The United Nations’ (UN) International Decade for the World’s Indigenous Peoples launched in 1994 (United Nations Department of Economic and Social Affairs/Indigenous Peoples, 2014). The 1999 Declaration on the Health and Survival of Indigenous Peoples by the World Health Organization’s Committee on Indigenous Health proposed a definition for indigenous health. Indigenous health was defined as a health concept that includes both the collective and the inter-generational continuum perspective of holistic health. It incorporated four identified, distinct shared dimensions of life co-existing simultaneously, namely, the spiritual, the intellectual, the physical, and the emotional.
Health care systems that may wish to successfully engage indigenous populations need to recognize the relationship that exists between the patient and his or her physical and social environment during the process of evaluation, planning, and treatment (Freeman, Reference Freeman2019; Terare & Rawsthorne, Reference Terare and Rawsthorne2020). As indigenous peoples have sought recognition of their identities and ways of life in mainstream culture, the integration of indigenous health worldviews is continuing to be recognized as foundational to best practices with regards to practitioner-patient interactions, and the designing and implementation of individualized patient care (UN, 2016, 2020; Williams, Potestio, & Austen-Wiebe, Reference Williams, Potestio and Austen-Wiebe2019; World Health Organization [WHO], 2010).
Indigenous peoples are described as the original “inheritors and practitioners of unique cultures and ways of relating to people and the environment [who have] retained social, cultural, economic, and political characteristics that are distinct from those of the dominant societies in which they reside” (UN, 2020, para 1). The Māori are the indigenous people of Aotearoa which is the Māori name for New Zealand, meaning land of the long white cloud (Fallon, Reference Fallon2021). Nearly one in seven individuals residing in New Zealand identifies as Māori, either as a person of Māori race or as the descendant of a Māori person (Britannica, 2021; Stats NZ Tatauranga Aotearoa, 2020; New Zealand Government, 2020). The Māori continue the process of renegotiating and reclaiming their heritage and language (te reo Māori), while residing within a society whose dominant race is composed of people of European descent, particularly those of British and Irish ancestry (Smith, Reference Smith1989; Swarbrick, Reference Swarbrick2015; Wilson, Reference Wilson2015, Reference Wilson2020).
Māori have a higher proportion of the population residing in either small urban or rural areas compared with the total population, which limits their access to public rehabilitation and health services, even though they proportionally have a higher prevalence of disability (Stats NZ Tatauranga Aotearoa, 2020). We sought to explore Māori engagement with rehabilitation and mental health services considering physical, social, and economic barriers they perceived to have experienced as the potential contributors to reduced service engagement and utility outcomes.
1. Disability Among the Māori
According to a 2013 New Zealand disability survey carried out by the Ministry of Health, approximately 176,000 of the Māori population identified as having a disability. Māori experience higher disability rates regardless of age to the national population (New Zealand Ministry of Health, 2013). Māori adults have been found to be about one and a half times more likely than non- Māori adults to report high or very high probability of an anxiety or depressive disorder, using the Kessler Psychological Distress Scale (K10) (New Zealand Ministry of Health, 2018). The K10 is an international measure used to screen populations for nonspecific psychological distress and serious mental illness (Andrews & Slade Reference Andrews and Slade2001; Kessler et al., Reference Kessler, Andrews, Colpe, Hiripi, Mroczek, Normand, Walters and Zaslavsky2002). The difference was even more pronounced in Māori males who were found to be twice as likely as non- Māori males to report a high or very high probability of having anxiety or depressive disorder. Māori were identified as experiencing significantly higher rates of mental illness, suicide and a greater prevalence of addictions (New Zealand Ministry of Health, 2018).
1.1. Rehabilitation and mental health services in New Zealand
Disability and mental health services in New Zealand are provided through public funding by the national government as universal healthcare through a complex network of providers and organizations (New Zealand Ministry of Health, 2021). Service delivery is regionally administered, with district health boards charged with the responsibility of planning, purchasing, and providing health services at the local level based on a set annual budget and need-based benefit packaging (New Zealand Ministry of Health, 2021; Tikkanen, Osborn, Mossialos, Djordjevic, & Wharton, Reference Tikkanen, Osborn, Mossialos, Djordjevic and Wharton2020). Disability services needs are initially assessed for by a Needs Assessment and Service Coordination service (NASC). Needs Assessment and Service Coordination service providers are government-contracted organizations to identify and outline support needs for eligible disability cases. Services are funded by the Ministry of Health and delivered by providers with some offering services specifically for Māori who have a disability, although the Māori remain over-represented among the population with disabilities and underserved (New Zealand Disability Support Network, 2021; New Zealand Ministry to Health, 2021).
