Rural Māori experiences of accessing heart health care: a Kaupapa Māori qualitative analysis
Taria Tane
1 * , Vanessa Selak 2 , Kyle Eggleton 3 , Matire Harwood 4
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Abstract
Rural Māori experience inequities in heart health outcomes compared to rural non-Māori and urban Māori. Access to health care is a significant contributor to these inequities. There is a wealth of literature that explores Māori access to health care; however, the voice of rural Māori within the literature is limited. Under Te Tiriti o Waitangi (The Treaty of Waitangi), Māori have legislative rights to access, engage, and participate in the health care system equitably.
This study aimed to investigate the barriers and facilitators of accessing heart health care for rural Māori.
The study was informed by Kaupapa Māori Theory, which centres on Māori worldviews and epistemologies. Rural Māori (n = 11) with lived experience of (or who had supported their whānau (family) member with) acute coronary syndrome, heart failure or cardiovascular risk assessment were interviewed, and reflective thematic analysis of the data was undertaken.
Three overarching themes were generated: rural Māori desires and expectations of heart health care; how the system engages with rural Māori; and knowing what is important to rural Māori when it comes to heart health.
Participants experienced many barriers to accessing quality heart health care, some of which were unique to rural settings. Participants sought heart health care that was close to home, culturally responsive, included a representative Māori workforce, involved their whānau, and valued partnership. System-level action is needed to adequately address inequities in health care access and outcomes in rural Māori and to meet obligations under Te Tiriti o Waitangi.
Keywords: access to care, cardiovascular diseases, health services, indigenous peoples, Māori health, Maori Peoples, rural health, rural population.
| WHAT GAP THIS FILLS |
| What is already known: Rural Māori experience inequities in access to cardiovascular care compared to non-Māori and urban Māori. Despite this, little is known about the barriers and facilitators that drive access to quality cardiovascular care along the disease continuum for rural Māori. |
| What this study adds: This study contributes new knowledge by prioritising the voices and experiences of rural Māori accessing heart health care, which have been largely absent from the literature to date. |
Introduction
Māori (the Indigenous Peoples of Aotearoa New Zealand) experience inequities in cardiovascular disease (CVD) prevalence and outcomes.1–3 Access to cardiovascular health care (referred to herein as ‘heart health care’) is a significant contributor to inequities in CVD outcomes in Māori,4,5 and rurality likely plays a role.4 Māori who live rurally experience inequities in mortality rates and a more significant burden of CVD risk factors compared to urban Māori and urban non-Māori.3,4 A higher proportion of Māori also live rurally (21.5%) compared to the total population of Aotearoa, New Zealand (15%).6
In Te Tai Tokerau Northland region, which is predominantly rural, Māori comprise approximately 32% of the total patient population, and 44% of Māori live in the most socially deprived areas.7,8 Poorer health outcomes in rural Māori communities may reflect the compounding of socio-economic disadvantage with barriers to accessing health care services.9 This is important to consider in regions like Te Tai Tokerau Northland, where intersections exist between ethnicity, rurality and social deprivation.
Reported barriers that influence access to health care for Māori include transport issues, health care costs, poor health care staff cultural competence, and low trust in the health care system.10,11 Important facilitators include whānau (family) support, being treated with respect, culturally appropriate care, building capacity of the Māori health care workforce, financial assistance, transport, support with system navigation and emotional wellbeing support.10,11 However, a recent review on barriers and enablers to access heart health care for rural Indigenous Peoples found limited research on the voice and experience of rural Māori.12
Efforts to address Māori health inequities have been inadequate to date, with even less attention given to the additional disparities that affect rural Māori. Equitable access and engagement, as well as systematic participation and partnership in the health care system, are legislative rights of Māori.13 Te Tiriti o Waitangi (The Treaty of Waitangi) guarantees Māori protection and sovereignty over their health,13 yet evidence suggests that the health care system has failed to systematically and meaningfully enact its responsibilities.13
This study aimed to investigate the drivers of access to heart health care for rural Māori living in Te Tai Tokerau Northland. The research question ‘What barriers and facilitators do rural Māori in Te Tai Tokerau Northland experience when accessing heart health care?’ was posed. This article presents the findings of qualitative interviews with rural Māori in Te Tai Tokerau Northland who have engaged with heart health care services.
