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The impact of dialysis on rurally based Maori and their whanau/families.

Introduction

This qualitative study explored the experience of Maori living in a rural area of Northland and being clients of the only available outpatient haemodialysis service. Thus the focus was on a New Zealand population not previously studied. The research adds to the growing body of knowledge concerning renal clients. Of the clients using this service 88.5% are of Maori descent. The demands of dialysis treatment are significant and, given the high proportion of Maori involved, it was timely to explore how Maori clients and their whanau/ families experienced this procedure.

Background

Maori are, arguably, disadvantaged with regard to the optimal management of their chronic diseases. Socioeconomic, educational, cultural and historical factors may impede access to services, which in turn impacts on health outcomes (Baxter, 2002). Maori tend to experience end stage renal disease (ESRD) more than the general population (Ministry of Health, 2010). A better understanding of Maori clients' experience of ESRD has the potential to allow health professionals, including nurses, to identify the key elements involved in the healthcare required for these clients, and therefore improve the quality of care.

McDonald and Russ (2003) reported that indigenous people in Australia and New Zealand (NZ) have a higher rate of ESRD compared with non-indigenous people. The Ministry of Health (2010) report illustrates this, as from 2002 to 2004 the incidence of ESRD in people over 15 years of age caused by diabetes nephropathy was 9.4 times higher in Maori compared with non-Maori. While some of this difference can be attributed to the higher prevalence of diabetes among Maori, the disproportionately higher rate would suggest that Maori with diabetes are more likely to have renal failure than are non-Maori (Baxter, 2002; Simmons, Shaw, Scott, Kenealy, & Scragg, 1994). Furthermore survival rate to six years was approximately 50%, whereas 75% of non-indigenous people survived to nine years. These figures are irrespective of treatment with haemodialysis, peritoneal dialysis or transplant (McDonald & Russ). In 2008 cardiac events were the most common cause of death in Maori treated with dialysis (47%) and in transplant (50%) (ANZDATA Registry, 2009).

The growing demand for haemodialysis services in New Zealand has resulted in the extension of services to nine satellite units (New Zealand Kidney Foundation, 2009). The number of people needing dialysis treatment is doubling every five or six years (Bennett, McNeill, & Polaschek, 2009), and with Northland's annual growth rate in kidney disease at 13 percent (Laird, 2008) the demand for services will increase further.

Method

The aim of this study was to describe the impact and experience of receiving haemodialysis for Maori clients living in a rural area. An interpretive methodology was used involving interviews with seven participants. These seven participants--three male and four female--were selected randomly from 12 who had given their consent from the possible total of 18 candidates. For the purpose of this study these seven were regarded as representing the full variance among those available.

All clients attending a satellite renal unit in mid Northland who met the study inclusion criteria of being aged over 20, identifying as Maori, and who had been in dialysis treatment for at least three months, were invited to participate. Information sheets were distributed by the clerk at the renal unit to avoid any seeming pressure due to the researcher working at the satellite unit. Enquiries from candidates were answered personally by the researcher. Candidates had the option to ignore the form if they did not wish to participate. Twelve candidates returned a signed consent form, giving a response rate of 66.7%. Ethical approval was obtained from the Northern Regional Ethics Committee and Northland District Health Board Maori Ethics Committee.

Participants were invited to attend a semi-structured interview at a time and place suitable for them. They were also invited to include their whanau/families if they so wished. All opted to have whanau/families present and participating in the interviews. Participant age ranged from 46 to 77 years (average 57) and all had been having haemodialysis for between four and ten years. Maori translations were provided for each question, although interviews were conducted in English. The taped interviews were transcribed for analysis.

Data analysis was styled on Diekelmann, Allen, and Tanner's (1989) seven stages of Heideggerian hermeneutical analysis in order to produce trustworthy conclusions through revealing the shared practices and common meanings of the participants'experiences. The seven stages were:

1. Reading the interviews as a whole, to gain an overall understanding of the texts.

2. Identifying the meanings evoked by the interviews and possible themes in the data.

3. Analysis of each document by the principal investigator. An in-depth interpretation of each text was written and given to participants.

