Reducing healthcare inequities for Māori using Telehealth during COVID-19 | OPEN ACCESS
View Article PDF
In Aotearoa New Zealand, Māori (the Indigenous peoples of New Zealand) experience significant ongoing health inequities compared to non-Māori[[1–3]] including higher mortality and morbidity rates across most health conditions.[[1,3]] Health inequities between Māori and non-Māori are due to differential access to the determinants of wellbeing including timely healthcare and differences in the quality of healthcare.[[3,4]] Despite the overwhelming need for quality healthcare to address these inequities, Māori access to culturally safe health services is limited.[[5]]
Māori whānau have previously described healthcare as inaccessible due to financial cost, transportation issues and other obstacles such as finding childcare. Travel barriers for rural patients to attend GP appointments are significant, and for working families there is difficulty in organising appointments around clinic hours, with families required to negotiate employer expectations and leave entitlements.[[6]] Additionally, the 2020 New Zealand Health Survey revealed significant differences by ethnicity, and these were even more stark for Māori wāhine (females)[[7]] who report high cost, no transport, prioritising childcare and experiencing discrimination, all as factors affecting access options and health outcomes.[[8]] In contrast, healthcare was more accessible when it included practical whānau support in the form of time, money and transport to attend appointments.[[6]] These barriers contribute to higher amenable morbidity and mortality rates for Māori, which in 2018 were 192.2 per 100,000 peoples compared to 77.7 per 100,000 for non-Māori non-Pacific peoples.[[9]]
The March 2020 COVID-19 Level 4 lockdown significantly influenced the patient–health professional interaction interface, requiring Telehealth (phone and online video) consultations almost overnight.[[10]] Telehealth utilises “information and communication technologies to deliver health care when patients and care providers are not in the same physical location”.[[11]] Provision of Telehealth GP clinics therefore has the potential to reduce, if not eliminate, the practical (eg travel) barriers for whānau.[[6]] Previous qualitative research with young, pregnant Māori women demonstrated how Telehealth-based antenatal care services promoted engagement and reduced access barriers.[[12]] Importantly, whānau also noted the positive influence of health professionals who take time to build rapport and develop continuity of care with patients,[[6]] a factor that may be impacted by Telehealth delivery. Hence, robust research is required that unpacks both the positive and mitigating potential of Telehealth delivery to Māori whānau.
This research aimed to investigate and inform the use of Telehealth with Māori. We sought to understand the experiences of Telehealth (phone and online video) versus in-clinic healthcare in primary care settings during COVID-19 lockdown in March 2020, from both patients and Māori provider perspectives.
Methods
A Kaupapa Māori research methodology was used.[[13,14]] This methodology operates using a Māori world view and takes on Māori ways of knowing, being and doing.[[15]] Māori aspirations for reducing inequities and attaining improved wellbeing are prioritised. The research is led and carried out by Māori health researchers and supports the ongoing professional development of the Māori health researcher workforce. A critical structural analysis was taken that contextualises data interpretations within historical and current influences on Māori health inequities, and ensures a non-victim blame, non-deficit analysis. Māori realities, in particular socioeconomic positions, are acknowledged.[[13–16]]
Fourteen qualitative semi-structured interviews occurred with participants who self-identified as Māori, lived in Auckland or Northland, and who fit one or more of the research criteria. The criteria included: 1) Māori health professionals 2) Māori patients/whānau who experienced at least one GP consultation using Telehealth during the COVID-19 lockdown period; and 3) Māori patients who opted for an in-clinic GP consultation (over Telehealth) during the COVID-19 lockdown period.
Purposive sampling was used to identify potential participants through the National Hauora Coalition Primary Health Organisation (PHO) and the research team’s networks—potential participants were then invited to participate. Information sheets were provided, and participants completed consent forms prior to interviews. Interviews occurred via phone call or online video call (Zoom) and followed a schedule. Interview questions included: what worked about providing telehealth consultations; why patients chose the Telehealth, or an in-clinic consultation option; what health providers or patients did not like about Telehealth consults; and how could Telehealth consultations be improved for Māori. Questions were explored in terms of access, barriers, and quality healthcare treatment for Māori.
A Māori interviewer employed te reo (Māori language), tikanga (Māori protocols) and whanaungatanga (Māori customary engagement rituals) to facilitate the interview process. Interviews ranged from 15 to 60 minutes in duration, were audio recorded and transcribed verbatim by a Māori researcher. A Kaupapa Māori thematic analysis was carried out by experienced Kaupapa Māori researchers to ensure that known Māori world views and realities were foregrounded, and a non-deficit approach was taken.[[17]] Researchers read and re-read transcripts and held in-depth discussions to identify, understand and refine results into themes. Data was collated into common themes and presented to the wider research team for review. The final themes were a consensus decision. Illustrative quotes are reported verbatim.
This study was categorised as low-risk (ie did not require full approval) by the New Zealand Health and Disability Ethics Committee review process. Additional ethical review was then completed and granted by the New Zealand Ethics Committee (NZEC)[[18]] on 20 November 2020.
Results
Fourteen participants including five Māori health professionals, six Māori telehealth patients, and six Māori in-clinic patients agreed to take part in the study. Note that three participants were eligible for more than one category (eg health professional and Telehealth patient). The results were categorised into three main themes: 1) benefits; 2) challenges; and 3) suggested improvements.
Benefits–Rangatiratanga (weaving components that benefit all)
Key benefits of Telehealth were identified by all participants and included time and economic savings, enabling of tino rangatiratanga and improved safety.
Health professionals and patients noted that Telehealth consultations minimised time needed to travel, to wait and to be seen at the clinic, and to process prescriptions, which was particularly useful for people who were working long hours, had lengthy travel or had young children to mind.
It was very efficient, it saved me a whole lot of time, and all of that [Telehealth consultation] took like half an hour. (Telehealth patient_10)
For some patients this [Telehealth consultation] was great, this was easier, this was faster, this was better. (Health professional_4)
All patients described Telehealth consultations as cost-effective because they were cheaper than in-person visits and reduced time off work. For example, some patients use Telehealth consultations during their lunch break at work. In addition, patients noted that there were no transport costs.
You definitely save time and effort and it’s cheaper, so I usually pay $18.00 to go in and that’s an enrolled patient but it was $10 over the phone… it saved time, saved energy, saved petrol, saved money. (Telehealth patient_6)
I’d recommend the phone consultations. It’s simple so it gets all the waiting and all that sort of stuff… out of the way. I could see it being really beneficial. (Telehealth patient_14)
Patients and health professionals described virtual consultations as a means for exercising tino rangatiratanga. The ability to self-determine aspects of the appointment, in ways that met their needs and made them feel in-charge.
