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Mental Health in Māori: What are the risk factors that contribute to poorer mental health outcomes within the Māori population?

Eliza Poulter

Introduction

One of the largest issues within the New Zealand nursing context, is around cultural competency particularly in regard to Māori iwi. Poor mental health is associated with higher mortality, psychological distress as well as poor social functioning (Idler & Benyamini, 1997). It is well established that Māori health outcomes are notably poorer than non-Māori. An example being that Māori are nearly two times more likely to report having anxiety or depression (Statistics NZ, 2012). In nursing competencies, specifically 1.2 and 1.5 relate to culturally safe practice, and also having the ability to apply principles of the Treaty of Waitangi to practice (NCNZ, n.d.). Because Māori iwi in New Zealand are experiencing significantly worse mental health outcomes (Williams, Clark, Lewycka, 2018); a priority in New Zealand nursing care should be equity of health treatment outcomes. Statistics New Zealand (2012) reported that Māori suicide rates were almost twice as high than non-Māori. There is considerable research around depressive, and anxiety disorders as well as intentional self-harm and suicide being reported in the Māori population (Bécares, Cormack & Harris, 2013). Despite this prevalence, seemingly little has been done to bridge the gap between Māori and non-Māori health outcomes.

Common themes within literature on this topic, are potential causes of the disparity between Māori and non-Māori. These themes are as follows: Māori are far less likely to be able to access healthcare when it is needed, they frequently experience mental health stigma, and ethnic discrimination (Williams et al., 2018). Despite the well documented mental health disparities for Māori, there is little published evidence of why these issues persist and what the best way is to address them (Williams et al., 2018). It is difficult to establish and measure the impact of structural racism and inter-generational trauma on the population (Williams et al., 2018), but what is clear is that this has contributed to a breakdown of culture. There is a language-loss, but also a loss of meaning of being Māori (Williams et al., 2018). There is evidence to suggest that protective factors for mental health include support of cultural identity, and community participation and support (Williams et al., 2018). Predominantly all of the studies used within this assignment have been specific to the New Zealand context, as Māori are the indigenous people of New Zealand. The following findings within my research of this topic have led me to ask the question, what are the risk factors that contribute to poor mental health outcomes within the Maori population? The aim of this assignment is to undertake a literature review to answer this question, but also to discuss recommendations for change to ensure Māori have improving health outcomes and are supported appropriately through their mental health treatment without facing bias and unfair treatment.

PECOT

Literature Review of Risk Factors for Poor Mental Health in Māori

From a review of the literature available, a number of publications found common themes that put Māori iwi, particularly youth, at risk of poor mental health. Research trends suggest that young Māori are the most at risk of developing anxiety, mood, and substance use disorders (Marie, Fergusson & Boden, 2008). They are also more likely to experience and engage in suicidal behaviour and ideation in comparison to non-Māori (Marie et al, 2008). The themes of most of the literature relate to the socio-historical factors being specifically associated with disproportionate representation of Māori iwi (Marie et al., 2008; Williams et al., 2018). They also identify greater disadvantage of Māori leads to higher rates of mental health issues (Marie et al., 2008).

Childhood Adversity and Socioeconomic Disadvantage

In one longitudinal study they measured 984 young people from birth to 25 years old, this included both male and female participants. The analysis of this group suggested that the elevated rates of poor mental health and disorders among Māori were largely related to socioeconomic disadvantage and childhood adversity (Marie et al, 2008). The themes highlighted in this literature were historical oppression; institutional racism, stress due to rapid urbanisation; unequal access to services; lack of ethnic matching between clinician and client which leads to clinical biases (Marie et al, 2008). What is suggested within the literature is that Māori are more likely to face exposure to hardships and disadvantages. In the study conducted by Marie et al. (2008), it stated that Māori are at a greater disadvantage, socially and economically. There is significant amounts of statistics and data to prove this. Data was gathered on mental health, cultural identification, socioeconomic factors as well as childhood adversity. This was to take into consideration the effects of mental health outcomes for that of the group. The participants were split into three categories, sole Māori, Māori/other identity and non-Māori. The results found that of the sample group, those who identified as solely Māori had higher rates of mental disorders than those of Māori/other and non-Māori. In the results section of the study it was determined that significance of ethnicity was a predictor of overall rate of mental health problems (Marie et al., 2008). The study at the time proved that Māori are still having higher rates of mental disorders than that of non-Māori, despite being categorised more diversely in this study (Marie et al., 2008). It is clear that childhood adversity and socio-economic status are both in itself risk factors to Māori hinengaro.