Methods
Methodology
The principal investigator, TT (female) (Ngāpuhi, Te Roroa), led and conducted this research as part of her doctoral research project. TT resides in a rural Te Tai Tokerau Northland community and acknowledges her position as both insider and outsider in the research. This is based on her identity as Māori, her whakapapa (Māori genealogy), and whānau with lived experience of heart health conditions (insider status), and prior training and experience within an academic and health system that has historically privileged Western knowledge systems14 (outsider status).
In addition to TT (with prior experience conducting qualitative research), the research team included MH (Ngāpuhi), a well-established Kaupapa Māori health researcher with extensive experience in qualitative research, KE, a Pākehā (New Zealander of European descent) health researcher with expertise in rural health, Māori health equity and qualitative research, and VS, who is a Pākehā epidemiologist with experience in Māori health equity research.
This research used Kaupapa Māori Theory (KMT) to inform the study design and analysis.14 The study leverages KMT’s critical, cultural and theoretical underpinnings to gain a deeper understanding of the lived realities of rural Māori, prioritise rural Māori experience and mātauranga (traditional Māori knowledge), to produce insights that can inform the improvement of heart health care services for the benefit of rural Māori.14,15 Importantly, the study is Māori-led, supporting Māori tino rangatiratanga (sovereignty) over the research process to achieve a positive difference that is for Māori, by Māori.14,16,17
The application of KMT in data collection included Tikanga Māori (Māori cultural protocols) of whanaungatanga (building connection and kinship), tino rangatiratanga (participants determined use of Te Reo Māori (Māori language)), and manaakitanga (showing respect, generosity, and support for others) via koha (gift). The use of KMT in the analysis provided a critical lens to support Māori reclamation of power by resisting colonial narratives that have historically dominated the research space.16
Recruitment
Participants were invited to take part in this study if they or their whānau had lived experience of having a cardiovascular risk assessment (CVDR) in primary health care, acute coronary syndrome (ACS) and/or heart failure; the participants themselves were aged 18 years or older; self-identified as Māori; lived in ‘rural areas’ of Te Tai Tokerau Northland; and provided informed consent (verbally or written).
‘Rural areas’ were defined using the Geographic Classification for Health (GCH), and participants were included if they resided in any ‘rural’ classification domain.18 Rural classification domains include ‘R1’, ‘R2’ and ‘R3’, with R1 denoting the least remote and isolated rural communities and ‘R3’ denoting the most remote and isolated rural communities.19
A purposeful sampling approach was used to identify and approach potential participants.20 Recruitment took place via existing professional and community networks via a study flyer. Potential participants contacted TT via email or a toll-free phone number. Some participants advertised the study via their own professional networks, forwarding contact details of potential participants to TT for initial contact. A participant information sheet and consent form were sent to eligible participants. An in-person or phone interview was then scheduled according to participant preference and availability.
Interviews
TT completed interviews, which were conducted in English. Some participants had whānau present and used Te Reo Māori to describe concepts of Te Ao Māori (Māori worldview). TT has experience speaking and understanding Te Reo Māori, so an interpreter was unnecessary. In-person interviews took place in public locations chosen by participants. The research team intended to interview up to 15 participants; however, recruitment was closed at 11 interviews as the research team felt that enough data had been collected to tell in-depth, complex and meaningful stories about the topic of interest (ie data saturation).21 Interviews lasted 30–60 min and were based on an interview guide (Supplementary File S1). Participants were offered to review their interview transcripts following interview completion.
Data management
Interviews were audio-recorded and transcribed verbatim using an external provider with competency in Te Reo Māori. Transcripts, interview recordings and participant information were stored on a secure University of Auckland cloud-based server. Māori Data Sovereignty Principles guided the overall study.22
Analysis
A reflexive thematic analysis (RTA) approach informed the data analysis.23 RTA was chosen as it allowed an organic approach to theme development, prioritised participants’ subjective experiences, and acknowledged TT’s active role and positionality in the research process.24 TT first familiarised herself with the data and then inductively generated initial codes using QSR International NVivo Software (Version 1.7.1, 2022). Codes were organised into common groupings, which then informed the development of initial themes. Initial themes were discussed and refined by the research team in an iterative process until there was consensus that the refined themes achieved insightful interpretations that adequately addressed the research question. A summary of the refined themes was then provided to participants to check the validity of the themes generated.
