Whānau Ora

This statement affirms and strengthens the commitment by the Royal Australian and New Zealand College of Psychiatrists (RANZCP) in recognising He Whakaputanga (Declaration of Independence) and Te Tiriti o Waitangi (Treaty of Waitangi) principles of tino rangatiratanga (self-determination), the right of Māori to health equity and meeting the needs of tangata whaiora. The concept of Whānau Ora builds on the knowledge and traditions of Māori, and whānau-centred practice. It is founded on long accepted best practice methodologies derived from holistic Māori models of health and wellbeing – Te Whare Tapa Whā, Te Wheke, Te Hoe Nuku Roa, and Te Pae Mahutongo.[1-4] The kaupapa of Whānau Ora is by Māori, for Māori, and shaped by Te Ao Māori, encompassing cultural norms, tradition, and heritage. 

The purpose of the Whānau Ora Framework is to improve health and wellbeing of whānau by acknowledging Te Ao Māori approaches in strengthening whānau capability. Its aspirational and strengths-based, commissioning approach puts whānau in charge of decision making, empowering self-determination through support and encouragement of their ideas and needs.[5]

The importance of Whānau Ora for Māori whānau

Whānau Ora is a Māori response to the delivery of social and health services to improve outcomes for Māori whānau.[6] The approach utilises the unique belief systems, values, and practices of tangata whenua to restore mauri ora (wellbeing) for whānau, hapū and iwi.[7] 

Whānau Ora

• Is an evidence-based, by Māori for Māori, approach to Māori health and wellbeing.[17, 6] 
• Māori whānau are recognised and supported as the principal source of connection, strength, support, security, and identity for health and wellness.
• Places Māori at the centre of decision and provides access to resources that support self-determination and develop whānau strengths.
• Enables whānau wellbeing to be aligned with Māori cultural and spiritual values, alongside social and economic priorities. 
• Incorporates Te Ao Māori approaches to foster te reo Māori, observe tikanga, interactions within whānau and marae kawa (protocols).
• Outcomes and analysis provide evidence of the effectiveness of service outcomes, experience of cultural safety, inequities or barriers to health and wellbeing, and where whānau were a catalyst for improving outcomes.  
• Aligns with the Sustainable Development Goal, Ensure healthy lives and promote well-being for all at all ages, including health equity.[3,8]

Introduction

Māori do not always experience the same level of hauora (health and wellbeing) as other New Zealanders due to the socio-historical impact of colonisation. Historically services for Māori were designed to meet the needs of institutions and focused on episodic or single-issue problems. Inequity was compounded by contracts which required Māori and community providers to meet organisational goals resulting in funding silos that did not enable collaborative practises.[9]   

The ongoing and systematic neglect of culture and cultural safety is identified as the single biggest barrier to advancing health and wellness. Outcomes for Māori show intergenerational consequences for health, mental health and wellbeing, and the prevalence of mental distress is almost 50% higher than for non-Māori.[5,7,8,11] The high economic and social costs of systemic bias impacts on the ability to provide effective care and resulted in intergenerational inequity. As a result, Māori are more likely to experience poorer outcomes when accessing mental health services, are 30% more likely than other ethnic groups to present with undiagnosed mental illness, be readmitted after discharge from hospital, secluded during admission, be compulsorily treated under the Mental Health (Compulsory Assessment and Treatment) Act 1992, and are over-represented as Mentally Disordered Offenders in forensic services.[9,11]

Providing care in purely clinical terms has left health systems ill-equipped to understand the wider determinants of health.[10] The status of Māori health equity was challenged in the Waitangi Tribunal through the WAI 2575 appeal.[12] Outcomes of the landmark case signified a new phase for Māori health and a system wide focus on cultural safety and equity.[13] The newly developed Te Tiriti  o Waitangi principles arising from the WAI 2575 appeal, Tino Rangatiratanga, Equity, Active protection, Partnership and Options, now apply throughout the health sector with the goal of increasing equity for Māori.[14] 

To achieve health equity for Māori, He Korowai Oranga, Māori Health Strategy, guides the New Zealand health sector regarding obligations to Te Tiriti o Waitangi.[15] It is translated through Pae ora, a holistic framework describing healthy futures for Māori through Whānau ora (healthy families), Mauri ora (healthy individuals), and Wai ora (healthy environments). Priorities, relationships, expectations and expected outcomes are described in the Whakamaua, Māori Health Action Plan.[22] 

