Māori attitudes to healthcare today are deeply rooted in New Zealand history. In this article, Deborah Bassett-Clarke discusses some reasons why the current model of pharmacy practice does not always meet the needs of Māori and may actually cause health inequities. Understanding these factors is an important first step to improving outcomes for Māori.
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New Zealand Māori are one of the most over-researched groups in the Western world. Consequently, Māori are now wary of researchers asking for their opinions and views when the health statistics do not ever seem to change. Māori consultation is often an afterthought, a tick-box process or omitted altogether in research because it is just “too hard”.
Te Tiriti o Waitangi,1 our founding document, has created much discussion over the years, and people wonder about the relevance of such an old document in today’s society. Although the ongoing legal implications of the Treaty are complex, the original three articles were simple.
The first article – was for the Crown to ask for governorship over Māori, who supported this idea to bring law and order to the country, having witnessed many unlawful incidents, especially at Kororareka (the old name for Russell).
The problem was the English version used the word sovereignty (total ownership), while the Māori version used a transliteration of governorship – kāwanatanga. This created immediate misunderstanding as most tribal chiefs signed the Māori version (because they couldn’t read English) and there were some tribes who never signed it at all.
The second article – was for Māori to retain sovereignty over their lands, fisheries and forests, unless they chose to sell them. That promise was broken during the land confiscations 25–30 years after signing. Loss of land sequentially led to loss of tapu, mana and, finally, health, leading to despondency and depression of epidemic proportions.2
At the time, it was thought by a debt-ridden government3 that Māori could only survive by adaptation, and following defeat in the Land Wars, only then would Māori succumb to European solutions.2 However, Parihaka, a model village of passive resistance in the Taranaki, proved that Māori could thrive independently of European influence.2 Sadly, even that village was finally confiscated and destroyed in retribution for war clashes elsewhere.3
The third article – was to give Māori equality with all other British subjects. The first two articles are collective responsibilities and the third is an individual responsibility. But equality does not necessarily mean equity (Figure 1).
According to many authors, Māori are primarily treated by mainstream health services using the biomedical model, and this may not fully suit their needs.4–10 The impact of colonisation as an explanation for poor Māori health outcomes often perplexes Pākehā,11,12 but what is not obvious is that our current legal, social, economic and communication processes, policies and procedures are all built on historical European models (even the Kīngitanga movement).13 If you believe in fairness and equity, a notice in a doctor’s reception area asking for immediate payment may be a barrier to a person with low income.12,13
Further to the above, the third article states that Māori have the right to the same fair and equitable treatment under the Crown as everyone else, but the reality is that they just don’t. Having been stripped of all their resources may help explain why Māori are still last on the list to get a share of the healthcare pie today.
This may be due to unique cultural aspects, but also because Māori are still perceived as the “exotic other” and healthcare professionals are often frightened to discuss medical issues for fear of causing offence or outright rejection of their suggestions. In fact, this can cause or exacerbate disparity/inequity of care, regardless of whether the bias is conscious or unconscious. Further, while healthcare outcomes continue to ratchet up for all, the inequity gap remains for Māori when compared with everyone else.
A significant contributing factor to poor health is urbanisation. Māori became urbanised faster than any other indigenous people in the world – in one generation – from 25 per cent in the 1970s to 95 per cent in the 1990s.5
This implies they are no longer easily able to garden, hunt or gather seafood (the second article) unless they return to their home marae (and some don’t know their whakapapa, or even where they’re from13); therefore, they may conveniently resort to processed and fast foods.4 Moving to the city has also destroyed the traditional method of the “village raising the child” where grandparents had significant input into educating and guiding rangatahi (youth).4
In 2010, Dame Tariana Turia identified a need for a clear focus on developing strengths within whānau (family) to facilitate behavioural change with respect to health outcomes.4
After years of observation of poor health outcomes for Māori (in both my private and professional life) and experiencing awkwardness, I conducted a cross-cultural study on attitudes and perceptions to medicine-taking across the four main ethnic groups in New Zealand. Twenty focus groups were conducted, of which four (two rural and two urban) had a total of 21 Māori participants. The study findings identified three key themes:6
1. Medicines are not viewed as optional
Western medicines are seen as compulsory because there are no other alternatives and native remedies are perceived to have been lost. Western medicines are also often thought to suppress rather than cure a condition.