You could go online on the website and then book in your appointment, but you could also select who you wanted to see … It was all very self-driven, so I didn’t have to ring anyone. I like that because I hate ringing people … you just book it in, you can see when you’re available … when they’re available … then she just called my phone. (Telehealth patient_10)
The de-centralisation of health clinics (ie no longer requiring patients to physically attend appointments at health clinics) resulted in improved flexibility of health service delivery. Patients were able to access doctors on their own terms, as well as increasing access to services and Māori health professionals who are otherwise inaccessible through their usual GP practice and local regions.
We could live wherever we wanted but we could still actually get consults from people [Māori doctors] we want to. (Telehealth patient_10)
My Kōhanga māmā … they've got multiple kids … trying to get one to the doctors and worry about the others is always a mission … having online or phone consultations can help counter those access barriers. (In-clinic patient_6)
I've already been back to the doctors … five times … had to tell [my] story to four men [doctors] … then this woman rang back [during COVID] … she's the only … wāhine Māori doctor … in the area that I live in … I've never seen her … and I’ve been there for years … that was the point of difference … she was Māori, she was caring, there was aroha in her tone … it was the first time I think someone heard me and it was on the phone.” (Telehealth patient_11)
The provision of telehealth platforms enabled patients and their whānau to stay safe in their homes from COVID-19. In addition, patients and health professionals noted that Telehealth mediums at times enabled an increased level of privacy and confidentiality, a concern in smaller communities.
I just thought the [clinic] was the most unsafe space [for COVID-19 exposure]. (In-clinic patient_5)
In… a small community, they’re worried about… the word going around, so actually being able to offer that [Telehealth], where they don’t actually have to walk through the front door and go report to their cousins that are on reception. So being able to provide that [Telehealth] for that particular community. (Health professional_1)
Challenges–Tikanga Aukati (unfair practices)
Whilst multiple benefits of Telehealth consultations were identified, a number of challenges were also highlighted including access to the necessary resources (eg Telehealth software, internet capable devices and internet data) and unmet health needs (eg physical assessment) due to prioritisation of COVID-focussed care.
When the call came to deliver the majority of primary care consultations virtually, health providers scrambled to obtain the necessary equipment and training (eg Telehealth software, operational processes). Patients and whānau also had to adapt quickly, however; their support to access resources and information was limited.
The Kuia and Kaumātua (elders) that we were trying to screen [for health concerns during COVID-19 lockdown]. We literally phoned everybody… [but] some of them don’t even have mobile phones. (Health professional_2)
[We were having] a tutu [play] around with the internet [website of healthcare provider]… [so that we were prepared] if we needed to get in touch with somebody through that lockdown; because it [accessing healthcare online] was just something totally new to us. (Telehealth patient_8)
Health professionals reported that the health system did not provide funding for patients and whānau to access Telehealth. Insufficient provision of Telehealth system infrastructure meant that many patients were not yet familiar with using technology to access Telehealth. Further, health systems were not meeting the financial costs associated with whānau accessing telehealth, eg paying for IT devices and internet data.
We’re moving to a digital space; how do we cater for that? … If you go into a clinic there's usually a Samoan or Tongan nurse or someone that can translate at the clinic but … a whole lot of our people… they're not… computer literate or savvy. (Health professional_6)
I think we have to breakthrough on some of the digital technology stuff, so having access to devices and spaces and places where you can do [a Telehealth consultation], and the data requirements to be able to do it. (Health professional_4)
New communication and literacy barriers arose between whānau and health professionals when using Telehealth compared with face-to-face consultations. For example, participants often reported that doctor’s ‘terms’ were difficult to follow and understand without non-verbal communication. Accordingly, the need for both whānau and health professionals’ health literacy development in a Telehealth-specific context was evident.
Health literacy stuff … how we talk to patients about digital health … how we provide that information. Are we understandable to our patients? … Doing some work on ourselves … our community might benefit. (Health professional_4)
Particularly challenging communication and literacy barriers surfaced when health professionals asked questions about symptoms. For example, when health professionals asked whānau to assess basic health symptoms such as ‘temperature’, whānau often did not have a thermometer at home, and were not trained to ‘read their temperature’.
Health professional communication and interpretation of health needs via Telehealth at times seemed to require patients and whānau to have the ability to complete physical examinations, as articulated here:
For instance, if they say to you over the phone ‘have you got a fever, are you hot?’ Well yeah, I’m hot, but, like, is it because I’ve got a fever or because it’s a hot day? … Just sort of figuring out, would they be able to diagnose it just like that? Whether I’ve got a fever or not? (In-clinic patient_12)
At times, choosing between Telehealth and in-clinic options, whilst prioritising COVID-19 versus other health needs, was challenging for health professionals, patients and whānau. Despite needing in-clinic healthcare, some patients chose to stay home and self-administer medical procedures rather than prioritise their health needs over others during the COVID-19 pandemic. When patients did seek in-clinic consultations during lockdown, health professionals were focussed on COVID-19 testing, leaving other health needs unmet.
I just phoned up … I have an abscess growing up the back of my mouth. It’s quite swollen … What do I do? Do I pop it? Do I cut it? Do I cause I can’t come in there … so they gave me antibiotics … it did nothing for the pain, so I ended up popping it myself ... I just got a really big needle and … cracked it and squirted it all out. (Telehealth patient_9)
[During in-clinic consultation] there was no focus on my actual sickness. All he wanted to know was, do you have COVID and how far away can you stay from me? … All I wanted was my antibiotics … what about my body aches? He didn't, I remember, he didn't actually ask what my other symptoms are, all he asked was three COVID questions. (In-clinic patient_13)
Suggested improvements–Mana enhancing
Building on the identified benefits and challenges of Telehealth provision, and the immediacy of COVID-19, suggested improvements for long-term delivery were made.
Telehealth systems that were more user-friendly with language options were recommended.
I think having forms in different languages, or websites that talk, so you can just push a button and then someone talks to you saying in the different language you know ‘push here if you need a doctor’ … we could streamline it that way… or you can touch the screen, ‘press here for the receptionist’ or ‘for Samoan press here.’ (Health professional_6)
Some healthcare organisation Telehealth systems involved the of sharing whānau health information between and across health system organisations. This was seen as a key highlight of moving consultations online. Sharing of key information in real time across the health system inevitably removed barriers that were previously created by organisational healthcare silos.
One of the things that happened in our system is barriers fell away between different organisations, everybody would share anything that was needed… if you had some information, research … everybody consistently made that available across networks, different Primary Health Organisations were sharing. (Health professional_4)
Participants appreciated the ‘options’ to attend an in-clinic, online or phone call consultation and wanted to see these continued. In addition, health professional utilisation of cultural competencies remains essential in Telehealth settings.
