A non-Māori’s guide to Māori and Health

Marae - A non-Māori guide for Māori
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The following article will equip you with the knowledge to engage with Māori in a culturally competent way, by highlighting key points pertinent to Māori culture, beliefs, and frameworks.

Background

Across the world, health disparities exist between indigenous and non-indigenous people (Gracey & King, 2009a) and New Zealand Māori are no exception.

💡 This includes higher infant mortality, suicide rates, disease burden and in turn lower life expectancy for Māori compared to non-Māori.
Ministry of Health, 2015

Social determinants of health are multifactorial and understanding these in terms of indigenous peoples historical experiences (loss of land and culture, individual and institutional racism and intergenerational influence) are paramount in reducing health inequities (Gracey & King, 2009b).

Colonisation has profound and long-lasting effects on indigenous causing alienation of land and economic resources, violence, suppression of culture (language, customs, way of living) and forced assimilation (Gracey & King, 2009a). Māori suffered their highest population decline after European contact with an introduction of foreign diseases such as typhoid, measles and influenza to which they had no previous exposure (Rice, 2011).

💡 By 1860, only twenty years after the signing of the Treaty of Waitangi, 65% of the land was removed from Māori ownership largely through Government confiscation or the effect of the Native Lands Act (Pool & Kukutai, 2011).

It was found that any given region of land loss was followed by a marked rise in Māori child mortality rates such that by 1890 40% of Māori female infants died before they were one.

With many Māori displaced and deprived of their economic base (land ownership, food and bartering resources) poverty persisted (Pool & Kukutai, 2011).

Contents

Why it matters in the modern-day

Moving forward to the current health status of Māori we see the effects of socio-economic disadvantage, resource alienation, political oppression and genetic predisposition for certain diseases (Durie, 2004).

The life expectancy gap for Māori versus non-Māori in New Zealand is about 7 years for both genders.

💡 Māori females live on average until 77.1 years and Māori males 73.0 years compared to non-Māori females 83.9 years and non-Māori males 80.3 years.
Ministry of Health 2015

This same report based on the 2013 New Zealand census showed that Māori were more disadvantaged than non-Māori across all socioeconomic indicators. The effect was such that Māori were more likely to have lower high-school completion rates, lower employment, lower annual income and live in rented accommodation that was overcrowded without telecommunication or motor vehicle access.

On top of these socio-economic barriers, Māori are also subjected to racism.

💡 Māori adults are 1.9 times more likely to experience racial discrimination including ethnically motivated verbal or physical personal attacks.

Racism includes negative stereotyping that influences perceptions of academic potential, employability, housing opportunities, or creates differences in the delivery of services.

💡 Māori were 3 times more likely to have experienced unfair treatment regarding renting or purchasing a house than non-Māori.
Ministry of Health, 2015

Māori adolescents suffer stereotypes of lower intellect (Webber, McKinley, Hattie, 2016) which the stereotype threat theory has shown can decrease the performance of those belonging to the negatively race-based stereotyping (Inzlicht & Schmader, 2012). Houkamau (2016) details further individual studies that highlight Māori receive different or delayed screening and treatment options for numerous medical conditions.

So what?

Expanding your knowledge on the effects of colonization on indigenous people and how these negative determinants have been perpetuated will aid in understanding the socio-economic, education and health status of many Māori today. This is crucial to identify barriers that need to be removed and targeted positive policies that should be in place.

There is a common misconception that someone’s circumstances are solely the result of that individual’s actions where we can clearly see they are historically influenced.

To say try harder or forget the past and start again would mean a redistribution of resources is required.

Equality and equity

Many believe that Māori are given special treatment and receive opportunities that are denied to others. This is to misunderstand equality and equity.

Equality refers to the state of having equal status, rights, or opportunities. The historical and systemic differences that Māori continue to face such as socio-economic deprivation or institutional racism hinders such rights or opportunities to be equal (Human Rights Commision, 2012).

Someone in poverty or prejudiced by racism does not have equal education, employment or health opportunities. Thus equitable policies including a redistribution of resources are required for the barriers to be removed and equality to be reached (Human Rights Commision, 2012).

The common analogy for explaining equality and equity is a group of individuals watching a baseball game whereby a tall person can see over the fence and the short cannot.

When each is given a box to stand on the tall person can still see and did not require the box in the first place while the shorter person required two boxes to see over the fence. This analogy is flawed in that is supports a deficit theory suggesting different ethnicities have inherently lower capabilities.

Modifying that analogy, Māori would be standing on a lower field (historical influences on health, mental well-being and socio-economic disadvantages) with a higher fence to overcome (racial discrimination and majority-informed monocultural policies).

Models for Māori health promotion

Numerous models have been designed in an attempt to encapsulate the key philosophies of Māori people towards attaining holistic health. Through understanding these models we can actively participate in Māori health promotion which is intimately connected to Māori culture. Below are a few models commonly in use.

