Table 1 presents the number and demographic profile of participants for each focus group. The focus groups reflected the fact that women make up the great majority of the New Zealand health care workforce [19], with all participants being female. Analysis of the data identified common themes: whakawhanaungatanga (actively building relationships), cultural safety and cultural alignment. However, there were also two key differences for KM and CHWs who (1) preferred a multi-disciplinary team (MDT) approach, and (2) described their experiences of feeling un/valued in their roles, when compared with dietitians. The themes are presented here.
Table 1 – Profile of Focus Groups
Focus Group
|
Number
|
Demographic Profile of the Focus Groups
|
Ethnicity – self- identified
|
Gender
|
Kai Manaaki
|
Seven
|
Six Māori
One Indo-Fijian
|
All female
|
Community Health Workers
|
Eight
|
Two Māori
Two Pacific Peoples (Cook Island Māori and Samoan)
Four New Zealand European
|
All female
|
Dieticians
|
Seven
|
Three Pacific Peoples (Tongan and Cook Island Māori)
Four New Zealand European
|
All female
|
Whakawhanaungatanga
Whakawhanaungatanga is a fundamental principle which Mead [20] explains as reaching beyond family connections to establish and maintain personal and culturally relevant connections. All the participants concurred in stating that whakawhanaungatanga was a key component in strengthening and establishing knowledge of self, whānau and the community. They felt this was essential not just for the individual, but for whānau connections too, in that it created a safe space to share their lived experience of having T2DM.
The KM’s perspective on whakawhanaungatanga illustrated the core premise of the concept:
“Trust building is important and how we build trust to them and then they tell things to us. … treating my patients like they are my sister, my brother my whānau which quickly establishes a relationship.”
“Talking about their families and about them first before diving into medical stuff … build up a relationship, establishing a really good rapport, it’s connection. … Trust building is important and how we build trust to them and then they tell things to us; which allows clients to feel safe.”
“We [Pacific Peoples] are more like a group rather than self … [in] understanding them and also understand how the Pacific and Māori live and what mattered to them, fitting into their world view” – Dietitian, Pacific.
They felt strongly that more could be done to highlight the importance of whakawhanaungatanga when working with Māori and Pacific Peoples and communities.
Whakawhanaungatanga has become a core fundamental of all the participants’ professional roles. This was spoken about by New Zealand European participants as a strategy used specifically to build culturally meaningful connections and relationships when working with Māori and Pacific Peoples and their whānau.
“Things like whakawhanaungatanga is vital, nobody ever writes about it, its intrinsic to this community” –CHW, NZ European.
“I think potentially as a non-Māori and non-Pacific there’s a barrier there right at the start in terms of ‘am I going to listen, am I going to understand … mistrust with what’s happened before’ so how can we start to engage them?” – Dietician, NZ European.
There was also reflection on how a cultural approach was essential for non-Māori, non-Pacific workers if genuine relationships were to be built so as to achieve better diabetes outcomes for clients and their whānau:
“quite a few years ago I would have thought that was like such bad practice … now I think it's so important, because I don't need a diet history to be able to do my job and do it well. So yeah, just massive changes of thought and process around how you do things and then obviously that's that for another time at building relationships … sometimes I'll spend an entire session just chatting [in order to know each other].
A culturally safe workforce
Delivering services in traditional settings such as marae (traditional meeting houses) for Māori and church for Pacific Peoples were effective for shifting power to clients, due to their experience of cultural affirmation. One CHW described the importance of traditional cultural settings or principles for services for Māori and Pacific Peoples:
“Being based on the whenua [land] of a marae is key to what we do and how we do it. I don’t think we can say that any other clinic in the whole of Auckland has as higher Māori ethnicity as we do. [It’s a space] where they can just be and interact with others and be heard” – CHW, Māori.
“Being on the marae and having the marae support, working within an organisation that is guided by kaupapa Māori values … it’s privilege” – KM, Māori.
Participants based in clinics in non-traditional settings, such as community-based marae (Māori meeting house), spoke about how this contributed to a culturally safe work environment. They strongly advocated that being based on the marae was beneficial not only to them as part of the health team but also, more importantly, to the clients and their whānau who accessed the services there.
“Being based on the whenua of a marae is key to what we do and how we do it. I don’t think we can say that any other clinic in the whole of Auckland has as higher Māori ethnicity as we do.”
Those who were based at the marae saw it as an example of best practice, and saw that other providers looked to them as a role model and a centre of excellence. The clinic is becoming a hub for the community:
“The clinic works like a centre of the community, so people feel like they can pop in anytime, walk in clinics to see someone; There is also a spiritual component … the idea of community, the idea of inclusion” – CHW, Māori.
“These are my brothers and sisters”
The importance of language was explained:
“I find the language that you use has to be simple … non-judgmental lens, taking that judgement out, because they are already feeling so crap … we don't use jargon from the clinic we use everyday language that we/they know. It’s about creating a supportive environment for people to thrive in and that’s also very important” – KM, Māori.
