Although Maori health status has improved over time, disparities between Maori and non-Maori remain. Modern threats to health emerge replacing the old health problems. Cardiovascular disease, diabetes and cancer are three main burdens of the contemporary health problems for Maori. Cardiovascular disease, a general term for heart-related and blood-related diseases, is a leading cause of death in New Zealand. Diabetes is almost three times more common in Maori than non-Maori and the majority of Maori with diabetes have type 2 diabetes. Cancer is a significant health concern for Maori as Maori had a higher risk of death from cancer after diagnosis. The factors affect Maori health statuses include socioeconomic environment, lifestyle and access to the health services. Auckland is the main region I will focus on for data collecting as it has the largest population.
Te Tiriti o Waitangi and Maori health model
Te Tiriti o Waitangi was signed on 6th February, 1840 by representatives of the British Crown and some Maori chiefs and it includes four principles partnership, participation, protection and permission (Waitoa, 2014). The treaty of Waitangi is a unique aspect of Maori health development. It was not until mid-1980s the Treaty was applied in relation to social and economic areas (Durie, 2011). However, low standards of health, education and household income are not convincible for Maori to have faith in the Treaty’s guaranty of ‘equal rights and privileges’.
Te Whare Tapa Wha is one of Maori health model that being widely using in the clinic. The model not only supports Maori to sovereign over their own health but assists non-Maori to understand the way Maori consider their health from their perceptions (Waitoa, 2014). Te Whare Tapa Wha focus on a holistic nature of health and it compares good health to the four walls of the whare which is balancing between Wairau, hinengaro, tinana and whanua (Durie, 2011). The approach emphasizes on diverse needs in the community. Consequently, improving health status of Maori is to address the needs of the whole community.
In this chapter I outline the methodology and research methods utilized in the research, and ethics consideration for undertaking the research along with explanation on how the research data and information was analyzed.
This study intended to outline the health status disparities between Maori and non-Maori, and analyze the possible causes that contribute to the disparities. To collate enough information and data to utilize to the research, the research methods would be applied as follow: a literature review, interviews (face to face), data analysis.
One Maori model of health was outlined. Three health burdens falling in Maori, which are cardiovascular diseases, type 2 diabetes and cancer, were reviewed. Current Maori health status was outlined. Factors associated with Maori health outcomes and barriers for Maori access to both primary and secondary services were discussed. The intention of the literature review was to assist the reader to acknowledge the three health issues that affect Maori health as well as the factors contributed to the poorer health outcomes of Maori group.
The research’s intent was to locate the possible causes leading to poor health status in the Maori point of view, to acknowledge the barriers for Maori access to the health services, to examine how Maori health model affect the health. Interviews would be conducted in one hapu in Auckland due to time limitation. The selection of participants was random and focused on senior group. Interviewees were asked about their view on the current Maori health status, the factors affect Maori health status, barriers to access to the health services as well as how would Maori model benefit the health.
As large amount of similar researches have been conducted, it would be convenient to gather the data through internet. Data would be collected on the government websites, related books and online journals. Significant disparities would be outlined to help with understanding of the trend and data would be used in comparison with Maori and non-Maori health status.
The health circumstances of indigenous people vary according to a multitude of dynamic factors that affect every aspect of their life. These factors include their historical, political, social and economic circumstances. The changing trends and paradigms of Hauora Maori are complex and they have gone through significant change over the past few decades. Colonization has played a vital role in the drastic change hauora Maori has gone through but it does not have just a simple explanation. To date socio-economic conditions, varying lifestyle, the availability and access to healthcare and their continued discrimination all play a part in the dynamics of hauora Maori.
Three Health Issues Affecting Maori in Auckland Region
Cardiovascular diseases (CVD) include all forms of vascular and heart disease. Although death from cardiovascular diseases is decreasing in Auckland and even in the whole nation, it is still the leading cause of death among all ethnicities and all socio-economic levels. According to the survey conducted by Auckland District Health Board in 2003, being one of major causes of death for both sexualities, it accounts for 39% of death in the Auckland DHB region. Maori and Pacific islanders are disproportionately affected. ‘In 2005, Auckland DHB’s age-adjusted mortality rate of CVD was 225 per 100,000 people, 9% less than the national rate of 246 and ranked the fifth lowest among all the 21 DHBs’ (Auckland District Health Board, 2006). CVD is causing approximately 40% of all death in New Zealand (New Zealand Guidelines group, 2003). The prevalence in Maori is more than two times than in non-Maori for both males and females. The mortality rate of cardiovascular disease was 139.8 per 100,000 in Maori compared with 61.2 in non-Maori. For males, the death rate was 170.0 per 100,000 in Maori while it was 78.2 in non-Maori. For female, the death rates for Maori and non-Maori were 109.7 and 44.2 respectively. (Curtis, Harwood, Riddell, 2007). The Health Improvement Plan of ADHB (2006-2011) states that the modifiable risk factors of CVD are smoking, diabetes, hypertension, high cholesterol, obesity and physical inactivity whereas Non-modifiable risk factors are heredity, ethnicity, age and gender (Auckland District Health Board, 2006).
