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Quality improvement interpreted as a complex adaptive system : implications and opportunities : a thesis submitted in partial fulfilment of the requirements for the degree of Doctor of Philosophy at Massey University, Palmerston North, New Zealand
(Massey University, 2024-11-01) Wilson, William
The effectiveness of quality improvement (QI) methods in healthcare has been challenged, especially under circumstances of high complexity. This thesis examines the implications for quality improvement if complex socio-technical systems such as healthcare are interpreted as complex adaptive systems (CAS). The research followed a mixed-method design. Informed by the complex systems and quality management literature, a conceptual model for quality improvement within CAS was developed — the complex quality improvement network (CQIN). An agent-based simulation model was then used to establish the plausibility and face validity of the model constructs and their interaction. Thematic analysis and crisp-set qualitative comparative analysis (QCA) were then used to examine the evidence for CQIN constructs within published quality improvement case studies. One applied case study was also conducted for deeper insight into the practical difficulties of interpreting a real-world quality improvement project as a CAS. Finally, the findings of the simulation modelling and the secondary data analysis were integrated into a Bayesian network model. Empirical evidence, in the form of consistency across cases and coverage within cases, was found for eleven of the twelve CQIN constructs. Multiple sets of sufficient conditions for reported improvement success were identified across cases. These sets were minimised to four strategies for successful quality improvement; i) strengthening agent network communication paths; ii) building shared understanding of problem and context amongst networked agents; iii) increasing problem-solving effectiveness; and iv) improved system signal integration. If the evolutionary foundations for CAS are in some way inhibited, the likelihood of quality improvement success is reduced. Healthcare quality improvement can be plausibly simulated using fundamental CAS principles. The first contribution to quality improvement discourse is the CQIN model, a CAS model of change applied specifically to quality improvement. A second contribution of this research is a complex quality improvement risk assessment model, the CQIN Bayesian Network. Practitioners can use this model to examine and test identified CAS-informed improvement strategies. The individual CQIN constructs make a third contribution by providing new categories of causal factors for the comparison of disparate quality improvement case studies.
Construction of health among the Rohingya refugees in Bangladesh : a culture-centred approach : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy, Massey University, Manawatu, Palmerston North, New Zealand
(Massey University, 2023-12-21) Rahman, Md Mahbubur
Rohingyas, the majority of whom are Muslims (followers of the religion of Islam) are the ethnic minority group of the Rakhine state of Myanmar, where they have lived for centuries. However, Rohingyas lost their citizenship rights through a state sponsored apartheid-like system in 1982 and since then they have been stateless. As a result of organised state-led persecutions and even genocide for decades, Rohingyas are now the largest stateless community of the world. It is estimated that around 3.5 million Rohingyas are now scattered throughout the world. Among them, only an estimated 600,000 Rohingyas are still living in Myanmar. However, the exact figure of Rohingyas in Myanmar is difficult to confirm. The largest group, more than 1.6 million Rohingyas, is in Bangladesh. The majority of the Rohingyas once living in Rakhine state of Myanmar fled to Bangladesh after the latest genocide perpetrated against them by the Myanmar authorities from August 2017 onwards. Most of the Rohingyas who fled from Myanmar are now living in 33 makeshift camps at Cox’s Bazar, Bangladesh. The Rohingyas have been living in the camps of Bangladesh for years without any citizenship rights or refugee status. In this thesis, the Rohingyas are deliberately designated as refugees as they fulfil all the conditions of refugees by various international laws. According to the 1951 Refugee Convention, "a refugee is defined as a person who owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality, and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country or to return there because there is a fear of persecution" [Article 1(a)(2), 1951 Refugee Convention]. Bangladesh is not a signatory to the 1951 Refugee Convention or its 1967 protocol and has avoided labelling the Rohingyas as “refugees.” Instead, Bangladeshi authorities refer to the Rohingyas as “Forcibly Displaced Myanmar Nationals” (FDMN) and do not afford them the right to work or freedom of movement. Rohingyas who fled persecution in Myanmar have reason to fear persecution if they return and so they have been staying in the camps for years. In the Bangladeshi camps, while the local authorities and international agencies barely manage to provide minimum basic needs, the Rohingya people suffer from a lack of provisions for long-term needs, such as adequate healthcare services and education. The current study explores various health issues concerning the Rohingya people living in 