MAORI OUTCOMES: EXPECTATIONS OF MENTAL HEALTH SERVICES(1).

• Author: Dyall, Lorna

INTRODUCTION

The purpose of this paper is to provide a broad overview of Maori expectations of mental health services in light of the growing number of Maori, 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 Maori views expressed through hui (meeting) (Department of Health 1991) and in different forums (Maori Mental Health Summit 1997) that there is a need to develop mental health services which are culturally appropriate and effective for Maori.

The paper also supports the watchdog role of the Mental Health Commission (1998) to advocate on behalf of Maori. 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 (Maori language), and

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

We believe that these key service components describe the quality of mental health care Maori 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 Maori adults in 2005 can expect to have the option of choosing a Maori 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 Maori 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 Maori Development) released a report "Trends in Maori Mental Health 1984-1993", which built upon a previous document released in 1993. Both reports have highlighted that Maori have different patterns of admission and discharge to mental health services in comparison to non-Maori.(9)

For example, in 1993 Maori 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 Maori were double that for non-Maori. Maori trends also suggested that the current mental health status of Maori is directly related to the social, economic and political position Maori occupy in New Zealand and as a group. "Maori 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 Maori outcomes and expectations of mental health services. The research is based on a series of focus groups held in Rotorua, in 1998, with different Maori stakeholder groups. The participants were Maori 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 Maori mental health.

The organisation of these focus groups was part of a collaborative research project investigating the outcomes Maori and non-Maori 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 Maori organisation which has wide community and tribal links.(10)

All participants of this part of the study have identified themselves as Maori, and their views provide insight into Maori 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 Maori and non-Maori 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 Maori and non-Maori 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 Maori and non-Maori?

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 Maori expectations of mental health services. Further papers are planned which will compare Maori and non-Maori 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 Maori cultural centre of the world and the place where Maori 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 O Uenukukopako, Ngati Pikiao, Ngati Rangitihi, Te Rangiteaorere and Ngati Tahu/Whaoa.

Rotorua district is the home for approximately 22,000 Maori (1996). Maori account for over a third of the population and the percentage of Maori 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 Maori families dependent upon income support, or employment that is seasonal or contractual for a limited period. Maori health status in this area is no different than the general health of Maori 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. Maori health status is increasingly being seen as a reflection of the socio-economic and cultural position of Maori 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 Maori and would be contributing to the results or outcomes local Maori wanted. However, the findings of this study suggest that although Maori 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 Maori stakeholders.

METHODOLOGY OF THE RESEARCH

Focus groups were used to explore with all participants their expectations of the outcomes(13) 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 Maori staff to contribute and be recognised as "experts" as well as participants in research (Dyall and Bridgman 1998). Focus groups also support Maori processes of participation in decisionmaking, 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 Maori who have been admitted to mental health services. The 40 tangata whaiora (Maori 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 Maori, 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 Maori 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...