MĀori outcomes: expectations of mental health services1



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MĀORI OUTCOMES: EXPECTATIONS OF MENTAL HEALTH SERVICES1
Loma Dyall2

Geoff Bridgman3

Anaru Bidois4

Henare Gurney5

Jenny Hawira6

Phyllis Tangitu7

Wi Huata8


INTRODUCTION


The purpose of this paper is to provide a broad overview of Māori expectations of mental health services in light of the growing number of Māori, both males and females, being admitted to in-patient and out-patient mental health care. The paper supports previous ministerial inquiries (Mason et al. 1987, 1996) and Māori views expressed through hui (meeting) (Department of Health 1991) and in different forums (Māori Mental Health Summit 1997) that there is a need to develop mental health services which are culturally appropriate and effective for Māori.


The paper also supports the watchdog role of the Mental Health Commission (1998) to advocate on behalf of Māori. The authors also argue for key service components to be included in the provision of all mental health services, such as:

  • the opportunities for a cultural assessment,

  • tangata whaiora (mental health consumer) and whanau (family) involvement in planning and care,

  • provision for the use of te reo (Māori language), and

  • the development of environments and processes where tikanga Māori (Māori cultural values) can be acknowledged.

We believe that these key service components describe the quality of mental health care Māori should expect. However, when reviewing the Ministry of Health (1997) and the Health Funding Authority’s (1998) planned targets we find that, for example, only 50% of Māori adults in 2005 can expect to have the option of choosing a Māori or mainstream mental health service — very conservative targets, in our opinion. Furthermore, the proposed Health Funding Authority (HFA) funding for the future development of kaupapa Māori mental health services only increases from 5.3% of the total mental health budget in 1998/99 to 6.4% in 2001/02.


In 1996, Te Puni Kokiri (Ministry of Māori Development) released a report "Trends in Māori Mental Health 1984–1993", which built upon a previous document released in 1993. Both reports have highlighted that Māori have different patterns of admission and discharge to mental health services in comparison to non-Māori.9
For example, in 1993 Māori had a higher likelihood of being admitted for alcohol and drug abuse problems and, if readmitted, a higher chance of being given a new diagnosis, such as, being schizophrenic or psychotic. Nationally, non-voluntary admissions for Māori were double that for non-Māori. Māori trends also suggested that the current mental health status of Māori is directly related to the social, economic and political position Māori occupy in New Zealand and as a group. "Māori culture is under siege" as result of past colonisation and assimilation policies (Te Puni Kokiri 1995, Durie 1997).
This paper presents findings from research in progress concerning Māori outcomes and expectations of mental health services. The research is based on a series of focus groups held in Rotorua, in 1998, with different Mäori stakeholder groups. The participants were Māori tangata whaiora, whanau members, and mental health workers. The study is unique for the range of participants that have been asked to assess the clinical and broad health outcomes mental health services achieve in New Zealand. A recent hui called by the Health Research Council in 1997 also has revealed that little research has been undertaken in relation to Māori mental health.
The organisation of these focus groups was part of a collaborative research project investigating the outcomes Māori and non-Māori consumers expect from mental health services in New Zealand. This research was undertaken in partnership with Lakeland Health, the major Crown mental health service delivery organisation in the Rotorua area and with Te Mana Hauora o Te Arawa, an independent local Māori organisation which has wide community and tribal links.10
All participants of this part of the study have identified themselves as Māori, and their views provide insight into Māori expectations of effective mental health services.


MENTAL HEALTH OUTCOME RESEARCH IN NEW ZEALAND


Since 1996, the Health Research Council of New Zealand has invited researchers to submit proposals to initiate research in specific areas that are considered important for the future development of mental health services in New Zealand. One of the areas identified is the need for the development of appropriate tools that can be used in New Zealand to assess whether mental health services are achieving the best outcomes for consumers. For any instruments to be valid in New Zealand, it has been recognised that they need to be supported by both Māori and non-Māori consumers and significant others.11


Rosenfield (1998) suggests that "outcomes research" deals with "all identified changes in health status and quality of life arising as a consequence of how a health problem is handled." Health status is defined as the "degree to which a person is able to function physically, emotionally and socially with or without aid" and quality of life is defined as the "degree to which persons perceive themselves able to function" (p.99).
The research investigated the following questions:


  1. What are Māori and non-Māori expectations of mental health services?

  2. Can selected overseas instruments for assessing outcomes be used in New Zealand?

  3. How do these instruments need to be modified to make them relevant to both Māori and non-Māori?

  4. How should adapted instruments be used in New Zealand, who should use them and in what setting?12

Information presented in this paper relates specifically to Māori expectations of mental health services. Further papers are planned which will compare Māori and non-Māori views and will evaluate participants’ responses and feedback to instruments selected for study.




