Maori women, like other women, rely on being well and healthy so they can undertake the various roles they have within their whanau and communities. Yet, their voices are generally absent and they are invisible and marginalised within the health setting. This is despite Maori women consistently

Socio-economic deprivation affects the ability of many Maori women to access and use the health services they may need. Health care providers who do not recognise or understand the world views and health needs of Maori women have the potential to further compromise their health outcomes. There seems little or no recognition that the health services Maori women receive may be less than optimal and might not meet their needs. (2,3)

The research I undertook for my PhD arose out of concerns and questions I had about colleagues' negative "opinions" of the repeated admissions of some Maori to acute hospital services. (4) The aim of the research was to explore Maori women's understanding of health and their interactions with health services, guided by the question: "What is happening for Maori women, their health and their interactions with 'mainstream" health services?"

Thirty-eight women who identified as Maori, aged 24 to 61, participated in the study. Their selection was aided by a collaborative endeavour with two Maori women advisors, known within the Maori community. The women came from a variety of backgrounds and lived in diverse relationships (permanent, non-permanent and alone). The majority had children, and many lived in homes with more than one family or generation. When unwell, health services were sought from either a medical practitioner or Maori health provider. The data was collected using semi-structured interviews with individuals and groups, depending on each woman's preference.

Health and well-being for Maori women is a complex construct, located in how they see themselves, what they believe is important, their past experiences, perceptions of "mainstream" health services, and the social roles they have.

Many Maori women feel they are forced to deal with competing world views when accessing "mainstream" health services, resulting in their beliefs and practices being relegated or totally ignored. In such cases, Maori women are then forced to make choices about the maintenance of their health and well-being, such as seeking traditional Maori healing treatments outside health services (such as tohunga or rongoa), often without informing their health care providers. They believe their beliefs and practices could co-exist alongside "western" biomedical practices--but it requires a process of listening and negotiation by all parties.

The dimensions important for Maori women and their health are:

* connecting through whanau;

* nurturing wairua;

* using matauranga; and

* undertaking self-care activities.

Their ability to have control over their health and well-being is compromised when they enter "mainstream" health environments and are confronted with world views and ways of doing things at variance with their own.

Maori women need to establish a trusting relationship and feel their health care providers are non-judgmental and genuine in their approach at all times, and have a willingness to listen. Continuity of health provider can also assist with this process. Being able to choose a health care provider is important, especially with regard to gender appropriateness.

Health determinants extend beyond genetics and disease processes to include factors such as socio-economic deprivation, ethnicity and race, colonisation, and racism, all reasons for differential access and use of health services by indigenous peoples. (5,6,7) Socio-economically, Maori women are more likely to experience deprivation and have life circumstances that reflect this.

The health status of Maori women

Maori women's life expectancy is 73 years, nine years less than the 82 years experienced by non-Maori. (8) The five major causes of mortality (by numbers) for Maori women are ischaemic heart disease, lung cancer, chronic obstructive pulmonary disease, cerebrovascular disease, and diabetes. Maori women are 1.3 times more likely than non-Maori women to be diagnosed with, and twice as likely to die from, breast cancer. They also experience adverse health effects of violence, with an assault and homicide hospitalisation rate five times greater than for non-Maori women. Maori women are twice as likely to be diagnosed with cervical cancer, and four times as likely to die from it. (8)

The 2006/07 New Zealand Health Survey, released early last month, (9) again highlights that Maori women have not increased the median number of visits to GPs in the last 12 months when compared to the 2002/03 survey; had the highest level of unmet need by GP services; are less likely to have been seen by a medical specialist in the previous 12 months; and more likely to have an uncollected prescription. Maori women reported that health professionals are less likely to treat them with dignity and respect, listen to what they have to say, and discuss their health care adequately "at all times" They also reported a higher prevalence of high or very high probability of an anxiety or depressive disorder.

Culturally appropriate health services

Culture's role and its significance in health and welt-being are well established. Being knowledgeable about specific aspects of Maori culture is fraught, given that Maori are not a homogenous group, and have great diversity within their beliefs and practices. Vital to meeting the health needs of Maori women is the establishment of meaningful relationships with health care providers that will enable Maori women to be heard. However, meaningful interactions cannot be achieved where a power imbalance exists. (10) Where institutional and personal racism is experienced, differential access to appropriate and quality resources, and health services is evident. (11,3)

The Maori women in my research encountered, time after time, health services and health care providers that were problem-focused and compartmentalised their health issues or problems. This resulted in their needs not being recognised and in interventions that were unsuitable or untenable. Predominately problem-based, biomedical approaches ignore the needs of Maori women, and the socio-cultural influences affecting their health and well-being. When interventions "go wrong" or outcomes are not achieved, it is not unusual for Maori women to be blamed and labelled "non-compliant':

Without effective access to and use of health services, with the needs of Maori women established within a culturally appropriate and acceptable manner, they will be destined to a legacy of poor health status. As one of the participants in my study said:

"... being a Maori woman means putting yourself to the end of the line to get health care and, when health services were accessed, you do "not get treated as a human ... there needs to be flexibility to do things outside of the traditional way in which health services are provided."

References

(1) Matheson, A. & Dew, K. (Eds). (2008) Understanding health inequalities in Aotearoa New Zealand. Dunedin, NZ: Otago University Press.

(2) Durie, M. (1998a) Whaiora: Maori health development (2nd ed.). Auckland, NZ: Oxford University Press.

(3) Reid, P., Robson, B. & Jones, C. P. (2000) Disparities in health: Common myths and uncommon truths. Pacific Health Dialog; 7: 1, 38-47.

(4) Wilson, D.L. (2004) Nga kairaranga orange--the weavers of health and wellbeing: A grounded theory. Unpublished PhD thesis, Wellington: Massey University.

(5) Ibrahim S.A., Thomas, S.B. & Fine, M.J. (2003) Achieving health equity: An incremental journey, American Journal of Public Health; 92, 161g-1621.

(6) Reid, P. & Robson, B. (2006)The state of Maori health. In M. Mulholland (Ed), State of the Maori nation: Twenty- first-century issues in Aotearoa. Auckland, NZ: Reed Publishing.

(7) Williams, D.R. (2002) Racial/ethnic variations in women's health: The social embededness of health. American Journal of Public Health; 92, 588-597.

(8) Ministry of Health. (2006) Tatau Kahukura: Maori Health Chart Book, Public Health Intelligence Monitoring Report No.5. Wellington, NZ: author.

(9) Ministry of Health. (2008) A portrait of health: Key results of the 2.006/07 New Zealand Health Survey. Wellington, NZ: author.

(10) Coates, C., Gray, J., & Hetherington, T. (2006) An "ecospiritual" perspective: Finally, a place for indigenous approaches. British Journal of Social Work; 36, 381-399.

(11) Jones, C. (2001) Cultivating cultural harmony. Kai Tiaki Nursing New Zealand; 7: 1, 10-13.

Denise Wilson, Ngati Tahina (Tainui), RN, PhD, is a senior lecturer in nursing (Maori health) at the School of Health and Social Services at Auckland's Massey University.

This article is a summary of a lecture she gave last month for Te Mata o Te Tau, the Academy of Maori Research and Scholarship. The Academy hosts four public lectures each year around the time of Matariki.