Diabetes is a complex multi-system metabolic disease and there are three types of diabetes named type 1, type 2 and gestational diabetes. Type 2 is the most common diabetes in the world which takes up more than 90% of all the diabetes. It is a high priority for the MoH. As it is mentioned in Diabetes Workforce Service Review (2001), diabetes prevalence is increasing at a rate of 8%-9% compounded per year in the nationwide. Meanwhile, the prevalence is higher in Maori, accounting for 5%-10% compared to other ethnics. There is also an increasing rate of younger ages being diagnosed Type 2 diabetes. (The Diabetes Care Workforce Service Review Team, 2011) According to Maori Standards of Health IV, the prevalence is three times in Maori than non-Maori, and death rates due to diabetes in the age group 45-64 years for Maori are nine times higher than that for non-Maori in New Zealand. In addition, Maori are likely to be diagnosed younger and develop diabetic complications (Harwood, Tipene-Leach, 2007). The Health Improvement Plan of ADHB (2006-2011) states that 14,000 Aucklanders are affected by diabetes with the prevalence increasing at a dramatic rate. Obesity, high blood pressure, gout, high cholesterol, and heart disease are the factors lead to diabetes (Auckland District Health Board, 2006).
Cancer refers to a range of diseases caused by out-of control cell growth that affect different sites in the body (AIHW, 2004). Due to a growth of population and the aging of the population, the number of people developing cancer is increasing in New Zealand. ‘About 16,000 New Zealanders develop cancer each year, while about 7,500 die from cancer'(Ministry of Health, 2005). The burden of cancer falls disproportionately on Maori. For the period 2000-2004, the age-sex-standardized prevalence rate of cancer for Maori was 9% higher than non-Maori, which is 219.0 per 100,000 population to 200.5 per 100,000. For the same period, the age-sex-standardized mortality rate of cancer for Maori was 117.5 per 100,000, which is 77% higher, compared to 66.3 per 100,000 for non-Maori (Cormack, Purdie, Robson, 2007). Factors contributing to the disparities in survival for a number of specific cancers between Maori and non-Maori include differences in exposure to risk, protective factors, in access to high quality treatments (Jemal et al, 2005).
Explanation for Health Disparities
One common explanation for health disparities between Maori and non-Maori is genetic factors (Hall, Stewart, 1989). Genetic factors have always been considered in diabetes and some cancers. However, to what extent genes contribute to the disease is unknown (Harwood, Tipene-Leach, 2007). Other factors including culture diversity, socioeconomic factors, educational achievement, lifestyles, access to health care and discrimination have been widely used for explain the disparities and inequalities in health outcome (Durie, 2007).
As a group, Maori are over-representation in the lower socioeconomic class. Apart from their employment, income levels are significant lower than non-Maori, other reasons such as disability and sole parent households also lead to socioeconomic disadvantages. ‘Maori are twice likely to receive an unemployment benefit’ (Durie, 2007). Socioeconomic factors such as income, employment, and housing as well as education level strongly affect health status. At the 1991 Censes, the unemployment rates for Maori accounted for 24.2%, compared to 9.0% for non-Maori. In 1991, 40% of Maori children under 15 year-old living in sole parent families, which increased from 19% in 1981. (Davey, 1993) In 2001, only 31.7% Maori owned or partly owned their houses compared to 59.7% of Europeans (Statistics New Zealand). The relative weakness in socioeconomic position of Maori in New Zealand society results in Maori inferior health status (Pubic health Association, 1992).
The gap of educational achievement between Maori and non-Maori is significant. Maori participation in education has increased rapidly. There is an increase in participation in early childhood education, staying at secondary school for sixth and seventh years as well as tertiary education. In 1993, 34% of Maori students left school without a formal qualification while that of 53% in 1986 (Ministry of Education, 1994). However, Maori tend to be enrolled in shorter courses rather than graduate with a degree. In 1996, compared to non-Maori graduates (31%), 22% of Maori graduated with a post-graduate degree or diploma. Meanwhile, Maori females surpass males at tertiary institutions (Durie, 2001). Educational underachievement is directly related to unemployment, low income, nutrition options that would lead to further disadvantages caused inferior health status of Maori.
