PUBH204: Challenges and Opportunities in Hauora Māori

What framework underpins the PUBH204 teaching and learning approach?

Ngā Hau e Whā o Tāwhirimātea (Ratima et al., 2022) – with whakawhanaungatanga, ako and tuakana-teina.

Define tuakana-teina and ako.

Tuakana-teina: peer mentoring (older/more experienced supports younger/less experienced). Ako: reciprocal teaching and learning.

Name the four core functions of public health.

Health assessment & monitoring; health promotion; health protection; preventive interventions.

Give an example of a health protection activity.

e.g. regulating marketing/sale of vapes, measles outbreak response, contaminated water, COVID-19 emergency response.

What is the WHO definition of health and why is it considered narrow?

"A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." Holistic, but still narrow compared with Māori models (no wairua, whānau/collective, relational dimensions).

Name the four dimensions of Te Whare Tapa Whā.

Taha wairua (spiritual), taha tinana (physical), taha hinengaro (mind/emotions), taha whānau (family).

Who developed Te Whare Tapa Whā and when?

Mason Durie, 1985.

Who developed Te Wheke, and what does the body/head represent?

Rose Pere, 1984. The body and head represent the whānau unit; introduced as a holistic health model at Hui Whakaoranga, Auckland.

What is He Ara Waiora?

A mātauranga Māori wellbeing framework adopted by Treasury (Wellbeing Budget Handbook, August 2024).

List the ten themes of the Hauora Rangatahi Māori model (McCarty, 2023).

Whanaungatanga, tinana, te ao Māori, kaitiakitanga, tuakiri, hinengaro, wairua, whatumanawa, mātauranga, hangarau.

Match: tuakiri, hangarau, whatumanawa, kaitiakitanga – what dimension do they represent?

Tuakiri = identity; hangarau = technology (positive and negative influence); whatumanawa = emotional wellbeing; kaitiakitanga = environment.

What is the key principle of Māori perspectives of wellness, and what does it mean for public health?

Wellness is holistic and relational (past, present, future; living and non-living). If health is holistic, public health approaches must be too.

Vaping case (2017): what question does the lecture ask about measuring success?

If policy success is measured mainly by smoking-reduction rates, which aspects of hauora are ignored (e.g. youth wellbeing, addiction, equity, wairua/whānau)?

Name the eight tentacles of Te Wheke.

Whanaungatanga (extended family); mauri (life force); mana ake (unique identity); hā a koro mā, a kui mā (breath of life from forebears); taha tinana (physical wellbeing); wairuatanga (spirituality); hinengaro (mind); whatumanawa (healthy expression of emotion). Head = waiora (wellbeing); body = whānau.

What does "hauora" mean literally?

Hau (breath) + ora (life) – the breath of life.

Why is the medical definition of health limiting?

Medical models are disease-based and view people in terms of disabilities; the WHO definition is more holistic but still narrow (no wairua, whānau, land, whakapapa).

Define positionality.

The perspectives we hold shaped by intersecting factors (identity, experience, background); understanding it helps us challenge bias and reflect on our understandings, actions and decisions. Sits atop whakapapa.

Why does positionality matter in public health?

It influences how practitioners understand problems and design/deliver services; acknowledging it challenges bias and the false belief in objectivity.

What are the requirements of Assessment 1?

Max 1000 words; reflect on your positionality re ONE of social determinants of health, racism, or privilege; personal perspective; at least two references; due 11:59pm Mon 10 August.

Name the three ethics behind the course AI policy.

Ethic of Prior Thought (knowledge has whakapapa), Ethic of What is Right (hidden labour, environmental cost), Ethic of Time (learning takes time).

Name factors that shape positionality (the "winds") and what they sit on.

Nationality, political ideology, relationship status, personal experiences, geographic location, education level, sexual orientation, profession – all above whakapapa (roots).

Which two political philosophies shaped Aotearoa social class (and when)?

The Welfare State (1935–49 onwards; Social Security Act 1938) and Neoliberalism / Rogernomics (from 1984).

Give five public health features of the Welfare State.

Universal family benefits; state housing and 3% mortgages; free school dental service; Plunket/maternity hospitals; superannuation; DPB 1974; free medicines/DHB services; health camps.

What is neoliberalism?

An economic ideology of free-market competition, minimal state intervention, free trade and capital, and transfer of control from public to private sector.

How did neoliberalism affect public health?

Limited public spending; individual responsibility; deregulated labour market (casual/zero-hour work, leaky homes); unaffordable private services; corporatised hospitals; growing inequality.