ROTORUA: CULTURAL HEART OF NEW ZEALAND


"Ko Te Arawa e waru pumanawa"

"The eight beating hearts of Te Arawa"

Rotorua is often described as the Māori cultural centre of the world and the place where Māori tourism is most visible. As a town, it is also fortunate in that it has a strong mana whenua presence and is the centre for the confederation of tribes, which link to the Te Arawa waka. Six predominant iwi in the area are Tuhourangi, Te Ure 0 Uenukukopako, Ngati Pikiao, Ngati Rangitihi, Te Rangiteaorere and Ngati Tahu/Whaoa.


Rotorua district is the home for approximately 22,000 Māori (1996). Māori account for over a third of the population and the percentage of Māori is over twice that of the national average of 15% (Statistics New Zealand 1997).
In recent years, Rotorua has experienced significant economic and social restructuring, with many Māori families dependent upon income support, or employment that is seasonal or contractual for a limited period. Māori health status in this area is no different than the general health of Māori in other parts of the country, for example, experiencing problems associated with drug and alcohol abuse, a growing rate of injuries and increasing disability as chronic health and aging problems increase. Māori health status is increasingly being seen as a reflection of the socio-economic and cultural position of Māori in New Zealand (National Health Committee 1998).
Taking account of unique features of the Rotorua area, it was expected that local mental health services would be sensitive to needs of Māori and would be contributing to the results or outcomes local Māori wanted. However, the findings of this study suggest that although Māori culture may be visible as a commodity and resource generally in Rotorua, this development has not occurred sufficiently at a local level in mental health to meet the expectations of Māori stakeholders.


METHODOLOGY OF THE RESEARCH


Focus groups were used to explore with all participants their expectations of the outcomes13 mental health services should achieve. Focus groups have not been used widely in international mental health research (Bridgman et al. 1998), but increasingly they are being seen as an approach that allows different groups, with a common identity such as age or stakeholder interest, the opportunity to discuss a particular issue and come to a collective view on it. In using this methodology, we have found focus groups are an effective way of empowering tangata whaiora, whanau members and Māori staff to contribute and be recognised as "experts" as well as participants in research (Dyall and Bridgman 1998). Focus groups also support Māori processes of participation in decision- making, such as holding hui (meetings) and allowing participants to contribute freely according to a defined issue for discussion.


The research involved, firstly, selecting a sample from Lakeland Health’s register of Māori who have been admitted to mental health services. The 40 tangata whaiora (Māori mental health consumers) living in the Rotorua city area, through an informed consent process, were invited to participate in one of four different focus groups, each group meeting twice.
The participants were selected, using stratified random sampling, to reflect as far as possible the national profile of Māori, in terms of age, gender and diagnosis, who were admitted to in-patient mental health care in 1993. This profile was chosen because it was the latest statistical data available in 1998, and information obtained could be considered from both a local and national perspective.14 Individuals were only excluded from the study if they were currently on the "crisis list" and considered too ill to participate.
With the approval of tangata whaiora the researchers then approached nominated whanau (family) members to invite them to participate in a whanau focus group. The objective was to enroll at least 10 whanau members, who provided support for tangata whaiora involved in the focus groups. An additional focus group was established for local Māori mental health workers.
Six different focus groups, with up to 10 participants in each, were established:

  • Rangatahi (young people): under 23 years of age (This group was predominantly male, reflecting the pattern of in-patient admission for Rangatahi.)

  • Wahine (women): 23—37 year age group

  • Tane (men): 23—37 year age group

  • Pakeke (older people): 37 years and over

  • Whanau (family members ), and

  • Māori mental health workers

A consistent set of questions was used as the basis for discussion for all focus groups, covering nine broad themes:



  • the meaning of wellness and unwellness,

  • the meaning of recovery,

  • the meaning of culture and its importance in service delivery,

  • the role and contribution of whanau, family and friends,

  • the role of the community,

  • the measurement of mental health outcomes,

  • the relationship between outcome measures and mental health policy, and

  • the evaluation of specific mental health outcome measures.