The Whānau Ora Framework carries an expectation that practitioners be equipped to intervene at a collective level, rather than individual, to provide holistic assessment and care encompassing, physical, psychological, socio-cultural, religious/spiritual, and values of Māori. This assumes that cultural practices are appropriately acknowledged and incorporated into treatment of tangata whaiora.[16] 

The essence of Whānau Ora 

a) Te Ao Māori – The Māori world 

Te Ao Māori is shaped by whanaungatanga, based on relationships between individuals, whānau, hapū, iwi, the spiritual world, and the natural world. Everyone and everything are traced to and explained through whakapapa, the ancestral layers that contribute to the ‘people, places, and things’ of the present and into the future. In this space, whānau relationships are based on working together to make decisions and act in ways that benefit whānau. Strong whānau are known to invest their time and energy in activities they can do together.[17]

b) Being Māori 

Despite uneven participation in Te Ao Māori and regional differences in Māori cultural expressions, a Māori perspective is a critical component of whānau experience. Whānau are part of wider society, with connections to a range of Māori organisations and communities. Though not all whānau share the same sense of ‘being Māori’ - they are Māori, and the Māori contexts within which whānau live provide benefits from being part of whānau-centred activities. These are characterised by distinctive experiences of cultural norms, social networks, tribal influences, common histories, and different degrees of acculturation or alienation.[12] 

c) Restoring whānau – 'putting the vibrant traditions of our people at the heart of whānau'

Whānau Ora reinforces and supports whānau to access services that are culturally safe and effective. It acknowledges and supports the collective strength and contribution of whānau in maintaining Māori kaupapa, and determining health solutions.[9]

Whānau Ora - Evidence of effectiveness 

Whānau Ora was established in two phases. The first (2010–2015) focused on strengthening provider capability to design and deliver whānau-centred services and a dedicated fund to integrate a whānau-initiated planning. The second phase (2013 onwards) concentrated more directly on funding whānau capability and activity.[9]  

A formative evaluation of the application of the Whānau Ora Framework by Te Puni Kōkiri found  whānau participation to be an essential element of Whānau Ora services. Creating the space for whānau to practise was proven to be beneficial for recognising and supporting holistic needs and contributed to improvements in whānau health and wellbeing. The Whānau Ora Framework supported funding needs, access to a wider range of services, cultural safety application across clinical settings, community, regional, and wider societal levels. It also supported training in cultural safety practices to influence equity.[5,9,18,19,20] 

At a broader policy level Whānau Ora practice has raised awareness and recognition of associations between social, economic, and cultural wellbeing, which resulted in improved understanding and actions to address cross government and agency collaboration on improving equity.[12]

The He Korowai Oranga Strategy reinforces the evidence-base and gains made by Whānau Ora initiatives in facilitating whanaungatanga. [6,21] Going forward, Whakamaua will provide guidance on continuing priorities and inform the health sector about progress with Māori health and disability outcomes.[22]

The Whānau Ora model of practice

By design, the Whānau Ora Framework is shaped by Te Ao Māori, cultural norms, traditions, and heritage. Its kaupapa is aspirational, strengths-based and assumes whānau have potential to create positive change if supported to determine services needed for their tangata whaiora. This means services are funded to increase the relevance of Te Ao Māori to the health and wellbeing of whānau. 

To be funded, Whānau Ora services must be culturally grounded, holistic, and focused on improving the wellbeing of whānau. Aspirations and challenges are identified through a whānau lens to inform whānau-centered care, and the Whānau Ora approach supports them to work as a collective, or across services without losing sight of the individual health needs of tangata whaiora.[21] 

For Māori and providers, the approach has significantly changed the context and options available for realising whānau wellbeing. Te Ao Māori and whānau-centred approaches are now delivered by a wider range of providers including kaupapa Māori services.[5,23] 

Benefits of Whānau Ora [14,24]

• Whānau are at the centre of service design and delivery. 
• Whānau strengths are acknowledged and effective working relationships are formed. 
• It is a catalyst for sustainable relationships with providers, funding bodies and other health and community stakeholders. 
• It strengthens the ability of providers to be more effective.   
• Practitioners who embrace the Whānau Ora philosophy show improved outcomes for Māori. 
• Services are measured to understand the impact and effectiveness for Māori health and wellbeing.   

