Bariatric surgery is currently the most effective treatment for severe obesity and obesity-related disease.1–3 Public funding for bariatric surgery in New Zealand has increased in the last decade. Dame Tariana Turia, a retired member of New Zealand parliament, advocated for increased awareness and funding of bariatric surgery following her own experience of bariatric surgery.4 Bariatric surgery is in high demand but remains elusive due to the cost of private surgery and limited public funding available in New Zealand.

Māori are the Indigenous peoples of New Zealand and have higher rates of obesity and obesity-related disease burden compared to non-Māori.5 The most recent New Zealand health survey reported that 30.5% of European adults and 50.32% of Māori adults in New Zealand were obese.6 Despite this, Māori appear to have reduced access to publicly funded bariatric surgery in New Zealand.7 Equitable access to publicly funded bariatric surgery is dependent on many factors, including adequate funding and resources, referrals from primary care, patient and wider societal attitudes towards bariatric surgery.8

Media portrayals of health issues impact perspectives of health and wellbeing and can ultimately undermine the fundamentals of health equity and justice.9–10 Māori representation in the New Zealand media often involves a blend of ethnic labelling practices and frequent positioning as economic threats via resource control and political activism, all of which influences discrimination against Māori in New Zealand.11 Obesity is often negatively stigmatised through notions of laziness and lacking discipline.12 Bariatric surgery can therefore be a contentious topic under discourses of resource scarcity, unfair distribution and public healthcare spending.13

Research critiquing the media surrounding the portrayal of bariatric surgery in New Zealand is limited. To our knowledge, this is the first study that seeks to investigate media portrayals of Māori and bariatric surgery in New Zealand. Given the intersectional tensions that exist within this space, we felt this was a worthy topic of research. The aim of this paper was to explore print and online news media articles portraying Māori in the context of bariatric surgery using an inductive approach to thematic analysis.

Methods

An electronic search of two New Zealand news media websites (Stuff and the New Zealand Herald) and two databases (Proquest Australia/ New Zealand Newsstream and Newztext) was performed from retrieve articles published between January 2007 and June 2017. Full texts were obtained to identify news articles reporting stories, opinion pieces or editorials concerning Māori and bariatric surgery. Two reviewers (JR and SF) independently performed the searches and examined and excluded irrelevant articles in an iterative process. Searches were last performed June 26, 2017 (Table 1).

Table 1: Key search terms for each database and online news website.

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News article ratings

Included articles were scored by two reviewers (JR and SF) using a five-point scale reported by Williamson et al to assess the level of reporting.14 This scale aims to provide a subjective opinion of the article as a whole with a specific focus on the portrayal of bariatric surgery. A score of 1 was ‘very negative’, 2 ‘negative’, 3 ‘neutral’, 4 ‘positive’ and 5 ‘very positive’. Overall scores of 3.5–5 were considered ‘positive’ and scores of 1–2.5 negative.

Thematic analysis

A thematic analysis using the NVIVO 11 was performed to identify common themes. A general inductive approach was used as described by Braun and Clarke.15 Articles were read through several times to find meaningful patterns leading to the formation of codes. Initial codes generated throughout the texts were revised, inspected and grouped appropriately into themes. Themes were named and defined, then compared for significant connections, both within and across the themes. Final readings of all articles were performed to contextualise the developed themes and to ensure study relevance and applicability. Two reviewers (JR and AG) independently performed the analysis and met to compare codes and finalise themes. Where consensus was not met, the senior author (MH) was consulted.

Results

The initial search yielded 1,138 print online news articles of which 246 (202 newspaper; 44 online) articles were relevant to bariatric surgery in New Zealand. Of these, a final 31 articles portrayed Māori and bariatric surgery and were included for final analysis (Figure 1).

Figure 1: Flow diagram depicting the selection process of relevant news articles.

