Pacific Mental Health in Aotearoa New Zealand

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) recognises that Pacific peoples (a) living in Aotearoa New Zealand are diverse and unique, with specific health and cultural needs.

The recent Bula Sautu report (b) noted the various cultural identities of Pacific peoples are not well understood in Aotearoa New Zealand and subsequently Pacific peoples are often viewed as one homogenous group.  For ease of readability the term Pacific peoples is used in the document, but the RANZCP acknowledges that Pacific nations and cultures may have differing approaches to addressing health and wellbeing.

While the RANZCP has been steadily expanding its engagement with mental health professionals and community groups throughout the Pacific region, the objective of this position statement is to work towards achieving equitable health outcomes for Pacific peoples living in Aotearoa. [1]

The purpose of the position statement is to recognise the importance of Pacific populations to Aotearoa, affirm the RANZCP’s commitment to improving Pacific mental health, and signal the right of Pacific peoples to effective health care that meets their specific cultural needs. The RANZCP’s Tu Te Akaaka Roa (New Zealand National Committee) developed the position paper to help psychiatrists understand the challenges for Pacific populations and to inform future development of policy, submissions, advice, and advocacy by the RANZCP.

Key messages 

• Pacific peoples in New Zealand experience persistent and significant inequities in health outcomes.
• Pacific peoples narrative is required to ensure an authentic perspective is provided in mental health research.
• Working with key stakeholders will assist with the development and funding of Pacific mental health research which is ethnically and culturally appropriate incorporating Pacific design, world views, values, and expertise.
• Sector wide support is required to increase the Pacific mental health workforce including psychiatrists’, psychologists, nurses, and allied health providers.
• Mental health and addiction issues concerning Pacific peoples can be elevated through support and promotion of strategies, policies and reviews authored by Pacific experts. 
• Mental health outcomes for Pacific peoples can be improved by promoting Pacific therapeutic models of care where there is evidence of effectiveness.

Background

As a Pacific country, Aotearoa New Zealand has close ties to other islands in the region. In addition, Cook Island, Niuean and Tokelauan people are New Zealand citizens. According to estimates from the 2018 Census, Pacific peoples make up over 8% of the New Zealand population and 15% of the Auckland population. By 2038 it is estimated that 10% of New Zealand population will identify as Pacific. Around two thirds of Pacific peoples were born in Aotearoa, with 40% identifying with more than one ethnic group. Compared with the general population, Pacific populations are young, with over 50% under 25 years of age.[2]

Pacific peoples, and especially younger Pacific peoples have higher rates of mental health issues compared with the general population but are the least likely of any ethnic group to access mental health services.[3] New Zealand-born Pacific peoples have higher rates of mental health issues than Pacific migrants, which could be because traditional Pacific belief systems and lifestyles (including living with extended family) provide protection against mental illness.[4]

A recent report  investigated Pacific peoples use of alcohol, noting Pacific adults are far less likely, than non-Pacific people, to have consumed alcohol in the last year. [5] However, those who use alcohol are more likely to report hazardous drinking compared to non-Pacific ethnicities. It is noted that young Pacific peoples who experience ethnic discrimination are likely to have a higher risk of frequent alcohol consumption. To effectively address alcohol misuse within Pacific populations there must be access to culturally appropriate drug and alcohol services, but in Aotearoa New Zealand there a few options available for Pacific populations. 

Responses from Pacific peoples to the Government Inquiry into Mental Health and Addiction called for Pacific ways of supporting people and families to improve mental health and wellbeing. The approach would include a genuine, holistic approach, incorporating Pacific languages, identity, connectedness, spirituality, nutrition, physical activity, and healthy relationships.[6] 

Signalling the importance of Pacific Health in Aotearoa New Zealand, the Associate Minister of Health (Pacific Peoples), is leading work to improve health outcomes and reduce the inequalities experienced by Pacific peoples. The Ministry of Health has produced Pacific-focused strategies since 2002, the latest of which is Ola Manuia: The Pacific Health and Wellbeing Action Plan 2020–2025. The Plan acknowledges the continuing need to address health inequities and is guided by a vision of ‘Pacific families are thriving in Aotearoa New Zealand’. Their focus areas for action include developing a culturally safe workforce and improving mental health and wellbeing outcomes for Pacific communities.[7] Specific to mental health, the Ministry of Health produced a suicide prevention strategy and associated action plan (2019). While this action plan has a Māori focus, there is considerable overlap between issues faced by both Māori and Pacific peoples: indeed, dual cultural identity is common. [8] 