Illustrative quotes are from participants in the Māori focus groups of the cross-cultural study:
We don’t have our own medicines to sustain us because very few people know Māori rongoā (medicine) anymore, so we have to revert to the European way of healing. So, we’re stuck – we’ve got to take their medicine or else; we’ve got no other option.
A swing back to traditional medicines was identified in this study. Other elements, such as mirimiri (massage), karakia (prayer) and rongoā (native herbal remedies) had value and were also considered medicines.
Despite the negative view of Western medicines, most participants in this study were adherent to medication and very adept at medication management.6
I try and take it as close as possible to breakfast, lunch and dinner. I’ve got a little bottle at home that I put my tablets in, and I put it right by the things I eat, and that reminds me.
2. More information needed about medicines
The level of knowledge about medicines varied widely, so it pays not to make assumptions, either way, about Māori understandings of Western medicines. Rather, we should explore Māori levels of understanding in a respectful way.
In general, they wanted to know more about side effects and mechanisms of action of medications so they can be better prepared and know what to expect. They felt healthcare professionals underestimated their desire for knowledge about their medicines.
These two themes relate back to article three of Te Tiriti o Waitangi (individual responsibility).
I think a lot of Māori people are sort of down to earth. I’m not saying we’re dumb or anything. I like things put simply. I like to be able to understand it.
Māori participants in this study felt that healthcare professionals should freely offer medicines information, and that they shouldn’t have to search for this information themselves.
They’re the resource, if you like, as to what’s out there. The source of information is there in front of you – why go sideways?
The concept of information being offered like a koha (gift), rather than having to ask, is common to all Polynesian and Asian cultures. This comes about partly because the healthcare professional is considered the expert and patients don’t know the important things to ask. Further, in asking, they may cause the healthcare professional or themselves embarrassment or whakamā (shame), rather like “losing face”.
What was not evident in this study was any mention of mamae (hurt – physical, sexual or psychological abuse), which can be carried for two to three generations as whakamā before manifesting as disease or illness, mainly because whakamā is seen as both a collective and individual responsibility (relates to articles two and three). In other words, the whānau is also responsible if a family member makes a mistake or gets sick.4
Māori are a collective rather than an individual-based society, so both positive and negative achievements reflect on them as a whole, rather than on just the individual. This explains another traditional concept, now lost due to urbanisation, of the individual keeping themselves well for the benefit of the community.4–6,8,13
Verbal medicines information was preferred initially, with written information provided as a backup to reread later to refresh the verbal information given.6
I do say that references of any form are critical, but Māori people, even now, don’t refer much to that type of written resource. They respond better to talking, then from that, they refer to the written resources.
3. Considerable dissatisfaction with the current healthcare system
This dissatisfaction was centred on frustration regarding poor communication with healthcare professionals, who were often difficult to understand. This may have been due to overuse of medical jargon, language barriers when professionals were from other countries, hearing and comprehension difficulties, or a generational aspect as all participants interviewed were over age 65.
Some participants commented on considerable disrespect towards elders (especially if they were of a high standing in their own communities) by younger, apparently arrogant, healthcare professionals. This observation was also evident in the Asian and Pacific focus groups, especially if the healthcare professional could not speak their own native language.
I’ve been frustrated with some of the foreign doctors. Some of them are rude. I feel like getting up and walking out, swearing at them and so on. Personally, I’m not used to that sort of style. I think they should show respect. They treat you as though you’re a bit of dirt.