Risk Factors within Primary Health Care

A survey undertaken by GP’s, aimed to establish common themes of mental disorders among Māori iwi that were presenting in clinics across the country (MAGPIE Research Group, 2005). It found that rates of mental disorders among Māori attendees at general practices were twice as likely to be presenting with mental health conditions (MAGPIE Research Group, 2005). Particularly, Māori wāhine were more likely than non-Māori to have a diagnosable mental disorder (MAGPIE Research Group, 2005). The rates of anxiety, depression, and substance use disorders were all higher for Māori iwi attending general practice clinics (MAGPIE Research Group, 2005). Treatment was offered to both Māori and non-Māori at similar rates, despite this there were differences in terms of social and material deprivation (MAGPIE Research Group, 2005). The findings within this study are supportive of the view that social deprivation plays a role within the over representation of Māori presentations with mental issues (MAGPIE Research Group, 2005). However, it states that there are further ethnicity specific risk factors involved with the higher number of Māori presenting with mental health issues (MAGPIE Research Group, 2005). Another finding of this study was that among those Māori patients that were offered treatment, there was a trend towards them having a higher severity of symptoms then that of non-Māori (MAGPIE Research Group, 2005). The results of this study, are somewhat minimal around identifying risk factors for Māori iwi. However what it does highlight are the increased number of presentations and severity of conditions. It is out of date in comparison with other studies reviewed but gives a starting point as to how many Māori were presenting at GP clinics during that time. What would have been most helpful in this study would be exact numbers of clients accessing their GP services, as it is discussed in many studies that access to health care when it is required is a risk factor for poor mental health outcomes.

Ethnic Density and Area Deprivation

Another study, undertaken in 2013, reviewed ethnic density and area deprivation in relation to Māori iwi. It discussed and looked at how the neighbourhood and racial discrimination impacts Māori hauora. The study specifically analysed the Māori sample from the 2006/07 New Zealand health survey. This analysis was used to look at the links between area deprivation and ethnic density, as well as experiences of racial discrimination (Bécares et al., 2013). Again, these themes are identified as factors for the Māori population that increase their likelihood of having poorer hinengaro (Bécares et al., 2013). The association between ethnic density and health was analysed using three outcomes. These were doctor-diagnosed common mental disorders, over-all self-rated health, and rates of psychological distress (Bécares et al., 2013). In this study, they described the elevated rate of disorder among young Māori because members of this group tended to come from socially disadvantaged backgrounds and also had higher levels of exposure to childhood adversity (Bécares et al., 2013). These risk factors and life processes that put Māori at higher risk of mental disorders are seemingly very similar as those that put non-Māori at risk (Bécares et al., 2013). These conclusions are drawn within the study by comparisons to international studies that show social disadvantage and childhood adversity as increased risk factors in many cultural settings (Bécares et al., 2013). Within this study, area deprivation was highlighted as a risk factor for poor mental health (Bécares et al., 2013). Area deprivation was consistently associated with increased odds of reporting poor mental health and was also linked to more reports of racial discrimination (Bécares et al., 2013). Throughout the entirety of this study common themes have arisen, however contrasted with Marie et al. (2008), it has acknowledged that ethnic density and having a strong sense of being Māori are actually protective factors (Bécares et al., 2013). The study states that ethnic density is protective of health and exposure to racial discrimination, one of the main risk factors for poor mental health (Bécares et al., 2013). Interestingly, what was found in this study was that living in poorer communities that have a high ethnic density was actually associated with positive wellbeing (Bécares et al., 2013). This potentially attributes to increased social support, increased access to cultural resources and reduced exposure to discrimination. There are a number of important conclusions to be drawn from within this study, that work within the frameworks to improve hinengaro for Māori iwi. Although this study is somewhat limited within its discussion of these risk factors and their implications for Māori hauora, it does outline the potential protective factors of ethnic density. This is something that can be explored further under recommendations for this issue.