However, this required time. The concept of ‘time for equity’ allowed appointments to go for an hour or longer to “show you value them and their time”. When we “just chill out listen, then they talk”. Consequently, clients described feeling heard, and were more likely to:
“actually, come up with the solution you don't have to do anything, don't make assumptions that we know any more than they do they know” – KM, Māori.
“sometimes our appointments would go for an hour or so, 'cause they just needed that time to sort of warm up and then really really get out what they were trying to say or wanted to know … there’s a valuing of their time and what they're talking about … it's a two-way thing it's not that anyone is better but because we had the time just sit there and listen and you know” – KM, Māori.
Cultural concordance – knowing the context within which Māori and Pacific Peoples with T2DM lived – was associated with better engagement and, subsequently, better outcomes. As one worker said, “these are my brothers and sisters. I know what works and what doesn’t.”
All groups felt that there were inadequate culturally specific resources to work with: “trying to find pictures [of healthy food options] that represent Māori or Pasifika people is really hard sometimes” with dietitians commenting that most resources were “very white” (CHW, NZ European).
Workers encouraged each other to know and incorporate their clients’ ‘normal day life’ into interventions, as these encouraged clients to engage with the programme. Participants agreed that this was easier for Māori and Pacific workers because they lived similar lives and were:
“Understanding [of] everybody’s work timetable, kids’ timetable, how are we going to put your food and medication around what you are already doing, and how can we adjust that for your whole family’s benefit. Go out to [local food] markets and understand where they shop and what food they eat” – CHW, NZ European.
All agreed that building Māori and Pacific workforce capacity in T2DM management was important as it allowed the workforce that was needed to reflect the Māori and Pacific population who had the highest incidence of T2DM. The dieticians, especially, strongly advocated that any workforce development should attract and retain more Māori and Pacific into health professional roles, which also supported the District Health Board goals of increasing more Māori and Pacific staffing.
Every one of the New Zealand European dieticians spoke about their self-awareness of unconscious biases, with one dietician acknowledging that some clients did not want to work with them because they were Pākehā (New Zealand European), which forced them to reflect on awareness and responsibility of cultural safety. This suggests all clinicians, regardless of their background or culture, may not be appropriate with anybody who walks through the door. A New Zealand European CHW also recognised the importance of a culturally appropriate person, of Pacific working with Pacific, as there was only one Pacific CHW in their organisation:
“Being in the community and working with Pacific Peoples means language is important, so having a PI CHW makes such a difference with supporting us with language, but also with the engagement, she can engage with them in a way that I can’t and that’s good.”
“So having someone who is Māori or Pacifica working in the team is essential. Just obviously having a [Pacific person] involved in the delivery of the programme, having someone from that ethnic background and can sort of relate. Having a [Pacific person] involved in the delivery of the programme, having someone from that ethnic background and can sort of relate to the kids, being the same age and being relevant.”
There was certainty from non-Māori and non-Pacific in recognising that professional development in cultural safety was necessary, in addition to building the capacity of the Māori and Pacific workforce.
Multidisciplinary team approach
The KM and CHWs both worked as part of a multidisciplinary teams (MDTs) and felt that this was best for managing T2DM for Māori and Pacific Peoples. An MDT approach was strength-based in the sense that different members of the health team had different roles based on their strengths or expertise. They described the importance of working in partnership with non-health service providers, including social or housing services, which facilitated access to interventions that addressed the wider determinants for health, such as poverty. For example, one KM described supporting a client to study for and sit their driver’s licence, which then enabled them to attend job interviews and finally attain employment.
The KM in particular felt that being part of a wider team meant that they contributed to the wider environment, and this had an impact on the health and wellbeing of the whole community. This influence occurred at multiple levels. For example, in the primary care clinics, they participated in team meetings, shared experiences and learnings about good practice, and advocated for clients and their whānau. One example was teaching clinicians (GPs and nurses) how they could do more to remove barriers to diabetes care. They knew where to locate or refer people for services and dismissed siloed care:
“I don’t know anyone outside the marae because we are so used to using who [multiple health and social service workers] we have here” – KM, Māori.
In contrast, the dieticians did not mention a multidisciplinary approach and their focus group discussion concentrated just on their own role.
Feeling un/valued
CHWs described feeling marginalised by some diabetes services because they were not in formally recognised roles. KMs are also not regulated yet they had a very different experience. They described a workplace that provided regular supervision and opportunities for peer support, in addition to access to programmes that fulfilled self-determined professional development needs. They felt valued for their cultural and social determinant expertise, and that they were contributing beyond the service to people and their communities.
“Actually, we were always treated like professionals of our field” – KM, Māori.
“even smaller ‘aha’ moment such as they are smiling, they brought their daughter or someone with them to learn some more, sometimes a community of people sitting there waiting for you” – KM, Māori
Again, there was no mention of this from dietitians.