Key determinants of Pacific mental health

There are persistent and significant inequities in health outcomes for Pacific peoples. Disparities in health and service outcomes for Pacific peoples compared with non-Māori non-Pacific people in Aotearoa New Zealand have been detailed in health system reports for more than two decades. There has been some improvement, but inequities persist across the health services from prevention to rehabilitation and end-of-life care.[9]The proportion of all deaths considered potentially avoidable is twice as high in Pacific (47.3%) compared to non-Māori non-Pacific populations (23.2%). Life expectancy at birth for Pacific peoples is more than six years lower than that of non-Māori non-Pacific people.  Pacific peoples are likely to have coexisting mental and physical health. [10]

The Bula Sautu  report notes there has been ‘a worsening trend between 2012 and 2019 for emotional and mental wellbeing among Pacific youth, with the proportion reporting significant depressive symptoms increasing from 14% to 25%, and those attempting suicide in the past 12 months increasing from 7% to 12%.’[11]
Due to discrimination, racism and historical events, such as the Dawn Raids (c) Pacific peoples living in Aotearoa have faced challenges such as poverty, inadequate housing, poor health literacy, with these factors impacting negatively on their health outcomes.

Barriers to care can include cost, location of services, appointment times, cultural and communication factors, family and other commitments, which can reduce Pacific peoples access to health services, including mental health and addiction. Concerns such as issues with extended family dynamics including temporary/permanent intra-family adoption, immigration (overstayer) status, and fear of stigma within families or faith groups may pose additional challenges.

Advocacy Issues for Pacific Mental Health and Addiction

Workforce development:

The Mental Health and Addiction Inquiry – Pacific Report (d) identified that the mental health workforce should better reflect the various Pacific populations in Aotearoa and funding should be made available to up-skill the existing workforce in cultural safety and competence training.

Increasing the Pacific medical workforce

An action plan addressing development of the mental health and addiction workforce [12] signaled the need for greater numbers of Pacific medical students, better retention of graduates and an increase in the number of specialty training places. There is evidence that these initiatives are starting to make inroads. Currently, 1.8% of the medical workforce are Pacific (for 8.1% of the population). [13] In 2020, Māori and Pacific students made up nearly 40% of first year health science students and 32% of all medical students at Otago University and 28.1% of first year medical students and 29% of all medical students at Auckland University. [14] Financial incentives such as the voluntary bonding scheme, and ensuring access to specialist training, and initiating peer support structures to aid workforce retention will also be crucial to continued progress. [15]

Cultural competency / safety

The growing demand for a competent health workforce to meet the needs of increasingly diverse societies has been widely acknowledged. Programmes such as the Pacific Immersion Programme at Otago are better equipping new graduates to work with Pacific peoples while a national non-government organisation (NGO) Le Va, was established to reduce ethnic disparities in the access to, and quality of mental health and addictions services, through a targeted workforce development strategy to achieve better outcomes for Pacific peoples. [16] [17] 

Cultural models and modalities of care

The Mental Health and Addiction Inquiry – Pacific Report also highlighted the need for shared cultural understandings, and for services to be able to culturally contextualise mental health and addiction behaviour and understand how service-users perceive their distress and illness. Powerfully, the authors contended that there was value in practitioners having the ability to contextualise and understand the cultural framing of experiencing trauma, intergenerational problems, spirituality, breaching tapu (sacred concept) and the consequences of broken relationships and other pressures. They recognised that the dominant models of mental health care conflict with, compete with, and uneasily co-exist with Pacific interpretations of the same symptoms.

Promising new models, (for example Te TUMU Waiora operating in areas such as Northland and Auckland and Fit for the Future in Waitemata) while being evaluated very positively, nevertheless lack ongoing funding. [18] New models feature additional Health Improvement Practitioner (HIP), health coach or health navigator roles, Awhi Ora social support, and provision for liaison with providers of a broad range of needs across the biopsychosocial spectrum.

Data and Evidence

There is a lack of robust evidence base to support best practice for Pacific mental health and addiction in Aotearoa New Zealand. Data sourced or programmes developed from overseas cannot be used to understand Pacific peoples experience of the mental health and addiction systems in Aotearoa New Zealand.  

Several reports (such as Bula Sautu, He Ara Oranga and Kapeli) note that a greater understanding of ‘the meaning of identity, cultural connectedness and wellbeing among Pacific young people is needed. (e) Further research and data are required to develop a comprehensive picture of the mental health challenges experienced by younger Pacific peoples. Pacific populations in Aotearoa New Zealand are young: 33.6 percent of Pacific peoples were aged under 15 years, compared with 18.5 percent of the total population. (f)

A paper  examining Pacific peoples and alcohol use, identified knowledge gaps in: understanding the context in which Pacific peoples drink alcohol, defining successful treatment options, obtaining recent data on alcohol use and quantifying the burden of alcohol on Pacific communities. [19]

Recommendations

Advocacy and advice

• That the RANZCP acknowledges the unique and diverse needs of Pacific peoples and advocates for an expansion of the Pacific mental health workforce, not only increasing the numbers of psychiatrists but psychologists, nurses and allied health providers.
• That the RANZCP continues to effectively contribute expertise in Pacific mental health service development, workforce planning and training, and to strategies, performance reviews and inquiries occurring in the sector.
• At every opportunity advocate for change within the mental health system so the ‘Pacific Way’ is valued, and Pacific peoples have greater autonomy over how services are developed and delivered. This includes supporting Pacific peoples to develop relevant Whānau Ora approaches. The RANZCP has developed a Position Statement on Whānau Ora which should be read in conjunction with this position statement.

