Whakawhanaungatanga: the importance of culturally meaningful connections to improve uptake of pulmonary rehabilitation by Māori with COPD – a qualitative study

Abstract

BackgroundPulmonary rehabilitation is known to improve function and quality of life for people with chronic obstructive pulmonary disease (COPD). However, little research has been conducted on the influence of culture on experiences of pulmonary rehabilitation. This study examined factors influencing uptake of pulmonary rehabilitation by Māori with COPD in New Zealand.MethodGrounded theory nested within kaupapa Māori methodology. Transcripts were analyzed from interviews and focus groups with 15 Māori and ten New Zealand non-Māori invited to attend pulmonary rehabilitation for COPD. Māori participants had either attended a mainstream hospital-based program, a community-based program designed “by Māori, for Māori”, or had experienced both.ResultsSeveral factors influencing uptake of pulmonary rehabilitation were common to all participants regardless of ethnicity: 1) participants’ past experiences (eg, of exercise; of health care systems), 2) attitudes and expectations, 3) access issues (eg, time, transport, and conflicting responsibilities), and 4) initial program experiences. These factors were moderated by the involvement of family and peers, interactions with health professionals, the way information on programs was presented, and by new illness events. For Māori, however, several additional factors were also identified relating to cultural experiences of pulmonary rehabilitation. In particular, Māori participants placed high value on whakawhanaungatanga: the making of culturally meaningful connections with others. Culturally appropriate communication and relationship building was deemed so important by some Māori participants that when it was absent, they felt strongly discouraged to attend pulmonary rehabilitation. Only the more holistic services offered a program in which they felt culturally safe and to which they were willing to return for ongoing rehabilitation.ConclusionLack of attention to cultural factors in the delivery of pulmonary rehabilitation may be a barrier to its uptake by indigenous, minority ethnic groups, such as New Zealand Māori. Indigenous-led or culturally responsive health care interventions for COPD may provide a solution to this issue.

Australian and New Zealand Pulmonary Rehabilitation Guidelines

“…Given the higher incidence of COPD in Indigenous Australian and New Zealand communities, it is important that Indigenous patients with COPD have access to PR. One barrier to attendance at PR may be the lack of attention to cultural needs within mainstream programmes . Currently in Australia, no PR programmes are specifically designed to accommodate the cultural needs of Aboriginal and Torres Strait Islander Peoples and there is little empirical data on what these needs are.…”

“…Currently in Australia, no PR programmes are specifically designed to accommodate the cultural needs of Aboriginal and Torres Strait Islander Peoples and there is little empirical data on what these needs are. In New Zealand, PR programmes provided for Māori individuals by Māori organizations have identified that attendance is enhanced by the opportunity to make culturally meaningful connections with other patients and staff within the programme, having culturally appropriate information available and communicating in a common Māori language . It is imperative that greater efforts are made to ensure safe cultural environments for the delivery of PR, either by Indigenous health professionals providing the PR programmes or by mainstream programmes providing a culturally appropriate environment to encourage and maintain attendance.…”

“…One barrier to attendance at PR may be the lack of attention to cultural needs within mainstream programmes. 138 Currently in Australia, no PR programmes are specifically designed to accommodate the cultural needs of Aboriginal and Torres Strait Islander Peoples and there is little empirical data on what these needs are. In New Zealand, PR programmes provided for M aori individuals by M aori organizations have identified that attendance is enhanced by the opportunity to make culturally meaningful connections with other patients and staff within the programme, having culturally appropriate information available and communicating in a common M aori language.…”

An audit of pulmonary rehabilitation program

“…21,22 This audit confirmed that Māori and Pacific Island patients attended significantly fewer sessions, even with the extra support of Whanau Care Services. Levack et al have recently explored factors influencing uptake of PR by Māori with COPD in New Zealand, 23 concluding that, to improve uptake, PR programs should consider cultural responsiveness and indigenous leadership.…”

Turning a challenge into an opportunity: pulmonary rehabilitation and socioeconomic deprivation

“…Non-white British people were under-represented among pulmonary rehabilitation participants in England and Wales compared with the general population 13. Similarly, indigenous people are nearly absent from pulmonary rehabilitation programmes and associated research,14 yet have health disparity beyond what is associated with socioeconomic status alone. Barriers to implementation of pulmonary rehabilitation here include staffing, resourcing and sustainability of programmes in rural and remote settings15 along with addressing cultural meaning and relevance for indigenous participants 14 15…”