Cultural Identity

Additionally one of the most current, and comprehensive studies I have analysed has discussed at length the protective factors of Māori youth, who have a strong cultural identity (Williams et al., 2018). Similarly to the other studies, common risk factors for poor mental health were again that Māori are far less likely to have access to healthcare when it is required, they frequently experience mental health stigma and ethnic discrimination (Williams et al., 2018).Of the sample participants of this study, 25.5% of the group identified as Māori had experienced some kind of ethnic discrimination in school, in health care or with the police (Williams et al., 2018). Of the participants in the study, Māori were found to be more likely to be living in higher areas of deprivation (Williams et al., 2018). 80.2% of Māori participants were living in medium to highly deprived areas. 6.5% of Māori’s surveyed reported a suicide attempt in the previous twelve months (Williams et al., 2018). More students who had a higher cultural identity reported experiences of discrimination (Williams et al., 2018). In the conclusion of this study, it was discussed that those participants with a stronger sense of Māori cultural identity were associated with improved wellbeing and reduced depressive symptoms (Williams et al., 2018). This was despite facing more ethnic discrimination. Views that are dominating discussion within the study’s conclusion are regarding the persistent differences between Māori and non-Māori. It is argued that this discrepancy between the groups is best understood as a result of Māori being dislocated from traditional cultural activities (Williams et al., 2018). Influences like colonisation and rapid urbanisation are identified as significantly impacting Māori social relationships and way of life (Williams et al., 2018). As a result of this colonisation, collective wellbeing of Māori iwi has been diminished (Williams et al., 2018). This has led to the Māori population being overrepresented in mental health statistics. Another point within the discussion recognised was that Māori are in a more marginalised position in society and are more likely to experience institutional racism as well as discrimination (Williams et al., 2018). So the themes that have been identified as risk factors for Māori, seem to be somewhat avoidable in the health system we have created. The findings of this study suggest that elevated rates of poor mental health were a result of a combination of factors, between cultural identity and social disadvantage (Williams et al., 2018). These findings are supportive of earlier works, like Bécares (2013), that have found having a stronger cultural identity is protective for hinengaro for Māori. Indigenous cultures have always maintained that having a strong sense of their cultural identity as well as having pride in their culture, was linked to wellbeing (Shahtahmasebi, 2014; Williams et al., 2018). But through the process of colonisation, these values and pride have been undermined by the dominant cultural perspective (Shahtahmasebi, 2014; Williams et al., 2018). As previously discussed, ethnic discrimination was common for Māori students attending education in New Zealand. The strong ripple effects of this discrimination has impacted the higher rates of self-harm and suicidality in Māori secondary school children (Williams et al., 2018). Williams et al. (2018), discusses that although socio-economic factors do put Māori at risk, experiences of discrimination are more powerful in mediating mental health access.

What all of these studies highlight is that mental health outcomes are strongly linked to cultural identity. The most current literature acknowledges that the concept of ethnic density is potentially the most effective way of promoting better outcomes and a stronger sense of cultural identity.

Implications for Health

Findings within the studies I have reviewed, show that ethnic density is a potential protective factor of health and exposure to racial discrimination (Bécares et al., 2013). The ethnic density’s effect is often concealed by the detrimental effects of lower socio-economic areas. But these areas have been linked to communities having a stronger sense of cultural identity (Bécares et al., 2013). Institutional structures and racist practices have created divisions and inequity between Māori and non-Māori (Bécares et al., 2013). They have created health and socioeconomic inequities between these groups, and contribute to the continually rising numbers of Māori presenting with poor mental health outcomes (Bécares et al., 2013). Access to services, goods and opportunities in New Zealand should be fair and equitable between all groups, but Māori are facing institutional racism preventing the group from accessing them (Bécares et al., 2013; Williams et al., 2018).

Māori that were presenting with the best overall wellbeing, often had a strong sense of community and cultural identity and were in areas of higher ethnic density (Bécares et al., 2013; Williams et al., 2018). Māori spiritualism is integral to their everyday life, and over time exposure to western society has impacted Māori’s sense of identity and willingness to be connected to their culture (Shahtahmasebi, 2014; Williams et al., 2018). Specifically, it was Williams et al. (2018), that found that Māori youth who have a strong sense of cultural identity were more likely to experience good mental health outcomes. Acceptance and partnership with those who are wanting to strengthen their cultural identity should be encouraged by all health professionals. The recommendations moving forward with these issues, stems largely from prevention and primary health strategies. Encouragement of being involved in their own communities and finding their own cultural identity. Being Māori means different things, for different people. Being open and understanding of this will help the clients feel more comfortable, and potentially impact their health experiences. For those working in a mental health setting, ensuring cultural and spiritual identity is encouraged as well as supported. Considerations around incorporating cultural identity within care of those who do have mental health disorders and do identify as Māori. Practice in a culturally safe way to prevent experiences of racial discrimination in health care. Hold others within the workplace accountable for their actions and words around cultural identity.

Recommendations

Recommendations for nurses, as well as all practitioners within the health sector, should be around cultural safety and understanding of Māori cultural identity. Because so many people have experienced racial discrimination as well as mental health stigma, this makes the population of Māori less likely to ask for help and more distrustful of health practitioners. It is hard to determine what kind of health interventions can be undertaken to strengthen the commitment to better outcomes for Māori iwi, but having a better awareness of the inequities constantly faced by Māori is a starting point for any practitioner.

1. As nurses, we should aim to always be practicing in a culturally safe and appropriate way that meets our competencies from the New Zealand Nursing Council.
2. We should always be considering how to honour the Treaty of Waitangi, and show respect for others differences, whether that is cultural or spiritual.