A member of the research team facilitated each focus group’s discussion, audiotaped and observed by a note taker. All participants were given the opportunity to provide feedback on the information collected in their own focus group and to comment on the overall themes emerging from the research.15 Notes, verified by participants as accurately representing their views, provided the basis for this paper and further analysis of the transcripts of tapes is in progress. It is planned, in future, to look at the key themes that emerge from these focus groups and compare them to the non-Māori focus groups.


To support tangata whaiora to participate in the research two local Māori consumer researchers were employed as part of the research team, in line with guidelines for ethical research in mental health (Mental Health Commission 1999). These members of the research team played a pivotal role in gaining the confidence of tangata whaiora to participate in the research.
Each tangata whaiora and whanau member who participated received a koha (gift of love) of $30 for each focus group session. In receiving a koha, participants commented that they appreciated being valued for their expertise and the insights that they could offer.
Many tangata whaiora and whanau members also commented that this was the first time that they had been consulted as to what outcomes mental health services directly or indirectly should be achieving on their behalf. This was a surprise to the researchers, for some tangata whaiora and whanau members had been mental health clients for a decade or more.
All focus groups, with the exception of the one for Māori staff, were held on a marae. Each focus group respected Māori protocol, with time set aside for powhiri (welcome), kai (food) and poroporoaki (farewell). These arrangements increased Māori participation, as did assistance with transport. 16


FINDINGS


The views expressed by participants through each of the focus groups are discussed in the sections below. The quotations in the text are excerpts from the notes taken during the focus groups and were verified by the participants as accurately expressing their views.



Rangatahi

"Ka Pu te ruha

Ka hao te Rangatahi"

"The old net lies in a heap

while the new net goes fishing"
Te Puni Kokiri (1997) reported that Māori youth, both males and females, were increasingly being admitted to in-patient mental health services for alcohol and drug abuse, and psychosis. Participants in this focus group reflected this trend.
Rangatahi have high expectations of the quality of life they want, for example, "the opportunity to work, to have their own place, to be in control of their life, to be on the ball, to have peace of mind and, overall, to be happy."
In being mentally unwell, Rangatahi acknowledged that sometimes their illness limited their ability to function, such as, "not being able to focus", "the need for medication" and, as a result of their mental state, they experienced "astral travelling". This last was described as "where the mind travels but the body is grounded". The issue of spirituality and the relationship it has to being Mäori was seen often by this group as the underlying cause of their illness or pathway to wellness.
Rangatahi were critical of the quality of care and the environment in which mental health care was provided for them. To achieve positive mental health for Rangatahi, they requested more:


  • Māori doctors and health workers,

  • involvement of kaumatua,

  • "Māori faces for Māori cases at Māori places",

  • Māori culture to be part of their treatment and recovery process,

  • sport to keep the body and mind fit and healthy,

  • Māori advocates to go between tangata whaiora, the whanau and the health system,

  • involvement of whanau in care,

  • Māori icons to be visible,

  • music, and

  • research into Māori medicines which could be used in mental health.

They also asked for the establishment of a "buddy system", Māori activities to be available, and staff who could be "mother figures", rather than young women who raised their sexual interest. They explained that many of the nurses who provided care for them were of a similar age to them and were often visible at pubs and clubs where they socialised. As a consequence they felt "whakama" (shy) in front of them, particularly in relation to personal matters.


Rangatahi demanded change. They wanted "urgently" the development of a "Māori mental health service" which had the "full involvement of Te Arawa" and which could utilise the many local marae available. They also wanted "Māori to take responsibility for our care and well-being", for often they felt excluded and "isolated from their own people." This was visible to them in the availability of educational scholarships for talented young Te Arawa people while no financial support was available for Rangatahi who had a mental illness.
Recovery was seen as a lonely process for Rangatahi with little support available. This feeling of isolation was reinforced by the mental health service constantly changing, such as, changing doctors who have "little heart" and who "treat us as just another statistic", and the limited communication they could establish with psychiatrists from overseas who were not fluent with New Zealand’s English and culture and who were difficult to establish relationships. As a consequence they did not share their real thoughts and their whanau encouraged them "not to speak to get out of hospital".
Culture was identified as central to the recovery of Rangatahi. It was suggested that "there is a need to totally overhaul Ward 4" (the acute admissions ward), and to recognise the whanau as central to our well-being whilst in in-patient care and in the community.