33 camps of Cox's Bazar, Bangladesh. To discover their health issues, the localised, lived experiences of Rohingyas have been studied to identify the current health policy approaches and interventions addressing their health needs. This research employs a Culture-Centred ethnographic data collection methodology, with 41 in-depth interviews including some Focused Group Discussions. Purposive and snowballing methods were used to identify and recruit the Rohingya participants. The researcher has applied the Culture-Centred Approach (CCA) to find out the Rohingya refugees’ health needs. The Culture-Centred Approach is a theory of health communication that works through centring culture along with structure and agency and believes the community should have a voice in defining their problems and finding solutions. This thesis argues that the construction of Rohingya healthcare services at the refugee camps of Bangladesh follow the top-down approach and the services are predetermined by the local authorities and international agencies. The Rohingyas are the passive users of all of their basic needs including the health needs. The voices of Rohingyas are not being heard and there is no attempt to hear them, even when critical decisions regarding their health and life are being made. From that point of view this thesis examines the lived experiences of Rohingyas living in the refugee camps of Cox’s Bazar, Bangladesh through dialogical exchanges between the researcher and the Rohingya refugees. The findings suggest a theory of “looking from below” through the lens of culture, structure and agency that enables a better understanding of Rohingya health issues in the ground-level micro-practices. The study demonstrates that, given proper opportunities to take part in the decision-making processes, the Rohingyas can improve their health utilising the existing health care facilities of the camps. This thesis also advocates the Rohingya refugees’ participation in any community engagement process so as to enable a better life for them in the refugee camps with the limited infrastructures and minimum opportunities. This study also argues for greater Rohingya involvement in medical care to provide facilities that may address the localised, culture-based health needs of the refugee community.
The key factors driving successful improvement in primary care : a mixed methods investigation of the determinants of quality improvement success in Aotearoa New Zealand : a thesis with publication presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy, Massey University, Palmerston North, Aotearoa New Zealand
(Massey University, 2023-11-30) Cullen, Jane
Primary care is where the population receives most of their health care and where successful quality improvement (QI) can have the biggest impact on health, wellbeing, equity, and health system performance. A better understanding of the factors that influence QI in primary care is urgently needed to support a high-performing primary healthcare system. Most prior studies into the determinants of effective QI have focused on secondary care organisations and large-scale collaborative efforts. Primary care services such as general practice present a different set of challenges. Various key contextual factors have been identified in the literature, but few studies explain how they relate to each other and QI success. This study sought to answer the following questions: 1. What are the contextual factors influencing primary care improvement interventions? 2. How do the contextual factors, improvement content (topic and planned changes) and the implementation process influence each other and the improvement outcomes in primary care? 3. How applicable for primary care assessment is the Model for Understanding Success in Quality (MUSIQ), a tool for assessing modifiable contextual factors developed in secondary care? This research was an explanatory sequential mixed methods study based in the Aotearoa, New Zealand (NZ) primary care setting of general practice and Primary Health Organisations (PHOs). Amulti-case mixed methods approach was followed in the first stage. Mainly qualitative data were collected from primary care interviews guided by the Consolidated Framework for Implementation Research (CFIR). This was compared with quantitative data from the MUSIQ survey. The second stage consisted of a national survey where emerging theory was tested by partial least squares structural equation modelling (PLS-SEM). The findings revealed that most teams did not use formal QI methods, instead relying on their people-centred relationship skills and networks to drive QI via distributed leadership. Teams were intrinsically motivated by community and patient need and drew on strengths developed within the complexity and uncertainty of the primary care settings to drive QI. The collaborative skills which are increasingly required in the modern primary care setting support the shared social processes of sensemaking for enacting change. The key success factors driving QI in primary care are identified and how they relate to each other explained. A primary care adaptation of MUSIQ has been proposed that may aid improvement practitioners and researchers to assess primary care contexts. The key strengths should be developed and supported across primary care services and capability, capacity and resources supported centrally to increase the ability of primary care to improve services more easily and effectively.
