Copyright is owned by the Author of the thesis. Permission is given for a copy to be downloaded by an individual for the purpose of research and private study only. The thesis may not be reproduced elsewhere without the permission of the Author. i WHAKAWHIRINAKITANGA AHUA: EXPLORING A M ĀORI MODEL OF HEALTH SERVICE DELIVERY Carole Ann Fernandez A thesis submitted for the degree of Doctor of Philosophy in Public Health (Māori Health) Massey University 2015 © Carole Ann Fernandez and Best Care (Whakapai Hauora) Charitable Trust ii © Copyright is owned by the Author of the thesis and Best Care (Whakapai Hauora) Charitable Trust. Permission to access the thesis in part or whole must be sought from the Author and Best Care (Whakapai Hauora) Charitable Trust. This thesis may not be reproduced without the permission of the Author and Best Care (Whakapai Hauora) Charitable Trust. iii Abstract Māori health service delivery is underpinned by Māori tikanga, philosophies, values and processes; and Māori providers have consistently developed and delivered tikanga-based services to meet the needs of Māori and whānau. This thesis explored a Māori model of health service delivery, Whakawhirinakitanga Ahua, developed by an iwi health provider, Best Care (Whakapai Hauora) Charitable Trust. It aimed to uncover if health service delivery was reflective of the model, and if it addressed the health needs of Māori accessing services at Whakapai Hauora. This research was undertaken within the interpretivist paradigm using qualitative methods aligned to Māori-centred research. It drew upon the experiences, attitudes and beliefs of 50 key informants; health professionals (Māori and non- Māori) who delivered services and Māori who accessed services at Whakapai Hauora. The primary focus is on collaborative processes involved in the delivery of integrated health care. Findings in this research indicated how Māori and non-Māori work together in a Māori health environment, how they work with clients and whānau, and also at the interface with mainstream services. It demonstrated how Māori utilise tikanga-based service delivery in the provision of care to individuals and whānau; and how non-Māori working at Whakapai Hauora utilise significant aspects of tikanga-based and Treaty principles in service delivery, in response to Māori health interests within the context of Government health priorities and social policy. This thesis draws a distinction between client-centred care and whānau focused care. While client-centred practice has been a widely accepted philosophy in holistic approaches to care, whānau focused care places whānau central to all service delivery processes. It challenges health professionals to reconsider the way in which they engage with Māori and whānau, shifting mindsets from working with individuals to whānau as a collective. It challenges health professionals to acknowledge the wider environment and the determinants that impact on health and wellbeing. This thesis also acknowledges the expertise and strengths from both Te Ao Māori and Te Ao Pākehā, and highlights the significance of health professionals having to walk in both worlds in order to facilitate better outcomes for Māori. iv Acknowledgements Undertaking this research has been a long journey for me, one that I will never forget. Being privileged to work with and among Rangitaane o Manawatu, the tangata whenua of the Manawatu in a Kaupapa Māori environment, has reaffirmed my own roots as an indigenous person. Although I am of mixed ethnicity, I identify as being indigenous and affiliate with my Javanese heritage. It is important for me, that I thank all who have helped me throughout this journey. I wish to acknowledge the late Whaea Ruth Harris and the vision she had for Best Care (Whakapai Hauora) Charitable Trust towards achieving the best outcomes in health service delivery for Māori, whānau, and the community it serves. I would also like to acknowledge the late Koro Ropata Te Hina and the late Kuia Kararaina Tait for all their aroha and awhi during my journey. I wish to acknowledge and thank Te Mauri O Rangitaane (Council of Elders), and Chief Executive Danielle Harris for their unwavering support while undertaking this research. I also wish to acknowledge Huataki Whareaitu; I thank you for your guidance in Rangitaanenuirawa. To my whānau ā kaupapa: Donna Cummerfield, Kiwa Whareaitu, Michael Armstrong, Jenny Wikeepa, Kararaina Oldridge, Daniel Kawana, Raewyn Skipper, and all the staff at Piki Kotuku Te Awhi Hinengaro and at Whare Tiaki; the Nurses, Community Health Workers and Doctors at Whakapai Hauora, I sincerely thank you for all your aroha and awhi as well. An acknowledgment also goes out to the staff of Whakapai Hauora who initially developed the model in 2003: Virginia Dyall-Kalidas, Kevin Collins and Donna Cummerfield, including the Piki Kotuku Team of 2003 who were also involved in its development. To all my supervisors, I thank you: Dr. Lesley Batten, for making me rise to this challenge; Professor Tairahia Black, for giving me the courage to continue with my research; Dr. Margaret Forster for your expert supervision in tikanga; and most importantly, my Primary Supervisor, Dr. Maureen Holdaway; for your expert supervision, for all your time, for having faith in me and staying with me when the journey got rough. No amount of words could thank you enough Maureen, for all that you have done for me. Finally most dear to my heart are my own whānau, my source of inspiration; my four older daughters: Aroha Taimai, Kairi Taimai-Watty, Piri Taimai-Brown and Waimarie Taimai (Ngāti Whātua); my younger daughter Meri Haami and son Pita Rhys Haami (Te Āti Haunui-a-Pāpārangi). Also my whānau from Singapore: I wish to acknowledge my late parents, Anthony Emmanuel Fernandez and my mother, Peggy Clunies Ross McCully. To my brothers Michael and Mark, I thank you all for your love, constant support and your faith in me to complete this work. v Table of Contents ___________________________________________ Abstract ............................................................................................................... iii Acknowledgements ............................................................................................. iv Table of Contents ..................................................................................................v List of Illustrations ............................................................................................ xiii Glossary of Māori Words.................................................................................. xiv Glossary of Abbreviations .............................................................................. xviii Chapter One: Introduction .......................................................................1 An introduction to this research ...........................................................................1 Background to this study ......................................................................................2 The rationale for this study ...................................................................................3 The aims and objectives of this study ...................................................................4 Parameters of this thesis........................................................................................5 Organisation of this thesis ....................................................................................5 Chapter Two: Literature Review ............................................................8 Introduction to the literature ................................................................................8 1. Māori health and wellbeing ...........................................................................9 “Tangata Whenua” ................................................................................................9 The current state of Māori health and wellbeing ................................................11 The Treaty of Waitangi .......................................................................................12 2. Movement and Changes in the Health Sector ...........................................13 Decades of Māori development .........................................................................14 Health reforms of the 90s and the emergence of Māori health providers ...................................................................................15 Strategic developments in the early 2000s .........................................................18 vi ‘Better Sooner More Convenient’ primary health care ......................................19 The whānau ora environment .............................................................................20 The Whānau Ora taskforce .................................................................................21 3. Collaboration .................................................................................................23 Collaborative care ..............................................................................................23 Integrated care .....................................................................................................24 International models of integrated care...............................................................24 Integrated care in New Zealand ..........................................................................26 Māori views of integrated care ...........................................................................27 4. Māori Health Providers ................................................................................28 Māori providers and whānau ora integrated services .........................................28 From outputs to outcomes-based performance in service delivery ...............................................................................................................30 Māori and mainstream provider alliances ..........................................................31 Summary .............................................................................................................33 Chapter Three: The Research Methodology .................................................34 Introduction ........................................................................................................34 The Acquisition of Knowledge and ‘Truth’....................................................34 Western and Indigenous Research Paradigms ..............................................35 Research and Indigenous Peoples ..................................................................37 The Theoretical Framework for this Study ...................................................40 The use of qualitative research for this study ....................................................40 Māori-centred research ......................................................................................40 Insider research ..................................................................................................42 Ethics of Māori health research .........................................................................43 My Position in this Research ............................................................................45 Indigenous roots ..................................................................................................45 Similarities between Māori and Kejawen beliefs ..............................................47 My approach to this study ..................................................................................48 Summary ............................................................................................................49 vii Chapter Four: The Research Methods ..........................................................50 Introduction ........................................................................................................50 Consultation ........................................................................................................50 Methods ..............................................................................................................51 Participant recruitment .......................................................................................51 Data Collection ..................................................................................................53 Semi structured interviews .................................................................................53 Interviews with Whakapai Hauora Health professionals ....................................54 Interviews with Whakapai Hauora clients .........................................................55 Secondary data ....................................................................................................56 Data Analysis ....................................................................................................57 Fieldwork ............................................................................................................58 