Te Whare Tapa Wha – The four cornerstones of health

Sir Mason Durie,1994

This is depicted as the four strong walls completing a wharenui (large meeting house). This model acknowledges that physical health (te taha tinana) is not isolated as it is influenced by te taha hinengaro (mental and emotional well-being), te taha wairua (spiritual well-being) and te taha whānau (social well-being).

The traditional concepts of engagement with the spiritual world and the importance of community for Māori people are incorporated as key in determining good health.

Te Pae Māhutonga – The Southern Cross Star Constellation

Mason Durie, 1999

Te Pae Māhutonga brings together additional elements. This is displayed as the Southern cross with two pointer stars. Some Māori iwi (tribes) have traditions about these stars representing an anchor of a great sky waka (canoe). The Southern Cross can be seen all year round making it extremely useful for navigation and associated with the discovery of Aotearoa (Wassilieff, 2006).

The four key points identified for health promotion make up the central cross; these are Mauriora, Waiora, Toiora and Te Oranga.

Te Pae Mahutonga

Mauriora: The word mauri is unique to Māori concepts as it describes the life-force of things whether living or inanimate. For example, greenstone with great presence can have mauri a life-force…

The Kaupapa Māori Theory

Smith, 1997

This theory was developed in the context of education intervention originally identifying six key principles that remain applicable to Māori health promotion and continue to be expanded on by Kaupapa Māori theorists.

  • Tino Rangatiratanga (self-determination): For Māori to control their own culture
  • Taonga Tuku Iho (Heritage): Highlights the integral nature of te reo Māori (the Māori language), tikanga (customs) and Mātauranga Māori (Māori knowledge) in shaping Māori worldview and acknowledging their legitimacy
  • Ako Māori (Māori pedagogy): Recognizes there are practices unique to or preferred by Māori as a way of learning in opposed to a one-fits-all
  • Kia piki ake i ngā raruraru o te kainga (Socio-economic mediation): Is the principle highlighting the need to address and alleviate causes for the socio-economic disparities faced by Māori
  • Whānau (family): And the process of building relationships (for example whether health advice given will be implemented or health services are further utilized can be influenced by the interaction of one health professional)
  • Kaupapa (Collective philosophy): Are the collective topics or aspirations of Māori communities.

Later Pihama (2001) identified Te Tiriti o Waitangi (The Treaty of Waitangi) as an additional principle which acknowledges Māori as the tāngata whenua (indigenous people) of New Zealand with intentions to protect Māori interests and the retention of autonomy.

The most recent principle āta (growing respectful relationships) extends further on the whānau principle to include the culturally respectful relationship we have with people, kaupapa and the environment (Pohatu 2005).

The Hui Process

The Hui Process is a conversation framework developed to improve cultural competency and enhance the Doctor-patient relationship with Māori (Lacey et al., 2011). Improving communication and rapport is correlated with greater patient adherence to medical advice (Zolnierek & Dimatteo, 2009), patient satisfaction (Jongen et al., 2017) and health care access and utilization (Truong et al., 2014).

💡 The word hui means to gather or meet and this process applies traditional principles that occur at Māori gatherings on the marae (tribal meeting grounds).

For example:

  • Mihi (greeting): A clear introduction of the clinician’s name and role, introducing the specific reason for the consult. The exchange of last names particularly in Māoridom can illicit links or reference points of where each person is from.
  • Whakawhānaungatanga (establishing relationships): This goes beyond rapport building to connecting on an individual level. Broadening your personal knowledge of te ao Māori deepens connections by recognising where the patient is from and the ability to engage their whānau. If the patient is observed using te reo Māori health professionals can utilize Māori words they are comfortable with (this acknowledges the colonial history of Māori being denied their language and avoids embarrassment for the patient).
  • Kaupapa (purpose): Once a connection is built the clinical purpose of the encounter can be addressed. Here models of Māori health promotion can be utilized to make for a more effective consult that incorporates principles of the Māori world and includes knowledge of the social and historical determinants that can influence the health of Māori. Knowing basic Māori etiquette is also important here to avoid offence by breaking tapu (sacredness) or removing someone’s mana (prestigious life-force).
  • Poroporoaki (farewell): Addresses the need to identify the end of the consult and what the next steps are for the patient and whānau. Here the clinician ensures they have understood what the patient has said, the patient understands the clinician and the next steps are explicit. This occurs in formal Māori events of exchange to ensure all business is complete or can be negotiated further.

Kuputaka – Glossary

Mauri – life force. A quality or presence that may be felt in objects, people or a collective. For example, in English a rock may be classified as inanimate whereas in the Māori language it can have a life presence highlighting the special connection and regard with which Māori hold nature.

Mana – a supernatural force of a person, place or object comparable to prestige. Mana can be inherited, lost and gained depending on actions taken

Noa – common, unrestricted. Something that is noa is free from being tapu and can remove tapu. Therefore you do not mix noa and tapu items. See tapu for an example.

Taonga – treasure, something of great value such as a social asset, resource or object.

