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TE TOTORONGĀ

(the way forward is reaching back)

BUILDING A CASE FOR ESTABLISHING THE FRUITS IN SCHOOLS PROGRAMME FOR EARLY LEARNING SERVICES

November, 2020

Healthy Families Far North, Ngā Tai Ora Public Health Northland

Extending the Fruits in Schools (FIS) programme to Te Taitokerau Early Learning Services (ELS)

Executive Summary

Mā muri, mā mua, kia tika

Early access to heathy kai sets up beneficial childhood, adolescent and adult health and wellbeing outcomes. Te Taitokerau pre-schoolers attending Early Learning Services (ELS) would progressively gain from the health benefits of the Fruits in Schools (FIS) programme that they do not currently receive.. Extending FIS to Te Taitokerau ELS, particularly for communities experiencing high deprivation, gives our tamariki, mokopuna, whānau, hapū and iwi the opportunity to determine their access and preference for healthy kai.

This statement proposes and advocates for the extension of the FIS programme to the following ELS in Te Taitokerau:

• 42 x Kōhanga Reo;
• 26 x Kindergarten;
• 36 x Playcentres;
• 101 x Education and care centres;
• 7,203 approx. pre-schoolers currently attending ELS.

FIS is a nationwide programme strongly linked to the Child Obesity Plan (Ministry of Health, 2016). As an initiative, FIS placed New Zealand ahead of the rest of the world with a identified target and comprehensive plan to tackle childhood obesity (Coleman, 2016, July 26). FIS provides fruits and vegetables to Year 1 to Year 8 students who attend a school deemed low decile. Initially in 2004, only 10 schools from certain regions were selected to pilot the government-funded scheme, but eventually the programme covered 557 schools, reaching over 120,000 students. The impact was felt by participating schools that covered all the pillars of health with Sir Professor Mason Durie’s health model Te Whare Tapa Whā. Principals noted “[t]he change in children’s general health has been huge, along with their attitudes to trying new things and experimenting. It’s also had an impact on healthier lunch boxes and we’ve become a water only school”. Both physically (te taha tinana) and mentality (te taha hinengaro), 98% of principals found that pupils knew more about nutrition and health with FIS activated at their school, and this was assisting students to build their health, wellbeing and resilience. An external evaluation of the programme undertaken on behalf of the 5+ A Day Charitable Trust showed good results with schools reporting improved dental outcomes, a reduction in general sores, an increase in overall healthy eating behaviours and an increase in student concentration. Records showed that the largest proportion of high-needs schools were in Counties Manukau (67 schools) and Northland (63 schools) (Watts, 2018).

The Fruits in Schools programme is managed by produce company United Fresh New Zealand Inc. and resulted in an interagency group being set up to support the health and wellbeing of future generations of New Zealanders. Each year, FIS attracts government funding of $7.8 million and has continued to grow to support more children and families. Emerging from the success of FIS on the basis of data analysis and user/provider insight gathering, the Minister of Child Poverty Reduction has announced the pilot of a new school project supplying free lunches to selected Year 1 to Year 8 students. The School Lunches Programmes (TSLP) guiding principle is reducing food insecurity by providing access to a nutritious lunch every day. Research indicates that reducing food insecurity for children and young people improves wellbeing, supports child development and learning, improves learners’ levels of concentration, behaviour and school achievement, reduces financial hardship amongst families and whānau, addresses barriers to children’s participation in education and promotes attendance at school, boosts learners’ overall health (Ministry of Education, 2020). Like FIS, TSLP is another piece of the chain linked together by the aims and objectives of the Child, Youth and Wellbeing Strategy adopted by the government to map the progress, direction and quality of data that provides real-time feedback regarding up-to-date outcomes for these two projects. The forecasted scope for TSLP was estimated at 21,000 students spread throughout approximately 120 schools by the end of 2021 with a costed out budget of $5 per student per day. The fruits of this labour will unfold over the forthcoming years.