4. Determining the credibility of each finding by returning to participants for their evaluation of how well it represented their experiences.

5. Continuing interpretation with material arising from further discussions with participants being treated as new data.

6. Identifying the themes as the researcher reviewed and re-examined the data, interpretations, and discussions with participants.

7. Preparing the final report using sufficient excerpts from the interviews to allow for readers to participate in validation of the findings (Polit & Beck, 2006, pp.411-412).

The written interview contents were checked by colleagues and discussed with the supervisor as well as being reconfirmed by participants in order to avoid researcher bias. Four themes were identified, and further refined by participants.

Findings

The four themes revealed were: facing their fear; stress from regular haemodialysis; learning, adjusting and changing their attitude towards their health status; and individual needs. Each theme will now be discussed more fully.

Facing fear.

This theme describes the participants' overall experience of facing their fear associated with having a lifethreatening condition. Delving into what fear meant for these people revealed it was related to lack of information and late referral. When they first received the diagnosis of renal failure, most felt overwhelmed by the changes and believed these would be extremely difficult to deal with. One participant stated:
   When I first got the letter telling me I needed
   dialysis, I tried to hide it. I felt like I was half a
   person, I was disabled. I wanted to just give up. I
   didn't want to depend on a machine. I didn't know
   what to do.


Another expressed similar fears:
   When I found out I had a kidney problem and
   required dialysis; I was more shattered than
   anything else. I was frightened. I ran away for as
   long as I could.


Fear of possible dependency and negative thoughts related to long-term survival were revealed. Most participants did not fully comprehend what the causes of their ESRD were, and how to deal with their illness in order to improve their prognosis.

Another aspect of fear was related to the participants' late referral to specialists able to explain and plan their care with them. Data from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA Registry, 2009) showed that in 2008 31.8 % of Maori patients were referred less than three months prior to commencing dialysis. One participant explained:
   When the doctor first told me I had renal failure,
   I didn't know what it meant. I didn't want to go
   to the hospital. But he told me if I didn't I'd have
   less than a month to live. That's what frightened
   me to go.


Late referral diminishes renal clients' opportunities to preserve kidney function and prevent chronic kidney disease progressing to ESRD, thereby reducing capacity to maintain quality of life (McLaughlin, 2004). As participants understood more about their renal condition the impact of their late referral became more evident to them.

Stress from haemodialysis.

Requiring haemodialysis is stressful as it involves lifestyle changes. A number of sub-themes related to stress were identified. Participants referred to issues affecting their quality of life. One barrier to health management is that haemodialysis is time consuming, and in addition there is the need to travel long distances to the Unit. Social isolation, especially for older people, was found to impact on participant's social life. Adherence to therapeutic regimes was a big challenge, especially when these involved changes in fluid intake and dietary habits. Also, while being on a transplant waiting list resulted in hope for participants, the consequences of long waiting times and perhaps not receiving a kidney transplant were very stressful. Each of these sources will now be described more fully.

Two important barriers to health management were identified by participants: financial, and cultural, aspects. Some participants admitted to reduced adherence to advised therapeutic regimes because of the costs of care. For instance there was not always enough money to buy healthy food, or for transport to attend clinic appointments. Most participants could not maintain employment because of their poor health and need for dialysis. Those who stopped being the breadwinner felt the loss of independence. The cost of attending numerous specialist appointments, prescriptions, and maintaining a healthy renal diet were all noted to have a negative impact on finances. Cultural aspects included a lack of confidence to negotiate for aspects of health care. It has been suggested that Maori are accustomed to being passive recipients of health care (Durie, 1999; Penney, McCreanor, & Barnes, 2006). This may be evident in the failure to ask questions. For example, in this study a participant stated:
   A doctor had warned me earlier on, he said my
   kidneys were only functioning 70%. I wasn't sure if
   my kidneys were failing or what. I never questioned
   him.