Wahine

"He wahine, he whenua, e ngaro ai te tangata"

"By women and land are men lost"
Participants in the Wahine focus group were aged between 23—37 years. They were typical of the many Māori women who have to juggle each day different roles and responsibilities, such as caring for children, maintaining links with whanau, managing social welfare to access health care, and managing their own health.
Being well for this group17 meant, "not being stuck at home", "able to do everyday chores", and having a sense of security that their children were not going to be taken away from them due to their illness. As well, their aim was to be independent and to live their lives without the "constant surveillance" and "intrusion" of the mental health service in their lives.
Being unwell often meant for Wahine, "having to ask for help from whanau members", having "your thoughts and actions reinterpreted", "having to accept medication" and having to "heal rifts your illness created amongst whanau members".
Recovery for Wahine meant, "getting well and able to get on with your life" and "being independent", "able to do things within your limits", and able to undertake education and training, and "having a job."
Wahine, like Rangatahi, know clearly the outcomes they expect from mental health services. Some examples were:


  • knowledge of what services are available locally,

  • the involvement of whanau,

  • access to a greater number of Māori key workers, and

  • a national Māori consumer network in place throughout the country which can be accessed anywhere.



Wahine also requested:

  • specific Māori activities for occupational therapy,

  • the police to be more educated and skilled to be able to treat tangata whaiora with respect,

  • greater economic and educational support for whanau so they can see and be involved in stages of recovery, and

  • greater support from health and social services so they don’t constantly have to fear losing their children.

Overall, it was considered the needs of Māori women were different from men and so they needed different support systems in place. Examples cited were, "Māori women need assurance that our kids are not going to be taken off us" and the new Māori women’s support group was considered "a great idea".



Tane

"E kore e hehekeheke he kakano rangatira"

"Our ancestor will never die, they live on in each of us"
Members of this group were male and similar in age to the Wahine focus group. Both focus groups were run at the same time and there was no criticism of these arrangements.17 Instead the specific Tane focus group gave participants the opportunity to discuss issues of importance to them.
Te taha wairua (spiritual matters) was at the forefront of the minds of Tane and this was an integral part of their well being. Tane have a clear view of the difference between spirituality and Christianity. Wairuatanga, or spirituality, related to their identity of being Māori, and belonging to a hapu or tribal group.
Being well for Tane meant, "keeping out of the in-patient mental health ward", "having peace of mind", "having balance between being Māori and Pākehā", being able to "cope with daily life" and "having wairuatanga"
To achieve positive outcomes for Tane the following were requested:


  • more Māori staff,

  • involvement of kaumatua and kuia (elders),

  • more respect and ability to control one’s own life,

  • more cultural understanding by the mental health system,

  • the public more informed and tolerant of mental illness,

  • greater recognition of the Treaty of Waitangi in action, not just in rhetoric, and greater involvement of whanau as valued members of the mental health team.

With the process of colonisation arid changes in the status of women in society today, many Māori men have been stripped of their traditional roles and responsibilities and have few of the symbols of male status in mainstream society. The position of Tane in New Zealand society affects their relationship with Wahine and with others, Men in this group, for example, did not talk about the importance of their relationships with women or children, but about their search for their identity instead. They considered "recognition of the Treaty of Waitangi" and the explicit partnership between Māori and the Crown was important and "needed to be reflected in the health care" they received. They concluded that the lack of recognition of the Treaty of Waitangi marginalised them and that it was time for Māori to develop their own mental health system.


Achievement and maintenance of wairuatanga was important for Māori men as it gave them self-esteem and respect. The majority of participants in this group living in Rotorua had no real hope of a permanent job, had no financial security, and saw for themselves a continued dependence upon government welfare and health services for support and accommodation.
A number of Tane did not want to live with others in supportive accommodation. They desired their own place, such as their own fiat where they could choose with whom they lived. It is often assumed that Māori do not have same aspirations as Tauiwi (non-Māori). However, for this group this was not true, they wanted to have the same choices as other citizens in the community (Te Puni Kokiri 1998).