Translating Whānau Ora into best practice

The Whānau Ora Taskforce recommended that the main goal for Whānau Ora providers and health practitioners would be to increase whānau access to a range resources and skills, enable gains for tangata whaiora and their whānau through development of skills and clinical expertise in whānau interventions.[24] It was thought that this investment would make substantial contributions to whānau health and wellness outcomes. 

Successful implementation of Whānau Ora services also requires better understanding about how comprehensive care can be delivered in an integrated system, and what resources would support whānau-centred practice. The health system needs practitioners who can demonstrate expertise  in whānau interventions, including working with Whānau Ora navigators, obtaining experience in whānau settings, understanding how to involve Māori communities, working across multiple provider organisations, and dedicated training in whānau-centred interventions.

Recommendations for improving responsiveness to Māori 

The RANZCP supports a growing Māori psychiatrist workforce and is committed to reducing variation by increasing responsiveness to Māori. Uptake of Whānau Ora services within the health sector has potential to increase the need for integration of Te Ao Māori practices within psychiatry services.[25]  The Takarangi Competency Framework may be implemented to strengthen understanding of Te Ao Māori approaches throughout RANZCP training and professional development programmes.[26. 27,28] The kaumatua also advises the RANZCP on matters relating to Māori. 

a) Develop deeper understanding of our colonial history (good and bad), often untold narratives in our educational institutions and medical training which caused the inequities we see today

• Engage in educational programmes which teach a true reflection of our colonial past and how to transform health care systems. 
• Engage in training which improves knowledge of Te Tiriti o Waitangi and how it can be applied to health and equity transformation.
• Align this with the college’s overall vision and national government strategy to address mental health inequities. 

b) Te Ao Māori

• Disseminate accurate historical facts to equip psychiatrists to work effectively across different settings and facilitate culturally safe care that acknowledges context, value systems and beliefs. 
• Incorporate the Te Ao Māori approaches within the training environments across the practice of psychiatry, research, and relationships with Māori.

c) Build effective relationships that benefit tangata whaiora 

• Increase exposure to practical learning opportunities with tangata whaiora and whānau.  
• Learn from whānau experiences of Te Ao Māori in relation to care, and foster whānau leadership, autonomy, and capability to support self-management, by involving whānau in caring for their tangata whaiora. 

d) Develop workforce capability 

• Develop a technically skilled workforce which is culturally safe and facilitates targeted and holistic approaches to support whānau aspirations for their tangata whaiora. 
• Increase capacity in the Māori mental health workforce through recruitment and support of Māori medical students, doctors in training (RMO’s) and registrars. 
• Integrate Te Ao Māori approaches within RANZCP training Fellows, Affiliates and Trainees to strengthen cultural competence, cultural safety, and whānau centred practises. 

e) Increase understanding of Whānau-centred services 

• Provide access to professional development to increase understanding of Whānau Ora services approach to placing needs and aspirations at the centre of care coordination.

f) Provide supportive environments 

• Whānau Ora resources are recognised and supported, e.g. funding, contracts, policies, referrals to Whānau Ora navigators, relationships with Māori and iwi providers, for enabling access to services and whānau participation in care. 

g) Influence outcomes for Māori mental health

• The RANZCP upholds the view of the Whānau Ora Taskforce, which noted that interventions that do not measure or do not take account of whānau, are futile, and greater evidence is needed to support whānau functioning and address wider whānau concerns in order to support tangata whaiora.[27] 
• Advocate for national analysis of outcomes for Māori against measures in the Sustainable Development Goals for Mental Health Status. 

Glossary

• Tangata whaiora – People who have mental health and addiction experiences.
• Hauora – Be fit, well, healthy, vigorous, in good spirits.
• Kaupapa – A way of doing things from a Māori perspective – the way Māori think, act and make decisions and plan. 
• Te Ao Māori – Māori world view.
• Mauri ora – Maximum health and wellbeing of individuals and whānau 
• Whānau – In broad terms it could mean extended family. But in Te Ao Māori it has a wider spiritual and emotional meaning that binds an individual to their marae and to the tipuna.
• Mana Motuhake - Self-determination.
• Whaiora – Health, wellness.

Additional Resources 

• The Takarangi Framework
• BPAC. Whānau Ora: the theory and the practice. BPJ:37. 2011. 
• Te Puni Kōkiri. Understanding whānau-centred approaches. 2015. 
• Wirihana R, Smith C. Historical trauma, healing and well-being in Māori communities. MAI Journal 3(3): 197–210. 2014.

