Good mental health is often taken for granted. Sometimes we don’t even realise we have a good state of mental health until all of a sudden we don’t. Many people in their lifetime, will struggle with some sort of mental illness. As a population group, Maori have on average the poorest health status of any ethnic group in New Zealand. Mental health in Maori is no exception and remains a very common problem. Poor mental health leads to poorer health in general. It affects social, spiritual, physical and mental health. There are a number of factors that contribute to this public health issue.
Inequities in the social determinants of health are key here in assessing why poor mental health is pervasive in the Maori population. Social determinants of health are all interrelated and therefore it is imperative to evaluate the effects of one determinant of health on another determinant of health that ultimately leads to overall poorer health status, or in this case, mental health. To try and combat this issue there are a few policies, practices and initiatives in place such as Te Rau Matatini.
From my own research I believe continuation of a strengths based approach in Heath Promoting Schools focussed on education around Maori mental health and, an increase in the number of Maori health promoters would be beneficial to Mental Health status amongst Maori. Poor mental health in Maori people are amongst the highest rates in the developed world (Mental Health Commission, 2012). Unfortunately, when a person’s mental health is affected, so too are other dimensions of health. For example, studies show that a person who suffers from a mental illness is more likely to have physical health implications (Osborn, 2001).
Maori cultures sees health as a four wall concept – the four walls being; Te taha wairua (spiritual wellbeing), Te taha hinengaro (mental wellbeing), Te taha tinana (physical 1 Hannah Sutherland wellbeing) and Te taha whanau (family wellbeing). This model of health is referred to as Te Whare Tapa Wha (Ellis and Collings, 1997). Using this framework, a person whose walls are all strong is representative of a healthy individual (Ellis and Collings, 1997). So when a Maori person has perceived poor mental health status, spiritual, physical and social health can also be affected.
There are other serious implications of poor mental health including suicide. Poor mental health status is positively correlated with instances of suicide (Compton, 2009). In 2002 the youth suicide rates (15-24 years) for Maori males and females were 43. 7 and 18. 8 respectively per 100,000 population, significantly higher than the non-Maori youth suicide rates (18. 0 for males and 9. 1 for females) (Supporting Families Organisation, n. d. ).
Evidently, poor mental health in Maori is a serious issue that has the ability to affect other dimensions of health and can ultimately lower overall health status and quality of life. When examining risk factors for poor mental health in Maori, it is important to start off considering determinants of health. The social determinants of health are defined as “the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness” (Wilkinson and Marmot, 2003).
These circumstances are influenced further by other factors such as social policies, politics and economics. Wilkinson and Marmot (2003) lists; social gradient, early life, work, social support, food, stress, social exclusion, unemployment, addiction and transport as significant determinants of health. Social gradient is one such determinant that plays a large role in determining the mental health of Maori.
Social gradient reflects an individual’s or population’s position in society which is determined by socio-economic status (Wilkinson and Marmot, 2003). People living in unfavourable circumstances 2 Hannah Sutherland experience poorer health than people who have a better socio-economic status (Wilkinson and Marmot, 2003). In New Zealand, there are large disparities in socio-economic status, particularly between Maori and non-Maori populations – Maori having lower status (Best Practice Journal, 2010).
Best Practice Journal (2010) reports that Maori people in low-income households had high prevalence of mental health disorders. A recent study, Te Rau Hinengaro: The New Zealand Mental Health Survey, identified that 40% of Maori in the lowest household income quartile had a mental health disorder in the previous twelve months (Oakley, Wells and Scott, 2006).
It could be argued that having a low social gradient affects feelings of empowerment – control over ones circumstances. Lack of empowerment is significant risk factor for poor mental health (Corrigan, 2002) When one lacks control over their own life, or more specifically, the ability to improve their own circumstances, an individual is likely to experience feelings of helplessness and futility which leads to poor mental health states such as depression (Corrigan, 2002). Evidently, social gradient is a significant determinant in mental health outcomes for Maori.
This can be due to lack of empowerment which is often related with instances of low social gradient or, numerous other factors that interlink with this particular determinant of which are still to be discussed. Closely related to social gradient, unemployment is another determinant of health (Wilkinson and Marmot, 2003).
Unemployment negatively affects health and unfortunately, rates of unemployment amongst Maori are overrepresented in New Zealand (Department of Labour, 2012). In 2012, the Maori unemployment rate was at 13. 5% – more than double that of the unemployment rate of all people (Department of Labour, 2012).