Tapu – sacred; a person, place or thing that is so revered that it becomes untouchable or has restrictions. For example the head is tapu so you should not touch someone’s head without asking. Do not let anything associated with the head touch the ground, be sat on, or put on the table (food is noa).

Tikanga – customary system of values and practises that is built over generations and is an integral base of culture.

Wairua – spirit or soul which exists beyond physical death. A persons wairua can be affected in life; strengthened or damaged. Some may experience wairua in objects, for example, a tree may have such a presence that it has a spirit which can felt, personifying nature, connecting to it like a person.

Whānaungatanga – relationship or family connection. In Māoridom family and community are very important as pre-urbanisation Māori lived and benefited each other in sub-tribes of extended family.

References

Durie, M. (1994). Whaiora, Māori Health Development. Oxford University Press.

Durie, M. (1999). Te Pae Māhutonga, A model for Māori health promotionhttp://www.hauora.co.nz/resources/tepaemahutongatxtvers.pdf

Durie, M. (2004) An Indegenous Model of Health Promotion. 18th World Conference on Health Promotion and Health Education, Melbourne.

Fahy, K., Lee, A., Milne, B. (2017) New Zealand Socioeconomic Index 2013. Retrieved from http://archive.stats.govt.nz/methods/research-papers/nz-socio-economic-index-2013.aspx

Gracey, M., King, M. (2009a). Indigenous health part 1: determinant and disease patterns. Lancet, 374, 65-75.

Gracey, M., King, M. (2009b). Indigenous health part 2: the underlying causes of the health gap. Lancet, 374, 76-85.

Houkamau, C. (2016). What you cant see can hurt you: How do stereotyping, implicit bias and stereotype threat affect Māori health? MAI Journal, 5(2), 126-7.

Inzlicht, M., Schmader, T. (2012). Stereotype threat: Theory, process and application. New York: Oxford University Press, Inc.

Jongen, C., McCalman, J., Bainbridge, R. (2017). The Implementation and Evaluation of Health Promotion Services and Programs to Improve Cultural Competency: A Systematic Scoping Review. Frontier Public Health, 27(5), 24.

Human Rights Commision Report (2012). A Fair Go For All – Addressing Structural Discrimination in Public Services. Wellington, New Zealand.

Lancy, C., Huria, T., Beckert, L., Gilles, M., Pitama, S. (2011). The Hui Process: a framework to enhance the doctor patient relationship with Māori. The New Zealand Medical Journal, 127(1347), 72-78.

Ministry of Health (2015). Tatau kahukura: Māori health chart book (3rd ed.). Wellington, New Zealand.

Muriwai, E., Houkamau, C., Sibley, C. (2015). Culture as Cure? The protective function of Māori cultural efficacy on Psychological distress. New Zealand Journal of Psychology, 44(2), 14-23.

Pihama, L. (2001). Tihei Mauri Ora: Honouring our voices: Mana Wahine as a kaupapa Māori Theoretical Framework. (Unpublished PhD thesis). The University of Auckland. Retrieved from http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.470.7833&rep=rep1&type=pdf

Pohatu, T. (2005). Aata: Growing respectful relationships. Retrieved from http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.617.5762&rep=rep1&type=pdf

Pool, I., Kukutai, T. (2001) Taupori Māori – Māori population change. Te Ara – The encyclopaedia of New Zealand. Retrived from https://teara.govt.nz/en/taupori-maori-maori-population-change/print#ref2

Rice, G. (2011). Epidemics – The typhoid era, 1810 to 1890s. Te Ara – The Encyclopaedia of New Zealand. Retrieved from https://teara.govt.nz/en/epidemics/page-3

Smith, G. (1997). The development of Kaupapa Māori: Theory and praxis. (Unpublished PhD Thesis). The University of Auckland.

Truong M., Paradies, Y., Priest, N. (2014) Interventions to improve cultural competency in healthcare: a systematic review of reviews. BMC Health Service Research, 14, 99.

Wassilieff, M. (2006). Southern Cross. Te Ara – the encyclopaedia of New Zealand. Retrieved from https://teara.govt.nz/en/southern-cross

Webber, M., McKinley, E., Hattie, J. (2016). The importance of race and ethnicity: An exploration of New Zealand Pākeha, Māori, Samoan and Chinese adolescent identity. New Zealand Journal of Psychology, 42(1), 50.

Zolnierek, K., Dimatteo, M. (2009). Physician communication adherence to treatment: a meta-analysis. Medical Care, 47(8), 826-34.

Professional reviewer

This article was reviewed for quality and edited by…

Justin Sung
Justin Sung
MBChB, BMedSci (Hons)

Justin is a medical doctor, University of Auckland graduate, published research author, certified teacher, and founder of JTT. He has assisted thousands of students into healthcare careers since 2011, making him New Zealand’s individually most experienced medical entry expert. He regularly works with schools and organisations to help students and professionals learn more effectively.

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