1.0 Background
Setting the scene: The Child Wellbeing and Poverty Reduction Group was established in February 2018 as a direct result of the Child Poverty Reduction Act 2018, a brand-new piece of legislation co-led by Minister of Child Poverty Reduction, Prime Minister Jacinda Ardern and Minister of Children, Hon. Tracey Martin. The spotlight (and priority) squarely put on a significant demographic of our society, historically hidden and previously not legislated for. But, even with this gold standard in attentiveness, systems outcomes are not shifting fast enough. Vulnerable communities are still experiencing higher levels of deprivation that fuel intergenerational unwellness and trauma for whānau. What we know is that “[u]naddressed, childhood trauma changes how we respond to the world, and when triggered, we make choices that sometimes have devastating consequences including domestic violence, addiction, murder, and prison” (Horstman, 2020), and that this is the breeding ground for child poverty. Child poverty — what these two words represent is particularly hard to reconcile alongside the relative wealth that Aotearoa New Zealand is renowned for, and yet the stark reality of the data tells us another story:

• 180,000 children are in poverty: before housing costs primary measure (16%)
• 250,000 children are in poverty: after-housing costs primary measure (23%)
• 150,000 children are in poverty: material hardship primary measure (13%)

(Statistics New Zealand, 2019)

Table 1: Food groups, specific foods in each group, advice and service size examples

• For the purposes of this background paper and the above table, a Ministry of Health (2012) definition for ‘children and young people’ are those aged from 2 to 18 years. When referred to separately, ‘children’ are those aged 2–12 years, while ‘young people’ are those aged 13–18 years. The term ‘pre-schoolers’ refers to children aged from two years up until their fifth birthday.

Add child obesity to the mix as another major concern with statistics showing 1 in 9 children aged 2–14 years identified as obese (Ministry of Health, 2018). One of the identified causes of obesity issues in children has been termed “unhealthy diet behaviours” (Egli, Hobbs, Carlson, Donnellan, Mackay, Exeter, Villaneuva, Zinn & Smith, 2020) and was found in neighbourhoods with high deprivation who had far more access to food outlets that sold unhealthy food over outlets that sold healthy kai. What was an important insight from this research was the need to expose children, as early as possible, to healthy food and to factor in environmental impacts such as the density of unhealthy food outlets and how susceptible children can be to this kai when there are significant issues relating to poverty.

The importance of a cultural approach that incorporates a ‘bottom up’ rather than ‘top down’ philosophy (Hamerton, Mercer, Riini, McPherson & Morrison, 2014) has proven to be an effective way to promote healthy kai and kai practices in predominantly Māori communities. Whakamaua: Māori Health Action Plan 2020–2025 (Ministry of Health, 2020) is a document that highlights the Ministry’s accountability to addressing health inequity and health loss for Māori, and therefore providing Māori with a directive to develop our own local solutions for tamariki, whānau and communities. Te Taitokerau and the Far North region have a significant number of Māori communities living with high deprivation, and a holistic framework that encourages healthy eating, physical activity and/or increased whānau education and awareness has proven to be a successful approach to working with Māori. National Māori health initiatives He Pī Ka Rere and Toi Tangata are combining kaupapa Māori with education within Early Learning Services (ELS) focused on nutrition, physical activity and embedding lifelong, positive relationships with healthy kai for tamariki mokopuna.

Another initiative, Under 5 Energize is a nutrition and physical activity-based programme focused on providing healthy food ideas and physical activity for Under 5’s. Similar to Brain Gym and supporting the ground-breaking neuroscience incubator, the Brainwave Trust, the point of difference for Under 5 Energize is its direct application of brain development. Advocate of a child’s first 1,000 days and child development expert, Nathan Wallis, is a household name when it comes to brain development for kids. Through the progressions involved in the fundamental skills development found in physical activity and the practice of repetitive movements and patterns, the vulnerable brains of our future leaders are trained i.e. wired how they naturally should be. Healthy food supports brain development in pre- schoolers, and research suggests for Māori children this needs to be further improved through such strategies as engaging local food systems and being community-based (Grant, Wall, Yates & Crengle, 2010). Children that understand that a healthy environment required for local food systems is needed for healthy food is more likely to look after the environment. Brain development is also a significant contributor to determining food preference for people, which starts in early childhood and continues onto adulthood (Beckerman, Alike, Lovin, Tamez & Mattei, 2017). Early exposure to healthy food sets people up with their lifelong food preferences, and incorporating consistent and regular access to healthy kai can lead to healthier eating habits and better health outcomes in the long run.