Giving [the patient] the option to choose which one was better, and quite a few went for the video call. Just that kanohi ki te kanohi stuff. Even though some of them called it fake kanohi ki te kanohi, for some it was still powerful enough to be able to give the same mana they get from being in-person kanohi ki te kanohi. (Health professional_1)
Educating healthcare service staff around the communication and delivery of information digitally (ie understanding Māori patient health literacy, realities and experiences when accessing Telehealth, and learning how to assess patients online) would improve Telehealth services.
I think we should do better in some of our information health literacy stuff… health literacy in terms of how we talk to patients about digital health. (Health professional_4)
Health professionals and patients clearly noted that access to technology, devices, and knowledge around their use were critical components of a successful Telehealth system for whānau.
For me the important things were… ensuring that our patients had access to that … a lot of whānau we serve don’t actually have that sort of technology available to them… that’s why they’d come into the clinic because they couldn’t talk over the phone. (Health professional_1)
A sense of connection with their health providers was essential to fully engage and benefit from the Telehealth consultation and therefore patients recommended training in ‘building online rapport’ for providers.
It does take a bit of time to develop that trust because whānau aren't just going to say, ‘hey this is my problem, and this is what I need’, right. (Health professional_3)
It wasn’t easy, and she had to try and earn that trust from me over a telephone. (Telehealth patient_11)
Discussion
This article presents a qualitative scoping investigation of the experiences of Māori whānau and health professionals’ provision and use of Telehealth during the 2020 COVID-19 lockdown. Participants represented a range of experiences: use of Telehealth, opting for in-clinic consultation, and design and provision of Telehealth services. Given the barriers Māori whānau face when accessing primary healthcare, and the impacts of these barriers on increasing inequities, this Kaupapa Māori study explored how a culturally appropriate Telehealth system might mitigate access barriers for Māori whānau, and thereby reduce health inequities.
Māori participants in this study described multiple benefits to Telehealth consultations during the 2020 COVID-19 lockdown. Telehealth consultations were introduced in Aotearoa based on international pre-COVID-19 studies confirming their feasibility, safety, effectiveness and accessibility in general practice,[[19]] in adults with diabetes[[20,21]] and in mental health.[[22]] Some studies suggest that Telehealth clinics have the potential to keep important care pathways, particularly for cancer, moving during lockdowns.[[23]] Telehealth is therefore likely to be beneficial to Māori who experience higher rates of chronic conditions, cancer and mental illness.[[24]] Knowing that international research supports the use of Telehealth consultations in these key Māori health areas is important, but prior to this study, there was limited evidence of Māori experiences.
The patients and providers described ‘reduced cost’ as a reason for choosing Telehealth over face-to-face consultations, confirming previous research on the cost-benefits of Telehealth consultations.[[25]] Wider benefits identified in this study, such as savings on transport and improved waiting times have also been reported internationally.[[26]] In addition, having access to a wider range of Māori health professionals (without geographic barriers) aligns with whānau preferences for cultural concordance.[[27]] However, the participants also described hidden costs and barriers, particularly with regard to digital access (equipment and broadband availability). Such barriers have the potential to widen disparities, as demonstrated in studies with peoples living with social deprivation, limited digital access[[28,29]] and disabilities.[[30]]
Therefore, the introduction of Telehealth consultations requires a comprehensive approach that ensures equity in broadband coverage across New Zealand,[[31]] access to equipment similar to the way education providers have delivered devices to students[[10]] and culturally safe ‘Telehealth literacy’[[32]] for both providers and patients. Of considerable concern were descriptions of unmet need when providers prioritised COVID-19 in the consultation over other health issues. This may be true for both Telehealth and in-person consultations. Clear processes are required to ensure that Telehealth during COVID-19 lockdowns does not result in poorer care despite the convenience.
This Kaupapa Māori study investigated experiences of Māori within the Telehealth context during the 2020 COVID-19 lockdown. The findings indicate Telehealth is a viable long-term option that with additional resourcing can support Māori whānau access to healthcare. Telehealth removes practical barriers as well as providing reasonably safe access to health services when there is high COVID-19 risk in the community. Future provision of Telehealth requires robust investment in necessary resources, systems and capabilities for both patients and health providers.
Summary
Abstract
Aim
Māori experience barriers to accessing timely, quality healthcare. The March 2020 COVID-19 lockdown in New Zealand required provision of Telehealth consultation options in primary care. Telehealth consultations have the potential to improve access to healthcare for Māori, and thereby reduce health inequities. Conversely, Telehealth may present additional barriers that contribute to inequities overall. This scoping project investigated Māori experiences of Telehealth consultations during the March 2020 COVID-19 lockdown.
Method
Semi-structured key informant interviews were completed with five Māori health professionals, six Māori Telehealth patients, and six Māori in-clinic patients, about their healthcare consultation experiences during COVID-19 lockdown. Participants were asked about what worked, what did not work, and for suggestions to improve future Telehealth provision to Māori whānau.
Results
Key findings are presented in three overarching themes: benefits (safety, cost, time, options); challenges (health literacy, access to Information Technology (IT), supply and demand, limited physical assessment); and suggested improvements (systems fit for purpose, supporting IT and health literacy, Telehealth as a routine option, rapport building, and cross system efficiency and information sharing).
Conclusion
Telehealth is a viable long-term option that can support Māori whānau access to healthcare.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1) Robson B, Harris R. Hauora, Māori standards of health IV: A study of the years, 2000-2005. Wellington, N.Z.: Te Rōpū Rangahau Hauora a Eru Pōmare; 2007.
2) Ministry of Health. Tatau kahukura: Māori health chart book 2015 (3rd edition). Wellington: Ministry of Health;2015.
3) Waitangi Tribunal. Hauora: Report on Stage One of the Health Services and Outcomes Kaupapa Inquiry. WAI 2575. Waitangi Tribunal report 2019. Lower Hutt, New Zealand: Printlink;2019.
4) Blakely T, Ajwani S, Robson B, Tobias M, Bonne M. Decades of disparity: Widening ethnic mortality gaps from 1980 to 1999. NZ Med J. 2004;117(1191).
5) Curtis E, Jones R, Tipene-Leach D, et al. Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition. International Journal for Equity in Health. 2019;18(1):1-17.
6) Graham R, Masters-Awatere B. Experiences of Māori of Aotearoa New Zealand's public health system: a systematic review of two decades of published qualitative research. Australian and New Zealand Journal of Public Health. 2020;44(3):193-200.
7) Ministry of Health. Ministry of Health New Zealand Health Survey 2019/20. Explore indicators. 2020.
8) Lee R, North N. Barriers to Māori sole mothers' primary health care access. Journal of Primary Health Care. 2013;5(4):315-321.