Participants did not ask for clarification about their illness from health professionals, nor did they understand the ramifications and how best to manage their chronic illness.

Participants and their families found the dialysis regimes and associated travelling stressful. Additional time was required to attend appointments such as renal clinic, eye clinic, podiatry clinic, appointments surrounding fistula creation, fistula assessment, cardiac function investigation and General Practitioner (GP) visits, and admission to hospital if complications arose. One participant said:
   A big issue for me is the travelling since we live so
   far away. It's the worst thing and does get stressful.
   We're sitting for all that time. It takes a lot out of
   us elderly; two hours on the travel, more than four
   hours on the machine and two hours back. Most
   of us are over 60, it's a long day. I think it's a big
   part of what makes people sick of being on dialysis.


Having haemodialysis three times a week and the additional appointments with specialists made it difficult for participants to take part in other activities, which tended to lead to social isolation. Participants reported that fluid and diet restrictions made them unable to eat and drink unreservedly like other people either in the Marae setting or at other special occasions. Often it was easier just to stop attending community activities. One participant responded:
   You miss out on a lot of things you used to do in the
   past. You lose your social life; you can't go visiting
   or go away.


For the participants in this study, adhering to the fluid and dietary restrictions, attending haemodialysis and following medication regimes, all required commitment.

Kidney transplant prevalence is relatively low in New Zealand due to a low donor rate often per million (Organ Donation New Zealand, 2006). Transplant is a big hope for New Zealand clients, but the long waiting for kidney transplant is heartbreaking for them. One participant described this experience:
   I tried hard to keep up on the waiting list for many
   years; I feel aggravated sometimes. I have been
   on the transplant list for many years and nothing
   happened. I hope that the next one may be me,
   but I am always disheartened.


Donor statistics show only 3.5% of donate kidneys are Maori, and there is also a low rate for living donors. This is thought to be influenced by Maori cultural beliefs (Ashton & Marshall, 2007). Being on the kidney transplant list was found to provide hope; however, the long wait for a kidney transplant is a stressful process.

Learning, adjusting and changing attitude.

Participants discussed the changes involved in learning, adjusting and changing their attitude towards their health status. Aspects described were having to overcome their initial grief and understand and manage their medical condition through different phases and physiological changes. Participants also reported how they lived according to the institutional routine of the dialysis unit, related to the scheduling and requirements for haemodialysis. For example, they had to learn to live with a fistula (vascular access for haemodialysis) and tolerate multiple needle punctures.

The benefits of acquiring knowledge were described by participants. The more they learnt and understood, the greater the benefit. For ESRD clients renal replacement therapy can last a lifetime unless a kidney transplant takes place. In this study participants understood that their life would never be the same as in the past, but with the support of whanau/families they saw hope and meaning in the future. One person articulated these feelings:
   At the beginning I thought, this can't be happening
   to me. But now it's just something that happened.
   I actually feel like I've gained rather than lost
   something with dialysis. As I lost my kidneys, I
   found my family and the things I'd forgotten to
   cherish in life. This change in attitude is like seeing
   every cloud has a silver lining.


Another commented:
   For my own health and wellbeing I have to look
   after myself. It's a big change.


Individual needs.

Participants came from different families and backgrounds and therefore each had their own priorities and requirements. All felt that support from whanau/ families was most important to them. In addition, health professional support and respect contributed to brightening their daily lives. The significance of family support cannot be stated strongly enough, as the following two participants explain:
   Without my family I wouldn't have the will to keep
   going. I can't live without them, and it is love
   keeping me alive not the dialysis machine. Without
   their love I would not keep coming back for dialysis.


