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| Journal of the New Zealand Medical Association,
14-March-2003, Vol 116 No 1170
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Mapping the themes of Maori talk about health
Fiona Cram, Linda Smith and Wayne Johnstone
The present research began with our interest in how Maori
health was being talked about, thought about, and experienced by urban Maori.
The study was part of a larger study in which Pakeha researchers also
interviewed Pakeha general practitioners (GPs) about Maori
health.1
Descriptions of a Maori view of health are invariably
holistic and centred on whanau health and wellbeing rather than the health of
the individual.2–4 Cultural concepts and
practices, such as tapu and noa and the ritual of tangi, have been described as
key components, as has the use of karakia and processes around food, exercise
and illness.3,5,6 These descriptions have
historically been formed by Maori and have, in turn, informed Maori, developing
over time as our understanding has grown of what promotes and what undermines
good health and wellbeing. For example, a view of Maori health that once
encompassed tinana (the physical element), hinengaro (the mental state), wairua
(the spirit), and whanau (the immediate and wider family), is now contextualised
within te whenua (land providing a sense of identity and belonging), te reo (the
language of communication), te ao turoa (environment), and whanaungatanga
(extended family).3,7
Practices and cultural concepts that are imperative to Maori
health and wellbeing have, however, often been undermined by dominant Pakeha
views on health.8 Maori also report perceptions
of Pakeha healthcare that are the legacy of past negative interactions between
Maori clients and Pakeha health professionals. These perceptions include
suspicions about treatment, the reluctance to even engage in an interaction with
health professionals, and behaviour referred to in the sociological literature
as resistance.9 Such actions have been
interpreted by some as evidence of whakamaa, the notion of culturally
appropriate shame or shyness.10 The actions may
also be part of a more general reaction to being treated in a patronising or
paternalistic way.7,11
The impact of Maori engagement with mainstream health
structures on Maori understandings of Maori health can be gauged by how active
such perceptions are in everyday talk about health among Maori. The present
study was also concerned to discover if any of the concepts embodied in
descriptions of Maori health are employed in the talk of Maori informants in
discussing Maori health. This will provide a picture of how active these
concepts are among Maori in the contemporary setting.
A major feature of the current research was that it was
carried out using Kaupapa Maori methods; namely, from the perspective that a
Maori world view is both valid and legitimate. Kaupapa Maori is ‘by Maori,
for Maori’ and is inherently about cultural survival and tino
rangatiratanga (self-determination).
In this sense, Kaupapa Maori is ‘a theory and an
analysis of the context of research which involves Maori and of the approaches
to research with, by and/or for Maori’.12
A Kaupapa Maori approach does not exclude the use of a wide range of methods,
but rather signals the interrogation of methods in relation to cultural
sensitivity, cross-cultural reliability, useful outcomes for Maori, and other
such measures. In this context, the use of in-depth interviews enabled us to
collect people’s views on Maori health at all levels, from personal
experience, to community and political perspectives.
MethodsThe present study used
qualitative methods within a Kaupapa Maori approach. Semi-structured interviews
were recorded with 28 Maori (aged 17 to 75 years) in urban Auckland, who were
recruited through marae-based health programmes. Marae-based health programmes
were selected as a starting point as it was found that Maori using these
programmes have experienced something of both Western and Maori health
practices. In this way, we would be able to talk to people about the
similarities and differences between mainstream and Maori health
services.
Interviews with participants followed an open-ended format; the interviewer raising relevant topic areas and encouraging participants to talk rather than pursuing set questions. The topics discussed were:
The interviews were
transcribed verbatim, checked against the audiotape, and returned to
participants for approval before inclusion in the database. Participants were
given pseudonyms and identifying markers were masked to preserve
confidentiality.
One of our roles as researchers working within a Kaupapa Maori framework is to listen to and document Maori experiences and meanings.13 As researchers, we carry the responsibility of re-presenting the realities of participants to wider audiences and we take this role very seriously. We therefore use the word ‘analysis’ cautiously. Our aim is to make space for Maori voices and realities to be heard and considered ‘valid’.14 At the same time, we want to be able to say something, as researchers and analysts, about the society that positions our participants in certain ways. This methodology is described more fully elsewhere (manuscript submitted). We therefore used some of the critical skills we have learnt from discourse analysis to engage with participants’ talk.15 ResultsTwelve
recurrent themes arose out of our reading of the transcripts. Rich descriptions
that included participants’ experiences, explanations, and ideas were then
developed for each of these themes. The present findings are the top layer of
this analysis. This overview provides the context in which individual themes can
be explored in future papers. Participants have seen and provided feedback on a
draft research report that was prepared solely for them.
Maori health
Participants answered the question ‘What is Maori health?’ in
a variety of ways. A number of participants talked about the importance of
defining health holistically, to encompass more than people’s physical
health. Participants spoke mainly about the interconnectedness of physical,
spiritual and mental health. For some respondents, Maori health was related to
specific Maori ways of providing healthcare. Other respondents linked the term
‘Maori health’ with ill-health. The impact of social and economic
wellbeing on health was mentioned and some participants talked specifically
about the disparities between Maori and Pakeha health.