Pakeke: Over 37

"Haere e whai i te waewae o Uenuku, kia ora ai te tangata"

"Good fortune comes to a man from the memory of going to the feet of Uenuku."
Pakeke included both males and females over the age of 37 years. In general, members had a long history of contact with the mental health services, and some had experienced long periods of institutionalised care, for example, at Tokanui Hospital. Together they had travelled many different painful paths, of which they hoped in the future many young people could avoid. This group expected and requested Māori tikanga to apply throughout the focus group process. Being well for this group meant learning how to conform to live in the community with their focus on "good hygiene", "taking my medication", following instructions from health professionals, and being able to cope and able to manage their illness, such as "not responding to hearing voices".
As a number of participants of this group had been institutionalised, being unwell could mean "not in control". Their expectations of mental health service were:


  • to be treated with respect,

  • to have access to health services when needed,

  • to have the opportunity to attend hui and social events which were important to them,

  • to have improved communication,

  • to have access to kaumatua and kuia,

  • to have more Māori activities such as kapa haka (Māori action songs) and te reo, and

  • to have opportunities for exercise.

From the collective experience of this group, Pakeke want to see the development of Māori mental health services by Māori for Māori, so that Rangatahi did not have to walk the same path that they had travelled. They could rely on their memory and experiences of being both Māori and a mental health consumer — as indicated in the whakatauki above. Participants in this group were the most experienced in the process and effects of custodial care on their health, and they were clear that radical changes need to be made in the mental health area. As a group they were willing to assist, for they saw themselves as playing a key role in mental health service development.



Whänau

"Kia mau koe kite kupu a te matua"



"Heed your parent’s advice"
Whanau participants were linked to tangata whaiora from all four tangata whaiora groups. A number of tangata whaiora also attended the whanau sessions to awhi (support) their whanau members and reciprocate the support they had received. The whanau appreciated being invited to participate for they often felt excluded from mental health services. They felt empowered when they could give something back to the mental health services for the care their kin and whanau had received. Reciprocity is important for Māori and the giving and receiving of koha is symbolic, it gives both the giver and receiver mana (power).
Whanau viewed health and well-being holistically. They were interested in broad health outcomes to be achieved for their kin. Like tangata whaiora, they considered being well meant, "being in control of one’s actions and thoughts" and for them their health was directly related to their kin. "If they were unwell they were unwell!" ... life is "like a roller coaster, up and down"
Although they were expected to be there for their kin who had contact with the mental health system, whanau felt that were not treated with respect. "Minimal information is shared ... there is no real information or training given on how to give or supervise medication." For example, they wanted to know what are the short and long-term effects of different types of medication... "rongoa Māori (Māori herbal medicines), it seems, is not an option."
No resources are available for kin to be involved in the recovery process, such as assistance with travel, accommodation and so forth. Similar to tangata whaiora, the majority of Māori whanau had little discretionary income to provide support to sick kin. Most whanau were dependent upon income support and this level of funding does not allow for any extras. Their expectations of positive outcomes from mental health services were as follows:

  • access to health care when needed,

  • more Māori staff,

  • education and information,

  • a support network for whanau,

  • financial assistance for whanau to be involved in treatment and the recovery process, and

  • whanau involvement in assessment and development of care plans for kin

Concern was raised about the close interface between mental health and prison services, and the difficulty of accessing kin in either system, particularly those who were in forensic services. The comment was made that if "whanau members do not know how to use and access the system, many Māori youth who are mentally unwell end up in the prison system rather than the mental health system." Whanau suggested that Māori should continually monitor the interface between the two systems. Māori should also develop outcome measures that are appropriate for Mäori for application to the justice system.
Caring for kin was seen by whanau as a kaitiaki (guardian) responsibility, even though at times it can be a challenge. In carrying out a kaitiaki role, whanau members expected "that the mental health services should have resources and support structures in place for them so that they could be equal partners with the clinical team."

Māori Staff and Māori Providers

Māori staff employed by Lakeland Health and representatives of selected Māori health providers were also invited to participate in a focus group. For Māori staff and providers being well meant for them, "feeling good", "having good health that you know is going to continue", a sense of security, having a job, a home and being independent, being able to set goals and achieve them, being able to move physically and able to have a quality of life.