The Consolidated criteria for reporting qualitative research (COREQ) informed reporting to ensure that important aspects of the study were included in this paper (see Supplementary File S2).25
Results
A total of 11 participants (female, n = 8; R2, n = 7) were recruited and interviewed, with the majority (n = 5) residing in the Kaipara district of Te Tai Tokerau Northland (Table 1). To maintain participant privacy and confidentiality, participants chose a pseudonym instead of their real name. Three overarching themes were generated in the analysis: rural Māori desires and expectations of heart health care; how the system engages with rural Māori; and what is important to rural Māori when it comes to heart health. Each theme is described below. A thematic schema is provided in Fig. 1, and subthemes with further supporting quotes are provided in Table 2.
| Pseudonym | Gender | Age group (years) | Lived experience or whānau support | Condition | GCH category | |
|---|---|---|---|---|---|---|
| Roselin | F | 70–79 | Lived experience | ACS | R3 | |
| David | M | 50–59 | Lived experience | ACS | R1 | |
| Freda | F | 30–39 | Lived experience | ACS | R3 | |
| Maria | F | 50–59 | Lived experience | ACS | R2 | |
| Ena | F | 50–59 | Whānau support | ACS and heart failure | R2 | |
| Bonnie | F | 60–69 | Whānau support | ACS and heart failure | R2 | |
| Jax | F | 40–49 | Lived experience | ACS and heart failure | R2 | |
| Charlie | F | 30–39 | Whānau support | ACS and heart failure | R2 | |
| Betsy | F | 50–59 | Lived experience | ACS | R2 | |
| Hone | M | 60–69 | Lived experience | High-risk CVD (CVRA) | R3 | |
| Mark | M | 50–59 | Lived experience | Heart failure | R2 |
F, female; M, male.
| Themes | Subthemes and supporting quotes | |
|---|---|---|
| Rural Māori desires and expectations of heart health care | A system under pressure cannot meet the needs of rural Māori | |
| And even then, I feel like it’s not quality treatment. Because they are so pushed under pressure. (Freda) | ||
| How many of our whānau have died because they didn’t get a follow-up? (Charlie) | ||
| It’ll be hard for somebody without having that care especially now with the shortage too; the staff are going completely off track now. (Ena) | ||
| And they say that they were short staffed, but. My experience is that though, if we are you don’t see it when you’re in there cause they’re just really attentive. (Roselin) | ||
| Access to heart health care closer to home | ||
| I would have a cardiologist or those who are halfway past the training point to go out and visit our kuia (elderly woman) and kaumātua (elderly man) so that they [kaumātua] don’t have to come all the way from [rural area] just to see a cardiologist for ten minutes and to drive all the way home. (Mark) | ||
| And they said “you can come in for an emergency appointment, but you might be sitting here for anywhere between 2 hours and 10 hours” depending on your level of discomfort. I was just like, “wow, I can’t do that.” We live too far away, you know, because it takes us two hours to get from the [rural settlement]. (Freda) | ||
| Like I said, make it more mobile services. They can get their outreach, not just to places like [rural area] makes it really good for the [rural area] whānau. But, places like [rural area] have to either travel to the forest or travel to [area]. And, there’s a big community down there. (Hone) | ||
| How the system engages with us as rural Māori | Valuing culturally safe heart health care | |
| Important, yeah, that whanaungatanga side of things, and some people forget that. They forget that’s a big important part of you; especially when you’re holistic like me. (Maria) | ||
| And I also agree with the holistic especially from the Te Whare Tapa Wha perspective of professionals working with whānau. (Bonnie) | ||
| And then we just kind of just axed her and, and we were disappointed as Māori that there’s this Māori liaison who really did nothing for us as Māori, you know, so. I think they need. Yeah, they needed to go. (Charlie) | ||
| Health care services’ ability to partner with rural Māori | ||
| People just get so caught up in the wrong conversation, or the clinical conversation. The intelligence of trying to get everything clinically right, that they forget that the person themselves is an enormously useful tool in their own change. (Betsy) | ||
| Having a connection and a relationship with your community, knowing where your communities are, knowing the dynamics of your community. This is what [doctor] did up in the [area]. He had all of that. One here next door that used to be there, [doctor], he was another one. Connection, relationships, understanding, the whole lot. Vitally important. (Hone) | ||