9) Ministry of Health. Amenable mortality SLM data. Data to support system level measures. 2021; https://nsfl.health.govt.nz/dhb-planning-package/system-level-measures-framework/data-support-system-level-measures/amenable.
10) Gurney J, Fraser L, Ikihele A, Manderson J, Scott N, Robson B. Telehealth as a tool for equity: pros, cons and recommendations. The New Zealand Medical Journal (Online). 2021;134(1530):111-115.
11) Ministry of Health. Telehealth. 2017; https://www.health.govt.nz/our-work/digital-health/other-digital-health-initiatives/telehealth.
12) Gasteiger N, Anderson A, Day K. Rethinking engagement: Exploring women's technology use during the perinatal period through a Kaupapa Māori consistent approach. New Zealand College of Midwives Journal. 2019(55):20-26.
13) Pihama L. Kaupapa Māori Theory: Transforming Theory in Aotearoa. He Pukenga Kōrero. 2010;9(2):5-14.
14) Smith L. Decolonising Methodologies. Research and Indigenous Peoples. Dunedin: University of Otago Press; 1999.
15) Wikaire E. The past, present and future of traditional Indigenous healing: What was, is, and will be, rongoā Māori. Auckland: Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, The University of Auckland; 2020.
16) Smith L. Decolonizing methodologies: Research and Indigenous peoples. 2nd ed. Dunedin: Otago Univerity Press; 2012.
17) Wikaire E. Data speaks: Predictors of success in tertiary education health study for Māori and Pacific students. Auckland: Te Kupenga Hauora Māori, University of Auckland; 2015.
18) New Zealand Ethics Committee. Welcome. 2021; https://www.nzethics.com/.
19) Ebad R. Telemedicine: Current and future perspectives. IJCSI. 2013;10(6):242-249.
20) Quinn L, Olajide O, Green M, Sayed H, Ansar H. Patient and professional experiences with virtual antenatal clinics during the COVID-19 Pandemic in a UK tertiary obstetric hospital: questionnaire study. J Med Internet Res. 2021;23(8):e25549.
21) Armstrong N, Hearnshaw H, Powell J, Dale J. Stakeholder perspectives on the development of a virtual clinic for diabetes care: Qualitative study. J Med Internet Res. 2007;9(3):e23.
22) Berryhill B, Halli-Tierney A, Culmer N, et al. Videoconferencing psychological therapy and anxiety: A systematic review. Family practice. 2019;36(1):53-63.
23) Connor M, Winkler M, Miah S. COVID‐19 pandemic–is virtual urology clinic the answer to keeping the cancer pathway moving? BJU international. 2020;125(6):E3-E4.
24) Health Quality and Safety Commission New Zealand. He matapihi ki te kounga o ngā manaakitanga ā-hauora o Aotearoa 2019. A window on the quality of Aotearoa New Zealand's health care 2019. Wellington: Health Quality & Safety Commission;2019.
25) Jacklin P, Roberts J, Wallace P, et al. Virtual outreach: economic evaluation of joint teleconsultations for patients referred by their general practitioner for a specialist opinion. BMJ. 2003;327(7406):84.
26) Murphy R, Dennehy K, Costello M, et al. Virtual geriatric clinics and the COVID-19 catalyst: a rapid review. Age and ageing. 2020;49(6):907-914.
27) Wikaire E, Ratima M. Māori participation in the physiotherapy workforce. Pimatisiwin J Aboriginal Indigenous Commun Health. 2011;9:473-495.
28) Atherton H, Brant H, Ziebland S, et al. Alternatives to the face-to-face consultation in general practice: focused ethnographic case study. British Journal of General Practice. 2018;68(669):e293-e300.
29) Mold F, Hendy J, Lai Y-L, de Lusignan S. Electronic consultation in primary care between providers and patients: systematic review. JMIR Med Inform. 2019;7(4):e13042.
30) Brant H, Atherton H, Ziebland S, McKinstry B, Campbell J, Salisbury C. Using alternatives to face-to-face consultations: a survey of prevalence and attitudes in general practice. British Journal of General Practice. 2016;66(648):e460-e466.
31) Wilson N, Summers J, Grout L, Baker M. Bumper issue of COVID-19 pandemic studies of relevance to Aotearoa New Zealand. New Zealand Medical Journal (Online). 2021;134(1538):9-17.
32) Huuskes B, Scholes‐Robertson N, Guha C, et al. Kidney transplant recipient perspectives on telehealth during the COVID‐19 pandemic. Transplant International. 2021;34(8):1517-1529.
For the PDF of this article,
contact nzmj@nzma.org.nz
Reducing healthcare inequities for Māori using Telehealth during COVID-19 | OPEN ACCESS
View Article PDF
In Aotearoa New Zealand, Māori (the Indigenous peoples of New Zealand) experience significant ongoing health inequities compared to non-Māori[[1–3]] including higher mortality and morbidity rates across most health conditions.[[1,3]] Health inequities between Māori and non-Māori are due to differential access to the determinants of wellbeing including timely healthcare and differences in the quality of healthcare.[[3,4]] Despite the overwhelming need for quality healthcare to address these inequities, Māori access to culturally safe health services is limited.[[5]]
Māori whānau have previously described healthcare as inaccessible due to financial cost, transportation issues and other obstacles such as finding childcare. Travel barriers for rural patients to attend GP appointments are significant, and for working families there is difficulty in organising appointments around clinic hours, with families required to negotiate employer expectations and leave entitlements.[[6]] Additionally, the 2020 New Zealand Health Survey revealed significant differences by ethnicity, and these were even more stark for Māori wāhine (females)[[7]] who report high cost, no transport, prioritising childcare and experiencing discrimination, all as factors affecting access options and health outcomes.[[8]] In contrast, healthcare was more accessible when it included practical whānau support in the form of time, money and transport to attend appointments.[[6]] These barriers contribute to higher amenable morbidity and mortality rates for Māori, which in 2018 were 192.2 per 100,000 peoples compared to 77.7 per 100,000 for non-Māori non-Pacific peoples.[[9]]
The March 2020 COVID-19 Level 4 lockdown significantly influenced the patient–health professional interaction interface, requiring Telehealth (phone and online video) consultations almost overnight.[[10]] Telehealth utilises “information and communication technologies to deliver health care when patients and care providers are not in the same physical location”.[[11]] Provision of Telehealth GP clinics therefore has the potential to reduce, if not eliminate, the practical (eg travel) barriers for whānau.[[6]] Previous qualitative research with young, pregnant Māori women demonstrated how Telehealth-based antenatal care services promoted engagement and reduced access barriers.[[12]] Importantly, whānau also noted the positive influence of health professionals who take time to build rapport and develop continuity of care with patients,[[6]] a factor that may be impacted by Telehealth delivery. Hence, robust research is required that unpacks both the positive and mitigating potential of Telehealth delivery to Māori whānau.