Being unwell meant "not being in control", having to "rely on others", and "not able to enjoy life". To meet the needs of tangata whaiora and whanau they considered "we need to step outside of the service to provide a service", we need to have care plans in place, we need to recognise that "discharge is only the beginning" and we need "more kaupapa Māori services".
Māori mental health workers argued that for successful outcomes to be achieved for Māori we need:

  • safety,

  • Māori health recognised as a separate identity,

  • Māori staff to be visible,

  • turoro18 (patients) to be able to return to whanau,

  • turoro to stay out of hospital,

  • turoro to be resourced to able to help care for each other (for example, through support groups) as they have the solutions to address many of their own problems,

  • turoro to have choices, such as being able to choose the nurse they want,

  • kaumatua and kuia to be involved in care, and

  • the whanau room to be available for use by whanau at any time.

IMPLICATIONS FOR SOCIAL POLICY

"Ma te huruhuru te manu ka rere"

"Feathers enable the bird to fly"
Key differences have been identified through holding focus groups with different stakeholders: tangata whaiora, whanau and Māori staff. The differences support the views expressed by Mason Dune (1994) that Māori are not a homogeneous group but are a diverse population with different needs and expectations and this must be taken into consideration when developing policy and planning services.
The research highlights clearly the differences between young and old, male and female and between tangata whaiora and family members in relation to their experience of mental illness and their expectations of the "results" or outcomes mental health services should achieve. However, the research overall shows that there are similarities in views between Māori mental health staff and tangata whaiora and whanau members:


  • All groups feel disenfranchised and this is directly related to the lack of recognition of the Treaty of Waitangi at all levels of public policy.

  • Mental health services do not include sufficient recognition of Māori cultural values and activities.

  • There is a need to employ a greater number of Māori staff to meet the expectations of tangata whaiora and whanau members.

  • There is a need for greater recognition and support for the involvement of kaumatua and kuia in all aspects of mental health care.

  • There is a need for greater support for the involvement of the whanau in the whole process of assessment, treatment and recovery.

  • Financial resources should be available to establish and support health-related services, which are appropriate for tangata whaiora and whanau, and allow them to access health care in relation to need, be involved in the recovery process and maintain wellness.

  • There is a need to support the development of Māori mental health and related health services to provide wider choices for tangata whaiora and whanau. Such services will also provide additional options for non-Māori,

  • There is a need to support the development of appropriate outcome instruments, which recognise and support Māori views of health and ill health.

All of these issues now need to be considered by policy makers in the development, resourcing and monitoring of social policy.




DISCUSSION


As well as the issues outlined above, a number of important themes emerged consistently across all of the focus groups that need to be considered for policy purposes and the future development of mental health and related services.



Control

The degree of control Māori individuals and whanau had over their lives was identified as important, and influenced people’s perception of wellness and unwellness. The participants of this study considered they were well if they felt they had some control over their lives and were able to make choices appropriate to the lifestyle they wanted to lead. Unwellness was experienced when people felt they had no control over their life and their well-being was directed by others, such as health professionals and government agencies.