Recently, the New Zealand government announced that it would be moving disability funding from the Ministry of Health and the Ministry of Social Development to the new Ministry for Disabled People (NZDSN, 2021; Palmer, Reference Palmer2021). The Ministry for Disability will combine and provide all available support services to people with disabilities regardless of how a disability was acquired, thereby widening the disability system while removing the current perspective of disability as a personal health issue to issues of environmental barriers that create disability. Disability will be viewed as an accessibility issue with physical, social, and attitudinal environments limiting the full participation of people with disabilities in areas such as employment, housing, transportation, and education as those environments are not yet universally accessible. The ministry was created following the 2020 Health and Disability System Review (HDSR) that largely failed to consult people with disabilities, their families, and advocates, including disability care givers, prior to making recommendations, while largely assuming that the government’s current system for allocating disability funding would remain the same.
In New Zealand, rehabilitation counselors receive minimal training through, for example, a one-year under-graduate diploma that provides broad general knowledge on the purpose, practice, and philosophy of rehabilitation, or as a supplemental topic to graduate-level studies nestled under another health-related, disease-focused field (Auckland University of Technology, 2021; University of New Zealand, 2021; University of Otago, 2021). These programs focus on disability as a disease-focused physical issue and view the psychological and social aspects by this same medical model of health care delivery. Through the one year of academic training, which can sometimes be provided fully online, students are to develop the knowledge and skills necessary to support people with disabilities toward full vocational and social integration (New Zealand Immigration, 2021; University of New Zealand, 2021). This is in contrast to the United States where Master’s level of study on average to a doctorate qualification in the same field are provided by some universities. In this system, rehabilitation counselors are only eligible for a professional certification following the successful completion of a qualifying Master’s program in rehabilitation counseling or clinical rehabilitation counseling (Commission on Rehabilitation Counselor Certification [CRCC], 2021). United States rehabilitation counselors are described as facilitators of independence, integration, and inclusion for people with disabilities into employment and the community through the counseling process (CRCC, 2021). Emphasis is placed on adopting a holistic view of the individual that uses systematic processes in assisting persons with physical, mental, developmental, cognitive, and emotional disabilities to achieve their personal, career, and independent living goals in the most integrated setting possible.
There is a general lack of research regarding culture and needs-informed strategies rehabilitation service providers could use to close the service utilization gap for Māori that currently exists. This gap has reduced the efficacy of service engagement and delivery in promoting high-quality rehabilitation and mental health outcomes of Māori people with disabilities (New Zealand Ministry of Health, 2009). The secondary impacts are untreated mental illness in Māori society leading to disability and an increase in substance use and abuse (Mental Health and Addiction Inquiry, 2021).
1.2. Māori health beliefs
Māori health perspectives are framed by a holistic approach to healthcare that integrates the spiritual wellbeing (te taha wairua), psychological wellbeing (te taha hinengaro), and physical wellbeing (te taha tinana) elements of the individual, as well as connectedness to family wellbeing (te taha whānau), including extended family and ancestors (whakapapa) (Capital & Coast District Health Board [CCDHB], 2017; Government Health & Safety Lead [GHSL], 2020; Health Navigator, 2021; Medical Assurance Society, 2019).
1.3. Te taha Wairua
Wairua refers to mental and spiritual health and resilience of Māori, the nonphysical aspects of a person that are both intensely personal and difficult to describe, including our emotions, character and soul. Wairua describes the capacity of the individual to have faith, recognizing intra- and interpersonal links with others and the world around.
1.4. Te taha Hinengaro
Hinengaro refers to the mental an emotional wellbeing of the individual. This can refer to the person’s heart, mind, conscience, as well as thoughts and feelings, including with respect to one’s present mood or ability to cope with distressing life challenges. If te taha hinengaro is considered strong, then the individual better able to cope with the stress of life’s presenting challenges, including the onset of a disability or chronic condition.
