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| Journal of the New Zealand Medical Association,
04-March-2011, Vol 124 No 1330
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Peter Jansen, Kira Bacal, Stephen Buetow
Improving the health status of Māori relative to
non-Māori and enhancing the experiences of all patients are features of
successive government strategies for health.1,2
Māori are a special focus of government policy, not
only because of their status as Treaty partners but also because they have a
lower life expectancy, greater morbidity and higher rates of disability than
other New Zealanders.3,4 A link between patient
experience of poor care and reduced access to high quality services, for example
in general practice,5,6 has been posited as a
key cause of the inequalities in health
outcomes.7–9
Regular reporting on surveys of patient experiences can
assist health providers to track improvements to their
services.10,11 Recent research has reported a
Māori perspective of Māori experiences of health
care,12,13 but few reports have compared the
experiences of Māori and
non-Māori.6,14
The New Zealand Health Survey 2006/7 reported that
Māori and the total population had similar access to primary health
care.14 Unknown however is how the 2001 Primary
Health Care Strategy, and the subsequent funding and establishment of Primary
Health Organisations, have changed inequalities between Māori and
non-Māori in access to, and experiences of, general practice services.
MethodsA 2005 multi-phase study developed an
experiences-of-care survey tool for measuring health care consumer perceptions
among Māori. (Note the distinction between ‘patients’ and
‘consumers’: ‘patients’ have engaged with the health
care system whereas ‘consumers’ include both actual and potential
patients.) The wider study sought to understand Māori experiences of care
and the impact of experiences on intention to revisit the same provider. Overall
results are reported elsewhere,15 whilst the
present report focuses on differences between Māori and non-Māori
experiences of care in the GP setting.
The 2005 study surveyed a sample of 651 Māori, who
had been identified from Māori electoral
rolls, using a modified telephone interview.
While not intended as a nationally representative sample, the sampling framework
ensured participants reflected the geographical distribution of Māori.
Using the same questionnaire, the same telephone data
collection service (Digipoll) and the same scripting for interviewers, a survey
of a random sample of 400 non-Māori consumers was undertaken immediately at
the conclusion of the Māori survey. This paper uses these data to compare
Māori and non-Māori experiences in relation to access to general
practice care.
A semi-structured personal questionnaire was
administered in the telephone surveys of Māori and non-Māori
consumers. It was used to gather information about issues that promote or
constrain their use and experience of health and disability services.
Development of the questionnaire was informed by a literature review of barriers
to Māori and non-Māori use of the services, a qualitative phase
involving hui (meetings), and review by Māori consumers and
Māori health experts.
Before finalising the questionnaire, four Māori
health professionals reviewed the questionnaire for clarity and validity.
Respondents were asked about their last experience of receiving health and
disability services in the 6 months before being contacted.
In the interview, we distinguished between respondents
who were answering on their own behalf from those answering on behalf of
another. Despite Māori households having higher numbers of children,
Māori and non- Māori respondents in this survey reported answering on
behalf on a child in similar proportions (11.6% vs 13.2%). Identical proportions
were answering on behalf of another adult in both groups (4%).
Analysis of the quantitative data collected on access
to general practice care involved the production of descriptive and inferential
statistics through the use of statistical software (STATA version 7). Tests of
differences in proportions (or means) between Māori and non-Māori were
performed, first for sociodemographic attributes and then for variables
describing access to general practice care at respondents’ last
visit.
ResultsTable 1 compares sociodemographic attributes of the groups
of Māori and non-Māori respondents respectively. It reveals
statistically significant differences between these groups at the 0.05 level.
Compared with the non-Māori group, the Māori respondents on average
were younger, had more household residents and were living in Census Area Units
with higher relative socioeconomic deprivation.
The Māori group also reported proportionately higher
levels than did the non-Māori group of unemployment, young households and
low-income households, as well as proportionately fewer respondents with no
chronic medical condition.
Table 2 compares Māori with non-Māori access to GP
care at respondents’ last visit. Proportionately fewer non-Māori than
Māori reported needing a visit on the day of their request. Regardless of
ethnicity, most respondents reported being seen within this, or another,
preferred timeframe, and getting an appointment at a time they considered
suitable. However, the respondents who did not report visits with these
attributes were more likely to be Māori than non-Māori. Of those who
were given an appointment, proportionately fewer Māori said they were
offered a choice of times or were seen on time. There was no reported difference
between Māori and non-Māori regarding the mean waiting times in the
clinic for those who stated they were seen late.