News article ratings

The mean score of all news articles was 3.7, indicating neutral to slightly positive reporting. Two articles (6.5%) were negatively framed (mean score = 2), 21 (67.7%) were positive (mean score = 4.3) and eight (25.8%) were neutral (mean score = 3). Scores between the independent assessors were highly correlated with a Kappa score of 0.72 (95% CI, 0.66–0.78, p<0.0001).

Thematic analysis

A mind map of the coding tree used to discern the major themes and discourses is presented in Figure 2.

Figure 2: Coding tree leading to the development of overarching themes following thematic analysis.

*Indicates main themes; GPs, general practitioners; whānau, family.

Access to bariatric surgery

The theme of access was dominant and largely underpinned by rhetoric regarding the exclusivity of bariatric surgery in New Zealand. Majority of articles (N=20, 65%) suggested this was attributable to high cost of surgery and lack of public funding. Arguments of cost-effectiveness and efficacy of bariatric surgery attempted to justify the need for more public bariatric procedures considering the demand:

“One of the more remarkable features of bariatric surgery and certainly of gastric bypass is the almost immediate end of diabetes, high-blood pressure and high cholesterol… for every patient funded for the surgery, at least another two, whose health would benefit from the procedure, are referred.”16

This dialogue often urged the New Zealand Government to fund more procedures due to the strain obesity and obesity-related diseases places on precious health resources.

Another perceived access barrier was lack of education and understanding of bariatric surgery. This was highlighted within primary healthcare. The common belief that diet and exercise form the best methods for treating obesity was challenged and it was suggested in two articles that general practitioners (GPs) generally lacked understanding of bariatric surgery:

“One of the most effective long-term forms of treatment for obesity is being denied to thousands of New Zealanders because of a lack of understanding among family doctors about the procedures available.”17

The notion of ‘gatekeeping’ was identified in relation to care being restricted and bariatric surgery framed negatively:

“I have been concerned at the complaints I have received from those needing surgery who have had to put up with negative attitudes towards bariatric surgery from some GPs.”18

A personal account from a Māori man implied a need to ‘persuade’ his GP to consider referring him for bariatric surgery:

“…for the sake of his health he needed to have bariatric surgery and persuaded his GP to refer him...”19

Attitudes towards bariatric surgery

Most articles (N=21) were positively graded due to positive attestations of bariatric surgery from both healthcare providers’ and patients’ perspectives. Six articles were personal accounts, of which five were from Māori. All patients described an overwhelmingly positive journey. These articles served as platforms for healthcare providers to advocate for bariatric surgery and their patients. Much of the narrative was formed in response to the negative stigma bariatric patients often face through their bariatric journeys:

“There is still huge prejudice against it. The belief that people that have bariatric surgery should be exercising, that they’re lazy and stupid.”20

Despite overall positivity in the reporting of the articles, an undeniable debate surrounding social justice and responsibility emerged. Two clear threads were observed. The first challenged the responsibility of the government and healthcare providers to support more bariatric procedures due to the potential cost-saving benefits long-term:

“If you look at the risks of heart attacks, diabetes, high blood pressure, strokes and joint replacements, the cost of not performing bariatric surgery may be greater than performing it.”21

The second argued individual responsibility of weight loss and challenged ‘taxpayer funding’ of bariatric surgery. The notion of bariatric surgery being an ‘easy way out’ arose several times and was equally contested by clinicians:

“Another myth… is it is the ‘easy way out’ for people too lazy to diet or exercise. Having much of your stomach removed with all the attendant possible risks is hardly a soft option.”22

It was also suggested that public funding of bariatric surgery is a ‘privilege’ granted by taxpayers. This elevated to suggest that taxpayers were being generous and that this generosity could run its course:

“The public health system already picks up the tab for some operations, and the argument has now shifted to how many more are taxpayers… willing to pay for.”23

Excerpts like this provided a platform for victim-blaming analyses against obese individuals who undergo publicly funded bariatric surgery. This further perpetuated perceptions of laziness and lack of control. A follow-on pattern from this was patient insecurity in admitting to having bariatric surgery. It was suggested that there was also a discernible difference between public and private bariatric patients in disclosing whether they had bariatric surgery:

“Poorer folk who’ve experienced this massive change will shout it from the rooftops… but richer folk will often tell their friends ‘I’m just exercising and eating well.’”24

Complexity of obesity and weight loss

Efforts to assist readers to better understand obesity and the experience of obese individuals in New Zealand were observed. Binary explanations of obesity were dismissed whereas complex descriptions of obesity were promoted. Negative stereotypes of bariatric surgery certainly arose from those associated with obesity. These stereotypes tended to oversimplify obesity in suggesting that obesity was a personal choice:

“Most of the public think being grossly overweight is simply a personal choice… They think it is down to a chips versus veges mentality.”22

Personal accounts of bariatric surgery revealed significant psychosocial stressors associated with obesity. Such reflections spoke to feelings of shame and the subsequent responses like binge eating that created never-ending cycles of depression. The excerpt below described the powerlessness of being obese:

“If you’ve never had to survive in this society at over 200kg you don’t understand… how powerless you feel.”19

Framing of Māori

The dominant theme focusing closely on Māori within the obesity-bariatric surgery context was the importance of whānau. Whānau was key in the decision and motivation to opt for bariatric surgery and to maintain a healthy lifestyle afterwards:

“And so, after talking with all our whānau, investigating all the options... I underwent gastric bypass surgery.”25

A small number of articles described the disproportionately higher rates of obesity and obesity-related disease in Māori compared with non-Māori in New Zealand. An emergent theme was that obesity and comorbidity burden was a ‘normal’ experience for Māori:

“He knew obesity was in the family, as well as heart disease and diabetes... This was perhaps a ‘typical Māori story’…”24

This excerpt was taken from an article that covered a New Zealand documentary series that followed several patients on their bariatric journeys. A sense of stereotypical reinforcement towards Polynesian communities in New Zealand was reported:

“…I think it reinforced some stereotypes: South Auckland; probably Polynesian; poor—there were people living in tents and caravans; maybe a bit lazy, or a bit crazy.”24

Māori advocacy

This last theme developed from an overwhelming presence of Māori advocacy for bariatric surgery. Dame Tariana Turia was present in 22 news articles (71%) where she promoted and endorsed additional government funding of bariatric surgery. Over the course of the 10-year study period, news article publications peaked in 2010 and 2014 following announcements by Dame Tariana regarding public funding for bariatric surgery (Figure 3). The need to address health inequalities in obesity and obesity-related disease for Māori and to ensure equitable access to publicly funded bariatric surgery was also emphasised:

“… We know that obesity, diabetes, heart disease and cancer are the most serious conditions affecting Māori… Investing in bariatric surgery for 1,000 of our peoples a year will have huge long-term savings in health.”26

Through personal accounts in five articles, Māori patients also supported the need for more public funding, having themselves experienced the positive life-changing benefits of bariatric surgery.

Figure 3: Proportion of bariatric and Māori articles in relation to the total number of bariatric news articles.

*arrows indicate New Zealand Government announcements for additional public funding of bariatric surgery.  

Discussion

Only a small proportion of articles (N=31, 13%) related to bariatric surgery in the New Zealand context discussed Māori individuals, peoples, contexts or spaces. The most dominant themes centralised on access and attitudes towards bariatric surgery. The overall rating of articles was neutral to slightly positive (mean score 3.7) due to high coverage on the benefits of bariatric surgery. Māori advocacy promoted awareness and public funding of bariatric surgery, but this did not appear to transpire into themes of health equity in terms of access to or outcomes following bariatric surgery for Māori. Negative stereotypical constructs of obesity emerged and most of the articles served as rebuttals to these narratives.

Obesity has been widely dissected in the media. Researchers have debated socio-medical and scientific discourses of obesity, fatness and weight loss in the media in an attempt to explore impacts on patient care.28–30 Negative stigma associated with obesity includes laziness, gluttony and even stupidity.31 These characteristics arose within the included articles and were applied to both the obese and bariatric recipients. These narratives contribute to socio-cultural constructions of ‘fatness’ that in turn impact understandings and management of obesity. Weight-based discrimination is real and directly impacts quality of life, stress and risk of depression.32 This, aside from the perpetuation of the Obesogenic environment, perhaps plays an important role as to why the obesity epidemic is so difficult to address in contemporary New Zealand society.