2.0 Case for Change
Te Ōhākī (conscious reminders) — Kei hea rātou? Kei hea a tātou mokopuna? Where are they? Where are our mokopuna? Whakamaua: Māori Health Action Plan 2020–2025 (Ministry of Health, 2020) specifically requires action for tamariki and whānau that improves access to health outcomes, stating that there needs to be shifts in the system that “create healthy and sustainable environments and communities in which to live and raise children” (p. 31). The inequities for tamariki mokopuna when it comes to accessing health outcomes through such avenues as nutritious food is deeply concerning. As evidenced in the diagram below (Table 2), preschool tamariki fail to feature in relation to the wider systems that impact FIS schools, despite being a significant contributing cohort to the primary schooling system, and a key age group for capturing baseline data as to what regular fruit and vegetables are being consumed prior to attending school.

Table 2: The wider systems influence on FIS. Source (Watts, 2018).

Te Whakatupuranga (the rebuild after COVID-19) — Many lessons have been learnt from our ongoing experience of COVID-19. For Te Taitokerau, it has provided real and pragmatic experiences of how Te Tiriti o Waitangi and Tino Rangatiratanga or the absolute independence of hapū, iwi and whānau are able to respond to the potential risks of matahuna or the unseen risk of a pandemic that could have had a serious, detrimental impact to the ongoing survival of whakapapa for Māori. The ability of hapū, iwi and whānau to react and be proactive in setting up roading checkpoints, testing stations, kai and hygiene distribution centres even before the government acted or provided funds demonstrated the mana of our indigenous collectivism. In relation to the kaupapa of FIS being extending to Te Taitokerau ELS, COVID-19 and the government and community response to it shows that anything is possible when it comes to advocating for these opportunities for our tamariki mokopuna.

Moving Forward; Budget 2020 — There is a consistent theme recurrent through Budget 2020 that captures the purposeful actions of a government and society increasing its efforts towards improving the quality of health and wellbeing for tamariki mokopuna. One of the drivers behind the Prime Ministers message of ‘what is important moving forward’ for our nation is a plan to reduce child poverty that focus on goals for our tamariki mokopuna. Outlined below are some of those Budget 2020 initiatives targeted at our tamariki mokopuna that provide a sustainable system for our most vulnerable:

• continued support for WellChild Tamariki Ora service providers to deliver child health services including immunisations, health checks and other essential services ($71.2 million over 4 years);
• additional funding to ensure that Kōhanga Reo continues to be a viable ECE option for Māori whānau. Increased funding for Kōhanga Reo staff aligns with evidence advising Government support of Māori education initiatives will help reduce child poverty ($93.4 million over 4 years);
• funding to maintain support to the 20–25% of children in early childhood education and schooling who require additional support to fulfil their learning potential;
• funding for a cost adjustment of 1.6 per cent for the Early Childhood Education (ECE) Subsidy for under twos, ECE Subsidy for twos and overs, 20 Hours ECE, Equity Funding (all components) and Targeted Funding for Disadvantage;
• funding to meet price and volume pressures facing providers of the Well Child Tamariki Ora (WCTO) programme, including Plunket, District Health Boards and B4 School Check providers.

Continued Government initiative support

• for the expansion of the Fruits and Vegetables in Schools. The Prime Minister spoke on this post- COVID-19 pandemic government budget response saying “providing a free and healthy lunch at school is one way to help make New Zealand the best place in the world to be a child and to make that difference immediately” (Davison, 2020 May). This initiative pivoted off the success of the Fruits in Schools programme first piloted in 2004.
• expanded school-based health services in deciles 1–4 schools, and free and low-cost doctors’ visits for children under the age of 14;
• continued funding KickStart and KidsCan.

The Prime Minister and Cabinets strategic goal to reduce child poverty is outlined below: Ten-year longer-term targets. By 2027/28, the Government aims to reduce the proportion of children in:

• low income households on the before housing costs primary measure from 16 percent of children to 5 percent — a reduction of around 120,000 children;
• low income households on the after-housing costs primary measure from 23 percent of children to 10 percent — a reduction of around 130,000 children;
• material hardship from 13 percent of children to 6 percent — a reduction of around 80,000 children.