Longitudinal outcomes of gender affirming hormone therapy on gender incongruence and psychosocial wellbeing : a mixed methods study : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Clinical Psychology at Massey University, Wellington, Aotearoa, New Zealand
(Massey University, 2023) Reynolds, Emma
Access to Gender Affirming Hormone Therapy (GAHT) has increased internationally and in Aotearoa, New Zealand, in recent years. While majority of research supports the positive impact of GAHT on gender congruence and wellbeing, there is a dearth of longitudinal data specifically within Aotearoa. To address this gap, I conducted a mixed methods study to explore the longitudinal outcomes of GAHT on gender congruence and psychosocial wellbeing. In study one, 35 participants aged between 18 and 59 years (m = 27.5) completed the Patient Health Questionnaire (PHQ-SADS) measuring somatic, depressive, and anxious symptomology, the Personal Wellbeing Index (PWI), the Transgender Congruence Scale (TCS), and a Visual Analogue Scale tracking their personalised goals (GTF). Survey scores were collected at baseline (prior to starting GAHT) and at a six month and 12 month follow up of GAHT commencement. Both binary and non-binary trans identities were included in this study. In total, 22 participants received oestrogen-based gender affirming hormone therapy (E-GAHT) and 13 participants received testosterone-based gender affirming hormone therapy (T-GAHT). Differences between survey responses over time were measured using repeated measures ANOVA. Quantitative findings revealed that scores on the TCS and GTF significantly increased over time, suggesting participants experienced enhanced gender congruence and progress towards their individual GAHT goals after one year of treatment. Responses from the PHQ-SADS did not significantly change over time suggesting that these symptomologies remained stable following GAHT. Similarly, responses from the PWI showed no significant change over time. Of note, participants mean baseline scores on the PHQ-SADS were within the minimal and mild ranges resulting in a floor effect for detecting any reduction in symptomology. Study two comprised of semi structured interviews with 10 participants from study one aged between 21 and 45 years (m=30). Qualitative analysis was performed using Reflexive Thematic Analysis. From this study, five participants were taking T-GAHT and five E-GAHT, six participants identified with a binary trans identity, and four identified with a non-binary or agender trans identity. Qualitative analysis yielded five overarching themes. The first theme highlighted the lengthy and thoughtful decision-making process of participants preceding the initiation of GAHT, reflecting participants' extensive contemplation and understanding of their gender identity and desire to seek GAHT. Themes two, three, and four explored the outcomes of GAHT on the physical body, sense of self, and social interactions. Changes in these three areas were mostly positive and well received, while discussions also acknowledged aspects that GAHT did not affect, such as certain physical changes and certain societal attitudes and reactions towards trans individuals. The fifth theme centred on the importance of support throughout the GAHT journey, encompassing interpersonal relationships, community support, and comprehensive healthcare services. Overall, the research indicated that GAHT did not significantly impact participants' mental health, physical health, or subjective wellbeing after one year. GAHT positively influenced feelings of gender incongruence and the achievement of specific goals. Participants' decisions to pursue GAHT were well considered, and they expressed satisfaction with the outcomes. Additionally, robust social support and access to comprehensive services were deemed essential alongside GAHT. These findings highlight many favourable longitudinal outcomes of GAHT across physical, emotional, and social areas with findings from the qualitative analysis providing further context for the quantitative findings. These findings also underscore the necessity for improved access to GAHT within primary healthcare settings, increased availability of additional gender-affirming services beyond the scope of GAHT, and the need for ongoing advocacy and support for trans people from wider society.