This research aimed to investigate and inform the use of Telehealth with Māori. We sought to understand the experiences of Telehealth (phone and online video) versus in-clinic healthcare in primary care settings during COVID-19 lockdown in March 2020, from both patients and Māori provider perspectives.
Methods
A Kaupapa Māori research methodology was used.[[13,14]] This methodology operates using a Māori world view and takes on Māori ways of knowing, being and doing.[[15]] Māori aspirations for reducing inequities and attaining improved wellbeing are prioritised. The research is led and carried out by Māori health researchers and supports the ongoing professional development of the Māori health researcher workforce. A critical structural analysis was taken that contextualises data interpretations within historical and current influences on Māori health inequities, and ensures a non-victim blame, non-deficit analysis. Māori realities, in particular socioeconomic positions, are acknowledged.[[13–16]]
Fourteen qualitative semi-structured interviews occurred with participants who self-identified as Māori, lived in Auckland or Northland, and who fit one or more of the research criteria. The criteria included: 1) Māori health professionals 2) Māori patients/whānau who experienced at least one GP consultation using Telehealth during the COVID-19 lockdown period; and 3) Māori patients who opted for an in-clinic GP consultation (over Telehealth) during the COVID-19 lockdown period.
Purposive sampling was used to identify potential participants through the National Hauora Coalition Primary Health Organisation (PHO) and the research team’s networks—potential participants were then invited to participate. Information sheets were provided, and participants completed consent forms prior to interviews. Interviews occurred via phone call or online video call (Zoom) and followed a schedule. Interview questions included: what worked about providing telehealth consultations; why patients chose the Telehealth, or an in-clinic consultation option; what health providers or patients did not like about Telehealth consults; and how could Telehealth consultations be improved for Māori. Questions were explored in terms of access, barriers, and quality healthcare treatment for Māori.
A Māori interviewer employed te reo (Māori language), tikanga (Māori protocols) and whanaungatanga (Māori customary engagement rituals) to facilitate the interview process. Interviews ranged from 15 to 60 minutes in duration, were audio recorded and transcribed verbatim by a Māori researcher. A Kaupapa Māori thematic analysis was carried out by experienced Kaupapa Māori researchers to ensure that known Māori world views and realities were foregrounded, and a non-deficit approach was taken.[[17]] Researchers read and re-read transcripts and held in-depth discussions to identify, understand and refine results into themes. Data was collated into common themes and presented to the wider research team for review. The final themes were a consensus decision. Illustrative quotes are reported verbatim.
This study was categorised as low-risk (ie did not require full approval) by the New Zealand Health and Disability Ethics Committee review process. Additional ethical review was then completed and granted by the New Zealand Ethics Committee (NZEC)[[18]] on 20 November 2020.
Results
Fourteen participants including five Māori health professionals, six Māori telehealth patients, and six Māori in-clinic patients agreed to take part in the study. Note that three participants were eligible for more than one category (eg health professional and Telehealth patient). The results were categorised into three main themes: 1) benefits; 2) challenges; and 3) suggested improvements.
Benefits–Rangatiratanga (weaving components that benefit all)
Key benefits of Telehealth were identified by all participants and included time and economic savings, enabling of tino rangatiratanga and improved safety.
Health professionals and patients noted that Telehealth consultations minimised time needed to travel, to wait and to be seen at the clinic, and to process prescriptions, which was particularly useful for people who were working long hours, had lengthy travel or had young children to mind.
It was very efficient, it saved me a whole lot of time, and all of that [Telehealth consultation] took like half an hour. (Telehealth patient_10)
For some patients this [Telehealth consultation] was great, this was easier, this was faster, this was better. (Health professional_4)
All patients described Telehealth consultations as cost-effective because they were cheaper than in-person visits and reduced time off work. For example, some patients use Telehealth consultations during their lunch break at work. In addition, patients noted that there were no transport costs.
You definitely save time and effort and it’s cheaper, so I usually pay $18.00 to go in and that’s an enrolled patient but it was $10 over the phone… it saved time, saved energy, saved petrol, saved money. (Telehealth patient_6)
I’d recommend the phone consultations. It’s simple so it gets all the waiting and all that sort of stuff… out of the way. I could see it being really beneficial. (Telehealth patient_14)
Patients and health professionals described virtual consultations as a means for exercising tino rangatiratanga. The ability to self-determine aspects of the appointment, in ways that met their needs and made them feel in-charge.
You could go online on the website and then book in your appointment, but you could also select who you wanted to see … It was all very self-driven, so I didn’t have to ring anyone. I like that because I hate ringing people … you just book it in, you can see when you’re available … when they’re available … then she just called my phone. (Telehealth patient_10)
The de-centralisation of health clinics (ie no longer requiring patients to physically attend appointments at health clinics) resulted in improved flexibility of health service delivery. Patients were able to access doctors on their own terms, as well as increasing access to services and Māori health professionals who are otherwise inaccessible through their usual GP practice and local regions.
We could live wherever we wanted but we could still actually get consults from people [Māori doctors] we want to. (Telehealth patient_10)
My Kōhanga māmā … they've got multiple kids … trying to get one to the doctors and worry about the others is always a mission … having online or phone consultations can help counter those access barriers. (In-clinic patient_6)
I've already been back to the doctors … five times … had to tell [my] story to four men [doctors] … then this woman rang back [during COVID] … she's the only … wāhine Māori doctor … in the area that I live in … I've never seen her … and I’ve been there for years … that was the point of difference … she was Māori, she was caring, there was aroha in her tone … it was the first time I think someone heard me and it was on the phone.” (Telehealth patient_11)
The provision of telehealth platforms enabled patients and their whānau to stay safe in their homes from COVID-19. In addition, patients and health professionals noted that Telehealth mediums at times enabled an increased level of privacy and confidentiality, a concern in smaller communities.
I just thought the [clinic] was the most unsafe space [for COVID-19 exposure]. (In-clinic patient_5)
In… a small community, they’re worried about… the word going around, so actually being able to offer that [Telehealth], where they don’t actually have to walk through the front door and go report to their cousins that are on reception. So being able to provide that [Telehealth] for that particular community. (Health professional_1)
Challenges–Tikanga Aukati (unfair practices)
Whilst multiple benefits of Telehealth consultations were identified, a number of challenges were also highlighted including access to the necessary resources (eg Telehealth software, internet capable devices and internet data) and unmet health needs (eg physical assessment) due to prioritisation of COVID-focussed care.
