Amohia Boulton,Jennifer Tamehana, Lynley Cvitanovic Ngā Pae o te Māramatanga

1. Supporting whānau resilience:can Māori health service provision make a difference? Amohia Boulton,Jennifer Tamehana, Lynley Cvitanovic Ngā Pae o te Māramatanga Horizons of Insight Seminar, Auckland 28 October 2011

2. Overview • Background to the Resilience Study: establishing the research partnership • Aims and methods • Findings • Reflections on the research • Conclusion – where to from here?

3. Background • Request for Proposals (RFP) released in 2008 • RFP released by the Partnership Programme (HRC), as part of the Whānau Ora Research Partnership • Four funders: NPM, HRC, ACC, Families Commission

4. RFP Purpose • Commissioners had two aims: • to seek research that would focus on “whānau resilience”, i.e. the collective health and wellbeing of whānau at a level beyond individuals, families and individual households • to address factors that both promote and contribute to whānau health by maximising whānau resilience

5. Partnership • Formed between iwi-based research centre (lead); University-based research centre, and Māori-governed primary health care provider • Research conducted between August 2009 - August 2011

6. Whakauae Research for Māori Health and Development • Ngāti Hauiti Iwi (tribe) - Central Rangitikei, Aotearoa • Whakauae - iwi research unit of, and for, Ngāti Hauiti • Tribally owned and accountable

7. Health Services Research Centre • School of Government, Victoria University • 22 staff • Projects regarding the organisation, planning, provision, use and effectiveness of personal and population-based health and disability services • Assoc. Prof Jackie Cumming, Director of HSRC– academic support

8. Te Oranganui Iwi Health Authority • Inter-tribal organisation governed by 3 Iwi • 139 staff, 6 service entities, 1 support service • Cultural framework (PitauWhakarae) based on values & principles encapsulated within vision statement: Kaupapa Ake • Jennifer Tamehana, CEO

9. WHANAU ORA – Organisational Driven Service Delivery Model GOVERNANCE Iwi Clinical & Provider ADVISORY Committees Groups C E N T R E O F E X C E L L E N C E MANAGEMENT CEO HR, QIM, Clinical, Cultural & Finance INFORMATION Research Development Analysis OPERATIONS / SERVICES Service Leaders / Managers Front line Primary Health Services SUPPORT Full administration, finance, service assistance MODELLING Service models, Maori health models, Strategies TE PITAU WHAKARAE – Organisational Cultural Quality Framework Organisational Elements

10. The Team • Dr Amohia Boulton (Lead), Dr Heather Gifford, Lynley Cvitanovic (WRMHD) • Assoc. Prof Jackie Cumming, HSRC • Jennifer Tamehana, CEO, TOIHA PHO

11. Foundation Principles • Kotahitanga – a unity of worldview, purpose and direction • Manaakitanga – recognising and respecting each other’s unique contribution • Tiakitanga – acting in a manner which respects the people who participate and for whom the research is being conducted

12. Principles in Practice • CEO as researcher • developed initial application • undertook document review, data collection • contributed to analysis • assisted with write-up and dissemination • Joint authorship • All team members have a responsibility to lead or contribute to writing of articles • Translational component

13. Our Aims • Determine • if Western concepts of resilience resonate with Māori primary health (MPH) approaches • the ways in which whānau resilience is enhanced by MPH services • Conduct research that • informs practice • contributes to Māori developmental aspirations

14. Research Questions • How is resilience reflected in MPH approaches? • What perspectives do whānau have on resilience? • How has engagement with MPH provider impacted on whānau resilience? • What are possible MPH provider characteristics that contribute to enhanced whānau resilience?

15. The Resilience Study • 2 phases • A) lit review, development of conceptual framework, testing of conceptual framework via series of KI interviews with TOIHA personnel • B) further testing the conceptual framework through a series of “Sequential Focus Groups” with whānau (clients of TOIHA)

16. Methods • Literature review • Development of the conceptual framework • Key informant interviews • TOIHA staff, managers and governance board members • Series of in-depth focus groups with TOIHA consumers • 6-8 whānau meeting regularly over four weeks

17. Conceptualising Resilience • Approach 1 • origins in psychology and particularly in social cognitive theory • contends that unless people believe they can produce the desired effects in their lives they have little incentive to act • individuals as agents, personal efficacy • limited for understanding the impact that history, culture or even environment have on resilience

18. Conceptualising Resilience • Approach 2 • underpinned by a social, contextual perspective • not simply an internal psychological state of wellbeing • “ecologically fluid, historically sensitive and culturally anchored” • holistic understanding of wellbeing

19. Our Working Definition “an individual’s capacity to navigate health resources and a condition of the individual’s family, community and culture to provide those resources in a culturally meaningful way” International Resiliency Project (undated), led by Michael Ungar, Dalhousie University

20. [1]distilled from key government strategies such as the NZ Health and Disability Strategy, the NZ Primary Healthcare Strategy, He Korowai Oranga as well as the Horne Report [2]primarily from Ungar

21. The SFG Method • First employed by researchers in Alberta to explore concept of “cultural competency” in an urban indigenous primary care clinic • Allows for deep exploration of particularly complex ideas and concepts • SFGs held with same people over 4 consecutive weeks