Explanations
for Maori ill-health In their explanations for the current status of
Maori ill-health, participants’ views ranged from the examination of what
individuals put into their bodies on a daily basis (eg, drugs, overeating) to
more social (eg, stress and poverty), and corporate (eg, tobacco company
advertising) explanations. These explanations fell into three interrelated
categories: individual, whanau and societal. Individual explanations included
the things people did that had an impact on their own health and/or the health
of others – for example, smoking and drinking. Whanau explanations
included occurrences and circumstances that undermined the foundations of the
whanau. The whanau was described as being under stress, with people therefore
missing out on whanau life (also see below). Societal explanations examined the
health system as well as the wider social system and its impact on Maori health.
Within this, people’s inability to afford healthcare was recognised by
many participants.
There were multiple, interrelated layers within each
explanation for contemporary Maori health status, and participants found that it
was sometimes difficult to establish the root cause of a problem or illness. For
example, smoking might be ‘caused’ by stress but what, in turn, has
caused that stress? Some participants were, however, clear that the root cause
of Maori ill-health was the disruption of whanau and hapu structures within the
historical and contemporary setting of colonisation in this country.
Traditional
ways The topic of healing was discussed within the context of traditional
Maori approaches and knowledge. These were closely linked to participants’
views on Maori health, particularly the holistic, relational nature of Maori
health. Traditional healing practices that existed in the past were seen to
still exist today, demonstrating the value to Maori of holistic healing
practices and the passing down of information from one generation to the next.
Participants also talked about healing in terms of both rongoa and wairua (see
below).
Rongoa Older
participants described their experiences of rongoa (remedies) and other
traditional healing practices from when they were younger. In addition, a number
of the participants, both young and old, continued to use rongoa and saw this as
compatible with the use of Western medicines. Two of the kuia (older women)
spoke about their own specialised knowledge of rongoa and sharing this knowledge
with others.
Integration
Some of the participants talked about using both Maori and Pakeha medicines.
These participants had often found Pakeha general practitioners to be very
understanding of their use of rongoa, and some went to great lengths to impart
knowledge to their doctor. In such cases, the interchange was usually with a
doctor who took time to listen to a patient and was willing to acknowledge other
forms of healing (although possibly because they see them as
harmless).
Wairua
Wairua (spirit) was the most widely mentioned aspect of Maori health.
Participants viewed wairua as the key to understanding health and illness as it
gives access to the whole person, not just their physical symptoms, allowing
healing to take place. This understanding was seen as being fundamental in Maori
health practitioners whereas Pakeha practitioners were seen as less likely to
understand it, often treating only the symptoms rather than what participants
saw as the cause of the problem or illness.
Whanau
The whanau was seen by participants as a basic support structure for Maori and
therefore an integral part of Maori health and wellbeing. Whanau buffers its
members from the wider world, including experiences of illness, treatment and
hospitalisation. However, this structure and balance is disrupted in a number of
whanau and participants talked about those whanau needing something to believe
in. There was also agreement about the importance of input from kuia and koroua
(older men) into whanau health and wellbeing.
Interacting
with the health system Participants’ experience and knowledge of
Pakeha doctors was not overly positive. In many cases, either they or a close
relative had not received good treatment and sometimes this had resulted in the
relative dying. Suspicion and even fear of the health system was therefore often
grounded in whanau experience. Participants had found that persistence and
assertiveness, often in the face of cultural misunderstandings, were required if
good healthcare was to be obtained from existing systems.
Rapport
Participants saw rapport as vital to the interaction between a doctor and a
patient. Rapport was described as the ability to communicate and included, for
example, whether or not information was provided and understood, and whether or
not the interaction was friendly. Participants liked Pakeha doctors who took the
time to find out about them and their families, who were genuinely interested,
and who did not talk down to them. Some participants thought that rapport
occurred more with young doctors than old, whereas others thought that the
principle of rapport was more ‘old school’. Participants felt that
rapport was especially important for older patients and those who were shy.
However, difficulties in doctor–patient communication could be overcome if
patients had support people who could speak on their behalf.
Whakamaa
Participants talked about whakamaa as a potential barrier to healthcare; it may
prevent people from going to see a doctor or, if they did see a doctor, prevent
them from telling the doctor what was wrong with them. This was connected with
rapport and the importance of a health practitioner taking time to put patients
at ease, as whakamaa will decrease as a relationship is built. Participants also
saw the value of personal support for Maori patients to facilitate access and
engagement with health services.
Promoting
Maori health Participants’ suggestions for promoting health among
Maori were based on acknowledging peoples’ circumstances and needs. For
example, health promotion is unlikely to be very successful if people are more
concerned about day-to-day difficulties brought about by poverty than they are
about their personal health. This is not to say that health promotion should not
also be about trying to ease the burden of poverty. Appropriate health promotion
was seen by participants as including the opportunity to:
Marae-based
healthcare delivery The marae provides people with a place to gather,
often facilitated by the provision of transport and allowing people to bring
their children. Participants thought that this accessibility was also about
providing good clinical service and connecting with people at a cultural level.