When the call came to deliver the majority of primary care consultations virtually, health providers scrambled to obtain the necessary equipment and training (eg Telehealth software, operational processes). Patients and whānau also had to adapt quickly, however; their support to access resources and information was limited.
The Kuia and Kaumātua (elders) that we were trying to screen [for health concerns during COVID-19 lockdown]. We literally phoned everybody… [but] some of them don’t even have mobile phones. (Health professional_2)
[We were having] a tutu [play] around with the internet [website of healthcare provider]… [so that we were prepared] if we needed to get in touch with somebody through that lockdown; because it [accessing healthcare online] was just something totally new to us. (Telehealth patient_8)
Health professionals reported that the health system did not provide funding for patients and whānau to access Telehealth. Insufficient provision of Telehealth system infrastructure meant that many patients were not yet familiar with using technology to access Telehealth. Further, health systems were not meeting the financial costs associated with whānau accessing telehealth, eg paying for IT devices and internet data.
We’re moving to a digital space; how do we cater for that? … If you go into a clinic there's usually a Samoan or Tongan nurse or someone that can translate at the clinic but … a whole lot of our people… they're not… computer literate or savvy. (Health professional_6)
I think we have to breakthrough on some of the digital technology stuff, so having access to devices and spaces and places where you can do [a Telehealth consultation], and the data requirements to be able to do it. (Health professional_4)
New communication and literacy barriers arose between whānau and health professionals when using Telehealth compared with face-to-face consultations. For example, participants often reported that doctor’s ‘terms’ were difficult to follow and understand without non-verbal communication. Accordingly, the need for both whānau and health professionals’ health literacy development in a Telehealth-specific context was evident.
Health literacy stuff … how we talk to patients about digital health … how we provide that information. Are we understandable to our patients? … Doing some work on ourselves … our community might benefit. (Health professional_4)
Particularly challenging communication and literacy barriers surfaced when health professionals asked questions about symptoms. For example, when health professionals asked whānau to assess basic health symptoms such as ‘temperature’, whānau often did not have a thermometer at home, and were not trained to ‘read their temperature’.
Health professional communication and interpretation of health needs via Telehealth at times seemed to require patients and whānau to have the ability to complete physical examinations, as articulated here:
For instance, if they say to you over the phone ‘have you got a fever, are you hot?’ Well yeah, I’m hot, but, like, is it because I’ve got a fever or because it’s a hot day? … Just sort of figuring out, would they be able to diagnose it just like that? Whether I’ve got a fever or not? (In-clinic patient_12)
At times, choosing between Telehealth and in-clinic options, whilst prioritising COVID-19 versus other health needs, was challenging for health professionals, patients and whānau. Despite needing in-clinic healthcare, some patients chose to stay home and self-administer medical procedures rather than prioritise their health needs over others during the COVID-19 pandemic. When patients did seek in-clinic consultations during lockdown, health professionals were focussed on COVID-19 testing, leaving other health needs unmet.
I just phoned up … I have an abscess growing up the back of my mouth. It’s quite swollen … What do I do? Do I pop it? Do I cut it? Do I cause I can’t come in there … so they gave me antibiotics … it did nothing for the pain, so I ended up popping it myself ... I just got a really big needle and … cracked it and squirted it all out. (Telehealth patient_9)
[During in-clinic consultation] there was no focus on my actual sickness. All he wanted to know was, do you have COVID and how far away can you stay from me? … All I wanted was my antibiotics … what about my body aches? He didn't, I remember, he didn't actually ask what my other symptoms are, all he asked was three COVID questions. (In-clinic patient_13)
Suggested improvements–Mana enhancing
Building on the identified benefits and challenges of Telehealth provision, and the immediacy of COVID-19, suggested improvements for long-term delivery were made.
Telehealth systems that were more user-friendly with language options were recommended.
I think having forms in different languages, or websites that talk, so you can just push a button and then someone talks to you saying in the different language you know ‘push here if you need a doctor’ … we could streamline it that way… or you can touch the screen, ‘press here for the receptionist’ or ‘for Samoan press here.’ (Health professional_6)
Some healthcare organisation Telehealth systems involved the of sharing whānau health information between and across health system organisations. This was seen as a key highlight of moving consultations online. Sharing of key information in real time across the health system inevitably removed barriers that were previously created by organisational healthcare silos.
One of the things that happened in our system is barriers fell away between different organisations, everybody would share anything that was needed… if you had some information, research … everybody consistently made that available across networks, different Primary Health Organisations were sharing. (Health professional_4)
Participants appreciated the ‘options’ to attend an in-clinic, online or phone call consultation and wanted to see these continued. In addition, health professional utilisation of cultural competencies remains essential in Telehealth settings.
Giving [the patient] the option to choose which one was better, and quite a few went for the video call. Just that kanohi ki te kanohi stuff. Even though some of them called it fake kanohi ki te kanohi, for some it was still powerful enough to be able to give the same mana they get from being in-person kanohi ki te kanohi. (Health professional_1)
Educating healthcare service staff around the communication and delivery of information digitally (ie understanding Māori patient health literacy, realities and experiences when accessing Telehealth, and learning how to assess patients online) would improve Telehealth services.
I think we should do better in some of our information health literacy stuff… health literacy in terms of how we talk to patients about digital health. (Health professional_4)
Health professionals and patients clearly noted that access to technology, devices, and knowledge around their use were critical components of a successful Telehealth system for whānau.
For me the important things were… ensuring that our patients had access to that … a lot of whānau we serve don’t actually have that sort of technology available to them… that’s why they’d come into the clinic because they couldn’t talk over the phone. (Health professional_1)
A sense of connection with their health providers was essential to fully engage and benefit from the Telehealth consultation and therefore patients recommended training in ‘building online rapport’ for providers.
It does take a bit of time to develop that trust because whānau aren't just going to say, ‘hey this is my problem, and this is what I need’, right. (Health professional_3)
It wasn’t easy, and she had to try and earn that trust from me over a telephone. (Telehealth patient_11)
Discussion
This article presents a qualitative scoping investigation of the experiences of Māori whānau and health professionals’ provision and use of Telehealth during the 2020 COVID-19 lockdown. Participants represented a range of experiences: use of Telehealth, opting for in-clinic consultation, and design and provision of Telehealth services. Given the barriers Māori whānau face when accessing primary healthcare, and the impacts of these barriers on increasing inequities, this Kaupapa Māori study explored how a culturally appropriate Telehealth system might mitigate access barriers for Māori whānau, and thereby reduce health inequities.