This puts Maori at a greater risk for mental health issues (Wilkinson and Marmot, 2003). Furthermore, over the last decade there have been significant changes in the economy that have seen more Maori 3 Hannah Sutherland people unemployed and on domestic welfare benefits (Ellis and Collings, 1997). These are considered risk factors for mental health disorders (Ellis and Collings, 1997).
Psychologists argue that unemployment is closely associated with incomplete psychosocial development (Erikson 1959 as cited by Goldsmith and Diette, 2012), feelings of helplessness brought on by a perceived lack of control (Seligman 1975 as cited by Goldsmith and Diette, 2012) and failure to obtain the nonmonetary benefits of work (Warr 1987 as cited by Goldsmith and Diette, 2012). From this information is it easy to see how Maori mental health is affected by unemployment given their high rates of unemployment. Social exclusion is another risk factor for mental health in Maori.
Social exclusion is often thought of in terms of processes in which both individuals and/ or certain communities of people are excluded from rights, opportunities and resources that are normally accessible to members of society (Popay, Escorel, Hernandez, Johnston, Mathieson and Ripsel, 2008). Unfortunately, the history of Maori is one full of social exclusion. Pakeha settlement in New Zealand, soon ensued by their laws and governance, has excluded Maori from their land and culture and has limited the opportunities available for Maori to be involved with economy and governance (Closer Together Org. , 2011).
Furthermore, racism is a pervasive issue in New Zealand and is a key player in social exclusion. Unfortunately, Maori are often subject to this kind of discrimination in New Zealand (Healthy Christchurch, 2011).
The fear of this perpetuating discrimination causes social isolation and unhappiness and there is strong evidence that associates this racial discrimination with poor mental health in Maori (Healthy Christchurch, 2011). Furthermore, experience of, or fear of discrimination discourages individuals from using essential institutions such as health care systems (Healthy Christchurch, 2011). I believe this to be a real problem because there are systems in place to help with mental health issues. 4 Hannah Sutherland Instead however, racism and discrimination prevent people seeking care and ultimately, health continues to deteriorate.
Evidently, social exclusion can act as a precursor for poor mental health and can also inhibit the betterment of it, thus fuelling the problem. From the above information it is easy to understand how Maori health outcomes are affected by social gradient, unemployment and social exclusion. However, it is important to recognize that these determinants do not only directly affect health outcomes but they also affect other determinants of health thus indirectly affecting health outcomes.
In brief, social determinants of health are actually all interlinked in some way. Unemployment is closely associated with social gradient. As discussed above, social gradient is dependent on socio-economic status and poor socio-economic status often results in poor mental health. Having poor social gradient often reflects an individuals’ or population’s access to and security of resources such as education and employment. Therefore, if someone has a poor social gradient, it is going to be more of a challenge to find employment.
Likewise, if an individual is who is the main income earner becomes unemployed it naturally becomes more difficult to withhold or gain a high socio-economic status. Similarly, without adequate financial provisions, knowledge and education – including education in early life for children, is a lot harder to secure. Education and knowledge is power and without it, health can be adversely affected.
For example Ellis and Collings (1997) argue that Maori communities lack knowledge surrounding the early signs and symptoms of Mental Health and what sorts of health care to access if these symptoms arise or persist (Ellis and Collings, 1997). This means that there are more instances of serious, compulsory admissions that could have been avoided if individuals were educated on the matter.
5 Hannah Sutherland Social gradient is particularly associated with stress which is also listed as a determinant of health (Wilkinson and Marmot, 2003). Stress is a symptom of social and psychological circumstances and is often experienced when an individual lacks control over their work and home life and lacks supportive networks (Wilkinson and Marmot, 2003).
Both of these factors are closely associated with social gradient (Wilkinson and Marmot, 2003). Individuals with low social gradient often live in unfavourable circumstances compared to those who have higher social gradient and thus are more likely to experience stress (Wilkinson and Marmot, 2003). In fact, it is argued that poverty is the principle cause of stress worldwide (Read, 2010). Stress is a problem that translates through many other determinants of health including but not limited to, addiction, unemployment, social exclusion and early life (Wilkinson and Marmot, 2003).
When a person is under stress for prolonged periods of time, health becomes vulnerable (Wilkinson and Marmot, 2003). Stress can lead to all sorts of ailments including physical conditions but most significantly mental health problems such as depression (Wilkinson and Marmot, 2003). Maori people have higher rates of low social gradient and so it is viable to say that this puts them at risk for being under prolonged episodes of stress. Similarly, stress experienced though other determinants such as work, can adversely affect social gradient.