Three-year intermediate targets. By 2020/21, the Government aims to reduce the proportion of children in:

• low income households on the before housing costs primary measure from 16 percent of children to 10 percent — a reduction of around 70,000 children.
• low income households on the after-housing costs primary measure from 23 percent of children to 19 percent — a reduction of around 40,000 children.
• material hardship from 13 percent of children to 10 percent — a reduction of around 30,000 children.

(Child Poverty Reduction Act, 2018)

The snapshot of data, research and insights draw a supportive picture that demands and promotes earlier intervention that naturally becomes a preventative health system and that will advance and exceed past and present outcomes.

Ngā Tamariki, Ngā Mokopuna, Te Tamaiti (the forgotten ones) — In some tāngata whenua traditions the word kōhanga, now synonymous with Te Kōhanga Reo, the Māori language nests, was also traditionally used for Whare Kōhanga, which in today’s language would be the ‘maternity ward’. There was a tohunga (doctor), māreikura (midwife) and a tāpui (nurse). There was tohi (rites), karakia (celestial and ancestral demands) and tikanga (best practice methods). The Whare Kōhanga was built by the child’s father in the centre of the Pā (mountain top, fortified village). All the best resources were channelled into what was being supplied to the mother and baby with the intent that both would recover and develop. Te Kōhanga Reo of today and the Whare Kōhanga of yesteryear are built on the same strong foundations — a quality of health and wellbeing where the focus is on our mokopuna.

B4 School Checks — is another initiative born out of the Child Obesity Plan, aimed at pre- schoolers aged 4 years old to assess their health and wellbeing status just before they start primary school. Assessments include weight, height and oral health checks, updates on immunisations and BMI’s (Body Mass Index). A child obesity health target was introduced with the childhood obesity plan. The Ministry of Health (2016) noted that “by December 2017, 95% of obese children identified in the Before School Check (B4SC) programme will be referred to a health professional for clinical assessment and family-based nutrition, activity and lifestyle interventions”. Although most 4 years old in the majority of New Zealand’s regions have been through the B4SC programme (2,202 in Northland, 973 with high deprivation), results in some regions are highlighting issues that point to a future of poor health and wellbeing issues for a lot of our young people, and more importantly for our high deprivation regions. In 2013 and 2014, the Te Toi Ora team from Bay of Plenty DHB reported that 8.6% of children assessed in the B4SC program were identified as obese which is a total of 665 children (or an average of 333 each year) and a further 14.3% of children were identified as being overweight, giving a total of 1,105 children who were either overweight or obese (Scarfe, 2016).

The statistics are a reality check in that 10.7% of New Zealand children (aged 2–14 years) are obese, with even higher rates among Māori children (14.7%) (Ministry of Health, 2016). What this shows is that “obese children are […] more likely to become obese adults and are therefore more at risk of developing long-term conditions such as type 2 diabetes, heart disease, dementia, some cancers, mental illness and chronic pain” (Ministry of Health, 2017).

Table 3: Ministry of Health (2019) table indicating that 44.1% of 368,000 children met their daily required vegetable and fruit intake guidelines for the 2018/19 period. What this table also highlights is that 55.9% of this demographic did not meet these guidelines.

3.0 Way forward
Poua Tō Mauri (our position) — The current social environment alongside the effects of COVID-19 has given Aotearoa New Zealand an opportunity to pause, observe and rethink. Fruits in Schools is a programme Healthy Families Far North and Ngā Tai Ora Public Health Northland are recommending and urging the Ministry of Education to extend to all 222 Early Learning Services operating in the high deprivation region of NDHB.

There are stressors associated with this pandemic that has the potential to cripple the most resilient systems. The projection of more business closures, job losses, more unemployment and more children falling into poverty needs to be responded to with calculated and intentional action to help flatten the curve of the many silent pandemics that exist within our society pre-COVID-19.

Moving Forward — we need to settle the past to heal the future.
Moving Forward — we need to educate our future leaders.
Moving Forward — we need to act intentionally and purposefully to build an environment conducive to growing healthy future leaders.
Moving Forward — will be moving backwards if we don’t act now.
Moving Forward — we need to be brave, courageous and engaging to ignite the fire within our future leaders.
Moving Forward — our collective believe that these tamariki mokopuna are our future leaders and they deserve this opportunity to be nurtured through expanding and extending the Fruits and Vegetables programme to Early Learning Services Northland-wide.