Some specific behaviors have negative impact on health outcomes such as smoking, alcohol and drug abuse, inappropriate diet and lack of exercise. A national survey has shown that 53% of Maori use tobacco, compared to 20% of non-Maori (MoH, 1999), the prevalence for Maori is higher in females than in males (Reid, 1993). Inappropriate diet contributes significant to diabetes, cardiovascular diseases and cancer. Although Maori exercise at about the some rate as non-Maori, some urban communities have lower levels of physical activity (Pomare et al, 1995). Due to inferior socioeconomic status, some Maori families cannot afford healthy food options as well as urban environment can prevent active lifestyle (Auckland Distract Health Board, 2006). Maori have a different drinking pattern from non-Maori. Maori drinks less frequently than non-Maori. However, on these occasions, the amount of alcohol consumed by Maori is nearly twice as much as non-Maori (Pomare, de Boer, 1988). In Auckland region, the data shows that alcohol use among Maori youth is less than in non-Maori youth (Auckland Regional Public Health Service, 2005).
Access to health care
30%-40% of excess mortality from diseases among Maori is preventable from available health care. High incident rate in Maori compared to non-Maori reflects differences in access to health care (Smith, Pearce, 1984). Maori and non-Maori access to both primary and secondary health care services differently. Research has shown that Maori are less likely to visit a general practitioner when health care is taken in to consideration, although the rate for GP visits is 12% higher than for the whole population (O’Dea, 1993). The barriers to access health services are addressed such as cost, transport, acceptability of the service and culture diversity (Pomare et al, 1991). According to a study at Middlemore hospital, the costs of travel were considered by 22% of patients as a reason for non-access to the health services (McClellan, Garrett, 1989).
International racial discrimination is viewed as a vital factor influence health and inequalities in New Zealand (MoH, 2002). Results from a national survey conducted among adults (15 years and older) about racial discrimination showed the prevalence of experiencing discrimination in Maori is the highest amongst all other ethnic groups and it directly relates to poorer health outcome (Harris et al 2006b). In the survey, 4.5% of Maori reported ever being treated unfairly by a health professional compared to 1.5% of non-Maori reported who had the same experience (Harris et al 2006a). The Maori Asthma Review reported that the attitude of doctors contribute to a reluctance by Maori to access to the health services (Pomare et al 1991). Doctors have been showed to be more likely to advocate non-Maori patients about their health than Maori patients (Mitchell, 1991), and compared to non-Maori, Maori receive lower than expected levels of quality cares (Malcolm, 1996).
The burden of cardiovascular disease, diabetes and cancer fall heavily on Maori people. Cardiovascular disease accounted for one third of all Maori deaths as the single most important cause of death. The modifiable risk factors of cardiovascular disease related to facilitate lifestyles. Over-representation in the lower socioeconomic class, Maori group tends to diet inappropriately resulted in diabetes, hypertension, high cholesterol and obesity which can cause cardiovascular disease. At the same time, high smoking rate and alcohol and drug abuse enhance the potential of gaining cardiovascular disease. Diabetes was accounting for 7% of Maori deaths. Unbalanced dieting contributes to diabetes. Maori presents poor education achievement that not only affects food preference but relates to employment rate and income level. As a result, the prevalence of diabetes in Maori is three-fold. Cancer is the leading cause of death in Maori women accounting for over a quarter of Maori deaths. Maori is exposed to risk. Maori are less likely to access healthcare services. On one hand, Maori considers about cost as some of them are not economically sustainable. On another hand, Maori considers cultural diversity as their model of health, Te Whare Tapa Wha for example, is not practiced and is concerned about the healthcare services provided by European doctors.
Treaty of Waitangi brought a significant influence on Maori people in New Zealand and non-fulfillment of Treaty concepts and obligations takes some responsibility of Maori inferior health status. However, inequalities in health outcomes do not occur because of one specific factor, the health disparities between Maori and non-Maori is socially, economically and culturally inferior as noted by high level of unemployment, low income, low house ownership, poor educational achievement, and risk-taking lifestyles. Besides, unequal access to primary health services and unequal success with interventions also contribute to Maori poor health status. Consequently, in order to improve the health of Maori, Maori-led programs should be designed to improve all aspects that affect Maori health. Maori provider organizations should be spread to meet the culture need of Maori so that it improves Maori access to healthcare services. Education in Maori should be focused as education is important to socioeconomic factors. Improving Maori education level in general equals to promoting employment, income as well as housing ownership that would reduce the feeling of whakama and discrimination and hinder the health status of Maori.
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