Supporting Pacific programmes and initiatives

• That the RANZCP seek to support and work more closely with Le Va, especially in their programmes to develop the Pacific mental health and addiction workforce, their engagement with Pacific communities and suicide prevention work. 
• Where evidence exists that Pacific aligned models of care enhance access and patient outcomes (for example Te TUMU and Fit for the Future) and that the RANZCP advocates for the ongoing funding of this work. 

Strengthening Pacific input / oversight

• That the RANZCP consider mechanisms for improving cultural oversight. 
• That the RANZCP work towards ensuring input and advice from Pacific consumer(s) to on matters relating to Pacific mental health and addiction, as Pacific world views, values and expertise are required to support Pacific approaches to mental health.

Supporting Pacific trainees

• That the RANZCP work with the Pasifika Medical Association to support Pacific trainees.

Strengthening workforce cultural competency and safety

• That the RANZCP support Le Va’s work to foster Pacific cultural competency/safety and provide training programmes. 
• That the RANZCP support the recommendations of the Bula Sautu report for development of educational curricula including modules and training materials that support best outcomes for Pacific people.
• The RANZCP work alongside the Pasifika Medical Association to support Pacific peoples into careers in psychiatry.

Supporting research on Pacific mental health and addiction

• That the RANZCP work with the Health Research Council (HRC) to support research projects with a Pacific mental health and addiction focus.  The HRC notes that Pacific health research design, methods, and approaches must be supported, underpinned by Pacific cultural values and beliefs, and conducted in accordance with Pacific ethical standards, values, and aspirations. The HRC has several scholarships and fellowships designed to foster the Pacific health research workforce, which the RANZCP could help facilitate access to for Pacific members.

Resources

1) Pasifika Medical Association

Pasifika Medical Association is a network of Pacific health professionals, working collaboratively to strengthen Pacific health workforce capacity and capability and meet the health needs of Pacific peoples in the region. They have excellent resources available from: 
Pasifika Medical Association Resources (pacifichealth.org.nz)

2) Resource Centre - Le Va

Le Va’s Engaging Pasifika cultural competency training programme is evidence-informed and equips health and disability services to connect culture and care. 

• Engaging Pasifika: Connecting Culture and Care - Le Va 
• Making an Impact: Engaging Pasifika - Le Va 

3) Oranga Tamariki
Working with Pacific peoples: Va'aifetū | Practice Centre | Oranga Tamariki 
Va'aifetū (guardians and guardianship of stars) is the Oranga Tamariki cultural-practice tool that informs practice design, review, and workforce support to best serve the needs of Pacific children and their families. There are many 8 versions of Va’aifetu – an example is provided at Va'aifetū — working with Cook Islands Māori families (PDF 466 KB)

4) Understanding Pasifika Mental Health in New Zealand – A review of the literature
This document provides a useful resource for psychiatrists practising in Aotearoa New Zealand. Kapeli S et al Understanding Pasifika mental health in New Zealand. 2020. MAI Journal, volume 9, 3, 2020 Available from: MAI_Jrnl_2020_V9_3_Kapeli_FINAL.pdf 

5) Bula Sautu – A window on quality 2021: Pacific health in the year of COVID-19. 
Health Quality and Safety Commission’s report provides a comprehensive overview of Pacific health Aotearoa New Zealand. It has useful data and so provides rich contextual information. Available from
Bula Sautu – A window on quality 2021: Pacific health in the year of COVID-19 | He mata kounga 2021: Hauora Pasifika i te tau COVID-19 (hqsc.govt.nz)

Footnotes

(a) ‘Pacific peoples is a collective term that refers to ethnic groups originating from the Pacific Islands. There are more than 16 culturally distinct groups within this wider group.

(b) Health Quality and Safety Commission, Bula Sautu – A window on quality 2021: Pacific health in the year of COVID-19. Wellington, Health Quality and Safety Commission.

(c) The Government made spot checks on Pacific peoples to see if they were overstaying their visas. The policy included early morning raids on Pacific peoples homes. As a result, many Pacific peoples experienced significant psychological harm.