Conclusion

In conclusion, the literature examined within this assignment has highlighted not only the prevalence of these issues within the New Zealand nursing context, but has also answered my research question of what are the risk factors that are contributing to poorer mental health outcomes within the Maori population. These are clearly identified as socio-economic disadvantages which limit ability to access services as well as take care of themselves (Bécares et al., 2013; Williams et al., 2018). They are also factors such as ethnic discrimination and mental health stigma (Bécares et al., 2013; Williams et al., 2018). It was stated that “the greatest threat to Māori is poor mental health” (BPAC, 2010). With suicide rates of Māori only increasing, at the highest number of suicides since the records begun (Flahive, 2018), this is clearly an area of immediate concern for those working within the mental health sector. These studies highlight the evidence that Māori are at risk, but how are we able to address this. There is need for primary health intervention and promotion of cultural identity. Further research must be done in to why Māori are at higher risk of experiencing adversity, whether that be family or childhood related. As well as research around how to promote access further to this group.

Glossary of Māori Terms

Hinengaro: psychological health

Iwi: people

Hauora: health

Pākehā: New Zealand European

Wāhine: women

Te Whare Tapa Whā: Māori health model

References

Bécares, L., Cormack, D., & Harris, R. (2013). Ethnic density and area deprivation: Neighbourhood effects on Māori health and racial discrimination in Aotearoa/New Zealand. Social Science & Medicine, 88, 76-82. https://doi.org/10.1016/j.socscimed.2013.04.007

BPAC. (2010). Recognising and Managing Mental Health problems in Māori. Retrieved from https://bpac.org.nz/BPJ/2010/June/mentalhealth.aspx

Durie, M. H. (1997). Identity, Nationhood and Implications. New Zealand Journal of Psychology, 26(2), 33. Retrieved from https://www.psychology.org.nz/wp-content/uploads/NZJP-Vol262-1997-5-Durie.pdf

Flahive, Brad. (2018). New Zealand Suicide Rate Highest since records began. Retrieved from https://www.stuff.co.nz/national/health/106532292/new-zealand-suicide-rate-highest-since-records-began

Getz, P. (2018). Māori suicide rates–the high cost of historical trauma. Kai Tiaki: Nursing New Zealand, 24(8), 11-13.

Idler, E. L., & Benyamini, Y. (1997). Self-rated health and mortality: a review of twenty-seven community studies. Journal of health and social behaviour, 21-37. Retrieved from https://www.jstor.org/stable/2955359

Lawson-Te Aho, K., & Liu, J. H. (2010). Indigenous suicide and colonization: The legacy of violence and the necessity of self-determination. International Journal of Conflict and Violence (IJCV), 4(1), 124-133. Retrieved from http://ijcv.org/index.php/ijcv/article/view/65

MAGPIE Research Group, University of Otago at Wellington School of Medicine, Health Sciences, & New Zealand. (2005). Mental disorders among Māori attending their general practitioner. Australian and New Zealand Journal of Psychiatry, 39(5), 401-406.

Marie, D., Fergusson, D. M., & Boden, J. M. (2008). Ethnic identification, social disadvantage, and mental health in adolescence/young adulthood: Results of a 25 year longitudinal study. Australian and New Zealand Journal of Psychiatry, 42(4), 293-300. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=105654480&site=ehost-live

Mckellar, D., & Rodrigues, A. (2017). Access to healthcare for people living in Aotearoa with a serious mental illness: a social justice issue. Whitireia Nursing and Health Journal, (24), 53.

New Zealand Nursing Council. (n.d). Competencies for Registered Nurses. Retrieved from https://www.tdhb.org.nz/services/nursing/documents/nursing-council-documents/Competencies%20for%20registered%20nurses.pdf

Schneider, Z., Whitehead, D., Lobiondo-wood, G., & Haber, J. (2013). Nursing and Midwifery research methods and appraisal for evidence-based practice (4th ed.). Sydney, Australia: Elsevier.

Shahtahmasebi, S. (2014). Indigenous populations and suicide prevention. International Public Health Journal, 6(1), 33. Retrieved from https://search.proquest.com/docview/1625577322?accountid=39660

Statistics New Zealand. (2018). Mental Health. Retrieved from https://www.health.govt.nz/our-work/populations/maori-health/tatau-kahukura-maori-health-statistics/nga-mana-hauora-tutohu-health-status-indicators/mental-health

Williams, A. D., Clark, T. C., & Lewycka, S. (2018). The associations between cultural identity and mental health outcomes for indigenous Māori youth in New Zealand. Frontiers in public health, 6. Retrieved from https://doi.org/10.3389/fpubh.2018.00319