1.5. Te taha Tinana
Tinana includes how an individual takes care of the body through physical activity, getting enough sleep, healthy eating, and so on. Tinana emphasizes the importance of an individual’s self-care regardless of current physical abilities. From this view disability becomes another way of being framed within the individual’s unique parameters regarding tinana, instead of a problem to be medically fixed or corrected toward a less disabled or non-disabled condition.
1.6. Te taha Whānau
Support systems surrounding the individual, including extended relationships and not solely immediate relatives, compose whānau. The client has a valued role within the whānau that contributes to the strengthening and wellbeing of the whānau. Through spending time with the whānau and doing things or activities with and for them, the individual gains feelings of purpose, connection, personal fulfillment, and wellbeing.
These four dimensions of health construct the four sides of a meeting house (wharenui), the place of community (GHSL, 2020; Health Navigator, 2021). When the meeting house is strong this means physical health, mental health, social connectedness and family health are all fully considered and supported in case management and intervention planning (GHSL, 2020). The wharenui’s connection to the land (whenua) is the foundation of understanding the Māori individual’s perspective of health in view of their support systems; the roots of the individual, the place of belonging. Strategies that integrate Māori health beliefs through consultation and inclusion in client support, may contribute to culturally responsive rehabilitation and mental health interventions that have greater treatment adherence and better results in service participation and health outcomes (CCDHB, 2017).
1.7. Purpose of the study
The purpose of this study was to explore how Māori adults understand their rehabilitation and mental health services needs and possible solutions for reducing the existing gaps in their service utilization and service provision at the local, regional, and national level.
2. Method
2.1. Research design
We employed a multiple case study design (Yin, Reference Yin2009) to explore Māori adults’ understanding of their rehabilitation and mental health needs, inclusive of barriers to services and solutions they preferred. A multiple case study design is the use of collective of cases, instead of a single case, to better evaluate and understand an issue and to theorize what those cases may indicate about broader contexts of that issue. It was appropriate to this study design with the goal to understand the phenomenon of low Māori engagement with rehabilitation and mental health services across different individuals and situations from a population with the highest recorded rates of disability and mental health issues in the country of New Zealand. The multiple case study design enabled identification of both similarities and differences between the cases.
2.2. Participants and procedures
Our participants were three Māori community members from New Zealand’s north island (females = 2; urban residents; 1 male, rural resident; age range 25–50), We recruited them using snowballing (Human Research Protection Program and Institutional Review Board, 2010). They all self-identified as having either received treatment from rehabilitation and/or mental health services or had provided primary care for a family member with a disability or mental health condition. Both female participants were primary care givers for a family member with a disability; one was the mother of a 14-year-old daughter with mild to moderate autism, while the other female participant was the middle-age younger sibling of a brother with acquired severe traumatic brain injury.
2.3. Data collection
Participants responded to semi-structured interviews on quality of care, care personalization, illness prevention, culture integration, economic and/or facilitator barriers, and perceptions of local, state, and national care services. Participant responses to the open-ended questions then provided guidance to additional clarification questions.
Participants were asked to respond to both closed-ended demographic questions, and open-ended questions on their personal interactions with rehabilitation and mental health services in New Zealand. These open-ended questions focused on the broader scope of rehabilitation and mental health care and service utilization, and to what extent these individuals perceived the services as sufficiently supportive and culturally aware. As follow-up facilitative questions, participants were also asked if they would return to use those services again and whether they would recommend the use of those rehabilitation and mental health services to other Māori in the future based on their personal experiences.
2.4. Procedure
The New Zealand Health Research Council Ethics Committee (HRC EC) approved the study. Participants provided oral consent to provide an added layer of privacy before commencing the interview. They completed the interviews at a place and time convenient for each of them and their unique circumstances. Participants were informed of the voluntary nature of the study and their right to withdraw from the study at any time without penalty.
