Primary Health Care and its role in reducing Family Violence in Maori

Family Violence (FV) is classed internationally as one of the most serious human rights issues,

and also as a major public health threat (Furniss, McCaffrey, Parnell, & Rovi, 2007). Primary

health care (PHC) services and strategies appear to be a suitable approach in dealing with FV

because FV requires a multifaceted approach which is one of PHCs main aims (King, 2001). FV

is of particular concern for the Maori population as in New Zealand the prevalence related to

Maori is higher then any other population group (Koziol-McLain, Rameka, Giddings, Fyfe, &

Gardiner, 2007).

This essay will discuss the magnitude of FV in Maori compared to other population groups.

Secondly the meaning of health and wellness will be explored, specific to the Maori population.

This will also be compared and contrasted with other population groups. Lastly the PHC concept

of accessibility, affordability, and acceptability will be linked to FV and Maori. From these links

practical implications for nursing will be suggested.

The Te Rito: New Zealand family violence prevention strategy defines family violence as “a

broad range of controlling behaviors commonly of physical, sexual, and/or psychological in

nature which typically involve fear, intimidation, and emotional deprivation” (Ministry of Social

Development, 2002). It usually occurs in close interpersonal relationships (New Zealand Family

Violence Clearinghouse, 2007).

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The specific health risks of individuals that experience FV are complex (Schimanski, 2009). It is

associated with many physical, mental, and emotional problems (Spangaro, Zwi, & Poulos,

2009). Even witnessing FV can harm individuals substantially (New Zealand Family Violence

Clearinghouse, 2007).

Furthermore the whole community is affected as the monitory and human cost is high (New

Zealand Family Violence Clearinghouse, 2007). According to the New Zealand family violence

clearinghouse website (2007) an estimated 5.3 billion each year is spent on increased use of

health services related to FV. FV can have lifelong implications for victims and increases the

chances of intergenerational abuse as the victim may continue the cycle of abuse into the next

generation (Marie, Fergusson, & Boden, 2008).

Police records in 2005 documented that there were 56, 380 occurrences of FV that 65,000

children witnessed (New Zealand Family Violence Clearinghouse, 2007). Although FV affects

the Maori population disproportionately it is also an issue for all families from all backgrounds,

cultures, and socioeconomic status (Ministry of social development, 2002). Surveys of women

between the ages of 16-64 who have ever had a partner found that 33% had experienced FV in

their lifetime (New Zealand Family Violence Clearinghouse, 2007). Perpetrators of severe FV

tend to be male and victims are mostly women and children (Koziol-McLain, Giddings, Rameka,

& Fyfe, 2008).

The Maori population is significantly over-represented as both perpetrators and victims of FV

(Ministry Of Social Development, 2007). Most research suggests a significant correlation

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between lifetime prevalence of FV and ethnicity (Koziol-McLain et al, 2007). To elaborate, it is

estimated that approximately 42% of Maori woman have experienced FV in their lifetime which

can be compared to the 20% estimated for European woman and 17% for pacific woman

(Koziol-McLain et al, 2007). According to a sample of mostly Maori women 3 out of 4 women

disclosed partner abuse in the last year suggesting the statistics may be much higher than this in

reality (Marie et al, 2008).

Furthermore Maori make up 50% of men sentenced for male assaults female even though they

make up only 15% of total population and it is estimated that approximately half of women’s

refuge cliental are Maori (Marie et al, 2008).

The definitions and meanings of health and wellness differ between individuals as well as

population groups (McPherson, Harwood, McNaughton, 2003). It is important to understand

these different perspectives as the needs of different populations differ according to these beliefs

(Palmer, 2004). In order to address FV, overall health and wellness must be improved to reduce

lifestyle factors (Palmer, 2004).