Another said:
   I want to see my grandchildren grow up as much
   as I can. I think dialysis actually brought my family
   closer together. My lifestyle is better now, I see my
   kids and I spend more time with my family. They
   are my happiness, I cherish them. I'm grateful for
   the opportunity to carry on with dialysis.


Discussion

Clearly haemodialysis treatment has a huge impact on Maori clients' cultural values, beliefs and lifestyles. These findings, indicate that for these clients experience of ESRD is related to education factors, socio-economic status, beliefs and cultural influence. This study supports previous findings that education enables people to better understand their illness and treatment (Klang, Bjorvell, & Clyne, 2001). There is a need for nurses to be instrumental in health promotion through partnership in negotiating health care for clients, and by respecting their needs and concerns. Horl (2002) suggested that an individualised and flexible approach may be most beneficial to ESRD clients.

The findings of this study suggest that earlier referral, soon after first diagnosis with chronic kidney disease (CKD), would reduce stress. Prompt intervention could also have a positive effect on health by decreasing progression to ESRD with its requirement for haemodialysis. The literature supports early referral as this provides opportunities for health education with regard to improved self-management and monitoring (Collins, 2003; Polaschek, 2003). Therefore, an added benefit of early referral, apart from reducing psychological stress and fear engendered by the unknown prospect of management and treatment; would be minimising complications and improved quality of life, and potential cost savings to the health system (McLaughlin, 2004).

Early detection of chronic kidney disease (CKD) is considered to be an effective approach to prevent or halt the emergence of ESRD. Appropriate timing for referral to nephrologists in the pre-dialysis stage would help CKD clients to achieve smooth transition into renal replacement therapy (RRT), as would the provision of psychological support from social workers. Early referral of CKD gives enormous opportunities for the renal team to provide appropriate intervention and education for self-care in order to prolong the progression of CKD and postpone ESRD (McLaughlin, 2004). Early intervention is associated with diminished impact of psychological anguish, and decreased physiological complications as well as being a major saving of budget (Davision et al., 2005; Rapisarda et al., 2006). The fear and emotional stress before clients required dialysis would be minimal. People with CKD are many times more likely to die of cardiovascular disease than the general population (Hostetter, 2004; Kundhal & Lok, 2005). Initiation of treatment for cardiovascular risk factors at earlier stages of CKD should be effective in reducing cardiovascular disease events (Johnston, Dargie, & Jardine, 2008).

Because they lived in rural New Zealand, travel and haemodialysis treatment engaged approximately 33 hours of participants' time each week. This combination of travel and treatment made many participants feel exhausted and weak. On a national level a recommendation is for the Ministry of Health to make satellite units a priority consideration in order to meet the rapidly increasing needs of dialysis populations (Laird, 2008). A satellite unit providing haemodialysis locally would save travelling, reduce fatigue and be more cost effective in terms of transport requirements. If local dialysis service can be provided, satisfaction with the service is likely to improve, and the physical impact from travelling long distances will be reduced. The effects of isolation are more pronounced for those living a distance from the health services they require. The advantages of having a local or satellite dialysis unit include the client having less distance to travel for dialysis treatment and thus cost saving for transport, and a shorter waiting time for a vacant machine--leading to a more stable client.