This shows unequal treatment and can be linked back to articles two and three. Whakamā, whakahīhī (boasting) and whakaiti (being made to feel small) are all frowned upon in Māori society because these behaviours affect the whole community. It also illustrates how Māori communicate differently to other New Zealanders.8
When trust and rapport have not been adequately established, Māori are much more subtle in their approach and, therefore, can appear disinterested in their medical condition and medications, or delay seeking help.6–9
Sometimes, Māori have had a bad healthcare experience, often years before. Sometimes, whakamā may explain why Māori are like this: shame or embarrassment about their condition; blaming themselves for not seeking help earlier; not wanting to burden their whānau, who are busy working; or shame and loss of face that their whānau didn’t recognise signs and symptoms earlier – making this both a collective and individual responsibility.4–6,8,13
My wife’s dad won’t have nothing to do with the doctors; he’s sick, but he won’t talk to anyone. How I try to help is by breaking those barriers. I’ll go and sit with him, talk about things, beat about the bush, and then I get him talking, man to man. I’ll throw in something that makes him think. I’ve been able to get him to start going and getting some care.
Although marae-based healthcare services are on offer, they do not suit everyone because the problems of miscommunication with doctors and pharmacists are the same everywhere.6
The key issues identified for Māori were for healthcare professionals to consistently provide clear explanations of the purpose and indication (if this is not done, the medicine will not be swallowed), mechanism of action, and two to three key side effects to look out, or be prepared, for.6
Māori generally prefer talking about medicines in a non-clinical environment where they feel more at home, and they feel less emphasis should be placed on high-technology digital resources.6
They feel the mainstream healthcare system doesn’t always meet their needs and that all new New Zealander’s (regardless of origin) should be educated about Te Ao Māori (the Māori world view) and the importance of Te Tiriti o Waitangi.6
Barriers to medicines use are impacted by conflict between the individual, the healthcare professional and the healthcare system. These can be divided into internal factors (psychological, health beliefs, attitudes and/or perceptions of conventional healthcare) and external factors (sociocultural group dynamics, the attitude of the healthcare professional and indifference/ignorance displayed by the healthcare system).
For Māori, concerns about medicines are mostly around efficacy and safety.6 There is a definite grade of scale between the patient’s level of trust of their clinician and their willingness to accept medicines.6,9
Health beliefs and culturally specific tendencies, including delay in help-seeking behaviour and denial of illness, were particularly apparent.6
Māori seek help in subtle, less overt ways due to their communal style of communication, which can be misconstrued as apathy or lack of interest.6,8,9 Achieving a workable therapeutic partnership, building rapport and gaining trust are of crucial importance, regardless of the ethnicity demographics of that partnership; it is purely about open and honest communication and gaining the patient’s trust.6
Māori participants were dubious about the efficacy of their medicines, partly due to mistrust of their healthcare professional (particularly hospital staff) and partly due to concerns about drug side effects.6
This finding has subsequently been described as “a long history of mistrust towards Western medicines”. Although the prescription may have been filled, if “medication mechanism of action, origin of medicine, aim of its use, likely side effects and length of treatment” have not been properly discussed, Māori “may still be without the final tools necessary to administer the medicine correctly, or they may feel a lack of trust and collaboration in the process such that they choose not to take the medicine”.9
Māori are often blamed for non-adherence, rather than drilling down to find the failure of the healthcare system to assess and address patient needs correctly in the first place, or why patients are not able to articulate exactly what help they need. One failure is episodic care by different GPs within a practice (ie, lack of consistency), then when presenting to a busy pharmacy dispensing 800–1000 prescriptions daily (ie, tight time frames). This implies that establishing trust and rapport is even less likely than a decade ago. Also, where is the ability to pause for reflection?
It was alright before, when you could go and see the same person, but now every time it’s a different person. They all keep changing.
On the other hand, the community pharmacist may be the only true constant for patients. We must think creatively and carve out small amounts of time to ameliorate disparity and inequity for Māori (even just five minutes). Perhaps individual pharmacists in a joint workplace could each have a dedicated list of patients (eg, by speciality or region).
A 2018 systematic review showed the importance of consistency. Patients seen by the same doctor each time were more likely to follow medical advice, more likely to engage in preventive care more often, and had fewer hospital admissions.14
Cost was identified as a barrier to adherence for some Māori but not all.6
Both Māori and New Zealand Europeans were suspicious that blister packaging was simply a generator of revenue for pharmacists and of no therapeutic value. Compliance packaging certainly is not a panacea, and some patients are even insulted when offered this because it might imply they have a faulty medicines management system.6
I’ve been prescribed the same pills since 2001, but I couldn’t afford them for three months.