(d) The Mental Health and Addiction Inquiry commissioned several reports -including a report providing Pacific voices on the mental health and addiction system. It can be accessed here Pacific-report.pdf (inquiry.govt.nz)

(e) Health Quality and Safety Commission, Bula Sautu – A window on quality 2021: Pacific health in the year of COVID-19. Wellington, Health Quality and Safety Commission, p 58.

(f) Statistics New Zealand, Age and sex by ethnic group for census usually resident population count 2018 census, Wellington, available from http://nzdotstat.stats.govt.nz/wbos/Index.aspx?DataSetCode=TABLECODE8277&_ga=2.157700030.584251917.1634864823-1992606319.1634864823#

Responsible committee: Tu Te Akaaka Roa – New Zealand National Committee 

References

1. Amos A. Training and advocacy for mental health in the Pacific Islands, 2020. Available from Training and advocacy for mental health in the Pacific Islands - PubMed (nih.gov).
2. Statistics New Zealand. Pacific Peoples Ethnic Group [Internet]. 2018. Available from: https://www.stats.govt.nz/tools/2018-census-ethnic-group-summaries/pacific-peoples
3. Oakley Browne MA, Wells JE, Scott KM (eds). Te Rau Hinengaro: The New Zealand Mental Health Survey. Ministry of Health, 2006. 
4. Ministry of Health. Pacific Peoples and Mental Health: A paper for the Pacific Health and Disability Action Plan review. Ministry of Health; 2008.
5. Nosa, V et al. Pacific peoples and alcohol: a review of the literature. New Zealand Medical Journal. 5 February 2021, Volume 134, No 1529, 2021.
6. He Ara Oranga: Report of the Government Inquiry into Mental Health and Addiction. New Zealand: Government Inquiry into Mental Health and Addiction; 2018. Available from: He-Ara-Oranga.pdf (inquiry.govt.nz).
7. Ministry of Health. ’Ola Manuia: Pacific Health and Wellbeing Action Plan 2020-2025.Ministry of Health; 2020.
8. Te Ara - the Encyclopedia of New Zealand. New Zealand identity - Understanding New Zealand national identity'[internet] available at http://www.TeAra.govt.nz/en/new-zealand-identity/page-1 .
9. Heath Quality and Safety Commission. Bula Sautu. 2021. Available from Bula Sautu – A window on quality 2021: Pacific health in the year of COVID-19 | He mata kounga 2021: Hauora Pasifika i te tau COVID-19 (hqsc.govt.nz)
10. Kapeli S et al Understanding Pasifika mental health in New Zealand. 2020. MAI Journal, volume 9, 3. 2020 Available from: MAI_Jrnl_2020_V9_3_Kapeli_FINAL.pdf. 
11. Heath Quality and Safety Commission. Bula Sautu. 2021. Available from Bula Sautu – A window on quality 2021: Pacific health in the year of COVID-19 | He mata kounga 2021: Hauora Pasifika i te tau COVID-19 (hqsc.govt.nz)
12. Ministry of Health. Mental Health and Addiction Workforce Action Plan 2017-2021. 2021. Available from https://www.health.govt.nz/system/files/documents/publications/mental-health-addiction-workforce-action-plan-2017-2021-2nd-edn-apr18.doc.
13. Medical Council of New Zealand. The New Zealand Medical Workforce in 2019. 2020. Available at The New Zealand Medical Workforce in 2019 (mcnz.org.nz)
14. Van Beyen, M Medical School: Who gets in and why | Stuff.co.nz. May 16 2020.
15. Ministry of Health. Voluntary Bonding Scheme [internet]. 2022. Available from Voluntary Bonding Scheme | Ministry of Health NZ.
16. Sopoaga F et al. Training a medical workforce to meet the needs of diverse minority communities. BMC Medical Education 17, 19 ,2017. Available from https://doi.org/10.1186/s12909-017-0858-7.
17. Pulotu-Endemann FK, Faleafa M. Developing a culturally competent workforce that meets the needs of Pacific people living in New Zealand. In Workforce development theory and practice in the mental health sector 2017 (pp. 165-180). IGI Global.
18. Appleton-Dyer S and Andrews S. Fit for Future. A report for the Ministry of Health. 2018. Available from: 2018 Synergia-ADHB-WDHB-FftF-Evaluation-overview.-FINAL-1-October-2018.pdf. 
19. Nosa, V et al. Pacific peoples and alcohol: a review of the literature. New Zealand Medical Journal. 5 February 2021, Volume 134, No 1529, 2021.

This information is intended to provide general guidance to practitioners and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation but takes no responsibility for matters arising from changed circumstances or information or material that may have become subsequently available.

Disclaimer: This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.