Waiting for a kidney transplant is associated with deteriorating health and increasing use of health resources, whereas transplantation improves quality of life, life expectancy, and is cost efficient (Ashton & Marshall, 2007; Howard et al., 2009; Niakas & Kontodimopoulos, 2008; Nolan, 2005). For Maori both donor and receiving of organs rates are much lower than those for non-Maori, with only 2.9% of Maori patients receiving a kidney transplant. Lewis and Pickering (2003) explain that this is related to traditional Maori beliefs about the movement between the realms of the living and the dead--aspects which raise concerns for donors, recipients, and their families. A study carried out in Australia showed that in processing the transplant waiting list, aboriginal participants were slower to be activated by comparison with non-aboriginals. The reason is multifaceted, including that aboriginal people often live in remote areas (Cass, 2009). In Canada aboriginal people were only one-third as likely to get a kidney transplant as caucasian Canadians, although they have more than twice the rate of kidney failure (Tonelli et al., 2004). In Canada, USA, Australia and New Zealand, compared to the caucasion populations, aboriginal peoples have a lower kidney transplantation rate, although they tend to have high rates of chronic kidney disease. The need to improve aboriginal peoples' kidney transplantation rates remains an important issue (Yeates et al., 2009). Whanau/families played a very important role in this study, providing emotional support during the interview. Participants and their whanau/families worked together to review how they went through their dialysis journey rightfrom the beginning of diagnosis. Whanau/families also provided their insights on how they worked together to learn therapeutic regimes ranging from fistula care to medication compliance, diet restriction and continuing education in order to maintain their loved one's wellbeing. This provided an opportunity for participants to acknowledge the importance of their whanau's devotion and endless love and how much it means to them every day.

Implications for Nursing Practice

This section provides a summary and incorporates recommendations for nursing practice. First, in the care of Maori patients with renal disease, nurses need to recognise a person's ethnicity, life and social context when considering goals for short term care and long term management. Without an understanding of the whole person, their socio-economic circumstances, background, priorities and concerns within their families, progress towards positive health outcomes is unlikely.

Educational input is associated with increased client autonomy, improving their quality of life, and increased compliance with therapy so delaying need for of dialysis. Education content needs to be simplified and key points expressed as clearly as possible. Inviting Maori dialysis clients to address their experience in the Marae situation is a good option for delivering clear information without cultural barriers. Two-way discussions about a renal client's journey makes people aware that this is related to their own quality of life. As people discuss more about CKD they understand more deeply how to look after themselves and their whanau. Clients should be encouraged to seek advice and verify information about their medical condition in order to understand how best to utilise prevention techniques or treatment (Holmes, Perron, & Savoie, 2006).

Early detection of kidney diseases is essential as it can reduce the extent of kidney damage, thereby decreasing incidence of ESRD and consequent need for haemodialysis. There is also a need to encourage people to consider organ donation. This can be achieved by making an organ donation card readily accessible to all, for instance on the back of a driving licence. More education and discussion around the subject of deceased or living kidney donation is needed in order to increase availability of kidneys for transplantation.

The target population for such education includes those who have, or are at increased risk of, developing CKD, and their families. This population group may manifest relevant pathological indicators or have a Glomerular Filtration Rate (GRF) less than 60 mL/min/1.73m2 for more than three months, with or without kidney damage. Interested parties in the detection and monitoring of kidney disease should include all health professionals caring for the target population, and those providing or paying for needed health care (Levey etal., 2003). An action plan for CKD is presented in Table 1.

Early stages of kidney disease can be detected through proteinuria--testing the urine for protein. Currently this is the single best predictor of kidney disease such as in diabetes, glomerular disease, and hypertension (Levey et al., 2003). People with bladder outflow obstruction, recurrent urinary tract infections, metabolic disorders causing recurrent kidney stones, long-term (more than 12 months) use of non-steroidal anti-inflammatory drugs (NSAIDs), neurogenic bladder (impaired bladder function) or with surgical urinary diversion should have their kidney function checked routinely also (Levey et al.). Identifying high risk populations should include those of Maori or Pacific Island descent, diabetics, and particularly people over 40 years old who are hypertensive, or who have a family history of kidney disease. As well, smokers and those suffering from alcoholism need to be included. Within New Zealand all individuals should be assessed as part of any routine health evaluation. Best practice in management strategies include regular assessment of blood pressure, blood sugar, nutrition, cardiovascular disease, anaemia, lipid levels, and bone disease. There is also need to advise about smoking cessation, limitation of alcohol consumption, and provision of educational support (Levey et al.).