The world health definition of health includes physical, mental and social wellbeing (Julliard,

Kilmenko, & Jacob, 2006). Studies have shown that most health care professionals also value

spirituality as part of their definition and that this does not necessarily mean religion (Julliard et

al, 2006). A general definition of wellness includes both physical functioning and ones feelings

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about oneself. Culture, values and background can affect what these ‘feelings entail’ (Julliard et

al, 2006).

The Maori philosophy of health is based on a holistic or waiora (well-being) model (McPerson et

al, 2003) which is similar to the PHC approach (Abel, Gibson, Ehau, & leach, 2005). One model

that is commonly used and demonstrates this is the Te Whare Tapa Wha model (Levien, 2007).

This model is composed of four walls of a whare (house). These walls symbolize the health and

wellbeing of a person (Levien, 2007). The walls all support and strengthen the individual as well

as the whanau and greater community (Levien, 2007). The four walls symbolize wairua

(spiritual), whanau (family), hinengaro (emotions), and tinana (physical). When unwellness is

present it is attributed to an unbalance in one of the ‘wall’s (Levien, 2007).

Maori living in New Zealand today experience the greatest inequalities and risk factors known to

contribute to poor health outcomes than any other population group (Dutton, 2006). Maori are

not only disproportionately represented in FV but also in almost every other disease catergory in

the New Zealand health system (Levien, 2007). It is likely that many of the numerous barriers

such as social and economic inequalities that Maori face in their health and wellness have their

roots in colonization (Levien, 2007). These risk factors are manifested in the walls of the Te

Whare Tapa Wha model and have great impacts on health and wellness of individuals as well as

communities (Levien, 2007). This health model is owned by the community and makes

interconnections between different aspects of life explicit (McPherson, 2003).

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According to the Maori model of health, to reduce family FV a holistic whole person, whole

community approach needs to be taken to reduce these inequalities which in turn will reduce FV

(Levien, 2007). Also an understanding of the importance of how whanau can contribute to FV

problems is important (Levien, 2007). While whanau, hapu and iwi can represent a source of

identity, strength belonging and values, and be a primary source of support, it can also be a site

of intergenerational abuse and alienation of the victim from society (Ministry Of Social

Development, 2007).

Prior to colonization the overall health of Maori was significantly better than it is today (Levien,

2007). One theory for the disproportionately high rates of health problems is explained by the

systemic theory of colonization which emphasizes external determinants effecting collective

wellbeing and individual cultural identity (Marie et al, 2008). This view proposes that Maori

social organization has been disrupted by historical and structural factors, along with European

beliefs, values and practices being imposed on the Maori culture (Marie et al, 2008). As a

consequence of this, cultural identities and concepts have been lost. This theory assumes that FV

is linked to the loss of these traditional cultural domains and weakened identities. Reinforcing

the whanau ora concept where sanctity of family is extremely important and strengthening

cultural ties has become key in targeting the underlying issues of FV (Marie at al, 2008).

PHC is a health care service that involves the community. It is a first level of contact and aims to

provide services such as prevention, early detection and treatment (Ministry of Health, 2008).

These services include screening for FV in as many PHC sectors as possible (Spangaro et al,

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2009). New Zealand’s PHC strategy was launched in 2001 with one of its main goals being to

reduce inequalities between different groups (National Health committee, 2000) such as Maori.

In 2002, PHC organizations (PHOs) were set up around New Zealand (Ministry of Health,

2010). These are not-for-profit organizations that are responsible for the health of the

communities and reducing inequalities (Ministry of Health, 2010). As a population group Maori

come from areas considered the highest deprivation areas (Marie et al, 2008).

The PHC strategy consists of aims called concepts (Ministry of social development, 2002). One

of which includes ‘acceptability’ (how culturally sensitive and welcoming the service is),

‘accessibility’ (conveniently located), and affordability (low or no cost) (Ministry of Health,

2010).