Give three ways the Welfare State failed Māori.

Segregated native schools with service-class subjects; state housing ignored whānau structure ("undesirable tenants"); no invalids benefits; unemployment benefits did not register Māori; no Plunket access; Māori health workers delayed to late 1980s.

Define egalitarianism and critique it.

Belief in human equality. Critique: a sociological myth – ruled by the hegemonic group, so the question becomes "who is equal?"

Define hegemony.

The social, cultural, ideological or economic influence exerted by a dominant group.

Define ethnicity (as used by Stats NZ).

The ethnic group(s) people identify with or feel they belong to; a measure of cultural affiliation – not race, ancestry, nationality or citizenship; self-perceived; can be multiple.

What did Barnett & Bagshaw conclude about privatisation and competition?

They led to income inequality and unequal distribution of the determinants of health – a burden borne disproportionately by children, the poor, and Māori and Pacific people.

What does "Ka whawhai tonu ahau ki a koe, ake ake!" signify here?

"I will fight on against you, forever and ever" – revitalisation of Māori culture and a renewed sense of sovereignty during the transition.

List the social determinants of health named in lecture.

Physical environment; culture, identity and language; income and social status; childhood experiences; whānau/social support and connection; historical and political contexts.

Explain the bedrock metaphor.

Bedrock = human rights, Te Tiriti, laws and economic/social systems; soil = resources (housing, income, education, food, services). Negative elements in the bedrock create unequal access to the soil.

Describe the TKHM modified Williams model (in order).

Colonisation (root driver) → basic causes → social status/position → surface causes → RESPONSES (behavioural, psychological, physiological, collective/individual resilience) → health outcomes: morbidity, mortality, disability, mental health, wellbeing (Curtis et al., 2023).

Who authored the TKHM modified Williams model and where?

Curtis et al. (2023), Discover Social Science & Health 3(10) – an Indigenous adaptation of a model for determinants of ethnic health inequities.

What does "wealth distribution in Aotearoa" show?

The richest 10% hold more than half the wealth; the poorer half of the population holds ~2%.

Where are Māori over-represented in NZDep neighbourhood deprivation?

The most deprived deciles (8–10); under-represented in the least deprived.

Distinguish horizontal and vertical pay gaps.

Horizontal: across similar roles; vertical: across seniority levels. Both contribute to inequity.

What does the lecture say about "trickle-down"?

It is described as an optical illusion – wealth at the top has not proportionately reached lower deciles.

Why do inequities require upstream intervention?

They result from layered causes from historical injustice to present systems privileging a European worldview; treating symptoms downstream does not change the structures producing them.

List the five stages of the TKHM modified Williams model from left to right.

Basic causes → Social status → Surface causes → Responses → Health outcomes, all underpinned by Colonisation.

What are the four types of RESPONSES in the TKHM model?

Behavioural (health practices, everyday resistance); psychological (internalised racism, self-esteem, stereotype threat); physiological (CNS, endocrine, metabolic, immune, cardiovascular); collective and individual resilience.

Name the surface causes in the TKHM model.

Social transmission (stigma, prejudice, stereotypes); stress (discrimination, threat); SES opportunities (education, employment, income, wealth, housing, incarceration); societal resources (neighbourhood, schools); health services (access, quality, health literacy).

Name the basic causes in the TKHM model.

Environments and epigenetics; racism/privilege; unequal treatment by societal institutions (political, legal, economic, cultural power); worldview/paradigm.

List the health outcomes in the TKHM model.

Morbidity, mortality, disability, mental health, wellbeing.

Life expectancy by ethnicity and sex (L5 slide)?

Māori men 73.4, Māori women 77.1; non-Māori men 80.9, non-Māori women 84.4 – a gap of roughly 7.5 years (men) and 7.3 years (women).

List the 11 factors on the Hauora Māori social determinants wheel.

Education; income & social status; employment & working conditions; housing; childhood experiences; whānau/social support & connection; historical & political contexts; culture, identity & language; social inclusion; physical environment (incl. connection to land); accessibility of health services/information/transport.

Explain the horizontal and vertical pay gaps.

Horizontal: people doing the same job paid differently (two builders on the same site: $27.70 vs $25.20 an hour). Vertical: people channelled into different levels of work (“you’re in admin” vs “you’re a cleaner”).

Describe the poverty cycle in the slides.

Poor housing → getting sick → missing school → not completing qualifications → low-income work → poor housing. "Poverty isn't just a lack of money, it's also a lack of options."

Define racism (as in lecture).