Healthcare and the oppression of sexual and gender diverse communities in Bangladesh : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy at the School of Social Work, Massey University, Albany, New Zealand
(Massey University, 2021) Khan, Kanamik Kani
Since Bangladeshi society is socio-culturally and religiously conservative, sexual and gender diverse communities live with stigma, violence, and discrimination. One form of discrimination lies in the healthcare system. The purpose of this study is to investigate the healthcare experiences of these communities to depict the oppression they face, and to understand the continuing influence of colonialism and patriarchy that maintain this oppression. To investigate this, healthcare is argued as either a human right from the social justice point of view or a tool for oppression for marginalised communities. The methodology used is phenomenological to examine the lived healthcare experiences of the participants. To collect data, I used qualitative methods including participant interviews, a focus group discussion, and key informant interviews. I worked as a volunteer with one local agency that works with sexual and gender diverse communities in Bangladesh. Volunteering helped to build networks and recruit participants. Thematic methods are used for data analysis and full ethics approval is obtained from Massey University, New Zealand. The participants live in a repressive environment with stigma, harassment, limited education and employment opportunities, lack of family support, mental health issues, and inadequate health support. They frequently experience — depending on their disclosure — humiliation, neglect, insults, and discrimination in healthcare settings. Lack of awareness and an unsupportive attitude from government representatives and institutions further contribute to their oppression. Although healthcare, in theory, is regarded as a human right, it is not fairly and equally provided for marginalised communities and thus cannot be claimed as a universal human right. Discriminatory healthcare experiences, stigma, colonial law, and sexual assaults imply that colonial values and patriarchy have an influence on the overall oppression of these communities. The most significant contribution of this study is to expose the patriarchal nature of Bangladeshi society as a legacy of the British Regime. This study offers methodological insights into how to conduct research in politically sensitive environments, which is another unique contribution to methodological knowledge. As a result of this research, it is clear that the Bangladeshi government needs to change its attitude, acknowledge the existence of these communities, and take initiatives to provide equal healthcare facilities for all.
Exploring the impact of telehealth videoconferencing services on work systems for key stakeholders in New Zealand : a sociotechnical systems approach : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Management at Massey University, Albany, New Zealand
(Massey University, 2020) Green, Nicola Jane
This thesis explores how the impacts of telehealth videoconferencing services (THVCS) on work systems are perceived by key stakeholders in New Zealand. Telehealth - the use of information and communications technologies to deliver healthcare when patients and providers are not in the same physical location - exemplifies how technological developments are changing the ways in which healthcare is provided and experienced. With the objectives of improving access, quality, and efficiencies of financial and human resources, THVCS use real time videoconferencing to provide healthcare services to replace travel to a common location. Despite the benefits of telehealth reported in the extant literature, there continues to be difficulties with developing and sustaining services. The aim of this inquiry is to understand how THVCS impact key stakeholders in the work system. Specifically, it seeks to examine the characteristics of THVCS in the New Zealand context, identify the facilitators and barriers to THVCS, and understand how the work system can adapt for THVCS to be sustained practice. The research design is framed by a post-positivist approach and underpinned by sociotechnical systems (STS) theory. STS theory and a human factors/ergonomics design approach inform the methodology, including the use of the SEIPS 2.0 model. Forty semi-structured qualitative interviews and contextual observations in a two-phase methodology explore the perceptions of an expert telehealth group, and providers, receivers, and decliners of THVCS. These data are analysed using the framework method of thematic analysis. The key findings suggest that to enable sustained THVCS in New Zealand, factors such as new ways of working; change; human connection; what is best for patient; and equity need to be recognised and managed in a way that balances costs and consequence and ensures fit across the work system. Theoretical contributions to knowledge are made through the development of a conceptual model from the literature, exploring THVCS with an STS theory lens and developing SEIPS 2.0. Methodologically, this inquiry contributes a theory-based, qualitative approach to THVCS research and draws on the perceptions of unique groups of participants. Significantly, the findings make practical contributions to the design of the THVCS in the New Zealand context.
Heart to heart - He ngākau māhaki : a thesis presented in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Public Health, Massey University, Wellington, New Zealand
(Massey University, 2019) Hoerara, Roy
This research investigates the patient experiences of Indigenous men from Australia and New Zealand who have accessed specialist treatment for heart disease. Using mixed methods – qualitative interviews and a quantitative survey – this research aims to understand the relationship between their patient experience and their patient journey. Twenty men - 10 Indigenous Australian and 10 Māori (Indigenous people of Aotearoa New Zealand) were recruited through health services. A series of semi-structured interviews was used to generate a grounded theory which describes their patient engagement and on- going patient journey. Ethical review in two countries was a particular challenge. Each country required both mainstream and Indigenous reviews, as well as locality assessments in each of the health services. Through this research I extrapolated a theory that Indigenous men co- construct their patient journey. They rely on others (clinicians, partners, family/whānau) to recall events and comprehend health information for their journey going forward. Underpinning the theory of co-construction were themes which demonstrate both similarites and differences for the cohorts. Demographics, health status, socio-economic status and historically poor access to heart healthcare were factors in common. Healthcare systems within each country explained many of the differences. The Australian cohort was based within a large city, whereas the New Zealand cohort resided in a smaller province, dependant upon more distant services. There was strong evidence of positive behavioural change, growing trust and confidence with clinicans, effective support from community groups and improving health literacy. An innovative feature of this study is a comparative Indigenous analysis which seeks to explain the findings. The main limitations of this research is related to the setting. All respondents were male, and they were recruited by the health agencies they engaged with, which will have resulted in some biases. The sample size was relatively small, especially for the survey – however this aspect was intended to be more exploratory. Future research is needed to develop Indigenous-specific patient experience measurement tools.