Sometimes both these can be provided by Maori practitioners; at other times a
non-Maori practitioner can be ‘trained’ to be Maori-friendly and
Maori involved in the health service can provide the cultural connections for
patients. And regardless of whether a health practitioner is Maori or non-Maori,
participants again stressed the importance of involving kuia and
koroua.
DiscussionThe
present study examined how Maori health was conceptualised by a group of urban
Maori who had knowledge of both mainstream and Maori-provider health services.
Participants’ conceptions of Maori health and their explanations for poor
Maori health demonstrated holistic constructions of Maori health, along with an
understanding of the various personal, whanau, and societal influences on health
and wellbeing. The findings confirm the ongoing strength of Maori health
concepts, as well as highlighting the depth of analysis by Maori of the causes
of current Maori ill-health. In addition, the importance that participants put
on wairua strongly suggests that they were not merely regurgitating Maori health
models that abound in current health policy.
Wairua, generally translated as the ‘spirit’, is
linked to both religious beliefs and relationships with the
environment.3 According to Durie, Maori
generally consider wairua to be the essence of Maori
health.3 He describes how this point was made
in 1982 by kaumatua Tupana te Hira during the welcome for fieldworkers involved
in the Maori Women’s Welfare League research project, Rapuora. Te
Hira’s views were shared by many kaumatua, and were being heard on many
marae. Durie argues that ‘without a spiritual awareness and a mauri
(spirit or vitality, sometimes called the life-force) an individual cannot be
healthy and is more prone to illness or
misfortune’.3
Participants in the present study articulated a similar view
when they described healing as occurring at the level of wairua, rather than
solely through the treatment of the symptoms of disease. In addition, a
disruption of wairua within whanau was linked to the inability of whanau to
nurture and support the wellbeing of individual members. Within the urban
environment, whanau may experience this disruption because of poverty,
unemployment, and/or lack of
education.16
However, as pointed out by some of the participants in the
present study, the root cause of the disruption of wairua needs to be found
within the processes used to colonise this country. If, as Durie
argues,3 a lack of access to tribal land is a
sign of ill-health for Maori, then a colonisation process that has marginalised
Maori from land must surely be woven through an explanation of poor Maori health
status.17 Likewise, the undermining of a viable
Maori economic base sourced from the land must have repercussions for
contemporary Maori poverty and
ill-health.18,19
While the burden of addressing the consequences of
colonisation cannot fall solely on the shoulders of health professionals, they
need to take into account the context within which they are delivering
healthcare to Maori, and the potential barriers to and facilitators of that
delivery process. The themes that emerged in the present study articulated
participants’ experiences and provided insights into the delivery of
healthcare to Maori. For example, Pakeha doctors should be mindful that Maori
patients may well have a holistic approach to health, with a particular emphasis
on wairua. In addition, they should recognise some of the ways in which the
health of individuals and whanau is challenged. The challenge of day-to-day
survival may well override health concerns for many Maori
whanau.20
Add to this the cross-cultural nature of many Maori
patient/Pakeha doctor interactions and the scene is set for miscommunication and
potentially negative experiences for Maori (and possibly also for
Pakeha).21 Maori also carry knowledge of
previous negative experiences that they, their whanau, and those in their wider
networks have had as a result of such interactions. However, when the
participants in the present study found that they were respected in mainstream
healthcare services, they were able to relate to and make sense of the
communications from their doctor. Rapport was therefore identified as a key
facilitator of Maori access to healthcare.
Pakeha doctors, however, may think they are establishing
rapport without fully appreciating that rapport is interpreted differently by
different cultural groups. This came out strongly in the present research in
participants’ talk about having to ‘train’ a Pakeha doctor so
that he could work on the marae. Several components of rapport were identified
in the present research, including the doctor taking time to listen,
communicating in understandable language, taking an interest in whanau health
history, and engaging with the patient to deliver a collaborative style of
healthcare. These elements not only facilitate healthcare delivery, they signal
cultural sensitivity on the part of the health practitioner.
In conclusion, Maori are concerned about their health and do
not want to be ill. When Maori find good healthcare service it will undoubtedly
provide a pathway to health for both themselves and their
whanau.22
Author information:
Fiona Cram, Senior Research Fellow; Linda Smith, Professor, International
Research Institute for Maori and Indigenous Education (IRI); Wayne Johnstone,
Research Associate, James Henare Maori Research Centre, University of Auckland,
Auckland
Acknowledgements:
This research was supported by a Health Research Council Limited Budget Grant to
Fiona Cram and Linda Smith. The authors acknowledge the support and input of
Suzanne Pitama and Tim McCreanor. Thanks also to the reviewers for their
suggestions and encouragement.
Correspondence: Dr
Fiona Cram, IRI, University of Auckland, Private Bag 92019, Auckland. Fax: (09)
367 7113; email: f.cram@auckland.ac.nz
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