"Sick unto death" barriers and facilitators to primary healthcare for Māori

Abstract

This qualitative study examined the barriers and facilitators that influenced access to and engagement with primary healthcare amongst a purposively selected Maori sub-sample from the Christchurch, New Zealand, cohort of the Hauora Manawa Study which is comparing heart disease amongst two diverse Maori communities (in Wairoa and Christchurch) with a non-Maori group in Christchurch. There was found to be a highly complex and multidimensional relationship between skin colour and/or social-ascription as Maori, and age, gender, and spatial and social-class location. The integration of Bourdieu's Theory of Practice (1977) and Shim's (2010) conceptualisation cultural health capital into a context-specific analytical framework was instrumental in mediating the dichotomous relationship between subjective patient experiences and objective institutional arrangements, including policies, practices and the relative power imbalances in a highly differentiated, racialised society. Access barriers regarding the reduced ability to maintain continuity of care with a known practitioner, since the restructuring of New Zealand's primary health sector at the turn of the century, represents the disjuncture between contemporary policy objectives and clinical encounters with predominantly non-Maori practitioners. Recognition of skin colour and/or self-defined social-ascription becomes a determinant of potential or realised exposure to differential treatment and/or utilisation patterns. Age and gender reflect the history, context, and tempo of demographic change precipitated by rapid Maori urbanisation from the 1950s-1960s. Lifecourse access to healthcare appears to condition pre-reflexive acceptance of Western medical care. In contrast, adult access (except in cases of medical emergencies) and/or gender-specific differences, reflective of the belated medicalisation of Maori childbirth and concomitant childrearing responsibilities, require clinical encounters conducive to overcoming heterodoxical beliefs occasioned by childhood dependence on traditional medicine. Notwithstanding increased intermarriage and access to societal infrastructure in the urban milieu, the transgenerational normalisation and entrenchment of the racialised social-class destination of Maori impedes equitable access to financial, symbolic cultural, social, political and cultural health capitals. Dominant group cultural capital is permanently marked by the class, social and ethnic origins of its acquisition, and the differences in ability to accrue cultural health capital appears to reflect the cumulative and interconnected relationship between broader inequities that pervade all aspects of social structures, institutions and social life. In the modern healthcare landscape, conditioned by healthism and concomitant expectations that patients assume greater management of, and have proactive dispositions towards, personal health and risk behaviours, accrued dominant cultural health capital has currency. Familiarity with biomedical concepts and language, verbal and nonverbal competencies, including health literacy, together with the interactional capacity to engage with health professionals and navigate care pathways constitutes an advantage. Barriers and facilitators to primary care access are not only conditioned by provider dispositions and bias, both intentional and unintentional, but indirect and symbolic, direct and material manifestations of colonial relations. Equitable Maori access to and engagement with primary healthcare requires the government, institutions, their representatives, and citizens to recognise the relationship between colonial power relations and societal, not individual, responsibility for interethnic disparities in health and other outcomes.