Understanding the social determinants of non-communicable diseases in Nepal : a systems perspective : a thesis presented in the partial fulfilment of the requirements for the degree of Doctor of Philosophy (PhD) in Health Sciences at Massey University, Wellington Campus, New Zealand
(Massey University, 2020) Sharma, Sudesh Raj
Non-communicable diseases (NCDs) constitute more than half of the total disease burden in Nepal. Global evidence indicates the problem of NCDs is influenced by the complex interaction of social determinants including behavioural, socio-economic and environmental. These determinants are the focus of global prevention strategies for tackling NCDs. The health system of Nepal, however, is yet to adopt this comprehensive prevention strategies. The main objective of this research was to understand the social determinants of NCDs in Nepal and identify leverage points for systemic actions in Nepal. The study utilized a systems thinking methodology which enabled a creative combination of case study methods and qualitative causal loop diagramming. In each of the two selected case districts (Bhaktapur and Morang), semi-structured interviews (n=39) and focus group discussions (n=12) were conducted with key stakeholders and community members. These case studies were informed by policy level interviews (n=24). Thematic analysis, guided by the adapted social determinants of health framework, helped to identify key themes and develop causal loop diagrams (CLDs). The findings of the thematic analysis, and CLDs, were then validated through local and policy sense-making workshops. The analysis showed four key interlinked thematic areas, each of which is being published as separate papers. The first paper describes the community and stakeholders’ perception and experience of the rising burden of NCDs. The social experience of NCDs metabolic risks such as hypertension and diabetes were shown to be normalised. Moreover, differences in social experience were observed based on gender and socio-economic circumstances. The second paper described the critical role played by tobacco and alcohol in the interaction of social determinants of NCDs. The analysis indicates that socio-economic circumstances was root cause of changing, and damaging alcohol and tobacco practices, and increased the vulnerability to exploitation by industries. The third paper revealed that poor dietary practices and physical inactivity were resulting due to changes in social practices shaped by worsening dietary and physical environment. Socio-economic circumstances, urbanisation and migration all contributed to the population being exposed to an obesogenic environment. While all three papers discussed specific health system challenges, the fourth paper elaborated on health sector challenges, including the curative focus and limited capacity of the health system both at district and policy or national level to prevent NCDs in Nepal. Three key leverage points for health system action on the social determinant of NCDs were identified by viewing the final CLD through the lens of Donella Meadows’ framework for identifying key health system action on the social determinants of health. These leverage points indicated that the health sector should focus on the development of a robust prevention system for effective NCDs action. Overall, the study highlighted the interactions of socio-economic, gender, commercial and health system determinants driving the NCDs problem in Nepal. The leverage analysis indicated that the health sector should focus on the development of a robust prevention system for effective action on complex problem like NCDs. The Ministry of Health could play a proactive role in creating the prevention system that could effectively guide all sectors towards collective action to impacting social and commercial determinants of health.