Furthermore, social gradient is also positively correlated with civic engagement. Wilkinson and Marmot (2003) argue that having a poor social gradient can lead to social exclusion. Limited access to resources such as health care, child care and even wider societal events and norms such as affordable recreational activities, for instance participating in a sports team, can marginalise individuals (Wilkinson and Marmot, 2003). Social isolation results in a lack of supportive networks that are essential in preventing and overcoming health issues such as depression (Wilkinson and Marmot, 2003).
Given the high 6 Hannah Sutherland unemployment rates amongst Maori and so too, generally lower social gradient status’, the risk for social exclusion is greater and thus the risk for impaired mental health is greater also. From this information you can see how social gradient, social exclusion, social support, unemployment and health outcomes are all closely related and impact on one another.
It is apparent from these determinants that health is multifactorial and complex. There is no single answer to improving Maori Mental Health as there are many interrelationships affecting health outcomes. In fact, links between the determinants are seemingly never ending. Given this fact, it is easy to understand why there is no single policy, practice or initiative in place that successfully works on its own to better Maori mental health. Of course however, there are a number in place working to minimise mental health disparities in Maori.
One such example includes Te Rau Matatini. Te Rau Matatini was established in 2002 and aims to develop the Maori workforce and to increase responsiveness to Maori mental Health needs through “increased mental health early recognition and intervention by strengthening the wider health and social service sectors’ knowledge of, and responsiveness to mild-moderate mental health needs” and also through “advanced development of indigenous mental health best practice founded on indigenous values, healing modalities and the highest clinical standards” (Te Rau Matatini Ltd, 2008)
Furthermore Te Rau Matatini aims to promote rewarding career opportunities for Maori, particularly in health and mental health, and support Maori health leadership development” (Te Rau Matatini Ltd, 2008). I see this leading to greater education and knowledge of mental health issues amongst Maori communities. Knowledge is power and this knowledge encourages empowerment, social support and social inclusion as opposed to social exclusion. I also see this bettering social gradient positions as more Maori are encouraged into the workforce and unemployment rates go 7 Hannah Sutherland down.
Again, here you can see the interconnectedness of the social determinants of health that have been taken into account by the Te Rau Matatini initiative. I believe that the next step for Maori Mental Health should be to continue the strengths based approach of the Health Promoting Schools initiative but with more of a focus on educating about mental health issues, such as early signs and symptoms, common causes, how to cope with mental health issues, and where to get help. Health Promoting Schools was developed by the World Health Organization in the late 1980s (Ministry of Health, 2013).
They define a Health Promoting School as one ‘that constantly strengthens its capacity as a healthy setting for living, learning and working’ (Ministry of Health, 2013). A strengths based approach uses the idea that people have strengths and resources for their own empowerment, therefore it encourages community engagement as tool and a focus on strengths rather than weaknesses (Tuhana, 2013). This has shown to be an effective technique (Tuhana, 2013).
Consistent with this initiative, engagement with parents and the wider community is a key factor and so it could be an idea to have a Maori Health promoter come into the school for a free information evening about mental health, where the wider community is invited to participate. This would educate and empower individuals, facilitate social inclusion and better social gradient and better quality early life. Focus should be placed around the four walls of health, that is, to include spirituality as a dimension of health which is important in Maori culture.
Other ideas could be less direct and could be more focused simply around community involvement where social inclusion facilitates the betterment of other determinants of health thus improving mental health and quality of life in general. Using a health promoter of Maori ethnicity could arguably be very beneficial. Research indicates that for a long time, Maori people have desired more Maori health practitioners 8 Hannah Sutherland (Kirkman, 2012).
It is perceived that a Maori health practitioner is likely to share the same cultural values and beliefs and thus could be as seen more relatable and approachable (Kirkman, 2012). Using this information, it is viable to assume the same for health promoters and therefore a Maori health promoter may encourage participation of Maori people. Promotion of health career pathways and training for Maori may be essential to the number of Maori health promoters actually available for this role however.
This is also why initiatives such as Te Rau Matatini are so important. In summary Maori mental health is a serious issue. There can be serious implications for Maori who suffer from poor mental health as it affects too, the other dimensions of health including family health, spiritual health and physical health. Mental health problems in Maori not sufficiently addressed has resulted in overrepresented suicide rates, particularly in Maori youth.