2.4.1. Ethical considerations
We digitally recorded the interviews for subsequent transcription and the data securely stored in the University of Wisconsin-Madison Institutional Review Board (IRB) and Health Insurance Portability and Accountability Act approved (HIPAA) (Centers for Disease Control and Prevention [CDC], 2018), password-protected cloud storage. Confidentiality and anonymity were maintained by using a digital recorder solely designated for the purposes of this research, not mentioning the participants’ names during the course of the audio-recording, providing a generic label on each audio-recording prior to transcription, using a secure dropbox to submit the audio files for transcription, and storing both the audio recordings and final transcriptions in password-secure cloud storage. Transcription services were provided by a HIPAA-approved provider familiar with New Zealand English and the Māori language. The principal investigator provided individual, pre-approved access to the de-identified data for analysis with name and timestamp recordings for each time the data was accessed.
2.5. Data analysis
The data was analyzed using interpretive phenomenological analysis (IPA) (Colaizzi, Reference Colaizzi, Valle and King1978; Smith & Osborn, Reference Smith and Osborn2015). This analysis approach aims to provide a framework for the detailed examination of participants’ personal lived experiences, and can be especially useful for analyzing topics or phenomena that are potentially complex, ambiguous, and emotion laden.
First, the principal investigator completed a line-by-line analysis for data integrity and then identified significant analytical themes (Abramson & Dohan, Reference Abramson and Dohan2015; Miles, Huberman, & Saldaña, Reference Miles, Huberman and Saldaña2014; Neale, Reference Neale2016). Second, three coders who had neither access to nor knowledge of who the research participants were also completed line-by-line analysis of the de-identified transcriptions and then identified significant analytical themes. Third, the results from these three coders were then reviewed, cross-checked and verified for coherence of the themes by the principal investigator. Finally, the principal investigator confirmed data interpretations with each of the participants to ensure that the interpretations where dependable and trustworthy. Pseudonyms have been used to record the findings of the analysis, while protecting participants’ anonymity.
2.6. Author positionality
The lead author was also the principal investigator for this study. The author identified as a black woman from Africa residing in the United States in an urban setting composed of a majority white race of European descent. She disclosed her professional and academic background as being in both clinical rehabilitation counseling and mental health counseling. These disclosures elevated the level of trust of participants when sharing their experiences as members of a minority population and increased their confidence in the lead author’s ability to understand the terminology they would use when describing their personal experiences with rehabilitation and mental health services. The three coders of the transcripts were also the coauthors for this study.
3. Findings and Discussion
Six themes emerged from the data analysis: (1) preference of Māori service providers who understand whānau culture; (2) an understanding of whakapapa or the family structure as an integral source of social support as counselors are planning for treatment; (3) establishing and maintaining trusting relationships within the Māori community before, during, and after intervention work; (4) financial difficulties in accessing rehabilitative resources; (5) limited access to health care facilities and services or lack of information about the services available; and (6) a general mistrust of government operated systems. We report with the verbatim evidence on each theme. For the statement attribution, we utilized pseudonyms to protect participants identities.
3.1. Theme 1. Preference for Māori service providers who understand Whānau culture
The rates of poor health outcomes remain high among the Māori in a country that predominantly uses a Western framework of health care as the foundation for practice (New Zealand Ministry of Health, 2013, 2018). The Ministry of Health acknowledges that when health care providers are Māori they tend to deliver health and disability services to predominantly Māori clients, although not exclusively (New Zealand Ministry of Health, 2021). Māori providers are known for using service delivery method that follow kaupapa; the health practice principles, approaches, and customs, that are distinctively Māori. This is in contrast to the Western methods of health care conceptualization, treatment planning and service delivery.