Alignment of big data perceptions in New Zealand healthcare : a thesis presented in partial fulfilment of the requirement for the degree of Doctor of Philosophy in Management at Massey University, Albany, New Zealand
(Massey University, 2019) Wannitilake Mudiyanselage, Kasuni Gayara Weerasinghe
The growing use of information systems (IS) in the healthcare sector, on top of increasing patient populations, diseases and complicated medication regimens, is generating enormous amounts of unstructured and complex data that have the characteristics of ‘big data’. Until recent times data driven approaches in healthcare to make use of large volumes of complex healthcare data were considered difficult, if not impossible, because available technology was not mature enough to handle such data. However, recent technological developments around big data have opened promising avenues for healthcare to make use of its big-healthcare-data for more effective healthcare delivery, in areas such as measuring outcomes, population health analysis, precision medicine, clinical care and research and development. Being a recent IT phenomenon, big data research has leaned towards technical dynamics such as analytics, data security and infrastructure. However, to date, the social dynamics of big data (such as peoples’ understanding and their perceptions of its value, application, challenges and the like) have not been adequately researched. This thesis addresses the research gap through exploring the social dynamics around the concept of big data at the level of policy-makers (identified as the macro level), funders and planners (identified as the meso level), and clinicians (identified as the micro level) in the New Zealand (NZ) healthcare sector. Investigating and comparing social dynamics of big data across these levels is important, as big data research has highlighted the importance of business-IT alignment to the successful implementation of big data technologies. Business-IT alignment is important and can be investigated through many different dimensions. This thesis adopts a social dimension lens to alignment, which promotes investigating alignment through people’s understanding of big data and its role in their work. Taking a social dimension lens to alignment fits well with the aim of this thesis, which is to understand perceptions around the notion of big data technologies that could influence the alignment of big data in healthcare policy and practice. With this understanding, the research question addressed is: how do perceptions of big data influence alignment across macro, meso, and micro levels in the NZ healthcare sector? This thesis is by publication with four research articles that answer these questions as a body of knowledge. A qualitative exploratory approach was taken to conduct an empirical study. Thirty-two in-depth interviews with policy makers, senior managers and physicians were conducted across the NZ healthcare sector. Purposive and snowball sampling techniques were used. The interviews were transcribed verbatim and analysed using general inductive thematic analysis. Data were first analysed within each group (macro, meso, and micro) to understand perceptions of big data, then across groups to understand alignment. In order to investigate perceptions, Social Representations Theory (SRT), a theory from social psychology, was used as the basis for data collection. However, data analysis led to the decision to integrate SRT with Sociotechnical Systems Theory (SST), a well-known IS theory. This integration of SRT with SST developed the Theory of Sociotechnical Representations (TSR), which is a key theoretical contribution of this research. The thesis presents the concept and application of TSR, by using it to frame the study’s findings around perceptions of big data across macro, meso and micro levels of the NZ healthcare sector. The practical contribution of this thesis is the demonstration of areas of alignment and misalignment of big data perceptions across the healthcare sector. Across the three levels, alignment was found in the shared understanding of the importance of data quality, the increasing challenges of privacy and security, and the importance of new types of data in measuring health outcomes. Aspects of misalignment included the differing definitions of big data, as well as perceptions around data ownership, data sharing, use of patient-generated data and interoperability. While participants identified measuring outcomes, clinical decision making, population health, and precision medicine as potential areas of application for big data technologies, the three groups expressed varying levels of interest, which could cause misalignment issues with implications for policy and practice.
Exploring the meaning of cardiovascular disease with Māori men : a thesis presented in partial fulfilment of the requirements for the degree of Master of Science in Health Psychology at Massey University, Albany, New Zealand
(Massey University, 2019) Lisipeki, Samantha
Ethnic disparities in health outcomes are an ongoing concern in Aotearoa/New Zealand. These disparities are particularly pronounced between Māori and non-Māori, and are especially apparent for cardiovascular disease (CVD). Despite these well-known disparities, research into how the social determinants of health manifest in the context of Māori people’s everyday lives and experiences of CVD is limited. Using a narrative approach, this research documents Māori male patients’ experiences of CVD within the context of everyday life. Four Māori males who have experienced cardiovascular care were recruited through the Waikato District Health Board secondary prevention service. The patients and their whānau (family) who wished to participate were engaged in three separate semi-structured interviews which explored topics involving their CVD diagnosis, experiences of CVD, their steps to accessing care and experiences of care. Overall, the cases revealed three key findings. First, various factors work in concert to influence participant access to cardiac care, which extend beyond individual decision making (such as structures of everyday life and resources). Second, there is considerable diversity in participant life circumstances, which are related to their experiences of care and its outcomes. Third, CVD impacted the lives of my participants differently and contributed to varying levels of illness disruption to their life narratives. This study contributes to a growing body of knowledge for addressing disparities in health outcomes between Māori and non-Māori.

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