There are a number of determinants that affect mental health and these are evidently not always direct in nature but influence other determinants of health too, which ultimately results in various health outcomes. There are initiatives in place to address mental health in Maori such as Te Rau Matatini which aims to progress Maori workforce development to enhance, mental health and wellbeing.
Strengths-based approaches to health have been successful in Health Promoting Schools and using this initiative with more of a focus on mental health awareness could be utilised to improve mental health in future in conjunction with the employment of more Maori health promoters. 9 Hannah Sutherland Reference List: Mental Health Commission. (2012). Blueprint II Improving mental health and wellbeing for all New Zealanders. Retrieved September 9, 2013 from http://www. hdc. org. nz/media/207642/blueprint%20ii%20how%20things%20need %20to%20be. pdf Osborn, D. (2001).
The poor physical health of people with mental illness. Western Journal of Medicine, 175(5), 329–332. Ellis, Pete M. Collings, Sunny C. D. (1997). Mental health in New Zealand from a public health perspective. Wellington, N. Z: Public Health Group, Ministry of Health. Compton, M. T. (2010). Clinical manual of prevention in mental health. Washington, DC: American Psychiatric Pub. Supporting Families. (n. d. ).
Suicide and suicidal behaviour amongst Maori youth. Retrieved September 12, 2013 from http://www. supportingfamilies. org. nz/Libraries/Documents/maori_and_pacific_you th. sflb. ashx 10 Hannah Sutherland Marmot, M. G. , Wilkinson, R. , ; World Health Organization (2003). The solid facts: Social determinants of health. Copenhagen: Centre for Urban Health, World Health Organization. Centre, B. P. (2010). Recognising and managing mental health problems in Maori.
Best Practice Journal, 28(54), 8-17. Oakley Browne M, Wells J, Scott K, (eds). Te Rau Hinengaro: The New Zealand Mental Health Survey. Wellington, New Zealand: Ministry of Health; 2006. Corrigan, P. W. (2002). Empowerment and Serious Mental Illness: Treatment Partnerships and Community Opportunities. Psychiatric Quarterly, 73(3), 217-228. Department of Labour. (2012).
Maori Labour Market Factsheet – March 2012. Retrieved September 12, 2013 from http://www. dol. govt. nz/publications/lmr/pdfs/lmr-fs/lmr-fs-maori-mar12. pdf. Goldsmith, A. , ; Diette, T. (2012, April). Exploring the link between unemployment and mental health outcomes. Retrieved September 20, 2013, from http://www. apa. org/pi/ses/resources/indicator/2012/04/unemployment. aspx Popay, J. , Escorel, S. , Hernandez, M. , Johnston, H. , Mathieson, J. , ; Rispel, L. (2008).
Understanding and tackling social exclusion: Final report to the WHO commission on social determinants of health from the social exclusion knowledge network. Geneva: Commission on Social Determinants of Health, World Health Organization. Closer Together Organization (n. d. ). Maori and Inequality. Retrieved September 12, 2013, from http://www. closertogether. org. nz/inequality-in-nz/maori-and-inequality/ 11 Hannah Sutherland Health Christchurch Organization. (2011).
City Health profile, Factors that affect our health and well-being: Racism. Retrieved September 12, 2013 from http://www. healthychristchurch. org. nz/media/44643/racism. pdf Read, J. (2010). Can Poverty Drive You Mad? New Zealand Journal of Psychology, 39(2), 7-19.
Te Rau Matatini Ltd. (2008). Who we are. Retrieved September 22, 2013 from https://www. matatini. co. nz/cms_display. php? sn=179;st=1 Ministry of Health. (2012). Health Promoting Schools. Retrieved September 22, 2013 from http://www. health. govt. nz/our-work/life-stages/child-health/health-promoting-sch ools Tuhana. (2013). Strengths Based Approaches. Retrieved September 23, 2013 from http://www. tuhana. org. nz/index. php/strenghs-based-approaches Kirkman, A. (2012).
Health Practitioners: Maori and Pacific Health Practitioners. Retrieved September 22, 2013 from http://www. teara. govt.nz/en/health-practitioners/page-6 12 View as multi-pages TOPICS IN THIS DOCUMENT Health, Health care, Mental disorder, New Zealand, Population health, Public health, Sociology, Unemployment RELATED DOCUMENTS essay of mental health stigma … a differentiation of a person resulting to a boundary between “us” and “them” (Link and Phelan 2001).
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