Māori participants in this study described multiple benefits to Telehealth consultations during the 2020 COVID-19 lockdown. Telehealth consultations were introduced in Aotearoa based on international pre-COVID-19 studies confirming their feasibility, safety, effectiveness and accessibility in general practice,[[19]] in adults with diabetes[[20,21]] and in mental health.[[22]] Some studies suggest that Telehealth clinics have the potential to keep important care pathways, particularly for cancer, moving during lockdowns.[[23]] Telehealth is therefore likely to be beneficial to Māori who experience higher rates of chronic conditions, cancer and mental illness.[[24]] Knowing that international research supports the use of Telehealth consultations in these key Māori health areas is important, but prior to this study, there was limited evidence of Māori experiences.
The patients and providers described ‘reduced cost’ as a reason for choosing Telehealth over face-to-face consultations, confirming previous research on the cost-benefits of Telehealth consultations.[[25]] Wider benefits identified in this study, such as savings on transport and improved waiting times have also been reported internationally.[[26]] In addition, having access to a wider range of Māori health professionals (without geographic barriers) aligns with whānau preferences for cultural concordance.[[27]] However, the participants also described hidden costs and barriers, particularly with regard to digital access (equipment and broadband availability). Such barriers have the potential to widen disparities, as demonstrated in studies with peoples living with social deprivation, limited digital access[[28,29]] and disabilities.[[30]]
Therefore, the introduction of Telehealth consultations requires a comprehensive approach that ensures equity in broadband coverage across New Zealand,[[31]] access to equipment similar to the way education providers have delivered devices to students[[10]] and culturally safe ‘Telehealth literacy’[[32]] for both providers and patients. Of considerable concern were descriptions of unmet need when providers prioritised COVID-19 in the consultation over other health issues. This may be true for both Telehealth and in-person consultations. Clear processes are required to ensure that Telehealth during COVID-19 lockdowns does not result in poorer care despite the convenience.
This Kaupapa Māori study investigated experiences of Māori within the Telehealth context during the 2020 COVID-19 lockdown. The findings indicate Telehealth is a viable long-term option that with additional resourcing can support Māori whānau access to healthcare. Telehealth removes practical barriers as well as providing reasonably safe access to health services when there is high COVID-19 risk in the community. Future provision of Telehealth requires robust investment in necessary resources, systems and capabilities for both patients and health providers.
Summary
Abstract
Aim
Māori experience barriers to accessing timely, quality healthcare. The March 2020 COVID-19 lockdown in New Zealand required provision of Telehealth consultation options in primary care. Telehealth consultations have the potential to improve access to healthcare for Māori, and thereby reduce health inequities. Conversely, Telehealth may present additional barriers that contribute to inequities overall. This scoping project investigated Māori experiences of Telehealth consultations during the March 2020 COVID-19 lockdown.
Method
Semi-structured key informant interviews were completed with five Māori health professionals, six Māori Telehealth patients, and six Māori in-clinic patients, about their healthcare consultation experiences during COVID-19 lockdown. Participants were asked about what worked, what did not work, and for suggestions to improve future Telehealth provision to Māori whānau.
Results
Key findings are presented in three overarching themes: benefits (safety, cost, time, options); challenges (health literacy, access to Information Technology (IT), supply and demand, limited physical assessment); and suggested improvements (systems fit for purpose, supporting IT and health literacy, Telehealth as a routine option, rapport building, and cross system efficiency and information sharing).
Conclusion
Telehealth is a viable long-term option that can support Māori whānau access to healthcare.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1) Robson B, Harris R. Hauora, Māori standards of health IV: A study of the years, 2000-2005. Wellington, N.Z.: Te Rōpū Rangahau Hauora a Eru Pōmare; 2007.
2) Ministry of Health. Tatau kahukura: Māori health chart book 2015 (3rd edition). Wellington: Ministry of Health;2015.
3) Waitangi Tribunal. Hauora: Report on Stage One of the Health Services and Outcomes Kaupapa Inquiry. WAI 2575. Waitangi Tribunal report 2019. Lower Hutt, New Zealand: Printlink;2019.
4) Blakely T, Ajwani S, Robson B, Tobias M, Bonne M. Decades of disparity: Widening ethnic mortality gaps from 1980 to 1999. NZ Med J. 2004;117(1191).
5) Curtis E, Jones R, Tipene-Leach D, et al. Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition. International Journal for Equity in Health. 2019;18(1):1-17.
6) Graham R, Masters-Awatere B. Experiences of Māori of Aotearoa New Zealand's public health system: a systematic review of two decades of published qualitative research. Australian and New Zealand Journal of Public Health. 2020;44(3):193-200.
7) Ministry of Health. Ministry of Health New Zealand Health Survey 2019/20. Explore indicators. 2020.
8) Lee R, North N. Barriers to Māori sole mothers' primary health care access. Journal of Primary Health Care. 2013;5(4):315-321.
9) Ministry of Health. Amenable mortality SLM data. Data to support system level measures. 2021; https://nsfl.health.govt.nz/dhb-planning-package/system-level-measures-framework/data-support-system-level-measures/amenable.
10) Gurney J, Fraser L, Ikihele A, Manderson J, Scott N, Robson B. Telehealth as a tool for equity: pros, cons and recommendations. The New Zealand Medical Journal (Online). 2021;134(1530):111-115.
11) Ministry of Health. Telehealth. 2017; https://www.health.govt.nz/our-work/digital-health/other-digital-health-initiatives/telehealth.
12) Gasteiger N, Anderson A, Day K. Rethinking engagement: Exploring women's technology use during the perinatal period through a Kaupapa Māori consistent approach. New Zealand College of Midwives Journal. 2019(55):20-26.
13) Pihama L. Kaupapa Māori Theory: Transforming Theory in Aotearoa. He Pukenga Kōrero. 2010;9(2):5-14.
14) Smith L. Decolonising Methodologies. Research and Indigenous Peoples. Dunedin: University of Otago Press; 1999.
15) Wikaire E. The past, present and future of traditional Indigenous healing: What was, is, and will be, rongoā Māori. Auckland: Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, The University of Auckland; 2020.
16) Smith L. Decolonizing methodologies: Research and Indigenous peoples. 2nd ed. Dunedin: Otago Univerity Press; 2012.
17) Wikaire E. Data speaks: Predictors of success in tertiary education health study for Māori and Pacific students. Auckland: Te Kupenga Hauora Māori, University of Auckland; 2015.
18) New Zealand Ethics Committee. Welcome. 2021; https://www.nzethics.com/.
19) Ebad R. Telemedicine: Current and future perspectives. IJCSI. 2013;10(6):242-249.
20) Quinn L, Olajide O, Green M, Sayed H, Ansar H. Patient and professional experiences with virtual antenatal clinics during the COVID-19 Pandemic in a UK tertiary obstetric hospital: questionnaire study. J Med Internet Res. 2021;23(8):e25549.