Study participants reported preference for Māori service providers to service accessibility. For instance, they stated that:
3.1.1. Māori service providers
“Got to have somebody who will understand my baby just not sit there and take it all in because they have to. But I want somebody to actually understand her and get along with her…to be able to sort of guide her they’ve got to know her and understand her properly. That’s what I feel. Yeah. I try the best I can but she’s not always going to listen to me, and I’m not always going to give her the right advice because I’m just her mum.” (Aroha, female, mother and care giver of daughter with mild to moderate Autism)
“They got to learn from us as well because some clinicians will say to us they didn’t really like to have family around at the rehabs because we got in the way and were argumentative. And then families will stand up and say, “Yes. We are because we get treated as if we’re nothing. We don’t understand your language. We’re scared for our loved ones.” So yeah. But rehabilitation? No. Definitely not. To me, there shouldn’t be any such thing as rehabilitation. A care place, care plan, somewhere around like that. Whānau can be very well looking at opening up a Māori module or Māori group around support for our whānau.” (Anahera, female, sister and care giver to a brother with severe Traumatic Brain Injury [TBI])
It was crucial to interpret the terms rehabilitation and mental health services within the context of the New Zealand universal health care and as they were interpreted by the participants. Using the medical models of health care services, these terms were defined by health care providers and study participants as services designed to fix what was medically wrong with the physical body. Vocational and social outcomes were assessed through physical functioning as the baseline for community integration. As with the 2020 Health and Disability System Review, Māori with disabilities and mental health concerns were not included in the development of the recommendations of the Review. The review also assumed that health care services would remain as they were, using the Western model of assessment and care.
3.2. Theme 2. An understanding of Whakapapa or the family structure as an integral source of social support as counsellors are planning for treatment
Closely related to a preference for Māori health care providers, was the role of whakapapa in understanding Māori health. Participants communicated the necessary but uncomfortable interaction with Western methods of rehabilitation and mental health services, which provided interventions designed for nuclear families with no inclusion of the extended family or the role of genealogies (whakapapa), a fundamental principle in Māori culture to understanding the Māori individual receiving or providing care within the wider context of the family and ancestry. Concerns emerged about further corroding Māori identity when receiving services from medical environments and social contexts designed for people of European ancestry or highly acculturated individuals to Western culture.
3.2.1. Whakapapa
Aroha: As for our culture, with her I’m going to be straight up and honest, she thinks she’s American because of her echolalia. She has that accent and so therefore she tends to think, “Oh, I’m just American.” Out of all my children, she’s probably the one that I felt hasn’t got too much time for Māori. Yeah. Because when we go home to our marae and whatnot, she’s just like, “Oh, there’s no Wi-Fi here.” …And so, when we speak of families now, it’s just in the house. Actually, just the marae structure sort of seems to be a better approach. Yeah. Our whole community way of life and living… everybody would just help.
Rawiri: Whether it be stroke, whether it be a heart attack, anything that involves trauma, I really believe that it’s beneficial to have a whānau hui, a family hui, or have support people that are there to support that individual at her appointments and to have that open conversation because there are times that individual will-- and I can reflect on myself where I have said yes to medical practitioners to whatever but not really understanding what the procedure is or what’s involved and what’s entailed in those decision-making. To make the right choice that is best for you and your family. But then looking back, there are some that may not have family to support them. (Rawiri, male, social worker and personal recipient of rehabilitation and mental health services)
Whakapapa is part of whānau, one of the four essential elements of Māori approaches health and health services providing culturally responsive rehabilitation and mental health services that encompasses the Māori holistic approaches to health and personal fulfillment by being a part of a larger community (GHSL, 2020; Health Navigator, 2021). It provides one of the four sides of a healthy, nurturing meeting house (wharenui); a place of community in matters of health. Māori health practitioners serving largely Māori clientele are known for practicing health care using these Māori principles, approaches, and customs as key to their service delivery framework (Medical Council of New Zealand, 2021).
3.3. Theme 3. Establishing and maintaining trusting relationships within the Māori community before, during, and after intervention work
Health care education, training, and skills development in New Zealand continues to make it a goal to develop culturally competent services to support Māori clients in order to develop relationships of shared decision-making power toward improving disability and mental health service outcomes (CCDHB, 2017). The development of the new Ministry for Disability as a response to accessibility needs and removing a two-tiered approach to disability support services, and the pushback against the recommendations of the Health and Disability System Review (HDSR) without collaboration of the populations planned on being served, are harbingers of the new trajectory for health service delivery (Health and Disability System Review 2020; Palmer, Reference Palmer2021). The integration of culturally sensitive treatment techniques by dominant society in rehabilitation and mental health service provision is becoming increasingly expected when supporting Māori clients.