An organised system of oppression that classifies and ranks groups into "races", devaluing and disempowering, and differentially allocating power and resources to those considered inferior.

Distinguish prejudice from discrimination.

Prejudice: making assumptions about people based on ethnicity. Discrimination: treating people unfairly based on ethnicity.

Name and define the three levels of racism.

Institutional (differential access to goods, services, power – within systems); personally mediated (prejudice/discrimination between individuals); internalised (acceptance of negative messages about one's own worth).

Define privilege.

The systematic accrual of advantage by a social or ethnic group – the flip side of racism; often unrecognised by those who hold it.

What is the fallacy of neutrality?

The false belief that public health practice is ethnically neutral/objective; in fact it is grounded in British colonial understandings and has its own positionality and bias (Loring & Curtis, 2024).

What NZ Health Survey finding links racism to mental health?

People who experienced racial discrimination showed markedly higher rates of psychological distress.

Which resources on privilege were referenced?

"Invisible Privilege" (Sacha Norrie) and "On a Plate" (Toby Morris, 2019).

How can unearned advantage be used?

To weaken the systems that cause unearned disadvantage (Think-Pair-Share prompt).

Define anti-racism (L6 definition).

The active process of identifying and eliminating racism by changing systems, organisational structures, policies and practices and attitudes, so that power is fundamentally redistributed and equitably shared.

"The two sides of inequity" – what is the point?

When there is disadvantage within a society there must also be advantage; privilege is the flip side of racism.

What do the 2023/24 NZ Health Survey racial discrimination charts show?

Reported racial discrimination rose between 2011/12 and 2023/24 (Māori ~10.5% → ~14%; non-MPA ~3.5% → ~6%), and people who experienced it had higher psychological distress in every ethnic group.

How many New Zealanders are of Māori descent (2023 Census)?

978,246 – 19.6% (about 1 in 5) of 4,993,923.

What percentage affiliate with Māori ethnicity?

17.8%.

Compare median age of the Māori and total NZ populations.

Māori 27.2 years vs 38.1 years total; almost half of Māori are under 25.

How much longer do non-Māori live on average?

7.4 years.

What proportion of Māori deaths are potentially avoidable?

53%.

Define avoidable mortality.

Deaths that could have been avoided by public health interventions targeting wider determinants, or by timely and effective health care.

Give the four areas of Māori health loss and their percentages.

Long-term conditions 20.6%; mental health 13.4%; cancer 6.4%; first 2000 days 5.1% – 45.5% combined.

Which four long-term conditions are the largest causes of death & disability for Māori?

Cardiovascular disease, diabetes, COPD, stroke.

Distinguish inequality, inequity and health equity.

Inequality: any difference between groups. Inequity: difference that is unnecessary, avoidable, unfair, unjust. Health equity: absence of inequity – not equal distribution of resources (Reid & Robson, 2007).

How much more likely are Māori to be diagnosed with / die from lung cancer?

~3.1x diagnosed, ~3.15x die compared with non-Māori.

What workforce statistic did L7 give for Māori in mental health?

Only ~1 in 10 psychologists in Aotearoa are Māori.

How would you critically discuss "one rule for all New Zealanders"?

It assumes equal starting points; equality ≠ equity. Inequity results from colonisation, racism and unequal power – treating everyone the same entrenches existing disadvantage. "Māori privilege" is a myth.

Is the health inequity a sign of Māori failure?

No – inequities result from deeper issues: racism, unequal power, privilege and institutionalised racism in the system.

Māori vs non-Māori: how much more likely to die from diabetes, ischaemic heart disease, stroke and COPD?

Diabetes 3.5x; ischaemic heart disease 1.9x; stroke 1.4x; COPD 2.2x.

How much more likely are Māori to have diabetes, IHD, stroke and COPD?

Diabetes 2.3x; ischaemic heart disease 1.8x; stroke 1.3x; COPD 3x.

How much more likely are Māori to be hospitalised for CVD, stroke and COPD?

CVD 1.8x (age 35+); stroke 1.8x (age 35+); COPD 3.7x.

List the five leading causes of mental health loss for Māori with percentages.

Anxiety & depression 5.0%; alcohol use 3.8%; schizophrenia 2.2%; drug use 1.4%; bipolar disorder 1.0%.

Māori anxiety, bipolar and depression statistics?

1 in 5 Māori adults have an anxiety disorder (40% more likely); 2.5x more likely to have bipolar disorder (3.5x among Māori tāne); 20% more likely to experience depression; twice the incidence of hazardous alcohol and substance use.

Lung cancer: smoking statistics from L7?