Uhi!
Wero!
Haramai te toki! Haumi ē!
Hui ē!
Tāiki ē!

For more information contact:

John Wikitera
Systems Innovator — Healthy Families Far North (021) 554 569
john.wikitera@whaingaroa.iwi.nz

Josephine Nathan
Manu Hāpori Hauora — Community Wellbeing Advisor Te Tai Hāpori — Community Wellbeing Team
Ngā Tai Ora — Public Health Northland
(021) 274 2458 / josephine.nathan@northlanddhb.org.nz

References

Beckerman, J. P., Alike, Q., Lovin, E., Tamez, M., & Mattei, J. (2017). The development and public health implications of food preferences in children. Frontiers in Nutrition, 4, 66.

Child Poverty Reduction Act. (2018).

Coleman, J. (2016, July 26). More kids benefiting from Fruit in Schools: Beehive media release. Retrieved from: www.beehive.govt.nz/release/more-kids-benefiting-fruit-schools

Davison, I. (2020, May). Budget 2020: Free school lunches needed more than ever, principals say. New Zealand Herald. Retrieved from: www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=12332054

Egli, V., Hobbs, M., Carlson, J., Donnellan, N., Mackay, L., Exeter, D., Villaneuva, K., Zinn, C., & Smith, M. (2020). Deprivation matters: understanding associations between neighbourhood deprivation, unhealthy food outlets, unhealthy dietary behaviours and child body size using structural equation modelling. J Epidemiol Community Health, 74(5), 460–466.

Grant CC, Wall CR, Yates R and Crengle S (2010) Nutrition and indigenous health in New Zealand. Journal of Paediatrics and Child Health 46(9): 479–482.

Hamerton, H., Mercer, C., Riini, D., McPherson, B., & Morrison, L. ( 2014 ). Evaluating Māori community initiatives to promote Healthy Eating, Healthy Action. Health Promotion International, 29 (1), 60–69.

Ministry of Education. (2020). Free and healthy school lunches. Retrieved from: www.education.govt.nz/our-work/overall-strategies-and-policies/wellbeing-in-education/free-and- healthy-school-lunches/

Ministry of Health. (2012). Food and Nutrition Guidelines for Healthy Children and Young People (Aged 2–18 years): A background paper. Partial revision February 2015. Wellington: Ministry of Health.

Ministry of Health. (2016) Annual Update of Key Results 2015/16: New Zealand Health Survey. Wellington: Ministry of Health.

Ministry of Health. (2017). Children and Young People Living Well and Staying Well: New Zealand Childhood Obesity Programme Baseline Report 2016/17. Wellington: Ministry of Health. Retrieved from: www.health.govt.nz/system/files/documents/publications/children-young-people-living-well- staying-well-childhood-obesity-programme-baseline-report-2016–17-jun17.pdf

Ministry of Health. (2019). New Zealand Health Survey Annual Data Explorer November 2019. Retrieved from: www.health.govt.nz/nz-health-statistics/health-statistics-and-data-sets/obesity- statistics#:~:text=The%20New%20Zealand%20Health%20Survey%202018%2F19%20found%20th at%3A,8.2%25%20of%20European%2FOther%20children

Ministry of Health. (2020). Whakamaua: Māori Health Action Plan 2020–2025. Wellington: Ministry of Health. http://www.health. govt.nz/publication/whakamaua-maori-health-action-plan-2020–2025

Scarfe, J. (2016). Before School Check Data — Body Size: Technical Report. Bay of Plenty District Health Board. Retrieved from: https://www.toiteora.govt.nz/vdb/document/1632
Statistics New Zealand. (2019). Child Poverty Statistics: Year ended June 2019. Retrieved from: www.stats.govt.nz/information-releases/child-poverty-statistics-year-ended-june-2019

Stewart, T., Duncan, S., Walker, C., Berry, S., & Schofield, G. (2019). Effects of screen time on preschool health and development. Ministry of Social Development, New Zealand.

Watts, C. (2018). External evaluation of Fruit in Schools final report. Wellington: Quigley and Watts.