We need to figure out bespoke adherence strategies, rather than just providing generic medicines information.
The debate about the causes and consequences of poverty has moved away from the lack of income of certain ethnic groups to focus on the dynamic social processes that perpetuate a disconnect in society in the world.10,11,15
Of course, poverty in New Zealand can be considered minor when compared with poverty elsewhere. However, the little things matter, such as not getting a supply of medicines at discharge and not being able to afford to fill the written prescription, losing medicines while moving wards in, or leaving, hospital and not being able to afford to replace them, or lack of synchrony of medicines causing endless trips back to the pharmacy, sometimes involving large distances travelled with significant adjunctive petrol costs.10
All of the above are more likely to happen to Māori and Pacific peoples as most are on the bottom of the income ladder. Indigenous peoples are often the most socioeconomically excluded in their own country. Poverty among indigenous peoples is different – it is complex, multigenerational, prevalent and deeply ingrained.15
We should not assume all people have easy access to medicines. We need to “listen to patients’ stories about their difficulties, to try to find ways around these, and to lobby against small (and large) changes in policies that have unintended negative consequences for people living in poverty”.10
This can be linked back to poor governorship (article one). When Māori lost their resources, they lost the power to make their own rules (article two) and govern their own society. Ensuring those living in poverty have a greater participation in their own therapeutic decision-making, allows them the impetus to improve their own living standards and their overall wellbeing.10–13,15
The Health Quality & Safety Commission’s Window 2019 report identified communication as a key issue, stating that Māori respond less positively when asked about their hospital experiences. Māori are less likely to receive diabetes monitoring and early referral for renal dialysis, despite being at higher risk. And even when Māori do engage, this doesn’t always mean decreased inequities. While previous Window reports showed a “closing of the gap” from 2007 to 2015, this has declined over the past five years.12
“We should not be trying to eliminate inequity (deficit) but creating equity so that Māori can determine how wellness looks for them”.13 It is more of an attitudinal shift rather than a policies and procedural shift – putting our tangata whenua lenses on, rather like Te Whāriki (the mat), a pre-school education programme that started in kohānga reo and has now been rolled out to mainstream pre-school education in both New Zealand and Australia.
Interestingly, the latest HQSC Window report notes that more Māori (55 per cent) state they receive information on side effects than other New Zealanders.12 However, the way it is communicated could be better, and in a less generic format, as one size does not fit all.6
Māori say, “We need to teach people how to talk to us and accept that we are all different. If I’m an apple, let me be the best apple I can be – don’t try and make me into a banoffee pie!”13
A 2016 study found that discharge patients did not always get time to process the information given to them because it was not consistent between doctors, nurses and pharmacists, done in a hurry, and they were either distracted by other family members or focusing on organising transport home.7
Further, although disruptive technology, new administrative methods and soft intelligence (text reminders, smart caps, eye drops that detect how many drops have been used by which user, long-term conditions services, robotics, compliance packaging, upskilling auxiliary staff) promote adherence, they do not ensure it and should not be a substitute for communication about medicines6–9 and fostering empathy with patients.10–13,16–18
In 2019, director-general of health Ashley Bloomfield stated, “In Aotearoa New Zealand, people have differences in health that are not only avoidable but unfair and unjust. Equity recognises different people with different levels of advantage require different approaches and resources to get equitable health outcomes.” The health system needs Te Ao Māori in partnership with Western medicine to enhance Māori health.13,17
Emerging cultural safety issues can go unnoticed in busy organisations. Barriers include the busy reality of work at the front line, a proliferation of information back and forth, and the inability to distinguish real warning signals from “white noise”.12,13,16
When a cabinet minister is diagnosed with stage III cervical cancer because she didn’t feel confident talking to her GP about persistent symptoms for up to six months, then everyone needs to sit up and take notice. And although the service is there, as advocated by our prime minister, it can be difficult for rural and low-income people to access – maybe pharmacists should be advocating for benchtop swab readers in pharmacies, as they have had in the UK for more than 10 years.