3.3.1. Trusting relationships
The ability of the rehabilitation and mental health service provider to adequately relate to and understand the interests and hobbies of a 14-year-old girl who is attending school with non-disabled peers, while living in a major urban setting:
Aroha: So, she specifically has hobbies, things that she likes, which are completely new to me, well new to us. And I am trying to understand, but she speaks a lot of fantasy and wanting to sort of switch-- and I tell her we can’t always live in fantasy because at the end of the day we’re in reality. And I think that’s where the worries come but most of the worries are her own. And she also writes on a website. Sort of what I would say are like Mills & Boon. Have you ever read Mills & Boons?
Aroha: So, boundaries. So, looking for services that would help her in establishing those boundaries because on one level you’re mum and you’re like I’m kind of way in over my head, which is [on something like this?] I would ask you the intersection between her negotiating autism and at the same time developing into a young woman. So, there’s that intersection. So, you’re kind of dealing with both and then maybe having a service that can say, “Okay. I’m going to spend time listening to her and we’re going to work on establishing appropriate boundaries.” So that kind of development of that skill. At the same time, she’ll get a lot of her thoughts out, discussed, and kind of compartmentalized, I guess, in a way that’s healthy. And she could have more independence because she knows how to deal-- because sexuality is kind of sensitive isn’t it?
Aroha recognized the complexities of having Māori perspectives on healthcare, while living in an urban, Western setting made up of single households instead of with her whānau. In attempting to address this limitation created by living in an urban setting with her siblings spread across the local neighborhood instead of in proximity to one wharenui (meeting house) on one whenua (land), she proposed having health service providers who had the attitude and disposition to become a part of her nuclear family. She wanted long-term commitment from her daughter’s health service providers so that they not only introduced the knowledge they head about rehabilitation and mental health counseling in working to support her daughter, but would also feel bonded to her family in a way that better informed the care they suggested and regard for the consequences of intervention they would suggest. Ideally, Aroha preferred Māori care but felt limited in her options and access to them (Medical Council of New Zealand, 2021). Study participant Rawiri, advocated for a greater effort by the New Zealand government to train more Māori disability support and menta health providers.
3.4. Theme 4. Financial difficulties in accessing rehabilitative resources
Barriers to accessible rehabilitation and mental health services also included the issues of cost. Issues such as cost of transportation to reach services in rural settings, and the high out-of-pocket cost of disability accommodations equipment or technology and mental health services was discussed.
3.4.1. Finances
Aroha: If she wants just a therapist who will sit and listen to her that will probably be on us. I would say 70%. I might be able to get sort of some through carer support but apart from that, yeah, we’d have to fully fund for her. So, we did get one sort of reference today, which was [name of organization omitted], and I actually googled that. And, yeah, there’s quite a bit of big cost there as well. And they’re basically saying that this is probably going to have to come out-of-pocket for you if you’re going to get that kind of service. And some services that are provided are very expensive then at that. And then you want her to be part of social engagement, if I’m understanding correctly. Social engagement but she’s also concerned about finances then.
Rawiri: So, looking back, [hearing aids] free for me right up to the age of 21. So, the latest hearing aids assessment that I have recently done-- it was going to cost about 9 grand for me to get some new hearing aids. So, I wish that I could go back and being a child and get that service again for free. But it is very, very costly in terms of hearing aids. Yeah. Hence the reason why I haven’t done anything about it because I just don’t have that type of money on the salary that I’m on.
Rawiri: So, in terms of funding, there needs to be more accessibility. There needs to be more funding in terms of disability and rehabilitation there. [New Zealand health care] need to have that so that people can do the work. If I look at rights for myself, being Māori, I am morbid obese. There needs to be more funding for our Māori and Pacific Islanders around weight surgery because we have high percentage and high risk and weight and obesity and heart disease and everything. More funding needs to be put into stuff like that, everything in terms of disability and whatnot.
The New Zealand Ministry of Justice found that Māori continue to experience the highest levels of poverty-related crime based on reporting of perceptions by Māori of having access to fewer economic opportunities compared to the general population (Johnsen, Reference Johnsen2021; New Zealand Ministry of Justice, 2020). Limited access to health care resources by Māori with disabilities was also a contributing factor to financial hardship (Palmer, Reference Palmer2021). In his interview, Rawiri alluded to the potential economic benefits of having accessible care as being of potential benefit to not only Māori economic restoration and wellbeing, but to the economic growth and development of New Zealand at the local, regional, and national levels (Kāpiti Coast District Council, 2013).