As a result of framing obesity as a self-inflicted phenomenon, bariatric surgery has struggled to acquire social acceptance as an effective treatment for obesity and obesity-related disease. Glenn et al critiqued news media coverage of a single, publicly funded bariatric clinic in Canada and deduced that obesity needed to be positioned as a medical condition in order to justify bariatric surgery as a necessary medical treatment.13 They also found that bariatric surgery was framed as lifesaving as opposed to cosmetic in order to justify government expenditure in the Canadian healthcare system. This was also found to be true in the majority of articles in this study where the justification or defence of bariatric surgery due to its efficacy and high demand were common.

It has long been reported that Māori suffer higher rates of obesity and obesity-related disease.5,33 However, the narrative of health equity for Māori was scarce over the included articles. This was surprising given the significant role Māori have played in championing increased public funding for bariatric surgery in New Zealand over the last decade.34 The New Zealand Ministry of Health states that national prioritisation criteria for bariatric surgery is “fair, transparent and equitable”.35 Although, no explicit targets for ethnicity were set as it may “give the appearance of one patient being favoured over another”.35 This statement perhaps alludes to a fear of inciting societal angst around unfairness in distribution of public resources through ‘race-based’ policies. It is a common occurrence that issues of concern to Māori are often minimised or silenced in mainstream media as a result of the normalisation of dominant Western views.36–37 The near absence in the media of the issue of equity for Māori in the obesity-bariatric context could indicate this issue is irrelevant and unimportant to wider New Zealand.

The media bridges the gap between the medical community and the general public.38 It presents issues and determines the level of importance attached to them, thereby influencing public understanding and awareness.39 News articles will focus on subjects that are prevalent, relevant and of interest to the public.40 Our analysis of print and online news articles related to Māori and bariatric surgery in New Zealand over 10 years shows that increasing wider societal acceptance and promoting further funding for bariatric surgery in New Zealand takes priority over addressing longstanding health inequities for Māori. The small number of articles that were related to Māori perhaps reflects the level of importance in the media.

A limitation we encountered in performing this study arose in our application of Williamson’s rating scale for scoring bariatric news items.14 This scale could be easily applied to determine whether the bariatric surgery component of the articles was framed as positive or negative. However, this scoring tool was originally used in a study based in the UK and as such it did not have the sensitivity to pick up the nuance of media bias against Māori in New Zealand. In staying true to this scale, we declared that media portrayals of Māori in the context of bariatric surgery were ‘positive’. However, several studies have shown the New Zealand media to be largely biased against Māori where Māori are often constructed as ‘inferior’ or ‘lazy’ (or both).36–37,41 Therefore, while the Williamson scale may have allowed for articles to be scored positively overall, given the deficit positioning of Māori in the New Zealand media, stories related to Māori and bariatric surgery are at risk of being read through uncritical lenses that may reinforce negative stereotypes against Māori. As such, neutral to positively scored articles related to Māori and bariatric surgery do not necessarily take into account the entrenched negative positions Māori occupy in the New Zealand media. To combat this, we critiqued the articles closely in our analysis to allow for the identification of discriminatory discourses against Māori in relation to bariatric surgery.

This study cannot determine the general attitudes and beliefs of New Zealand society, Māori, bariatric or other communities present in the included articles. However, examining the position of the media is important in monitoring what messages are being emitted and how this could guide policy-makers’ and healthcare providers’ decisions. The media is a source of health information and is therefore critical in shaping public opinion regarding health equity, obesity and bariatric surgery. Health equity between Māori and non-Māori in the context of bariatric surgery in New Zealand has not yet been explored in depth. Our analysis of the media provides one method of understanding how this important issue is perceived in the media and the wider New Zealand context.

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