A community-based workforce benefits Māori and Pacific people with diabetes
Tania Mullane - Whitireia New Zealand, Te Pūkenga: A culturally-anchored workforce of community-based, non-clinical workers in South Auckland is delivering diabetes self-management education to Māori and Pacific people – and a new study indicates this model is proving effective.
With funding from the National Hauora Coalition, the Head of Nursing Pacific at Whitireia New Zealand, Tania Mullane, conducted focus groups with the workers, who were either dietitians, community health workers or kai manaaki (skilled case managers). Her aim was to find out more about their perspectives, challenges and successes in delivering these services.
“Culturally-comprehensive Type 2 diabetes mellitus [T2DM] management programmes, aimed at addressing inequities in Māori or Pacific diabetes management and workforce development, are not extensively available in New Zealand,” she says. “This is despite the high prevalence of T2DM in these communities.”
Separate focus groups with seven dietitians, seven community health workers and seven kai manaaki took place in South Auckland, New Zealand. The groups were asked about their practices when working with T2DM in the community, the strategies they utilised and how they measured or qualified success.
“To analyse these results, I developed the Tangata Hourua research framework, which supports qualitative research looking at Māori and Pacific people together,” Mullane says. “The Tangata Hourua framework combines Kaupapa Māori methodologies and Pacific core values, provides cultural boundaries for all involved, allows indigenous themes to emerge and for participants to identify values that resonate with them. This supports self-identity and allows for self-improvement and growth, while providing cultural parameters to maintain safety for researchers and participants.”
The analysis identified three themes common across the groups: whakawhanaungatanga (actively building relationships); cultural safety; and cultural alignment.
“Generally, all three groups agreed that their roles required good relationships with the people they were working with and an understanding of the contexts in which Māori and Pacific peoples with T2DM live,” she says. “Some of the most positive impacts came from a kai manaaki or community health worker building positive relationships with the client and becoming their main contact person. Because they were part of a multidisciplinary team, their role in taking information back to the clinicians was vital.”
If a client missed a series of appointments, for example, their community-based health worker was well-placed to shed light on their personal circumstances.
“The workers knew the barriers their clients faced, such as running out of petrol and being unable to pay for more. This meant the client was regarded more favourably, rather than just another non-attender,” she says. “The community-based health worker could also step in to provide support – they could be adaptable about when and where they met with clients and how long they spent with them.”
Building a trusting relationship was also critical for influencing lifestyle change.
“T2DM is all about behaviour, and if you don’t build trust and understanding it becomes more difficult to influence positive behaviours for better health outcomes,” Mullane explains. “Support doesn’t always need to come from people with a clinical background. It is most important to have people with an understanding of Māori and Pacific lifestyles and circumstances who are able to act on that knowledge appropriately – professionally, clinically or culturally.”
She says it is also helpful to have an appreciation of social determinants of health and the impacts of poverty on health practices and decisions.
“It’s not only about the means or ability to buy food, but also whether people can afford to make healthy choices. It’s so much cheaper and easier to eat badly.”
Mullane says some of the Pākehā dieticians she spoke to made an effort to visit the local markets and food stores near their clients’ homes. This allowed them to see what food was available at what cost, so they could make realistic recommendations for improving their clients’ health.
“Diabetes is an epidemic and for as many people who have it, there are three times as many who are prediabetic. Diabetes is not going away, but this community-based model shows signs of being effective and successful in supporting people’s health.”
The key to its success, Mullane says, is that it invests in the right people in the right place to deliver the right service – one that is culturally anchored, client-centred, not service-centred.
“By supporting community based, non-clinical workers to build meaningful and culturally-safe relationships with Māori and Pacific people, we have the potential to improve diabetes outcomes,” she says. “Deliberate strategies to improve cultural safety, such as educating health professionals and fostering culturally-safe practices, must be priority when funding health services that deliver T2DM prevention programmes.”
Another aspect of her PhD focused on secondary data from another study which had asked clients with T2DM and their whānau about their experiences working with the kai manaaki, and was also themed using the Tangata Hourua Framework
“When I conducted the focus groups with health workers, I found their responses – on the whole – mirrored the themes identified from the client and whānau responses.”
She says this is a model that could be adopted in other parts of the country, too – and the recent health reforms and the new Māori Health Authority present the prime opportunity to do this.
“Gone are the days of sitting in your health service and waiting for people to come to you. If you really want to effect change, you have to know and understand your community.”
Tania Mullane has more than 16 years of leadership experience in educational institutions in Aotearoa, incorporating innovative practice approaches in the learner lifecycle. These include for Māori, Pasifika and International learners at all levels of study and areas such as recruitment, student experience, retention and academic outcomes. Her Master's thesis, which looked at how Māori learners’ educational needs are best met within a mainstream tertiary organisation, was extensively referenced in the Tertiary Education Commission publication ‘Doing Better for Māori in Tertiary Setting’ (2012). She has clinical experience in primary health, working within Māori and Pasifika communities for seven years. Contact Tania Mullane