There are four Maori health organisations throughout Northland to ensure delivery of quality health care. These include Te Hauora O Te Hiku O Te Ika in the Far North, Hauora Whanui in the Mid North, Te Hauora O Te Tai Tokerau in Whangarei, and Te Ha O Te Ora in the Kaipara. As well there are contributions from other health providers. Together these highlight improving access and enhancement of Maori health services to ensure these are culturally appropriate, and have an overall focus on keeping people healthy.

The strength of Maori communities is built on the well being of each family. To promote and produce better health outcomes for Maori in relation to the prevention of renal disease, the start has to be with the whanau's health education regarding their eating habits. Dietary health risks are associated with high intakes of protein, fats and salt alongside poorly controlled diabetes. Obesity is related to bad eating and lack of exercise (Scholp, 2000).

Maori models of intervention assist practitioners to negotiate tensions which are inherent within efforts to deliver more effective services. An example is the Te Whare Tapa Wha model of the four walls of a whare (house), where each wall represents a dimension of Maori health: taha wairua (spiritual), taha tinana (physical), taha whanau (extended family), and taha hinengaro (mental, intellect) (Durie, 1985, p. 483). The attributes of this model (Table 2) affirm a positive Maori identity in a context where Maori values, beliefs and practices are respected. It provides an holistic view congruent with nursing values and actions in all areas of health (spiritual, physical, mental and whanau/families) (Rochford, 2004). The model removes barriers from services and promotes delivery of health information to foster Maori perspectives of health to Maori communities such as schools, marae, and whanau/families (Barton & Wilson, 2008). To meet individual needs it may be necessary to provide a range of measures including a smoke cessation plan, suggested dietary modifications, regular assessment of blood sugar level, as well as advice about nutrition, cardiovascular disease, anaemia, lipid levels, limiting alcohol consumption, and overall educational support. Also important are ways of increasing exercise level by a group activity, ensuring medication compliance, checking blood pressure and blood results regularly and establishing routine appointments with a general practitioner. All these need to be negotiated with respect for the client's own goals, with short and long term targets being set up in the process. As health providers, we have to respect individual priorities and work alongside clients to support their lifestyle change and health promotion. The He Korowai Oranga Maori Health Strategy (King & Turia, 2002) noted that key factors required for improving Maori health include: a good plan, leadership and commitment, workforce capacity, and funding and resources.

For Maori, to modify any lifestyle one must start with the family. Health providers should take action to improve ongoing education according to the community's needs regarding wellness and disease prevention. These needs could be assessed using family input to identify what are seen as priorities. Each core family acts as a small unit, and extended family members could unite with them to form discussion groups. A family spokesperson could then communicate to a health provider their perceived needs and the resources needed for the education of the whanau e.g. how to prepare a healthy meal by modifying dietary resources and traditionally used cooking methods--always taking care to be working within their socio-economic means. With a dietitian for consultation the group could develop and demonstrate their own ideas and health practices, maybe at the local marae. Another idea might be to arrange a monthly sharing of a healthy meal in the marae, also inviting a health educator to address their priorities and check blood pressures, and urine for sugar and protein. Such a gathering could catch those who 'fall through the net' because they rarely make GP visits.

Whanau groups based around their marae may provide more supportive lifestyle patterns, such as participation in Maori culture groups and competitions, communal food collection from the sea or bush, and sporting activities. Rural schools could be encouraged to form 'gardening groups' where children can learn basic lifestyle skills e.g. collection of organic residue to recycle and build worm farms to enrich compost and create a resource for growing vegetables. Home grown vegetables can save daily spending and also be shared with whanau or used for marae occasions. Working bees can help their elderly with cleaning, gardening or perhaps even painting their homes, thereby improving physical fitness by the exercise. Such support of each other has far reaching benefits for health--mental, physical and emotional. Health providers, through contact with family/whanau groups, can co-operate and facilitate the setting of short and long term goals so giving people the feeling and knowledge that they have done something important to help themselves and their whanau. Having a healthy family then produces a stronger community. Health providers must be committed and enthusiastic in supporting clients in their quest to reach full potential. Each small step contributes to success for whanau and the community.