| If it is just those things that [sister] just touched on and maybe it’s at the grassroots where the trust between patients and health professionals is nurtured. Of going, “cool, from my first initial, um, exposure or experience within getting my heart right or whatever it might be, I had a great experience that’s going to feed me to go to the next one” because if you don’t, as I said, if you go to your GP and they’re like, “Oh, you’re fine, I’ll just give you Panadol”. You and your mind are not going to trust the next person. (Charlie) | ||
| Understanding rural Māori heart health priorities | The role of whānau | |
| I gave up smoking last year and backed right off my drinking. Well, you know, I want to be around for the boys. Well, there’s that. No-one will guarantee tomorrow but if we can at least try to be around a bit longer. (Mark) | ||
| Well, like I said, with everything that was going on, um. I think like my biggest strength that I had at that time was my sister. Like, um, because information was being told to me. But it was all too much information for me to be able to kind of process. Um, and, you know, she was able to sort of retain all the information and, and sort of decipher it better than I could. Um, which gave us strength as a family to be able to advocate for ourselves. (Jax) | ||
| I was absolutely gutted, to be honest with you. And then it made it hit home when my brother said, you need to do something about this, like immediately you need to be here for my nephews. You need to be here for your family. Because you’re just ignoring it. (Freda) | ||
| Heart health knowledge | ||
| Understanding the medication for us was helpful. So when doctors come in and we’re saying, “Hey, prescribe this, this and this,” and I’m like, “No, she’s already having this. And don’t forget that gives her a side effect. So she’s taking that. Um, what does that mean for her heart? If she stops that medication, what are we going to see? Those effects within her body and her mind?” Um. Yeah. You almost become just as in tune with the medical. (Charlie) | ||
| And so I’m pretty conscious about my health now. I wasn’t before. Eat healthy. That’s about it really. Just stay on a nice, healthy track. I’ve stopped smoking. I haven’t smoked cigarettes in years, but I don’t smoke vapes. I don’t drink. (David) | ||
| Yeah, just the educating, and I don’t know how you get it out there more because I know it’s out there. There’s a lot of education and information out there, but people aren’t using it, aren’t taking it in. (Ena) |
Theme 1. Rural Māori desires and expectations of heart health care
This theme describes the desires and expectations of heart health care by Māori living rurally.
Participants expected quality heart health care following their heart event. However, widespread staff shortages were leading health care teams to go ‘completely off track’ (Ena) from the level of care expected by whānau:
And even then, I feel like it’s not quality treatment. Because they are so pushed under pressure. Like for myself, when I went through that, I don’t feel like it was quality. (Freda)
Betsy understood the minimum entitlements for her follow-up care post-hospital discharge but felt ‘really disappointed’ when she heard nothing from her local rural Māori Health Provider:
I would have expected a phone call at minimum – at minimum, as follow-up for recovery stuff, a phone call, a visit, something. But nothing. (Betsy)
Participants felt that health care teams were doing ‘whatever they could’ (David) and were ‘really attentive’ (Roselin) even though it was apparent that health care teams were short-staffed.
Participants understood the unique barriers and challenges that affect rural heart health care delivery compared to that delivered in urban areas.
One example was the lack of cardiac specialist support at local rural hospitals. Mark understood that cardiologists were ‘busy’; however, was still disappointed that he had only ‘only ever spoken to [a cardiologist] twice’ out of ‘25, nearly 30’ heart health care appointments.
Participants felt that enhancing access to specialist support in rural Māori communities, particularly for kaumātua (elderly), afforded the greatest opportunity for improving access to heart health care:
I would have a cardiologist or those who are halfway past the training point to go out and visit our kuia (elderly woman) and kaumātua (elderly man) so that they [kaumātua] don’t have to come all the way from [rural area] just to see a cardiologist for ten minutes and to drive all the way home. (Mark)
Geographic barriers (eg distance and travel times) were regular hurdles for some participants accessing timely rural heart health care appointments. For Ena, timely access to emergency response teams was also not realistic living rurally, and it was ‘quicker to just be driven to a hospital than ring the ambulance up here.’
