Appendix 2 Statement on best practices when providing care to Maori patients and their whānau



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Appendix 2 - Statement on best practices when providing care to Maori patients and their whānau



Revised draft, proposed amendments have been tracked



Purpose of this statement





  1. This statement outlines the attitudes, knowledge and skills relevant to doctors in their dealings with Māori patients and their whānau (families). This resource has been developed to enable doctors and Māori patients to achieve optimum outcomes. It may be used by the Health Practitioners’ Disciplinary Tribunal, the Council and the Health and Disability as a standard by which conduct may be measured.




  1. This resource should be read in conjunction with the Council’s Statement on cultural competence. A resource booklet entitled Best health outcomes for Māori: Practice implications has also been developed which addresses the disparity between mainstream and Māori health outcomes, discusses cultural concepts and provides advice for doctors.



Introduction





  1. Doctors in New Zealand work with a population that is culturally diverse. This is refl ected by the many ethnic groups within our population, and also in other groupings that patients may identify with, such as disability culture, gay culture or a particular religious group. The medical workforce itself includes many international medical graduates and a variety of ethnic groups. Cross cultural doctor-patient interactions are therefore common, and doctors need to be competent in dealing with patients whose cultures differ from their own.




  1. Patients’ cultures affect the ways they understand health and illness, how they access health care services, and how they respond to health care interventions. The purpose of cultural competence is to improve the quality of health care services and outcomes for patients.




  1. Benefits of appreciating and understanding cultural issues in the doctor-patient relationship include:

  • Developing a trusting relationship.

  • Gaining increased information from patients.

  • Improving communication with patients.

  • Helping negotiate differences.

  • Increasing compliance with treatment and ensuring better patient outcomes.

  • Increased patient satisfaction.




  1. Cultural appreciation or understanding also has the potential to improve the efficiency and cost-effectiveness of health care delivery.



Health and other disparities





  1. Research shows that numerous disparities exist between Māori and non-Māori:




  • Avoidable death rates are almost double for Māori than for other New Zealanders, and Māori die, on average, 8–10 years earlier.

  • Māori have a higher rate of disability, illness and serious injury.

  • Māori have reduced access to medical care and rehabilitation services12.

  • Māori have lower injury claim rates.

  • Māori obtain fewer referrals, fewer diagnostic tests, and less effective treatment plans.




  1. These overall disparities in Māori health persist even after allowing for confounding factors such as poverty, education and location, suggesting that culture is an independent determinant of health status and access to services.




  1. Research shows that Māori are at greater risk from certain illnesses:




  • Excess cancer deaths among Māori account for two thirds of the excess male cancer deaths and one quarter of the excess female cancer deaths in New Zealand, compared to Australia.

  • There is a higher incidence of obesity in the Māori community, which contributes to higher incidence of diabetes (eight seven percent for Māori, three percent for other New Zealanders).

  • Māori infants die more frequently from SIDS and low birth weight than non-Māori children.

  • Māori women have rates of cervical and lung cancer that are at least twice those of non-Māori women.




  1. When evaluating presenting problems and developing a working diagnosis, doctors should be conscious of the increased incidence and prevalence and the presentation at a younger age of many conditions in Māori patients.




  1. Studies demonstrate that some doctors treat Māori differently from non-Māori, most often due to cultural (mis)understanding and unconscious bias. For example, two percent of Māori diagnosed with clinical depression were offered pharmaceutical intervention compared with 45 percent of non-Māori patients with the same diagnosis3.


The impact on Māori of differential approaches to treatment and care





  1. Māori make up 14.715.4 percent of the New Zealand population (as of 200120124). The poor state of Māori health has widespread impact on New Zealand society, both in terms of avoidable human suffering and financial expenses of lost work days and increased health care expenditures.




  1. Different standards of health care not only cause poor outcomes for individual Māori, but also affect their whānau, and may influence the entire community’s perceptions and future behaviour.



Key issues for Māori





  1. Like other ethnic groups, Māori demonstrate diversity across communities and between individuals. Doctors should learn the preferences of each patient, Māori or non-Māori, and strive to put them at ease in order to create and sustain a respectful, trusting therapeutic relationship. Most patients consider that respectful questions about cultural background and preferences demonstrate the doctor’s concern and respect.