Responsible committee: Te Kaunihera and Tu Te Akaaka Roa (New Zealand National Committee) 

References

1. Durie M. Te Whare Tapa Whā: A Māori perspective of health. Social Science & Medicine, 1985;20(5):483–6.
2. Pere R, Nicholson N.Te Wheke: a celebration of infinite wisdom. Ako Ako Global Learning. NZ. 1991.
3. Durie M. Te Hoe Nuku Roa Framework: A Māori identity measure. The Journal of the Polynesian Society, 1995; 104(4):461–70.
4. Durie M. Te Pae Māhutonga: A model for Māori health promotion. Health Promotion Forum of NZ Newsletter; 1999.
5.    Kopua D. Factors that facilitate and constrain the utilisation of a Kaupapa Māori therapeutic approach with Mahi-a-Atua. Australian Psychiatry. 2019;27(4): 341-7.
6. Te Puni Kōkiri. Whānau Ora Review. Tipu Matoro kit e Ao. Final Report to the Minister for Whānau Ora. 2018.
7. Elder H. He pūāwaitanga harakeke, he rito whakakīnga whāruarua: Gaps are filled by the flowering harakeke. Australian Psychiatry. 2019. Vol; 27(4):332-3.
8. Ministry of Agriculture and Fisheries. Sustainable Development Goals for Mental Health Status. NZ. 2019.
9. Te Puni Kōkiri. Understanding whānau-centred approaches – Analysis of Phase One Whānau Ora research and monitoring results. 2015.
10. Napier A, Ancarno C Butler B, Calabrese J, Chater A, Chatterjee H, et al. Culture and health. Lancet; 2014: 384:1607-39.
11.  NiaNia W, Bush A, Epston D. Huarahi Oranga: an introduction to Māori concepts informing a Māori health and psychiatry partnership. Australian Psychiatry. 2019;27(4): 334-6.
12. Came H, O’Sullivan D, Kidd J, McCreanor T. The Waitangi Tribunal’s WAI 2575 Report: Implications for Decolonizing Health Systems. Health and Human Rights Journal. 2020;22(1):209.
13. Ministry of Health. Document to inform discussions to develop a Māori Health Action Plan to implement He Korowai Oranga 2020 -2025. Consultation Document. Ministry of Health, NZ. 2019.
14. Waitangi Tribunal. Haurora Report on Stage 1 of the Health Services and Outcomes Kaupapa Inquiry. NZ. 2019.
15. Ministry of Health. He Korowai Oranga. NZ. 2020.
16. Royal Australian and New Zealand College of Psychiatrists. The relevance of religion and spirituality to psychiatric practice. RANZCP;2018.
17. Ministry of Education. Te Whariki Online. Te Ao Māori. NZ. 2020.
18.  Bhui K, Dinos S. Preventive psychiatry: A paradigm to improve population mental health and wellbeing. British Journal of Psychiatry, 2011;198(6):417-419.
19. Allen J, Goldblatt P, Daly S, Jabbal J, Marmot M. Reducing health inequalities through new models of care: A resource for new care models. Institute of Health Equity. 2018.
20. The Royal College of Psychiatrists. No health without public mental health - The case for action. London; 2010.
21. Mulder R. The heart of the matter: Social and cultural factors impacting mental health. Australian & New Zealand Journal of Psychiatry. 2017;51(2):113 –4.
22. Ministry of Health. Whakamaua: Māori Health Action Plan 2020 – 2025. New Zealand. 2020. 
23. Lawson-Te Aho, K. Definitions of whānau: A review of selected literature. Family Commissions Report, April NZ; 2010.
24. Durie M, Cooper R, Grennell D, Snively S, Tuaine N. Whānau Ora: Report of the Taskforce on Whānau-Centred Initiatives to the Minister for the Community and Voluntary Sector. Ministry of Social Development, NZ. 2010.
25. The Medical Council of New Zealand. Cultural competence, partnership and health equity – Consultation on revised documents. 2019.
26. National Addiction Workforce Development. Matua Raki, The Takarangi Competency Framework.
27. The Royal Australian and New Zealand College of Psychiatrists. Continuing Professional Development Program Guide. 2018.
28. The Royal Australian and New Zealand College of Psychiatrists. Consultation on the proposed changes to the accreditation standards for New Zealand vocational training and recertification providers. 2019. 

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.