Participants desired solutions to these challenges that focused on reducing transport barriers by funding ‘taxi rides for rehabilitation’ (David), having heart health care services ‘go to the kaumātua and our kuia’ (Mark) or utilising local rural Marae (culturally sacred meeting place). As Ena pointed out, urban marae with health and social services are often showcased in the media, which was not the case for rural marae:
I just find that if something’s at the marae people would go back, and it’s such a waste to see them [marae] sitting there and not being utilised especially when you look at the one in [city]. (Ena)
Theme 2. How the system engages with us as rural Māori
This theme discusses the health care system’s ability to ‘fully engage and understand Māori’ (Hone) who live rurally. There were two subthemes – culturally safe heart health care and partnership with rural Māori.
All participants felt that culturally safe heart health care was ‘an important part’ (Maria) of wanting to engage with the health care system. Delivering ‘Te Whare Tapa Wha’ (Māori health model) (Bonnie) model of care, ‘whanaungatanga’ (Maria) and ‘karakia’ (Māori ritual or prayer) (Charlie) were some examples of culturally safe approaches that were ‘more relevant to us as Māori’ (Freda).
Participants felt that Māori health professionals delivered culturally safe care:
They go around to Māori patients, or any patients who want some cultural support; karakia, they kōrero (speak) with you, they see how things are going. (Maria)
However, the lack of Māori working in health care, including heart health care, was noted:
No Māori though. No Māori in that space. (Betsy)
For Freda, paying ‘whānau to look after our whānau’ and ‘supporting training and opportunities to get our people qualified to be able to be in that space’ were potential solutions to boosting Māori representation in the health care workforce.
Some participants experienced poor cultural support across the system that ‘really did nothing for us as Māori’ (Charlie), leaving participants feeling ‘ashamed and underwhelmed’ (Charlie) because engagement was ‘shallow’ (Betsy).
Participants observed that some health care staff, particularly urban hospital staff, focused only on ‘trying to get everything clinically right,’ which was a missed opportunity for them to partner with patients themselves as an ‘enormously useful tool in their own change’ (Betsy). However, participants felt that rural health care professionals were effective at partnering with their rural Māori patients, meaning ‘people had much more faith and trust’ (Hone) and could ‘open up’ (Hone) to them. Rural health care teams treated whānau with ‘respect’ (Betsy), understood the ‘dynamics’ (Hone) of their rural community, were concerned about the wellbeing of participants and their whānau ‘collectively’ (Freda), and understood ‘manaakitanga’ (Freda). The strong relationship between rural health care professionals and their community often showed in manaakitanga from their local community:
I think they’re well looked after by the people, you know. I know when I was in there they would come in and say “oh, we knew you wouldn’t eat” so they brought me in sandwiches. Some guy going to the doctor will bring them in a crayfish. (Roselin)
Participants said that successful partnerships with health care professionals required trust to be ‘nurtured’ (Charlie) early on. Relationships with health care professionals that were based on trust and respect were important, as it assured participants that they were in safe hands and that they were not ‘just a guinea pig’ (Maria). When participants reported low trust in the health care professionals and services, they would fight ‘right to the bitter end’ (Jax) if they were feeling unwell before seeking help or would wait until it became an ‘emergency process’ (Hone) because they had ‘no confidence’ in the health care system (Hone). Hone also felt that this reflected the lack of trust at a ‘national level’ and was ‘inter-generational, which goes back to colonisation’.
Theme 3. Understanding rural Māori heart health priorities
This theme describes important contextual factors that influence rural Māori in their heart health journey: the role of whānau in participants’ heart health decision-making and the value of heart health knowledge.
