Practical solutions for improving Māori health

Nā tō rourou, nā tāku rourou, ka ora ai te iwi
With your food basket and my food basket, the people will be well

Plan to improve Māori health

A simple practice plan sets out the broad direction for what you want to achieve and sets the basis for developing practice goals.

A practice plan to identify and address inequities in primary health care for Māori can be developed from PHO Māori health strategies. Practices should contact their PHO managers to facilitate the development of their own practice plan.

Set realistic goals for your practice

You do not have to change everything at once. The first step may be to implement workforce development so all members of the team know the importance of the changes to be made.

Simple initial goals may include:

• Correctly recording ethnicity (see BPJ 9)
• Recording smoking status
• Flagging patients for a BP check next time they attend
• Comparing immunisation rates between Māori and non-Māori

Practice software can be used to simplify the achievement of these goals.

Build trusting therapeutic relationships

Māori place great emphasis on establishing a trusting relationship with their healthcare providers. Patient satisfaction and acceptability of treatment reflect the ability of providers to show they understand their patients and are understood by them. As Professor Mason Durie notes, a culturally appropriate approach by the provider is an important element, in determining both the "willingness of people to access services and the success of any treatment or care then delivered."¹

Primary care providers may lack knowledge of Māori culture. This can result in misunderstandings, incorrect assumptions and inherent biases, each of which can lead to needs not being met.

Māori willingness to see a health provider is impacted by previous poor experiences. One study which collected the opinions of Māori and Pacific stakeholders identified examples of barriers to care including:²

• Fears (embarrassment, wasting GP time, causing offence or receiving offence)
• Humility (to act in a "lowly position of honour", desire not to voice disagreement)
• Mistrust (historically, prevailing health care systems have not met the needs of Māori; low expectations for the service; anticipation that misunderstanding will result)

Clearly, if Māori are to achieve equitable access to care and equitable outcomes, health care providers must improve their relationship with Māori.

Take time for introductions

Māori rely heavily on interpersonal connections and these are the basis on which an effective therapeutic relationship can be established. Any link is useful, for example through people, places or activities in common. Investing time in a brief chat will pay off in the long term by establishing an effective ongoing relationship with the patient and whānau.

Let the patient tell their story

Dr Paratene Ngata, a Māori GP from Tolaga Bay says: "It is important to first develop the relationship with your patient. You do this with effective communication. This is not your ability to tell the story from a clinical or scientific perspective, but to listen to the story from your patient, and reflect that back to them in the correct context in which they are able to fully participate in their own treatment. The development of the relationship with the patient and possibly their whānau will support a positive outcome from your intervention".

This view is consistent with that of Dr Rawiri Tipene-Leach, a Māori GP from Hawkes Bay. He stressed the importance of ensuring the storytelling was from the patients perspective, not his own. "As a clinician your skill is to reflect that anecdotal evidence and incorporate both views into a management plan - your view which incorporates the clinical and scientific perspective and that of your patient, which may have a particular cultural slant."

Understand the unique illness experience for individual patients

The key to patient-centred medicine is to see the health issue through the eyes of the patient. One way to gain an understanding of the illness experience is to use the FIFE format as a framework for open questions. This gives a chance to explore the Feelings, Ideas, effects on Function and Expectations of the patient. The aim is to gain an understanding of the unique nature of the illness experience for each patient. The focus is on illness rather than disease and how it is affecting this particular patient. This approach then helps guide your management of the illness on an individual basis.

Use open questions to check understanding and agreement

When communicating with Māori, health professionals need to ensure that the message being communicated is the same message that is being received. Many Māori have a natural desire to seek a consensus and to avoid disagreements about small matters. They may defer to the authority of those in the practice team who are, after all experts in health care, but that does not necessarily mean they agree with what you are saying. The values of harmony and respect may be more important than expressing disagreement.

Unfortunately, this desire for consensus in no way means that once the patient is out of your presence they will proceed with the treatment plan, so it is important not to interpret "yes" or silence as agreement.

Best practice tip: Using open questions is a good approach to check a patients understanding. For example, you could say, "to make sure we’ve covered everything, can you tell me what you understand about…".

Best practice tip: Consider printing out the consultation notes for your patient to take away with them.

Some Māori may prefer to communicate in their own language

Dr Rawiri Tipene-Leach says that many of his elderly Māori patients prefer to communicate fully in Māori language (Te Reo Māori) as this allows them to tell their story in their own context. This leads to very trusting, effective relationships where patients are more likely to report health outcomes. However, as most GPs are unlikely to be conversant in Te Reo Māori, this may be difficult to implement. The use of translation services can be an option where available.