3.5. Theme 5: limited access to health care facilities and services or lack of information about the services available
Reduced access to information and resources about the health care services available to Māori was a limitation to Māori service-seeking. Financial limitation with regards to transportation for those Māori living in the rural or small-town settings contributed to the accessibility of services, even when the services were known (Stats NZ Tatauranga Aotearoa, 2020). Medical professionals were also relied upon to properly evaluate the needs of their Māori patients and provide referrals that aligned with their Māori patient’s goals. The necessary referrals did not occur and the reasoning for this remained unclear to the participants, especially as the need was explicitly stated.
3.5.1. Limited access to services and information
Aroha: So, we went today, and I didn’t feel like they had the services that she needs to help her. So, she specifically wants to talk about how she’s feeling and what is frustrating her. So, it’s really frustrating for me them not being able to help her. Yeah. That service anyway. I haven’t tried her with counseling because we haven’t been offered it. … And I thought maybe the doctor might have referred her but no. He referred her to mental health.… because she did say to the doctor, “I just need to talk to somebody about how I’m feeling and my feelings,” and that’s where his referral went to… they have behavioral therapists and everything like that.
Rawiri: There was one surgery that Mum wasn’t happy about because she didn’t realize that she was signing consent for grommets, I think. But while I was under anesthetic, the surgeon thought that it would be best to remove, I think, all of my adenoids, and it wasn’t until I come out of recovery, that I had blood and whatnot, that Mum asked what happened. I think Mum became quite upset about that, but it wasn’t until I believe that he explained the reason why, that I think Mum was like, “Oh, okay. Yeah. Yeah.” It’s very important that they explain the services well, particularly to Māori and Pacific Islanders…it’s really important that they use plain simple English rather than medical jargon. A lot of our whānaus have been not really understanding what the doctors or medical practitioners or disability practitioners are saying. They will just nod their head and go, “Oh, okay. Yeah.”
Rawiri: If I reflect on where I’m currently working at the moment, I work rurally, and the main hospital, [name omitted] Hospital, is three-and-a-half-hour drive. A lot of our [Māori] families that I work with – out in the wop-wop is what we call in New Zealand – out in the far countries and whatnot, particularly our Māori families, don’t have transport to get to medical appointments or to get to the hospital. And so, a lot of them are very isolated in terms of transportation. We need to be bringing the services to those that live rurally. The closest hospital from where I live, which is [name omitted] Hospital, is an hour-and-a-half drive.
Majority of Māori reside in small urban or rural settings, limiting their access to public rehabilitation and health services, even though they proportionally have a higher prevalence of disability compared to any other ethnicity residing in New Zealand (Stats NZ Tatauranga Aotearoa, 2020). Limited access to health care services means that disability and mental issues go untreated, creating a situation whereby conditions either get progressively worse and/or secondary health conditions emerge as a result (Mental Health and Addiction Inquiry, 2021).
3.6. Theme 6. General mistrust of government operated systems
Concerns communicated around closing the rehabilitation and mental health utilization gap were centered around a need for culturally-informed care with a view of health through family-inclusive holistic care that is an essential part of Māori beliefs about health. Issues arose around who would be responsible for providing and overseeing the health care. The view of current government health care was a Western-structured and inflexible approach to disability and mental health that did not align with Māori kaupapa (principles). Experience with the New Zealand government form of health care produced distrust and a weariness of any government-led interventions to address any rehabilitation and mental health service usage gaps.
3.6.1. Government mistrust
Aroha: I would prefer cultural rather than [government]. Because government, I feel that they’re on a system of what I call systematic enslavement. Government designs are not intended for you to come out of it better or improve. Essentially what we miss being urbanized, mana whenua, is our community, our marae-based structure, which is always somebody there to lift you, to help, always, emotionally, there was no financially, but emotionally, physically, and spiritually. That is a service. And I feel that’s what’s sort of missing. They’re [government] not encouraging. There’s no services here that encourage my family to be close. You know what I mean? Yeah. They’re not encouraging the wider [whānau approach]; most services should be encouraging the wider approach.