22. Findings • Whānau understandings of resilience • How engagement with a MPH provider has impacted on whānau resilience • Range of MPH provider resources/ mechanisms contribute to enhanced whānau resilience

23. Whānau Understandings of Resilience • Personal quality • inner strength, “toughness’, flexibility, resourcefulness • values allowing individual to overcome adversity • relies on connections to people & things • no agreement regarding resilience being a “learned” attribute or on why some people appear more resilient than others

24. Whānau Understandings of Resilience • Resilience as a process • movement away from risk, harm, or a “bad” life to one which is “better” • requires a catalyst • result of journey is “self-reliance” - individual strength as part of a strong, supportive, functioning whānau • no agreement on why, when or how the journey is instigated

25. Whānau Understandings of Resilience • Resilience and the collective • traditional examples of collective resilience • modern challenges to the traditional family unit requires a new form of resilience • concept of a Māori collective resilience depends on whether Māori still regard their iwi, hapū, marae as their community • Māori are mobilising themselves into new communities

26. Findings • Whānau understandings of resilience • How engagement with a MPH provider has impacted on whānau resilience • The range of MPH provider resources/mechanisms that contribute to enhanced whānau resilience

27. Impact on resilienceof engagement with a MHP • May provide the impetus for change in behaviour or lifestyle • balance between offering support & “dictating” to the client • Role model for whānau & supports individuals & whānau to become self sufficient • balance between “doing for” clients &“empowering” clients

28. Impact on resilienceof engagement with a MHP • Two types of client would not turn to a MHP for support : • those who would not seek assistance from any “outside organisation” - extreme examples of self-reliant whānau, turning to their own whānau networks first for advice & support • those who didn’t recognise a need to change or improve their situation

29. Findings • Whānau understandings of resilience • How engagement with a MPH provider has impacted on whānau resilience • The range of MPH provider resources/mechanisms that contribute to enhanced whānau resilience

30. What does TOIHA offer? • Experienced kaimahi to inform, educate, teach, demonstrate through role modelling, healthy lifestyles • Support for people to achieve their own goals in a manner that respects them & their rangatiratanga • Aroha & caring for people as if they were one’s own

31. [For example] these kids can only be on there ‘cos the child is the client. But you’re working alongside the parent … to… nurture this child I suppose. So if that parent has issues with themselves, that’s where they work … in this whānau base. They’ll work on the parent to rectify their, ... be it addictions or what have you, which will then flow on to this child and they come back to the child about how best to look after this child ... so get them to access whatever resources they need.KI02:15

32. One person, she has been in our service for years. Huge drug and alcohol abuse, lots of trouble, spent lots of time in prison, you know? ... Lots of sad history in the whānau through abuse, murders. She has come right through our service, she’s been with us about six years. She is now our consumer rep … she is at UCOL completing her mental health workers certificate yeah, and we just follow up on her and make sure she’s ok … and it’s all through the work that we’ve all done together...her care worker and the organisation as a whole because we’re able to inter-refer.KI07:9

33. Features of a resilience-promoting health service • Whānau centric • Uses Māori processes and strengthens Māori identity • Strong governance and leadership who role model the highest ethical, cultural, and professional values • Staff have the “right” mix of professional and personal values

34. Features of a resilience-promoting health service • Range of public health and primary healthcare facilities under one roof - physically located in one place • Outreach services for more rural and isolated members of the community • “Wrap-around” services

35. Reflecting on the results • Māori primary health care providers can and do support individual and whānau resilience • provide resources • support and enable personal autonomy • facilitate whānau-based problem solving • provide a whole of whānau perspective on health

36. Reflecting on the results • Resilience is more than one’s personal attributes or a “state of being” • Resilience is about how the collective can respond to and mitigate the effects of trauma, marginalisation and stress

37. Link to Whānau Ora • Whānau Ora Taskforce principles to guide service integration and delivery • utilising a whānau or family approach to well being • active and responsive government • whānau-centred design and delivery of services that offer opportunities for engagement and action • appropriate resourcing (Whānau Ora Taskforce 2010)

38. Link to Whānau Ora • Principles are consistent with an expanded or “thicker” description of resilience: “seamless set of negotiations between individuals who take initiative, and an environment with crisscrossing resources that impact on one on the other in endless and unpredictable combinations” (Ungar 2005:95)

39. Link to Whānau Ora • WO and resilience may be regarded as both a process and an outcome • However, resilience implies a “static” quality while WO is a goal towards which one can perpetually strive

40. Conclusions • Whānau Ora will not be achieved without a degree of resilience on the part of whānau members • MPH providers must use the full range of resources at their disposal to configure services to support those individuals and whānau who, recognising their own resilience, want to take the journey towards better health and achieve the ultimate goal of whānau ora

41. Areas for Further Study • Under what conditions will whānau and individuals decide to change their behaviour towards more healthy choices? • To what extent are these decisions independent of providers/dependent on whānau? • How can “crisscrossing” resources be used in a more cohesive manner to support whānau

42. Acknowledgements • The research participants • TOIHA Board members • TOIHA managers and staff • Whanganui whānau • Health Research Council of New Zealand • NgāPae o te Maramatanga • ACC • Families Comission

43. Comments/questions

44. For further information • Dr Amohia Boulton • Whakauae Research for Māori Health and Development • amohia@whakauae.co.nz • www.whakauae.co.nz