Written patient information in Te Reo Māori can be useful, however it is important not to assume that all individuals are literate in Te Reo Māori. Anecdotal evidence shows that the most popular resources contain partial translation of common recognisable terms.

Engaging patients in their health issues

One of the barriers to health care for Māori, in fact for many people, is getting them to make an appointment with their doctor in the first place. Once there, it cannot be assumed that the patient will return regularly, so it is important to regard each encounter as an opportunity to engage people in their own health care and address wider issues.

As a clinician your skill is to reflect that anecdotal evidence and incorporate both views into a management plan - your view which incorporates the clinical and scientific perspective and that of your patient, which may have a particular cultural slant.

Practices or individual GPs can develop their own processes for addressing health issues, regardless of the reason for the patient encounter. Some examples may be:

• CVD risk assessment for patients presenting with gout
• Smoking cessation advice for patients presenting with "winter ills"
• Blood pressure check when attending for asthma inhaler repeat

Often time constraints will prevent GPs from addressing multiple issues within one appointment. Simply flagging a patient for later review is a step in the right direction.

Agree on realistic patient health goals

A good way to approach a health issue is to break it up into manageable pieces and deal with one thing at a time. Often patients will resist change and it is difficult to implement several changes at once.

Realistic goals are pertinent to the patient, achievable and measurable.

Set patient centred goals

Clinical goals are not always relevant to the patient. It may be more meaningful to a person with asthma, to set a goal of completing a netball game without breathlessness, than focusing on improving peak expiratory flow rate.

The framework, Te Whare Tapa Wha, describes the four cornerstones of Māori health; spiritual, psychological, physical and family. This is maybe be useful framework on which to establish patient centred goals (see BPJ 11).

Set goals that are achievable

Goals should be achievable and built upon as the patient makes treatment gains. For example, an activity goal for a person with heart failure may at first be to walk to the letterbox without being out of breath. This activity goal can be increased once treatment has begun to have an impact on the illness.

Set goals that are measurable

You can only know when a goal has been achieved when it is measurable. For example reaching target uric acid levels in gout, finishing a netball game without breathlessness, reducing rescue inhaler use to three times a week.

Make it easy for patients to come back

Give patients a reason

Use patient centred goals to give patients a reason to come back to measure progress and set new goals. Validate the reason for their attendance. Make a follow up appointment at the time if possible, otherwise put them on the recall list.

Use reminders

Depending on what you have agreed upon with your patient previously, phone, text, email or write to remind them of appointments or recall them for follow up. Create an expectation that they will attend.

Make the environment welcoming

It may seem unimportant but how at ease patients feel in your waiting room may determine how likely they are to come back.

Consider barriers to access

Financial barriers may be an issue for some patients. Consider how your practice could offer solutions to this barrier, for example setting up regular small payments or accessing targeted funding. Practical barriers may also include transport, getting time off work and child care. Possible solutions could be the use of volunteer drivers or courtesy vans, flexible clinic times and child friendly facilities.

Form partnerships

Whānau often have an important role in healthcare

Know what part whānau play in the healthcare of your patient. The person taking responsibility is not always the patient, or in the case of a child, it is not always their parent. The role of the patient may be to receive treatment, while the role of whānau may be to support the patient and communicate with the doctor. Welcome whānau participation in consultations and involve them in treatment decisions and goals. Whānau may be helpful in assisting you to ensure that information has been understood by both you and your patient and an agreed plan is in place.

Māori health providers

Māori providers range from sole practitioners for example some Rongoā providers, to large organisations for example Māori PHOs, Ngāti Porou Hauora.

There are around 240 Māori health providers delivering a range of health and disability services throughout New Zealand. These services include Tamariki Ora (Well child checks), Whānau Ora (supporting at risk whānau), disease state management (assisting people with chronic conditions such as diabetes and respiratory disease) and Aukati Kai Paipa (smoking cessation).

Primary care clinicians can use Māori health providers to complement the services they already provide and to ensure a more holistic approach. This may especially be of benefit for patients in rural areas or where access (financial, cultural or transport) is an issue.

If you are unsure who the Māori providers in your area are, then details can be found at: www.maorihealth.govt.nz or through your DHB.

Encourage and support community initiatives

Consider investing time in the wider community in which you practice. In a Māori community time spent attending marae and community events will strengthen relationships.

Many practices have established initiatives with local community groups, schools or businesses, for example "Ngāti and Healthy" (see Cardiovascular disease and diabetes in Māori).

Remember: It’s not too hard. Any step you take is better than doing nothing at all.