Being the insider ................................................................................................58 A Māori analysis ................................................................................................59 Establishing the Research Rigour ..................................................................59 Triangulation ......................................................................................................60 Respondent validation .........................................................................................60 Ethics .................................................................................................................62 Approval ............................................................................................................62 Informed consent ...............................................................................................63 Anonymity and confidentiality ..........................................................................64 Managing potential risk or harm ........................................................................64 Culturally safe research ......................................................................................65 Dissemination of information ............................................................................66 Summary ............................................................................................................67 Chapter Five: Best Care (Whakapai Hauora) Charitable Trust ..........................................69 Introduction .........................................................................................................69 Tānenuiārangi Manawatū Incorporated ..............................................................69 Best Care (Whakapai Hauora): an iwi health, social and disability support service provider ...............................................................70 Whakapai Hauora Vision ...................................................................................70 Whakapai Hauora Mission Statement ................................................................71 viii Striving for excellence in Te Ao Māori and Te Ao Pākehā ................................71 Strategic direction of Government and funding implications .............................72 Health inequalities in the MidCentral Region ...................................................74 Strategic direction of Whakapai Hauora ............................................................75 Whanau ora from the perspective of Whakapai Hauora ....................................76 Whakawhirinakitanga Ahua as a Māori Model of health service delivery ...................................................................................................79 The recognition of Whakawhirinakitanga Ahua as a Māori model of health service delivery ........................................................................83 Summary .............................................................................................................84 Chapter Six: “It’s all about collective care” ......................................85 Introduction ........................................................................................................85 1. Understanding models of health service delivery: ...................................85 Māori views of a holistic model of health service delivery ................................86 Non-Māori views of a holistic model of health service delivery ...............................................................................................................87 A collaborative model of health service delivery ................................................88 2. Barriers to access and collaboration ...........................................................90 Limited funding and resourcing ..........................................................................91 An overlap of health services ..............................................................................93 Mainstream provider awareness of Māori health providers .............................................................................................................95 Attitudes towards Māori providers .....................................................................96 Attitudes towards clients .....................................................................................97 Navigating through complex systems of care .....................................................98 3. Working from a “Kaupapa Māori worldview”..........................................99 Differences between mainstream and Māori health service delivery ...................................................................................................99 Working at the primary and secondary care interface ......................................101 Building and sustaining relationships ...............................................................103 ix Collective decision making ...............................................................................105 Whānau focused care ........................................................................................108 Providing additional support .............................................................................110 Balancing dependence and independence .........................................................112 Performance measurement in service delivery .................................................114 Culturally appropriate services .........................................................................115 Non-Māori perspectives of culturally appropriate services ..............................117 4. The journey towards health and wellbeing ..............................................118 A change in behaviour ......................................................................................119 Seeing the big picture........................................................................................121 Cultural identity and wellbeing .........................................................................122 Summary ...........................................................................................................124 Chapter Seven: “They should walk a mile in my shoes” .............125 Introduction ......................................................................................................125 1. Holistic health and wellbeing .....................................................................125 It’s about whānau ..............................................................................................126 A one-stop shop service provider .....................................................................129 2. Barriers to accessing services .....................................................................132 Cost and waiting times ......................................................................................132 Negative experiences with mainstream services...............................................134 Positive experiences with mainstream services ................................................137 Barriers to accessing wider support services ....................................................139 3. Gaining control over health and wellbeing ...............................................142 Self-navigation through services.......................................................................143 Kaupapa Māori services ....................................................................................144 Care and management of chronic illness ..........................................................148 Summary ...........................................................................................................154 x Chapter Eight: Weaving the research findings together .............155 Introduction ......................................................................................................155 Theme 1: Health and Wellbeing ...................................................................155 Holistic concepts of health and wellbeing ........................................................156 A whānau focus in health and wellbeing .........................................................157 Client-centred practice ......................................................................................157 Cultural competence .........................................................................................158 The complex nature of wairua in holistic care ..................................................159 Working in partnership .....................................................................................161 Working together as a whānau ..........................................................................161 Working together as a team ..............................................................................162 Māori provider experiences with mainstream services .....................................162 Client and whānau experiences with mainstream providers .............................164 Preference for Māori providers .........................................................................166 Going the extra mile..........................................................................................167 Reciprocal relationships towards intersectoral pathways in service delivery .................................................................................................169 Summary ...........................................................................................................170 Theme 2: Values Based Service Delivery ......................................................171 Understanding health information ....................................................................171 Being informed .................................................................................................172 Connecting face-to-face (kanohi ki te kanohi)..................................................173 Sharing whakapapa and stories to connect ......................................................173 Sharing kai to connect ......................................................................................174 Effective communication and collaboration in service delivery ......................175 Effective communication within the organisation ............................................176 Streamlining service delivery ...........................................................................177 Summary ...........................................................................................................178 Theme 3: Whānau Focused Care .................................................................179 The intergenerational transmission of Māori culture, values and knowledge .................................................................................................179 xi Whānau capacity and influences ......................................................................180 Working with high risk clients / whānau .........................................................182 Māori health service delivery ...........................................................................183 Knowledge and empowerment ........................................................................184 Navigation through the care continuum ...........................................................185 Working at the interface ...................................................................................186 Summary ...........................................................................................................187 Chapter Nine: Discussion .......................................................................189 Introduction ......................................................................................................189 Exploring Whakawhirinakitanga Ahua ......................................................190 Aspiring to achieve whānau ora .......................................................................190 Whakawhirinakitanga Ahua pathways towards whānau ora ...........................190 Whakawhirinakitanga Ahua as a model to facilitate intersectoral collaboration ................................................................................192 Service navigators ............................................................................................193 Gauging whānau ora success ...........................................................................194 Influences Affecting Health Service Delivery ..............................................195 Organisational culture and tikanga Māori ........................................................195 Māori provider capacity and capability ...........................................................196 Wider Influences on Health Service Delivery .............................................197 The current health climate ...............................................................................197 Addressing the broad research questions .........................................................202 Implications of this Research ........................................................................202 Māori and mainstream providers .....................................................................202 What this research challenges ..........................................................................203 Possible improvements to Whakawhirinakitanga Ahua ...................................205 Whakawhirinakitanga Ahua holistic framework from a Te Ao Māori perspective .................................................................................205 Whakawhirinakitanga Ahua holistic framework from a Te Ao Pākehā perspective ....................................................................208 xii The web of relationships within Te Ao Māori .................................................210 The web of relationships within Te Ao Pākehā ...............................................210 Research Reflections ......................................................................................211 Strengths and Limitations to this Research .................................................213 Strengths ..........................................................................................................213 This study’s original contribution to knowledge ..............................................214 Limitations .......................................................................................................215 Conclusion ......................................................................................................216 References ........................................................................................................219 Appendices .......................................................................................................238 xiii List of Illustrations _______________________________________ Table 1: Basic Beliefs of Research Tradition at the Interface of the Interpretivist Paradigm and Te Ao Māori .................................39 Table 2: Tikanga-based Framework from which both Māori and Non-Māori operate at Whakapai Hauora .................................................123 Table 3: Whakawhirinakitanga Ahua Pathways towards achieving Whānau Ora ............................................................... 152-153 Diagram 1: Whakapai Hauora Pathways towards Whānau Ora (Ministry of Health Whānau Ora Awards (in 2004) ...........................................78 Diagram 2: A Depiction of Whakawhirinakitanga Ahua (when developed in 2004) ............................................................................. 82-83 Diagram 3: Whakawhirinakitanga Ahua Holistic Framework from a Te Ao Māori perspective .......................................................................207 Diagram 4: Whakawhirinakitanga Ahua Holistic Framework from a Te Ao Pākehā perspective .....................................................................209 Picture 1: Nga kete o te mātauranga ...................................................................81 xiv Glossary of Māori words ______________________________________________________________ ahua: to form, make aroha: love aromatawai: assessment awa: river awhi: embrace hapu: sub-tribe, clan hauora: health, wellbeing; health centre hinengaro: mind, mental hōhā: bored, annoyed iwi: tribe, nation ihi: the power kai: food kaimahi: worker, employee kanohi ki te kanohi: face to face kapa haka: Māori cultural performance karakia: prayer kaumātua: elder kaupapa: strategy, theme kawa: protocol, etiquette korero: speak, narrative koro: grandfather xv kotahitanga: unity, collective oneness kuia: elderly woman, grandmother kupu: talk, statement, discussion Kura Kaupapa: Māori language immersion school mana: prestige manaaki/manaakitia: to care for, show respect manaakitanga: entertain, hospitality, generosity manuhiri: visitor marae: meeting area of a village or settlement including its buildings and courtyards mātauranga: knowledge, education, information mihimihi: a greeting to welcome visitors mokopuna/moko: grandchild nga kete o te mātauranga: the baskets of knowledge noa: free from tapu ora: to be alive, well, safe Pākehā: non-Māori, European, Caucasian pakeke: adult powhiri: welcome, opening ceremony puku: stomach pupuri taonga: the capacity for guardianship rangatahi: youth raranga: to weave, weaving taha Māori : a Māori perspective xvi tamariki: child tangata whenua: people of the land tangata whaiora: mental health consumers tapu: sacred, forbidden tauiwi: non-Māori, foreigner tautoko: to support, to advocate, to agree Te Ao Māori: the Māori world Te Ao Pākehā: the non-Māori world te reo: the language Te Whare Tapa Wha: Māori model of health developed by Dr. Mason Durie tika: to be true, correct tikanga: protocols, practices, customs tinana: body, physical tino rangatiratanga: self-determination, sovereignty tohunga: a skilled person in healing tohatohatia: the capacity to share tūpuna: ancestor tūrangawaewae: a place to stand and belong waiata: song wairua: spirit, attitude wairuatanga: spirituality waka: canoe wana: the authority xvii wehi: to be awesome whakamā: shy, ashamed, embarrassed whakamana: the capacity to empower whakatuaki: proverb whakapapa: genealogy whakapiki tangata: empowerment whakapono: faith, trust whakatakoto tikanga: the capacity to plan ahead whakatuia: integration whakawhanaungatanga: coming together as a family/group whānau: family whānau pohara: restricted family whānau tukino: unsafe family whānau tumokemoke: overwhelmed family whānau wewete: laissez-faire family whanaungatanga: relationship, kinship wharenui: main building of a marae where guests are accommodated whenua: land xviii Glossary of Abbreviations _______________________________________________________________ AOD Alcohol and Other Drug BSMC Better Sooner More Convenient (Care) CBG Research (Carol Boustead & Barry Gribben) Research CEO Chief Executive Officer COPC Community Orientated Primary Care CYFS Child Youth and Family Services DHB(s) District Health Board(s) DNA Do (Did) Not Attend GP(s) General Practitioner(s) IFHC(s) Integrated Family Health Centre(s) IT Information Technology MDHB MidCentral District Health Board MOU Memorandum of Understanding MPDS Māori Provider Development Scheme PHO(s) Primary Health Care Organisation(s) RHA(s) Regional Health Authority(s) TMI Tānenuiārangi Manawatū Inc.