80% of lung cancer is caused by smoking; people living in high deprivation are 3.4x more likely to smoke; Māori are 2.9x more likely to be current smokers.

Breast cancer figures from L7 (diagnosis, death, screening)?

Māori 38% more likely to be diagnosed and 41% more likely to die; screening coverage 59.1% vs 64.5% (70% target) – 10.9% below target, 5.4% fewer eligible wāhine Māori screened.

List the Kahu Taurima maternal figures and the midwife workforce figure.

Maternal suicide 3.4x; pregnancy-related deaths 2x; 25% fewer in LMC care in first trimester. 11% of midwives Māori in 2021 (6.5% in 2005) vs 30% of newborns Māori.

What strengths-based points did L7 end on?

Māori population nearly 1 million and growing; Māori are living longer than ever; educational achievement rising (proportionality graduating from medical school).

What was WAI 2575?

The Waitangi Tribunal Health Services and Outcomes Kaupapa Inquiry, identifying pathways (e.g. colonisation, education, employment, income, housing, criminal justice, deprivation) to Māori health inequities.

Which entities did the Pae Ora (Healthy Futures) Act 2022 create?

Te Aka Whai Ora (Māori Health Authority – closed 2024), Te Whatu Ora (Health NZ), Te Pou Hauora Tūmatanui (Public Health Agency).

What happened to Te Aka Whai Ora?

The Māori Health Authority was closed in 2024.

What are the 5 priority areas of Pae Tū: Hauora Māori Strategy?

Māori leadership/governance; whole-of-government commitment; Māori workforce and sector growth; culturally safe, whānau-centred, preventative primary care; accountability for system performance for Māori health.

What are the 5 priority areas of the GPS on Health 2024–27?

Access, Timeliness, Quality, Workforce, Infrastructure.

What changes would the Healthy Futures (Pae Ora) Amendment Bill make?

Remove reference to the Māori Health Authority; reduce IMPB role (no longer working directly with Health NZ or monitoring local services); reverse name order to Healthy Futures (Pae Ora) Act.

Describe barriers to healthcare access at the four levels.

System (geography, cost, public funding); service/provider (hours, appointments, location, cultural safety); health professional (trust, continuity, cultural competence, communication); patient (past negative experiences, transport, competing priorities).

Name four measures showing services do not give Māori the same benefit.

Sub-optimal asthma control; less positive communication with hospital staff; higher inappropriate prescribing; longer waits for hip fracture surgery.

Which services are especially hard to access for Māori?

Maternity, oral health, hospital appointments, specialist appointments, specialist diagnostic equipment. Cost is a much more frequent barrier.

What do IMPBs do?

Iwi Māori Partnership Boards represent local Māori perspectives on the health needs and aspirations of their communities.

State HMAC Population Priorities 1–3.

1 communicable disease protection across life-course; 2 māmā and pēpi quality care in pregnancy and early years; 3 early prevention of long-term illness for tamariki and rangatahi.

State HMAC Population Priorities 4–9 briefly.

4 rangatahi mental health & resilience; 5 rangatahi healthy behaviours; 6 faster cancer pathways; 7 pakeke early primary care and diabetes/CVD outcomes; 8 kaumātua living well with co-morbidities; 9 IMPBs supported.

What is the strengths-based approach of Kaupapa Māori health service delivery?

Services built on Māori values (e.g. Ngāti Kahungunu, Ora Toa, Kokiri Marae) that increase access and quality of care for Māori and focus on community strengths, not deficits.

What three pathways did the Waitangi Tribunal (WAI 2575) identify as contributing to Māori health inequities?

Access to healthcare; quality of care (including racism, bias and discrimination, unmet need, slower pathways); access to the social determinants of health (colonisation, education, employment, income, housing, justice system, deprivation).

Five priority areas of the Government Policy Statement on Health 2024–27?

Access, timeliness, quality, workforce, infrastructure.

Name four changes proposed in the Healthy Futures (Pae Ora) Amendment Bill.

Remove Māori Health Authority reference; reduce IMPB role; repeal health sector principles; replace partnership/active protection with “consider Māori interests”; shift Māori decision-making to national advisory roles; reverse Act name order.

Five priorities of Pae Tū: Hauora Māori Strategy?

Māori leadership and governance; whole-of-government commitment; growing the Māori health workforce/sector; culturally safe, whānau-centred preventative primary care; accountability for system performance for Māori.

What does "Ka mua, ka muri" mean and why does it matter?

"Walking backwards into the future": the past is central to and shapes the present and future; we learn from those who went before.