When these concepts are directly linked to FV in Maori, accessibility becomes paramount as

victims of FV may be watched and controlled by their perpetrator (Spangaro et al, 2009). In

order for ‘screening’ to take place; which is an important tool in identifying FV; the victim must

be first able to have easy access to a PHC provider as this increase the likelihood of the victim

attending and also be provided with a place where the client is able to speak in private

(Spangaro et al, 2009). Another essential point of accessibility related to Maori and FV is

making sure there is an open door policy in place meaning that anyone who turns up is seen

regardless of appointment time (McPherson, 2003). A FV victim may only have limited time to

seek help and may not be able to plan ahead (Palmer, 2004).

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Acceptability for Maori is related to providing a culturally safe setting for the client (Ministry of

Health, 2010). Examples of this are providing ethical matching to those who want it, such as a

Maori nurse with a Maori client and also making PHOs available on Maraes where some Maori

may feel more welcome, safe and be more inclined to share FV experiences (Koziol-McLain et

al, 2007).

Affordability is providing health care services that are affordable. PHOs attempt to achieve this

by getting funding based on demographics, e.g. area of higher deprivation which a

disproportionate number of Maori live in receive higher funding (Marie et al, 2008). There is

evidence to suggest PHC have reduced cost barriers for Maori but not eradicated them yet

(Jatrana, & Crompton, 2009).

Many initiatives to reduce FV are in place (Ministry Of Social Development, 2007). An example

is the Health Sector Early Intervention project which has been operating in clinical settings since

2002. This project developed and published guidelines to the process of screening for FV. A

national network of DHB coordinators have been developed to overview the project and train

health professionals responsible to carry out the screening (Ministry Of Social Development,

2007).

The nurses’ role in terms of the PHC approach to reducing FV in Maori is diverse (Furniss et al,

2007). The development of trust between client and nurse is an important first step that lays the

foundation for methods of preventing and identifying FV (Levien, 2007). In order to gain trust

each interaction with the client needs to be culturally safe (kawawhakararuruha) (Levien, 2007).

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When this trust is achieved the nurse is in the position of supporting, identifying, and educating

individuals around issues of FV (Levien, 2007). Moreover this can initiate discussion in

communities where the education and information can be passed on (Marie et al, 2008). This

exchange of information can begin to change negative cultural beliefs such as ‘whanau violence

is ok and normal’ (Levien, 2007). Furthermore it can provide and support ‘tino rangatiratanga’

which means, to empower Maori to take control of their health outcomes and factors influencing

these (Levien, 2007).

In order to provide these services adequitly nurses need to know the importance of screening, the

health implications, and have the realization that FV isssues are part of the nursing role (Furniss

et al, 2007). Research suggests that some of the barriers nurses face to providing this are lack of

time and privacy to screen, and lack of education around screening, disclosure, and cultural

safety (Furniss et al, 2007).

Nurses need ongoing education and to acknowledge their own individual beliefs and values, and

how these impact on the client (Furniss et al, 2007). Also it is important for the nurse to note

that cultral safety encompasses the realization that each individual has there own cultural identity

that is determined by them (Levien, 2007).

Different perspectives on the meanings of health and wellness necessitate different strategies to

combat FV. The Maori health model Te Whare Tapa Wha can be used to understand the Maori

health perspective and needs to be used in developing strategies suitable for Maori. As FV is a

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multifaceted problem it needs a multifaceted solution. A major part of this is reducing the

inequalities and health barriers that many Maori face. Strengthening Maori cultural identity and

whanau ties is an important step in reducing these barriers and providing health care that is

assessable, affordable, and acceptable to Maori. This is achieved by low cost PHOs, cultural

safety, and local healthcare. Nurses play an important role in reducing FV as they perform the

majority of the screening, they can also educate and inform the community around this issue.

Nurses have identified time and privacy as the biggest barrier against screening. New protocols

need to be developed around how this process should take place and more research needs to be

done on how effective screening is and if there is a better way. Another area the author views as

lacking is ongoing adequate training for nurses and other health professionals around FV.

Word Count: including title, 2198

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