An important skill that pharmacists need to develop is learning to read the patient and tailor a bespoke adherence medication strategy for each patient. Pharmacists need to consider that Māori have a right to drive, design and prioritise what they think is important in terms of their healthcare, data collection and reporting.12
Sovereignty over their own data is important and needs to focus on ways to create, interpret and report information that draws on indigenous notions of health and wellbeing. We need to think about the guardianship of big data sets, collaborative international research, data sharing or cloud-based storage, and how Māori would like to be consulted about workable solutions that are agreeable to both parties.12,13
At the time of writing, I await the decision on DHB amalgamation and hope we come full circle to the village healthcare model with slimmed down specialist hospitals and most healthcare occurring in the community setting18 – in partnership with Māori, walking alongside, hand in hand in the same direction. Remember, it is about the journey, not the destination.
Finally, to quote GP Lance O’Sullivan: “What are you all afraid of?” Successful, healthy, happy Māori individuals can and have contributed greatly to the rich, diverse fabric of our community and our nation.
Māori concepts are strongly interrelated and have different meanings in different contexts. The following descriptions provide a brief explanation of the model developed by the author (Figure 2).
Whakapapa (genealogy) is very important to Māori because “it is the foundation to all ongoing engagement”.4 The first question asked upon meeting anyone, including healthcare professionals, should not be “what is your job?” but “where are you from?”
This is because forming links and connections is a way of shifting the awkwardness of the clinical conversation to the familiar and more informal; that is, shifting the mood from tapu (unknown, awkward) to noa (known, common, familiar).13,16
It is not meant as a challenge. Māori are genuinely curious about where you are from, your genealogy and if you might be related to them.13 Given the three degrees of separation that exists in New Zealand, that’s not that much of a stretch of the imagination.
Knowing about family medical history also helps identify comorbidities or diagnose disease, and provides insight into attitudes towards medicines.
For example, much is known about ethnic differences of drug metabolism, but very little is known about differing psychosocial aspects of medicine-taking. Changing the mood of the conversation, gaining rapport and establishing trust will favourably impact upon attitudes and perceptions to medicines and, ultimately, medication adherence.6
Whanaungatanga is considered a subset of whakapapa. Defined as relationship or kinship, it is the development of a relationship through shared experiences and working together, which gives people a sense of belonging. Whanaungatanga – also known as whakawhanaungatanga – is a good icebreaker when having conversations about medicines and can definitely change negative attitudes to medications and adherence.4,6,13
Healthcare professionals often complain that Māori do not give them the full story. However, spending some time talking to Māori about issues that matter to them goes a long way towards establishing trust and rapport. This small amount of effort will make them feel comfortable and safe enough to disclose fully how they are feeling and the underlying reasons for this.4,6–9,13
Manaakitanga is defined as hospitality, kindness, generosity, support.13,16 The process of showing respect, generosity and care for others is linked to whanaungatanga, usually by providing food, showing respect, or introducing yourself and what you do before launching into the task or question in hand. It is also considered a subset of whakapapa because whānau naturally provide hospitality and want to welcome you into their homes or lives. The provision of koha is a reciprocal process and recognised in many different cultures.4
Mauri is an indication of how a person is feeling at any given point, often triggered by past events or memories. It is sometimes described as the individual’s vitality or life spark. Imagine a person in an inpatient mental health unit feeling very depressed – their spirit would be very low, even static or mauri moe (asleep). Being sensitive to the patient’s state of mind is important to remember when communicating with Māori.4,6,13,16
Tapu is often defined as sacred, restricted or forbidden but actually searches for influencing factors that underpin why a person became ill in the first place.16 Māori pay particular attention to each encounter with a health professional because it is considered part of the therapeutic relationship (no matter how small).4,6 Tapu can be divided into three parts:17
Mana is defined as prestige, authority, status or charisma, or the accumulation of all of the above. By giving Māori power and control/ownership (article one) over their own medical conditions and allowing them to be in a therapeutic partnership (articles two and three) for the management and treatment of those conditions, their mana is restored and their mauri awakened. This, in turn, strengthens their whanaungatanga, manaakitanga and whakapapa.4,6,8,9,13,16,17
Find explanations of concepts central to Māori culture at: maoridictionary.co.nz
The Pharmacy Today suite of CLASS activities provides meaningful independent and peer group learning that you can put into action, while helping you complete your annual recertification requirements.
