, Chris, Michael Parsonage, David McDaid, Martin Knapp, Matt Fossey, and Amy Galea. 2012. Long-Term Conditions and Mental Health.

London: The King’s Fund. http://www.kingsfund.org.uk/publications/long-term-conditions-and-mental-health. • NZ Guidelines Group. 2012. Effective Behaviour Change in Long-Term Conditions. Wellington: Ministry of Health.

http://www.health.govt.nz/publication/effective-behaviour-change-long-term-conditions. • Paglia, Angela, and Robin Room. 1999. “Preventing Substance Use Problems Among Youth: A Literature Review and Recommendations.” Journal

of Primary Prevention 20 (1): 3–50. • Robertson, Ruth. 2008. Using Information to Promote Healthy Behaviours. London, United Kingdom: King’s Fund.

http://www.kingsfund.org.uk/sites/files/kf/KBH_Using_info.pdf. • Thackeray, Rosemary, and Brad L. Neiger. 2002. “Using Social Marketing to Develop Diabetes Self-Management Education Interventions.” The

Diabetes Educator 28 (4): 536–44. • Waldron, Geraldene. 2007. “Let’s Beat Diabetes: Social Marketing Action Area”. presented at the LBD Information Sharing Workshop, Counties

Manukau Health, November 6. • Whitehead, Lisa. 2009. Living with Chronic Illness. 6. Innovative Practice Fund. Wellington: Families Commission.

http://nzfamilies.org.nz/publications/research-reports/living-with-chronic-illness. • Wilkinson, Amanda. 2013. “The Rhetoric and Reality of Long-Term Condition Self-Management in New Zealand”. Thesis, University of Otago.

https://ourarchive.otago.ac.nz/handle/10523/4233. • Winnard Doone. 2015. Prevalence of various LTC from self-report in the NZ Health Survey 2011-13. Counties Manukau Health. • Winnard, Doone, and Wing Cheuk Chan. 2012. International Evidence about Interventions to Reduce Unplanned Hospital Use. Counties

Manukau Health. • Winnard, Doone, P Watson, S Boladuadua, K Butler, Dean Papa, T Ahern, M Lee, S Hallwright, and S Russell. 2014. “Populations Who Have

Received Care for Mental Health Disorders”. Counties Manukau Health. • Woods, N. F., B. C. Yates, and J. Primomo. 1989. “Supporting Families during Chronic Illness.” Image-the Journal of Nursing Scholarship 21 (1):

46–50. • World Health Organization. 2014a. Global Status Report on Noncommunicable Diseases 2014. Switzerland: World Health Organization. • ———. 2014b. The Impact of Chronic Disease in New Zealand. Switzerland: World Health Organization.

http://www.who.int/chp/chronic_disease_report/en/.