Whānau were a powerful motivation for participants taking charge of their health, particularly around the responsibilities of being ‘around a bit longer’ (Mark) for their partners, children and mokopuna (grandchildren):
He’s [Ena’s dad] realised that he actually wants to be there for his grandkids. (Ena)
Whānau were also participants’ primary support throughout their heart health journey. For Jax, her ‘biggest strength’ was her sister, who advocated for Jax’s needs and treatment, assisted Jax with decision-making and helped to ‘decipher’ and ‘process’ information. Ena also spoke about her wider whānau being available to support her father as one of the last kaumātua for their hapū (sub-tribe):
Our whānau and my dad being the kaumātua, and the last one; I actually do know that if we called on the rest of the family, cousins and that, that everyone would pull together and come in. (Ena)
Some participants prioritised the needs of their whānau ahead of their own health needs:
I’m not paying more attention to myself because COVID pressures came to bear on all of my adult children who came home. (Betsy)
Participants did not want to ‘burden’ (Freda) whānau with their heart health events. For Freda, this intersected with a type of rural ‘resilience’ or ‘tough skin’ from growing up in an isolated settlement, leading to Freda trying to ‘sort it out myself’ when experiencing a heart event.
For many participants, heart conditions were entrenched and experienced throughout the whānau, and they felt fortunate and grateful that they were still alive:
I’ve got three sisters or three sisters and a brother who have died and they’re all the same thing with diabetes and heart. So, I’m fortunate because I’m a lot older than them, too. (Roselin)
Participants valued learning and understanding their heart condition, as it assisted them in making informed health care decisions and guided self-management post-heart event. Jax and Charlie spoke about the importance of their whānau being ‘in tune with the medical’ (Jax):
So, when doctors come in and were saying, “Hey, prescribe this, this and this,” and I’m like, “No, she’s already having this. And don’t forget that gives her a side effect.” (Charlie (Jax’s sister))
Participants also discussed practical ways of building heart health knowledge. Health professionals ‘breaking it all down and explaining in a way that they [whānau] understand’ (Ena) using visual ‘props’ (Jax), ‘outreach groups’ (Charlie), and mobile education ‘buses’ (Ena) were some of the ideas and approaches to aid whānau in building heart health knowledge.
Participants reported being more ‘conscious’ (David) about their health and were actively improving their lifestyles. However, some participants felt that knowledge about heart health and healthy kai (food) was lacking. Ena felt that heart health information was readily available; however, it was not delivered in a way that rural Māori could understand, which meant that ‘people aren’t using it, aren’t taking it in’ (Ena).
Discussion
This study explored rural Māori experiences and aspirations for optimising heart health care services in Te Tai Tokerau Northland. Interviews with rural Māori generated three overarching themes: rural Māori expectations of heart health care; how the health care system engages with rural Māori; and what is important to rural Māori in their heart health journey. The findings of the study support other research investigating Māori experiences of health care10,11,26–28 and research exploring the experiences of rural Māori accessing health care in other contexts.29–31 This study adds to a limited body of knowledge investigating Māori experiences of heart health care.12
Health care research has tended to investigate rural communities from a deficit perspective, often compared to urban contexts.32 However, the findings of this study offer an alternative lens by asserting that rural Māori communities and rural health care providers have several strengths and solutions that are key to optimising heart health and heart health care. Rural Māori are connected, supportive, and advocate for their collective wellbeing despite the entrenchment of heart conditions experienced by whānau. Optimal heart health care should, therefore, be situated within the context of whānau, understanding both the critical role that whānau have in the heart health journey and intricate whānau dynamics that may influence individual health care behaviours. Ultimately, participants wanted to live well and ‘take charge’ of their heart condition, motivated by their whānau and their responsibilities to their mokopuna. These findings are similarly expressed by Brewer et al, who conducted a qualitative study on Māori and Pacific people’s experience of cardiovascular care, where whānau were participants’ motivations to ‘seek and accept care’.28
Participants desired heart health care that authentically responds to their cultural needs. However, participants also said that health care providers inconsistently delivered culturally responsive care. Although culturally safe health care is an essential prerequisite for all Māori engaging in health care,11 the emphasis that participants placed on their cultural needs within health care contexts speaks to the particular importance of culture to rural Māori. In some instances, this may reflect rural Māori reporting higher levels of cultural connectedness than urban Māori.33 When considering the qualities of optimal heart health care for rural Māori, cultural safety should be prioritised in health care delivery and included as a measure of quality. Central to this is ensuring a representative Māori health care workforce.34 One existing model of care that responds to the cultural needs of rural Māori and addresses access barriers is the Manaaki Manawa Cardiac Rehabilitation Programme. Manaaki Manawa is a Kaupapa Māori approach to cardiac rehabilitation that Māori health care providers are currently delivering to some rural Māori communities in Te Tai Tokerau Northland. Given that culturally safe models of care do exist in the north, securing the longevity and expansion of programmes like Manaaki Manawa may be a practical and tangible step towards addressing inequities in access to care and heart health outcomes in rural Māori.