  1. Some areas where cultural differences may arise and cause confusion or misunderstanding with a Māori patient and their whānau include:




  • Interpreting and sending non-verbal signals.

  • Methods of expressing agreement and disagreement.

  • Communicating medical information.

  • Presence and inclusion of family members in medical settings.

  • The use of karakia (prayers).




  1. Māori culture emphasises familial and community ties, and a world view that acknowledges the wisdom of the past as well as connections to the present, through historic places, ancestors, and the physical world. Doctors should keep this in mind to help understand the behaviours of many Māori patients.



Māori culture competence standards and educational framework





  1. To work successfully with patients of different cultural backgrounds, a doctor needs to demonstrate the appropriate attitudes, awareness, knowledge and skills.




  1. Attitudes




  1. A willingness to try and develop a rapport with Māori patients. The most effective way to understand the communities you serve is by establishing relationships with local Māori, including Māori health professionals in your area. Attending hui (meetings), sports activities, and community events at local marae will further strengthen the doctor-patient relationship.




  1. A preparedness to ask patients about their preferences and a willingness to follow their lead. Traditional Māori practices, such as reciting a karakia before a medical procedure, may be desired by a patient and/or their family.




  1. Awareness and knowledge




  1. An awareness that assumptions based upon skin colour or appearance can be misleading.




  1. An awareness that Māori tradition strongly prefers face to face communication. On initial meetings, this manifests as an expectation of formal introductions before proceeding to the purpose of the visit. Moving too quickly to the ‘problem’ before some initial sense of contact has been established can result in withdrawal or undue passivity.




  1. An understanding that Māori place great emphasis on the spoken word. The proper pronunciation of names is seen as a sign of respect. If unsure about the pronunciation of a Māori word, ask for help before attempting to say it. Admitting uncertainty and asking for guidance shows an understanding of the importance of names in Māori culture and demonstrates respect for heritage.



  1. An awareness that body language can be different between Māori and non-Māori. For example, direct eye contact can be seen as a sign of disrespect in Māori culture, and for this reason a Māori patient may choose to look at a neutral area of the room while speaking or listening. Do not automatically interpret a lack of eye contact as anxiety, anger, boredom or fear. It may represent any of these, or could be a sign of respect to you as a doctor. If you are unsure about this or any other non-verbal signals, ask your patient.




  1. Skills




  1. The ability to ask patients about their ethnic background. Asking the question demonstrates not only respect for the patient’s individual heritage, but provides an opportunity to discuss their cultural preferences.




  1. The ability to involve whānau when a patient brings them to a consultation. In addition to providing comfort to the patient, the presence of other whānau members at consultations can lead to improved care by providing additional background information during the medical history, helping the patient to understand your instructions, and assisting the patient in carrying out treatment plans.




  1. The ability to ensure that patients understand their condition and treatment plan, and not to simply rely upon printed instructions. Māori communities sometimes have lower rates of literacy in English than non-Māori.




  1. The ability to seek advice when appropriate. Tangihanga (mourning and funeral rites) are important and complex so whenever possible ask the whānau spokesperson (or the patient) about their preferences. Māori staff or knowledgeable community members may also be able to help determine the family’s wishes. A medical team’s ignorance of Māori practices could unintentionally make a difficult time for the family infinitely harder.


Related Council statements and resources





  • Statement on best practices when providing care to Māori patients and their whānau




  • Best health outcomes for Māori: Practice implications



1 Harris R et al. Effects of self-reported racial discrimination and deprivation on Māori health and inequalities in New Zealand: cross sectional study. The Lancet vol. 367, issue 9527, 17 June 2006, pg 2005-2009.

2 Ministry of Health. The Health of Māori adults and children. March 2013.

3 Arroll B et al. Depression in patients in an Auckland general practice. NZMJ 2002 April 26;115 (1152): 176-9.

4 ACC (Te Kaporeihana Awhina Hunga Whara). Summary Guidelines on Māori Cultural Competencies for Providers. 2004. Wellington, ACC. Statistics New Zealand. Māori population estimates, 15 November 2012.


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