However, from the first point of contact with mental health services, many Māori do lose control over their lives. A third of Māori admissions to mental health services occur on a non-voluntary basis through committal or by direction by specific government agencies, such as justice or social welfare (Te Puni Kokiri 1997). The impact of the Mental Health (Compulsory Assessment and Treatment) Act (1992), set up to protect the rights of mental health consumers, is now being reviewed, but it has not been assessed as to whether it is achieving the right outcomes for Māori (Te Puni Kokiri 1993).
The Health & Disability Commissioner Act 1994 and the Code of Rights for Consumers of Health and Disability Services are also being reviewed. It would be appropriate to question whether these Acts assist Māori to have greater control over their lives as consumers of mental health, health or disability services (Health and Disability Commissioner 1999). Recognition of the Treaty of Waitangi in both the Health and Disability Commissioner Act and Code is now being proposed. These two developments are significant in health and disability policy development, but if enacted they will be of little value if people as individuals and groups do not know how to utilise the systems currently in place so that they can exercise their rights.
Many of the outcomes that Māori now expect from mental health services are already incorporated into the requirements to be met in both of the above Acts. However, from a Māori point of view they are not happening and therefore perhaps it is timely for Māori to seek financial compensation through the Complaints Tribunal for poor quality health care.
The importance to people of having control over their lives also calls for policy makers and deliverers of mental health services to support the importance of "tino rangatiratanga" (self-determination) for Māori at both an individual and a collective level. Tane as a focus group, for example, considered their greatest dissatisfaction with mental health services was the lack of recognition of the Treaty of Waitangi and the disrespect given to Māori as a treaty partner. As a consequence, this group felt isolated in both Māori and non-Māori settings, and members were constantly searching to find out who they were and where they belonged.
Increasingly, Māori are calling for constitutional change to enable Māori to have greater say in policy making in New Zealand and to have more political authority. Māori also want to see the development of new health, legal and education systems, which are based upon Māori values and aspirations. These proposed changes are important even though some New Zealanders, including some Māori, consider they are "radical" ideas.
Increasingly there are calls now for the development of a comprehensive, national, integrated, Māori mental health system that will allow both Māori and non-Māori mental health consumers choice in accessing mental health services. Currently, across the country Māori mental health services are being developed, but few are able to provide in-patient acute care.
No Māori providers have contracts to provide in-patient acute forensic care. It is this area of care where Māori are often admitted due to the nature and circumstances surrounding their admission and their diagnosis. In being admitted to forensic services, tangata whaiora movement in and out of the community is often governed by staff in the mental health system in conjunction with the Director of Mental Health and the Minister of Health.
The third issue that is raised in relation to control is that if Māori mental ill health and the general health status of Māori is to change, there is a need for Māori to have greater privacy and control over their lives. Participants commented that they often felt that their behaviour was subject to scrutiny and therefore they were vulnerable to intrusion from staff of government and related agencies.
Of the 40 tangata whaiora who participated in this study, almost all were dependent upon income support even though they wanted the opportunity for education and refraining, full or part-time employment, and the ability to live where they wanted. Without these options in place, other individuals and agencies determined their life and their choices.

Recovery

This research identified that for Māori, recovery is not a passive but an active process. Involvement of the whanau is essential. Being active, physically fit and involved in meaningful Māori activities is crucial to the process of recovery and maintenance of wellness. The lack of Māori content in Māori care means that mental health services are unlikely to achieve the outcomes Māori want.



Māori Participation

Māori involvement and Māori participation in all stages of the planning, implementation and monitoring of service delivery is essential to achieve the right outcomes for Māori. There was a strong and growing view that the time was right in Rotorua for "Māori faces for Māori cases at Māori places." With this development it was seen that, "kaumatua and kuia will be involved, tangata whaiora and whanau members will be less isolated from the Māori community and there will be greater respect to Māori as a Treaty of Waitangi partner".


The requests for more Māori involvement have implications for mental health workforce development. In 1994, only 0.6% of the mental health clinical workforce identified as Māori (Bridgman and Heron 1999). The Ministry of Health’s (1997) target for Māori proposes a 50% increase iii the Māori mental health workforce between 1997—2005. If this target is achieved, Māori will account for just over 1% of the total mental health clinical workforce. These aspirations are only likely to be met by the employment of Māori staff who have limited access to clinical training.

Māori Outcomes

Māori participants in this study supported the concept of the development of "outcomes" which were appropriate for Māori. If suitable outcome instruments could be developed which included Māori expectations, it is considered that "the quality of care provided and progress achieved in terms of recovery could be assessed."




CONCLUSION


"Ta nga rangatira tana kai he korero,

ta te ware he muhukai"

"Advice is the food of chiefs"


The challenge that lies ahead is for those involved in the planning, purchasing and delivery of mental health services to heed the advice that has been given. Further papers are planned comparing Māori and non-Māori expectations of mental health services, and the range of questions that should be asked to ensure mental health services are achieving the appropriate outcomes for consumers and whanau. The findings of this part of the research highlight the fact that any overseas outcomes instruments selected in New Zealand need to be adapted to ensure that they include the right questions which are important for Māori, so that useful feedback can be given on the outcomes that have been achieved.
The Mental Health Commission, an independent "watchdog" for mental health services, has now an important role to play ensuring that mental health services are achieving the right outcomes for Māori. This statutory body has identified clearly in its "Blueprint For Mental Health Services in New Zealand" (1998) the range of components of care which it considers should be offered to Māori clients in either mainstream and kaupapa Māori services. These components are consistent with what the Māori participants of this study expect of mental health services.
Overall, participants considered that the development of Māori outcomes would only be undertaken if those who develop policy, or purchase or provide mental health services, took seriously the advice and feedback offered by Māori. The high expectations by Māori for mental health services perhaps suggest that the Ministry of Health and the Health Funding Authority should review both their targets and their strategies for achieve them.