In the context of education and training, professionals such as diabetic nurses, dietitians, GPs, and practice nurses can provide educational resources to schools and social groups, as well as marae and Maori communities. Improving the methods of delivering information or education for high risk clients needs to focus on early detection and early intervention. Renal services need to explore all possible avenues to increase medical, nursing, and the allied health workforce, support for remote area staff, increasing recruitment and developing the roles of Maori staff.

Conclusion

This study identified themes from interviews with Maori participants living in rural Northland. From first diagnosis through to requiring regular haemodialysis they had to face fear, deal with stress, learn, adjust and change to a new lifestyle. Each person had to find their own way to deal with ESRD. In understanding Maori clients' experience of living with dialysis health care providers can better support clients' management of their daily life. Improving people's health depends on effective education in order to promote self management. Early referral is shown to promote better quality of life and to be cost effective for people with chronic renal disease.

Advocacy for organ donorship (living and deceased) is crucial to people on the kidney transplant waiting list.

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Li-Chin Shih, RN, MN, Staff Nurse, Clinical Nurse Specialist-Dialysis Access, Renal Unit, Northland District Health Board

Michelle Honey, RN, PhD, FCNA(NZ), Senior Lecturer, School of Nursing, University of Auckland

Shih, L-C., & Honey, M. (2011). The impact of dialysis on rurally based Maori and their whanau/families. Nursing Praxis in New Zealand, 27(2), 4-15.
Table 1.

Action Plan ofChronic Kidney Disease.

Stage    Description                GFR(mL/min/1.73m2)

         At increased risk          [greater than or equal
                                    to] 90 (with CKD risk
                                    factors)

1.       Kidney damage with         [greater than or
         normal or reduced GFR      equal to] 90

2.       Kidney damage with         60-89
         mild reduced GFR

3.       Moderate reduction         30-59
         GFR

4.       Severe reduction of GFR    15-29

5.       Kidney failure             <15
                                    (or dialysis)

Stage    Action

         Screening CKD risk reduction

1.       Diagnosis and treatment
         Treatment of comorbid conditions,
         slowing progression, CVD risk
         reduction

2.       Estimating progression

3.       Evaluating and treating
         complications

4.       Preparation for renal replacement
         therapy

5.       Renal replacement therapy (if
         uremia present)

Note. Source: Levey et al. (2003).

Table 2.

He Korowhi Oranaa Maori Health Strateav (Te Whare Tapa Wha Model).

Objective: To foster whanau development and health

Tapa Wha        Pre-Requisites or Desired Conditions
Dimensions

Whanau          Participation in society
(family)        Relationship development
                Leadership development

Tinana          Services organised to meet the needs
(physical)      of whanau
                Removing barriers to services

Wairua          Access to Te Ao Maori
(spiritual)     Understanding of Maori needs, values
                and beliefs
                Tikanga &te reo Maori

Hinengaro       Developing an inclusive society
(mental,        Valuing diversity
intellect)      Strengths-based approach

Tapa Wha        Strategies
Dimensions

Whanau          Maori representation and participation in
(family)        decision-making
                Capacity building plans
                Health Care Provider development strategies
                Education programmes for health providers,
                school, Marae and whanau

Tinana          Inclusion of whanau needs in DHB health needs
(physical)      assessment methodologies.
                Co-ordination and integration of health services
                Quality service framework
                Marae-based services

Wairua          Maori models of care
(spiritual)     Kaupapa Maori
                Health promotion programmes

Hinengaro       CKD programmes & services
(mental,        Social and health policy
intellect)      Intersectorial initiatives

Note. Source: Rochford (2004).
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Author:Shih, Li-Chin; Honey, Michelle
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Date:Jul 1, 2011
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