Improving the health of our children: Project Energize bang for the health $

[Editor note, Blakely and Wilson: This is an invited blog by Professor Elaine Rush, in which she overviews the recent Budget from a child health perspective, and then lays out the case and evidence for Project Energize].

The highlight of the 2014 Budget for children was $90 million to make GP visits and prescriptions free for children aged under 13 from 1 July 2015. There was also $40 million for a new Healthy Families NZ campaign to encourage New Zealanders to eat healthier and exercise more. This is modelled on the Australian Health Together Victoria Programme which encompasses more than schools and is a systems approach. This is needed too – we need to work upstream, downstream and with communities. We also need to have evaluations to show that this type of investment is working – accountability for the money that the government and agencies charged to invest in New Zealand for the people.

There is already an evaluated child nutrition and physical activity programme in New Zealand that started in 2004 and has grown to reach more than 50,000 primary school children – Project Energize. Funded by the Waikato District Health Board (DHB) and delivered by a team of Energizers with Sport Waikato. The programme covers children living in:

• 10% of the land area of New Zealand; and now includes all the 244 primary schools in the Waikato, and 44,000 children.
• 10% of New Zealand’s primary school children and of these 14%, or one out of seven Maori children, living in New Zealand.
• No Waikato primary school child is left out.

In 2011 we reported here and here that on average, compared with children measured earlier this decade, that the 2011 Waikato children:

• Weighed less (0.5 BMI units) and the prevalence of obesity and overweight was less.
• Ran 550m, about 10% faster.

[Editorial note: an RCT was deemed impossible, thus a before-after design was used.]

The cost?

Project Energize costs $45/child/year, or 20c a school day. The programme is also cost- effective at saving health care money over the life of the child – we have estimated a cost-effectiveness ratio of $25,000 per quality-adjusted life-year (QALY).

[Editorial note: it is always hard to estimate the long-term health impacts (largely non-communicable disease rates in middle to older ages) for a childhood intervention. This Project Energize evaluation assumed the difference in BMI effect (initially 0.5 BMI units) faded by 1% per annum from five-years post-intervention. For a sensitivity analysis of 5% per annum the cost-effectiveness deteriorated to $120,000 per QALY. However, this is a notoriously difficult area to get ‘solid’ evidence in, and we simply have to accept that there is uncertainty about the long-term health impacts of childhood interventions].

How did Project Energize work?

A team of 27 Energizers plus a Manager worked together, with regular training and meetings together. One Energizer looks after a cluster of 8 to 12 schools and shares their time between supporting and showing how the children can eat healthy, be active and have fun – the Energizer is part of the school and wider community. Each Energizer divides their time among their schools and community, based on an agreed action plan to meet the needs of the school.

Project Energize is expanding

The Northland DHB has contracted Sport Northland for a two-year pilot of Energize in a cluster of decile 1 to 2 schools – 84% of the 2,000 children are Māori. Also Counties Manukau Sport has dedicated funding to two clusters of schools – in Franklin and Mangere – reaching around 5,000 children.

There is the Under 5 Energize programme that is taking off in Thames, Huntly, Hamilton and Tokoroa and reaching more than 4,000 children/120 preschools.

All these programmes have robust ongoing evaluation and accountability procedures in place including school stocktakes, needs analyses and action plans and testing of new resources as they are developed. There is a comprehensive induction, training, support and a reporting process for the Waikato Energize programme and other Energize providers to ensure accountability and quality control. Evaluation is supported by myself. Evaluation includes tools such as the 550m run used in the Waikato, measures of time spent in physical activity during class and parental surveys of food consumed by children.

There is even a pilot programme in Cork, Ireland.

The latest initiative is Energized Practices which applies the Energize model to medical centres. This is a 15 month NZ Ministry of Health Innovation Fund project to support Green Prescription (GRx) diabetes innovation and best practice.

Project Energize in the Waikato is funded by the Waikato DHB. It could be used in other regions as an all-inclusive model to be included in the Healthy Families New Zealand initiative. The whole-package of the evidence-based Energize way of working is necessary to ensure the desired and proven outcomes of improved health; for children through schools and with teachers, families and communities.

In summary, New Zealand has a decade-old child nutrition and physical activity programme in the form of Project Energize. There is evidence that it is effective and cost-effective, and it is in expansion mode within New Zealand and internationally.

Declaration of Interest: Elaine Rush is the lead investigator for evaluations of Project Energize and works closely with Sport Waikato.