Table 1. Comparison of Māori and
non-Māori survey participants on sociodemographic attributes
Table 2. Access to GP care for Māori
compared with non-Māori
DiscussionThe results of the multi-phase study of Māori
experiences of health services included a pilot survey developed through
literature reviews and a qualitative phase. This paper has compared data from
Māori who were interviewed by telephone for this pilot survey with data for
non-Māori who were interviewed immediately after the survey of Māori
was completed.
As characterises the New Zealand population, there were
sociodemographic differences between the Māori and non-Māori groups
interviewed about GP contacts. The Māori group was younger and more likely
to live in areas of high deprivation. A greater proportion of non-Māori
than Māori were retired. While similar proportions of each group reported
being in paid employment, a larger proportion of the Māori group stated
they were unemployed.
In line with report six of the National Medical Care
survey,6 a greater proportion of Māori
than non-Māori reported an urgent health need at their last visit to a GP.
What appears ‘urgent’ to one person is not necessarily
‘urgent’ to another, but the data indicate a difference between
Māori and non- Māori in what they perceived to be an urgent health
need.
Regardless of their ethnicity, most respondents reported
seeing a GP when they wanted. This finding should be seen in the context of most
Māori having a primary care provider they can go to when the need
arises.16 Respondents who said they could not
see a GP when they wanted were more likely to be Māori than non-Māori.
Similarly, the 2006/7 New Zealand Health Survey found that Māori women were
more likely than women in the total population to feel unable to see their
primary health care provider within 24 hours when
wanted.14
Unmet need for a GP was reported to be highest for
Māori, after adjustment for age, in the 12 months before the Health
Survey.14 These findings are consistent with
lower mean annual exposure by Māori than Europeans to general practice care
in New Zealand.17
In our study, Māori were less likely than
non-Māori to report being offered a choice of appointment times. Other
studies have similarly reported that practice staff demonstrate poorer
communication with Māori than non-Māori, for example about their
health care.14 Further research is needed to
test how (and why) experiences of, and access to, GP care have changed since our
survey, particularly because changes to New Zealand health policy have continued
to erode the "redistributive effect of the original needs-based
formulas."18
It is also worth noting that in many general practices, the
gatekeeping of timely access to the GP is controlled not by the clinicians but
rather by non-clinical office staff such as
receptionists,19 a distinction the present
study could not make. Indeed, recent evidence from the United Kingdom exposes
consumer concerns regarding the receptionist role in
triage.20
Our findings may therefore reflect differences among office
staff, rather than GPs, in offering access to primary medical care. For example
Māori may have a cultural tendency to be noho whakaiti—to
not cause a ruckus—and so may not appear worried, upset, or assertive to
staff in the face of an urgent health need.15
All practice staff need to receive appropriate pre-service and in-service
training so that they can communicate safely and effectively with consumers
whilst addressing their needs.21,22
Our study was restricted to households with telephones. It
also surveyed self-selected respondents, i.e. people who chose to participate
and presumably wanted to share their experiences. Although many Māori
prefer kanohi ki te kanohi (face to face) communication, we used
telephone contact to maximise our geographic reach while minimising time and
costs.
Lastly, since people’s recall of events is often
flawed, reported experiences may have varied from their actual ones. We used
identical methods with both populations to control for any potential bias,
however, and have no reason to believe that either population was more likely to
over- or under-report their experiences in a systematic fashion.
Our study was strengthened by our use of experience-based,
rather than satisfaction-based, questions. The latter may not reflect true
attitudes (i.e. some people, especially Māori, are reluctant to be seen as
rude or critical) and/or may reflect an acceptance of inequalities (e.g.
satisfaction is reported as high because expectations are extremely low). By
inquiring about experiences, people's reports can be compared to best practices
and assessed more objectively.
Despite years of political mandates to improve or eradicate
health disparities, Māori still report being less likely to be offered
choices at their general practice, to be seen on time, and to be seen within
their preferred timeframe. These findings suggest additional work is needed to
align Māori experiences of general practice care with those of their
non-Māori neighbours.
Competing interests: None known.
Author information: Peter Jansen, Senior
Medical Advisor, Accident Compensation Corporation, Auckland; Kira Bacal, Phase
2 Director, Medical Programme Directorate, Faculty of Medical and Health
Sciences, University of Auckland; Stephen Buetow, Associate Professor,
Department of General Practice and Primary Health Care, University of
Auckland
Acknowledgements: Ngā mihi nui ki a
koutou katoa. We thank all those participants who shared their experiences and
insights. Special thanks to the Ministry of Health, the Health Research Council
and the Accident Compensation Corporation who funded the study of Māori
experiences of care.
Correspondence: Dr K Bacal, Phase 2
Director, Medical Programme Directorate, Faculty of Medical and Health Sciences,
The University of Auckland, Private Bag 92019, Auckland, New Zealand. Email: k.bacal@auckland.ac.nz
References:
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