Practice-based evidence is gaining increasing recognition in the clinical arena. It revolves around receiving feedback in each session about effectiveness and engagement that leads a clinician to modify sessions according to the needs of the client. The Outcomes Rating Scale (ORS) is used to monitor progress of therapy and also the usefulness of sessions (Millar et al, 2006, cited in Drury, 2007). The ORS has been researched extensively and has good reliability and validity data. Drury (2007) then developed a Kaupapa Outcomes Rating Scale (KORS) based on the ORS. The four dimensions are based on Te Whare Tapa Wha and appear also to be adapted from Hua Oranga. The KORS requires the client to rate on the line about how well they have been doing in the following areas:
hinengaro – thinking, feeling and acting in a manner that allows you to set goals for yourself
tinana – looking after your physical health in a manner which will maximise your ability to move without pain or distress
whānau – communication and relating with your whānau in a manner that is confident and clear.
Drury notes that:
An increasingly dominant voice in mental health would have us colonise clients with empirically validated treatments on the grounds that this is ‘scientific’ and ‘best practice’. This form of colonisation can be countered through the development of scientific tools that monitor client progress and the alliance from the client’s viewpoint, thus meeting cultural safety standards better and allowing the clinician to employ a wide variety of therapeutic options. The Kaupapa Outcomes Rating Scale is one such tool. (Drury, 2007:21) Drury (2007) argues that using KORS in clinical settings can contribute to a client-directed, outcome-informed (CDOI) approach to therapy; in essence, a way of delivering practice-based evidence. This may be a component that Kaupapa Māori programmes want to consider as a part of building an evidence base.
Evaluation of whānau ora
The literature pertaining to Māori research on outcomes measurement derives primarily from Kingi and Durie (2000). As discussed earlier, Hua Oranga is a Māori measure of mental health outcome designed to reflect cultural outcomes of mental health care (Kingi & Durie, 2000), and is based on Te Whare Tapa Wha. In line with the holistic approach of Te Whare Tapa Wha, a triangulated approach to the Hua Oranga measure was used where information was obtained from tāngata whaiora, caregivers/ whānau and clinicians. The researchers emphasised that Hua Oranga was to be used in addition to other clinical outcome measures or where a culturally relevant outcome was relevant (Kingi & Durie, 2000). While Hua Oranga measures cultural outcomes based on a Māori model of health, the format, administration and process are based on models used in standardised outcomes measurement tools.
Hua Oranga has the potential to be used in both generic and Kaupapa Māori services. The questions, used especially under te taha wairua and te taha whānau, have direct applicability in both generic and Kaupapa Māori programmes dealing with conduct problems. The usefulness of using Hua Oranga in a generic programme would be to ensure the programme and practitioners are mindful of and implement content and processes subsumed within Te Whare Tapa Wha. There is also the potential for it to be used to evaluate whānau ora. While ongoing reliability and validity data is still being collected, Hua Oranga has been identified in the Ministry of Health as a Māori outcomes measure.
One of the limitations of Hua Oranga was in relation to the applicability of the measure to Māori tamariki and rangatahi. A modified version for tamariki and rangatahi, Tupu Ranga, was advocated for in 2004 (Cherrington, 2004), utilising simplified questions and different processes, such as drawing to gain information from the child and/ or adolescent. However, to date, no further modifications or research has been conducted.
Hua Oranga has the potential to be developed within the conduct problems arena for both Māori and generic programmes. In evaluating the achievement of whānau ora for Māori who present to providers with conduct problems in their whānau, there is also the potential for questions to be adapted in relation to whānau outcomes rather than individual outcomes. For example, under te taha wairua, the questions could be adapted to be:
does the whānau feel more valued?
does the whānau feel more content?
does the whānau feel stronger as a Māori whānau?
does the whānau feel healthier from a spiritual point of view?
However, further consultation is needed by TRK to determine whether Hua Oranga would fit with the concept of whānau ora. In doing so, consideration would need to be given to what might constitute measurement of whānau ora. The Ministry of Health (2002) considered measurement to include:
a secure identity, a sense of belonging, high self-esteem
a control over one’s destiny (MOH, 2002).
In Section 2, the diagram representing a Māori view towards conduct problems was discussed. The focus was on whānau ora, while the surrounding circles were factors that had the potential to influence whānau ora. All these areas would need to be considered if a holistic approach to evaluation of whānau ora was to be pursued. In this case, questions assessing measures of whānau ora could be based on the following areas:
Kaupapa Māori services
other sector involvement.
Indicators of whānau ora is an area that requires further consideration by TRK.