Anahera: What do I think of them? Like any company, it’s all about money and maintaining minimum services for big bucks. That’s how I see it. So, what I’m seeing now is that you’re getting staff in there with really limited experience. Yeah. I know, a lot of them, they don’t even have their qualifications. Services. I wouldn’t say that they’re the best services. Yeah. I think it’s just minimal services really and not very good ones.
The development of the New Zealand Ministry for Disability Service, with its own accessibility board, was in response to people with disabilities feeling like an afterthought in government health care priorities (Palmer, Reference Palmer2021). Perceived priority care, funding and support given to people with accident-related injuries and not nearly as much for those with congenital disabilities gave the appearance of government favoritism with regards to who gets the best care compared to the other in this two-tiered system under the Ministries of Health and Social Development. There is increasing advocacy for culturally competent health care practitioners by Māori with disabilities in order to receive better care and achieve greater social inclusion as a result (CCDHB, 2012; Palmer, Reference Palmer2021).
4. Implications for Theory and Practice
Applying the World Health Organization (WHO, 2006) Knowledge-To-Action (KTA) framework, Māori cultural mental health and wellbeing could be addressed as follows:
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1. A recognition of the importance of Māori community support in understanding the impacts of mental illness and disability.
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2. Developing an awareness of culture and needs-informed rehabilitation services among Māori.
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3. An engagement of Māori people by rehabilitation service providers and strengthening the rapport that exists between them, toward increased Māori knowledge, recruitment, and support on the part of the service providers.
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4. Engagement of Māori people in continued development of rehabilitation-oriented outreach programs, that will continuously evolve to meet their needs and produce culturally competent rehabilitation service providers and training programs that support Māori values and culture, and respect Māori history.
The KTA translation solutions could include, for example, encouragement and promotion of culturally-informed support or education groups for training rehabilitation and mental health counselors regarding working with Māori individuals and families. Practice implications for rehabilitation counselors and mental health providers could be creating accessible services that increase opportunities for potential Māori clients presenting with such conditions as use and misuse of alcohol and other drugs (AOD) (Best Practice Advocacy Center New Zealand, 2010), especially as it has been found that Māori are four times more likely than non-Māori people to die of an alcohol related condition (Connor, Broad, Rehm, Vander Hoorn, & Jackson, Reference Connor, Broad, Rehm, Vander Hoorn and Jackson2005). Accessible services can be an efficient step to closing the rehabilitation and mental health service utilization gaps.
5. Limitations and Future Directions
The sample size of three participants was a limitation in this study. Therefore, the evidence we present may lack in some aspects that could emerge with a better scoped study. Self-advocacy was a common theme in each of the interviews but future research could consider the cultural capital that is required for successful engagement with rehabilitation and mental health support services. Follow-up interviews of the three participants could be carried out as a part of a longitudinal analysis of KTA-generated solutions as they are implemented, evaluated, and re-tailored using the new effectiveness information gathered (Graham et al., Reference Graham, Logan, Harrison, Straus, Tetroe, Caswell and Robinson2006).
6. Conclusion
Overall, this study found Māori perceive rehabilitation and mental health service gaps as issues of barriers to accessing services and limited knowledge or understanding of the services that are available to them. The use of the Western disease-based model of health as the standard in designing health care services and delivery might explain why Māori not only have the poorest health outcomes of any group in New Zealand, but also the lowest participation in health care support systems. Rehabilitation and mental health providers are encouraged to adopt an indigenous, holistic perspective to health as a way to increase Māori engagement with services. These needs and recommendations could be addressed through rehabilitation and mental health services counselor education, training, and skills development in Māori service engagement, utilization processes, and means.
Acknowledgements
Global Health Institute, University of Wisconsin-Madison.Institute for Regional and International Studies – University of Wisconsin – Madison.
Financial Support
Global Health Institute, University of Wisconsin-Madison.
Scott Kloeck-Jenson Fellowship, Institute for Regional and International Studies – University of Wisconsin – Madison.
Conflicts of Interest
None.
Ethical Standards
The author asserts that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.