‘Social capital’ and ‘asset-based approaches’ refer to the potentially higher availability of social resources that support social cohesion within rural communities.32,35 These social resources are underpinned by values such as connection, respect, relationships, trust, reciprocity and support.36,37 In some instances, the higher the availability of these social resources, the higher the reports of positive health and wellbeing in rural communities.36,37 Participants treasured connection, respect and partnership with health care staff and when these values were in action, participants felt understood and supported in their journey. Participants also discussed the connection and manaakitanga they experienced with other community members. This study demonstrates that rural health care professionals and rural communities carry social capital that may also have protective factors relating to heart health.
Participants highlighted the systemic barriers and challenges that inhibit rural Māori access to quality heart health care, some of which were uniquely rural. Previous research notes the need for equity and fair distribution of resources to rural communities according to health and social needs.38 Tangibly improving heart health outcomes in rural Māori requires an all-of-government approach that authentically recognises, understands and addresses the longstanding health and social disadvantages that rural Māori experience. Consistent commitment from the Crown is also needed to adhere to obligations under Te Tiriti o Waitangi and to ensure that equity-based initiatives survive beyond government terms.
Strengths and limitations
This research is the first, to our best knowledge, to explore the experiences of rural Māori accessing heart health care directly. The study was led by a rural Māori researcher and supported by a research team with expertise in Māori health, health equity and rural health. The participants in this study were recruited from rural areas of Te Tai Tokerau Northland, with the Kaipara district being overrepresented in the cohort. Therefore, the experiences of participants in this study may be district- or region-specific.
Implications for health policy and practice
The recently released New Zealand Rural Health Strategy describes a national strategy using insights and strengths of rural communities to improve wellbeing and address inequities for rural communities, all while expressing commitment to Te Tiriti o Waitangi.19 To meet these intentions, the voices and experiences of rural Māori must be understood and prioritised to ensure that rural health care models are equitable and fit-for-purpose. To ensure rural heart health care models that are responsive to the needs of rural Māori communities, further research is needed to understand health care provider perspectives on the factors that influence heart health care access for rural Māori.
Conclusion
The findings of this study suggest that rural Māori have valuable experiences and insights that can optimise heart health care delivered to rural Māori communities. Further situating these insights within the context of Te Tiriti o Waitangi will inform system-level actions needed to achieve equitable heart health outcomes for rural Māori. However, any systemic action requires a long-term commitment from the Crown to ensure Māori rights and health equity remain a priority.
Data availability
The data collected in this study cannot be publicly shared due to ethical or privacy reasons.
Conflicts of interest
Both TT and KE have no competing interests to declare. VS reports funding from the Healthier Lives – He Oranga Hauora – National Science Challenge, the Heart Foundation of New Zealand, the Health Research Council of New Zealand (programme and project grants), and the Auckland Medical Research Foundation (project grant). MH reports funding from the Healthier Lives – He Oranga Hauora – National Science Challenge, the Heart Foundation of New Zealand and the Health Research Council of New Zealand (programme and project grants).
Declaration of funding
This research is funded through the University of Auckland Doctoral Scholarship.
Acknowledgements
The authors would like to thank the participants who took the time to share their stories and contribute to this research, the wider Manawataki Fatu Fatu (Māori and Pacific hearts in unison for Achieving Cardiovascular Care for Equity StudieS) team for their collegial support, the National Heart Foundation of New Zealand and Healthier Lives – He Oranga Hauora – National Science Challenge of New Zealand, co-funders of the Manawataki Fatu Fatu programme, and the University of Auckland for their doctoral scholarship funding.
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