For more information on CLASS and to download the associated CLASSact and CLASSmates documents, click here.
This activity has been endorsed by The Royal New Zealand College of General Practitioners (RNZCGP) and has been approved for up to 0.75 CME credits for continuing professional development purposes (1 credit per learning hour). To claim your CPD credits, log in to your Te Whanake dashboard and record these activities under the appropriate learning category.
Archives New Zealand. Te Tiriti o Waitangi – The Treaty of Waitangi. tinyurl.com/ArchivesTeTiriti
Riseborough H. Days of darkness: Taranaki 1878-1884. Auckland, NZ: Penguin; 2002.
Chamberlain MO. Whenua. Kaingaroa, NZ: SHIHvillage Publications; 2011.
Ruakere BT. The experience of living with bowel cancer for Māori in the Taranaki. DHSc thesis, Auckland University of Technology; 2016. orapp.aut.ac.nz/handle/10292/10559
Sachdev P. The New Zealand Māori and the contemporary health system: response of an indigenous people to mainstream medicine. In Okpaku SO (Ed), Clinical Methods in Transcultural Psychiatry. Washington, DC: American Psychiatric Press; 1998.
Bassett-Clarke D, Krass I, Bajorek B. Ethnic differences of medicines-taking in older adults: a cross cultural study in New Zealand. Int J Pharm Pract 2012; 20(2):90–98.
Naidu R, Bassett-Clarke D, Tordoff J. Examining how parents and caregivers administer medicines at home. Master’s thesis, University of Otago; 2016.
Metge J, Kinloch P. Talking past each other: Problems of cross-cultural communications. Wellington, NZ: Victoria University Press; 1979.
Te Karu L, Bryant L, Harwood M, et al. Achieving health equity in Aotearoa New Zealand: the contribution of medicines optimisation. J Prim Health Care 2018:10(1):11–15.
Norris P, McIntosh B, Tordoff J, et al. Poverty, medicines and health care: It’s the little things… J Prim Health Care 2015:7(2):170–71.
Pharmac. Hauora Arotahi. tinyurl.com/HauoraArotahi
Health Quality & Safety Commission. A window on the quality of Aotearoa New Zealand's health care 2019 – a view on Māori health equity. tinyurl.com/HQSC-Window19
Personal communication with Tawhiti Kunaiti, Te Tihi team leader at THINK Hauora orientation days, 8–9 April 2021, Raukawa Marae, Ōtaki.
Pereira Gray DJ, Sidaway-Lee K, White E, et al. Continuity of care with doctors-a matter of life and death? A systematic review of continuity of care and mortality. BMJ Open 2018;8(6):e021161.
Hunter B. Indigenous Social Exclusion: Insights and Challenges for the Concept of Social Inclusion. Family Matters 2009;82:52–61.
Bassett-Clarke D. Cultural competency or cultural safety: Check box mentality or genuine understanding? New Zealand Pharmacy Journal 2009;2(2):18–25.
Tate H. Towards Some Foundations of a Systematic Māori Theology - He tirohanga anganui ki ētahi kaupapa hōhonu mō te whakapono Māori. PhD thesis, Melbourne College of Divinity; 2010. tinyurl.com/TatePhD2010
Gawande A. Being Mortal: Illness, Medicine and What Matters in the End. London, UK: Profile Books Ltd; 2015.
Focusing on the experiences of older Māori in primary care, this course comprises four short videos, an independent reflection, downloadable posters and additional resources.
The course is endorsed by RNZCGP and CNA(NZ) and meets PCNZ recertification requirements. Reflection templates are included for you to complete.