Mason Durie

Mental health and Maori development

Objective: The objective of this paper is to illustrate trends in Maori health, examine earlier health policies and to suggest avenues for improved mental health. Method: Several sources of historical and contemporary data have been reviewed and there has been some analysis of mental health policies as they relate to Maori. The interplay between culture, socioeconomic circumstances and personal health has been used as a context within which strategic directions are discussed. Results: Five strategies are highlighted: the promotion of a secure cultural identity, active Maori participation in society and the economy, improved mental health services, workforce development, autonomy and control. It is recommended that mental health services should be more closely aligned with primary health care, Maori youth, Maori-centred frameworks, and evidence-based practices. Conclusions: Improvements in Maori mental health require broad approaches which are consistent with Maori aspirations and coordinated across the range of sectoral and disciplinary interests. Active Maori participation in the process and the retention of a cultural base will be critical if the current trends are to be reversed.

Providing health services to indigenous peoples

A combination of conventional services and indigenous programmes is needed Although indigenous health is influenced by many factors outside the formal health sector, access to quality health services is none the less an important determinant of good health.1 In New Zealand, efforts to improve Maori health have resulted in substantial shifts across the entire health sector. The primary driver for reorienting health services is linked to health gains and a reduction in disparities between Maori and non-Maori. However, the position of Maori as indigenous people adds another dimension, reflected in section 8 of the New Zealand Public Health and Disability Act (2000), requiring health services to recognise the principles of the Treaty of Waitangi, an 1840 agreement that saw sovereignty exchanged for Crown protection. Because of the treaty, Maori occupy a position that is not afforded other non-indigenous ethnic minority groups, even where comparable standards of health exist. Of the several approaches to improving health services for indigenous health two broad directions can be identified: increasing the responsiveness of conventional services and establishing dedicated indigenous programmes. Both approaches are endorsed in legislation and government health policy. The …

Prevalence of mental disorders among Maori in Te Rau Hinengaro: The New Zealand Mental Health Survey

Objective: To describe the prevalence of mental disorders (period prevalence across aggregated disorders, 12 month and lifetime prevalence) among Māori in Te Rau Hinengaro: The New Zealand Mental Health Survey. Method: Te Rau Hinengaro: The New Zealand Mental Health Survey, undertaken between 2003 and 2004, was a nationally representative face-to-face household survey of 12 992 New Zealand adults aged 16 years and over, including 2595 Māori. Ethnicity was measured using the 2001 New Zealand census ethnicity question. A fully structured diagnostic interview, the World Health Organization World Mental Health Survey Initiative version of the Composite International Diagnostic Interview (CIDI 3.0), was used to measure disorder. The overall response rate was 73.3%. This paper presents selected findings for the level and pattern of mental disorder prevalence among Māori. Results: Māori lifetime prevalence of any disorder was 50.7%, 12 month prevalence 29.5% and 1 month prevalence 18.3%. The most common 12 month disorders were anxiety (19.4%), mood (11.4%) and substance (8.6%) disorders and the most common lifetime disorders were anxiety (31.3%), substance (26.5%) and mood (24.3%) disorders. Levels of lifetime comorbidity were high with 12 month prevalence showing 16.4% of Māori with one disorder, 7.6% with two disorders and 5.5% with three or more disorders. Twelvemonth disorders were more common in Māori females than in males (33.6% vs 24.8%) and in younger age groups: 16–24 years, 33.2%; 25–44 years, 32.9%; 45–64 years, 23.7%; and 65 years and over, 7.9%. Disorder prevalence was greatest among Māori with the lowest equivalized household income and least education. However, differences by urbanicity and region were not significant. Of Māori with any 12 month disorder, 29.6% had serious, 42.6% had moderate and 27.8% had mild disorders. Conclusion: Mental disorders overall and specific disorder groups (anxiety, mood and substance) are common among Māori and measures of severity indicate that disorders have considerable health impact. Findings provide a platform for informing public health policy and health sector responses to meeting mental health needs of Māori.

Te Ira Tangata: A Zelen randomised controlled trial of a treatment package including problem solving therapy compared to treatment as usual in Maori who present to hospital after self harm

BackgroundMaori, the indigenous people of New Zealand, who present to hospital after intentionally harming themselves, do so at a higher rate than non-Maori. There have been no previous treatment trials in Maori who self harm and previous reviews of interventions in other populations have been inconclusive as existing trials have been under powered and done on unrepresentative populations. These reviews have however indicated that problem solving therapy and sending regular postcards after the self harm attempt may be an effective treatment. There is also a small literature on sense of belonging in self harm and the importance of culture. This protocol describes a pragmatic trial of a package of measures which include problem solving therapy, postcards, patient support, cultural assessment, improved access to primary care and a risk management strategy in Maori who present to hospital after self harm using a novel design.MethodsWe propose to use a double consent Zelen design where participants are randomised prior to giving consent to enrol a representative cohort of patients. The main outcome will be the number of Maori scoring below nine on the Beck Hopelessness Scale. Secondary outcomes will be hospital repetition at one year; self reported self harm; anxiety; depression; quality of life; social function; and hospital use at three months and one year.DiscussionA strength of the study is that it is a pragmatic trial which aims to recruit Maori using a Maori clinical team and protocol. It does not exclude people if English is not their first language. A potential limitation is the analysis of the results which is complex and may underestimate any effect if a large number of people refuse their consent in the group randomised to problem solving therapy as they will effectively cross over to the treatment as usual group. This study is the first randomised control trial to explicitly use cultural assessment and management.Trial registrationAustralia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12609000952246

Public Health Strategies for Mäori

When the New Zealand Department of Public Health was established in 1900, Mäori health status was compromised to the extent that survival itself was threatened. The remarkable turnaround was unexpected and owes much to pioneer Mäori professionals, especially the first Mäori medical practitioner, Dr. Maui Pomare, who graduated in the United States in 1899. As “Medical Officer to the Mäoris,” and later as Minister of Health, he made major changes through a five-part strategy: recognizing Mäori community leaders as leaders in health, improving access to societal goods and services (especially housing and education), appealing to cultural practices that were linked to good health, wise use of political power, and developing a skilled Mäori health workforce to complement community leadership. Although mental health disorders and lifestyle illnesses have largely replaced infectious diseases, malnutrition, and tuberculosis, Pomare’s strategy has continuing relevance and warrants serious consideration as a model for health promotion.

Indigenous mental health 2035: future takers, future makers and transformational potential

Objective: The aims were to review progress in Indigenous mental health over the past 25 years and to identify possible directions for the next 25 years. Method: Māori involvement in health and health care was used to illustrate key Indigenous developments since 1984. Challenges in the decades ahead were discussed in the context of demographic transitions, life course epidemiology, global trends, technological innovations and health leadership. Results: Progress was measured by a range of indicators including Māori-referenced life expectancy, Māori agendas for health, strengthened cultural identity, the dissemination of health knowledge, and Māori participation in the health sector. In contrast to being ready to respond to change (future takers), active planning for the future (future makers) was seen as a better way of achieving Indigenous aspirations. One option for health advancement currently being developed in New Zealand involved an integrated approach premised on intersectoral delivery and a focus on families. Conclusions: Indigenous health will be advanced by dedicated approaches to family wellbeing that avoid fragmentation, focus on positive strengths, and lead to positive outcomes for family members and the family as a whole.