Abstract
Background
Unfair, avoidable health inequities persist in New Zealand because they are deeply rooted in health and social systems that systematically privilege non-Māori. The ongoing impacts of colonisation can be seen in entrenched patterns of ethnic inequities, with Māori continuing to experience the poorest health status on most measures compared to other New Zealanders, including a higher community prevalence rate of bipolar disorder. There is some research data about Indigenous peoples with bipolar disorder, but a dearth of research designed on ways to improve health outcomes for this population.
Method
A Kaupapa Māori methodology and qualitative methods were used to carry out interviews with 24 Māori patients with bipolar disorder, and 19 members of their whānau. A semi-structured interview schedule, informed by a systematic literature review and adapted cultural competence framework, was used to explore the impact of the New Zealand healthcare system on Māori patient and whānau experiences of bipolar disorder. Questions explored how participants conceptualised the role of the determinants of hauora on their wellbeing over time. An adapted coding framework was used to analyse the impact of clinical, structural and organisational features of the New Zealand health system on hauora, and to identify barriers to and potential enablers of health equity at each level of healthcare for Māori with bipolar disorder and their whānau.
Results
Themes from the analysis of clinical factors were clinical care, clinical culture, and clinical work with whānau. This analysis of clinical factors identified that the efficacy of clinical care for bipolar disorder was dependent on Māori patients and whānau having clear pathways through care, and being able to access timely, consistent care from clinically and culturally competent staff. The safety of care for Māori was influenced by the clinical culture in bipolar disorder services, embedded into care settings, and expressed by staff. Clinical work with whānau needs to be prioritised, by equipping staff with skills and resources to tailor care and enhance whānau and patient wellbeing. Themes from the analysis of structural factors were accessibility, delivery, and scope. To improve the accessibility, delivery and scope of bipolar disorder services for Māori, a redesign of operational, environmental, staffing and navigation points is required to overcome equity barriers. Themes from the analysis of organisational factors were executive management, organisational culture, organisational design, incentive structures, and information management and technology. Analysis of organisational factors identified that extensive transformation and re-organisation of New Zealand healthcare is therefore needed to achieve health equity. Recommended changes include executive management implementing organisational changes to the culture of healthcare by establishing equity in partnerships with Māori, embedding cultural safety in the organisation of healthcare, and focusing on whānau wellbeing. To support organisational changes, healthcare incentive structures are needed to diversify, develop and retain a culturally competent health workforce, together with information management and technology systems to guide continued whole system equity-oriented improvements. Changes in health outcomes and health equity for Māori with bipolar disorder requires a consistent Crown commitment to resource structural, organisational and clinical transformation of the healthcare system.