BIBLIOGRAPHY


Andrews, G. et al. (1994) The Measurement of Consumer Outcomes in Mental Health, Australian Government Publishing Service.


Bridgman, G.D., S. Webster and M. Heron (1998) "Analysis of the Wellness Conceptualisations from Staff, Consumer and Caregiver Focus Groups" Building Bridges, Community Mental Health Conference, 21—23 October, Christchurch Convention Centre.
Bridgman, G.D. and M. Heron (1999) "Workforce Development for the new environment of integrated services" invited presentation to Integrating Mental Health Care, 19—20 April 1999, Airport Hotel, Wellington.
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Stedman, T, P. Yellowlees, G. Melsop, R. Clarke and S. Drake (1997) "Measuring Consumer Outcomes in Mental Health" Department of Health and Family Services, Canberra, ACT.
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1 This research was funded through an HRC grant.

2 Ngati Maniapoto; Senior Lecturer, Medical School, Auckland University.

3 Pākehā; Director, Mental Health Research & Development; Senior Lecturer, School of Community Studies, UN1TEC.

4 Te Arawa: Ngati Rangiwewehi; Ngati Ranginui: Ngati Pirirakau; Ngai Ta Rangi: Tuwhi Whia; Researcher for the Māori component of the Mental Health Outcomes Project.

5 Te Arawa: Ngati Whakaue, Tuhourangi; Researcher for the Maori component of the Mental Health Outcomes Project.

6 Te Arawa: Ta Arawa: Ngati Pikiao; Consumer researcher for the Mäori component of the Mental Health Outcomes Project.

7 Te Arawa: Ngati Pikiao, Tameteatutahi-kawiti, Tuwharetoa, Ngati Rangitihi, Tuhourangi/Ngati Wahiao; Takitimu: Ngati Ranginui, Pirirakau, Tauranga Moana; Mataatua: Ngati Awa, Te Pahipoto; Tumuaki, Maori Health, Lakeland Health.

8 Kahungunu: Waipatu, Nati Pahauwera; Consumer researcher for the Maori component of the Mental Health Outcomes Project.

9 These two reports were prepared by Lorna Dyall and Geoff Bridgman for Te Puni Kokiri as part of its statutory role to facilitate Maori improvement in health, employment, education and training, and economic development, and to monitor the effectiveness of services to ensure their adequacy for Maori,

10 Appreciation is extended to the mental health staff of Lakeland Health and local kaumatua support for this research project. It is hoped the results will support the development of mental health services, which meet Maori needs and expectations.

11 At a workshop organised by the Health Research Council of New Zealand in 1997, to help interested researchers develop proposals for research related to mental health outcomes, the participants concurred that any outcome instruments used in New Zealand needed to be endorsed by both Maori and non-Maori. This paper reports on Maori findings only, but a similar research project has been co-ordinated by Geoff Bridgman, in Auckland, to identify non-Maori expectations of mental health services.

12 These questions were decided through an Advisory Group, which includes representatives of key stakeholders in mental health, such as the Ministry of Health, the Mental Health Commission and Te Puni Kokiri.

13 Because the term "outcome" was not widely understood by participants, the focus groups discussed the "results" they would expect mental health services to achieve that would contribute to the participants’ improved quality of life.

14 A separate focus group also allowed participants to complete a number of assessment tools selected for study and to critique them from a Maori perspective. This paper does not include the results of this part of the research.

15 Ahui was held in December 1998. All participants of the study were invited to attend and critique the findings of each focus group and general discussion. The findings of the present paper are a summary of the paper prepared for the December hui.

16 Cigarettes were also offered to assist habitual smokers participate in the research, Despite the promotion of "smokefree" amongst Maori, approximately 5O% of Maori adults are still smoking. Maori mental health consumers are a significant group of smokers, who often started whilst in care, and now use smoking as a support mechanism to cope with living in the community and with their illness.

17 Generally, most hui held on marae involve all present, and participants would not be separated into different groups on the basis of gender, age or tribal affiliation


18 The word turoro means someone who is sick and is a word often used for someone who is a patient in hospital. As Maori mental health consumers live in the community, and from time to time may become ill requiring care, they prefer the term"tangata whaiora" as it recognises that people are not sick all of time and wellness is part of their general health status.

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