21) Armstrong N, Hearnshaw H, Powell J, Dale J. Stakeholder perspectives on the development of a virtual clinic for diabetes care: Qualitative study. J Med Internet Res. 2007;9(3):e23.
22) Berryhill B, Halli-Tierney A, Culmer N, et al. Videoconferencing psychological therapy and anxiety: A systematic review. Family practice. 2019;36(1):53-63.
23) Connor M, Winkler M, Miah S. COVID‐19 pandemic–is virtual urology clinic the answer to keeping the cancer pathway moving? BJU international. 2020;125(6):E3-E4.
24) Health Quality and Safety Commission New Zealand. He matapihi ki te kounga o ngā manaakitanga ā-hauora o Aotearoa 2019. A window on the quality of Aotearoa New Zealand's health care 2019. Wellington: Health Quality & Safety Commission;2019.
25) Jacklin P, Roberts J, Wallace P, et al. Virtual outreach: economic evaluation of joint teleconsultations for patients referred by their general practitioner for a specialist opinion. BMJ. 2003;327(7406):84.
26) Murphy R, Dennehy K, Costello M, et al. Virtual geriatric clinics and the COVID-19 catalyst: a rapid review. Age and ageing. 2020;49(6):907-914.
27) Wikaire E, Ratima M. Māori participation in the physiotherapy workforce. Pimatisiwin J Aboriginal Indigenous Commun Health. 2011;9:473-495.
28) Atherton H, Brant H, Ziebland S, et al. Alternatives to the face-to-face consultation in general practice: focused ethnographic case study. British Journal of General Practice. 2018;68(669):e293-e300.
29) Mold F, Hendy J, Lai Y-L, de Lusignan S. Electronic consultation in primary care between providers and patients: systematic review. JMIR Med Inform. 2019;7(4):e13042.
30) Brant H, Atherton H, Ziebland S, McKinstry B, Campbell J, Salisbury C. Using alternatives to face-to-face consultations: a survey of prevalence and attitudes in general practice. British Journal of General Practice. 2016;66(648):e460-e466.
31) Wilson N, Summers J, Grout L, Baker M. Bumper issue of COVID-19 pandemic studies of relevance to Aotearoa New Zealand. New Zealand Medical Journal (Online). 2021;134(1538):9-17.
32) Huuskes B, Scholes‐Robertson N, Guha C, et al. Kidney transplant recipient perspectives on telehealth during the COVID‐19 pandemic. Transplant International. 2021;34(8):1517-1529.
For the PDF of this article,
contact nzmj@nzma.org.nz
Reducing healthcare inequities for Māori using Telehealth during COVID-19 | OPEN ACCESS
View Article PDF
In Aotearoa New Zealand, Māori (the Indigenous peoples of New Zealand) experience significant ongoing health inequities compared to non-Māori[[1–3]] including higher mortality and morbidity rates across most health conditions.[[1,3]] Health inequities between Māori and non-Māori are due to differential access to the determinants of wellbeing including timely healthcare and differences in the quality of healthcare.[[3,4]] Despite the overwhelming need for quality healthcare to address these inequities, Māori access to culturally safe health services is limited.[[5]]
Māori whānau have previously described healthcare as inaccessible due to financial cost, transportation issues and other obstacles such as finding childcare. Travel barriers for rural patients to attend GP appointments are significant, and for working families there is difficulty in organising appointments around clinic hours, with families required to negotiate employer expectations and leave entitlements.[[6]] Additionally, the 2020 New Zealand Health Survey revealed significant differences by ethnicity, and these were even more stark for Māori wāhine (females)[[7]] who report high cost, no transport, prioritising childcare and experiencing discrimination, all as factors affecting access options and health outcomes.[[8]] In contrast, healthcare was more accessible when it included practical whānau support in the form of time, money and transport to attend appointments.[[6]] These barriers contribute to higher amenable morbidity and mortality rates for Māori, which in 2018 were 192.2 per 100,000 peoples compared to 77.7 per 100,000 for non-Māori non-Pacific peoples.[[9]]
The March 2020 COVID-19 Level 4 lockdown significantly influenced the patient–health professional interaction interface, requiring Telehealth (phone and online video) consultations almost overnight.[[10]] Telehealth utilises “information and communication technologies to deliver health care when patients and care providers are not in the same physical location”.[[11]] Provision of Telehealth GP clinics therefore has the potential to reduce, if not eliminate, the practical (eg travel) barriers for whānau.[[6]] Previous qualitative research with young, pregnant Māori women demonstrated how Telehealth-based antenatal care services promoted engagement and reduced access barriers.[[12]] Importantly, whānau also noted the positive influence of health professionals who take time to build rapport and develop continuity of care with patients,[[6]] a factor that may be impacted by Telehealth delivery. Hence, robust research is required that unpacks both the positive and mitigating potential of Telehealth delivery to Māori whānau.
This research aimed to investigate and inform the use of Telehealth with Māori. We sought to understand the experiences of Telehealth (phone and online video) versus in-clinic healthcare in primary care settings during COVID-19 lockdown in March 2020, from both patients and Māori provider perspectives.
Methods
A Kaupapa Māori research methodology was used.[[13,14]] This methodology operates using a Māori world view and takes on Māori ways of knowing, being and doing.[[15]] Māori aspirations for reducing inequities and attaining improved wellbeing are prioritised. The research is led and carried out by Māori health researchers and supports the ongoing professional development of the Māori health researcher workforce. A critical structural analysis was taken that contextualises data interpretations within historical and current influences on Māori health inequities, and ensures a non-victim blame, non-deficit analysis. Māori realities, in particular socioeconomic positions, are acknowledged.[[13–16]]
Fourteen qualitative semi-structured interviews occurred with participants who self-identified as Māori, lived in Auckland or Northland, and who fit one or more of the research criteria. The criteria included: 1) Māori health professionals 2) Māori patients/whānau who experienced at least one GP consultation using Telehealth during the COVID-19 lockdown period; and 3) Māori patients who opted for an in-clinic GP consultation (over Telehealth) during the COVID-19 lockdown period.
Purposive sampling was used to identify potential participants through the National Hauora Coalition Primary Health Organisation (PHO) and the research team’s networks—potential participants were then invited to participate. Information sheets were provided, and participants completed consent forms prior to interviews. Interviews occurred via phone call or online video call (Zoom) and followed a schedule. Interview questions included: what worked about providing telehealth consultations; why patients chose the Telehealth, or an in-clinic consultation option; what health providers or patients did not like about Telehealth consults; and how could Telehealth consultations be improved for Māori. Questions were explored in terms of access, barriers, and quality healthcare treatment for Māori.
A Māori interviewer employed te reo (Māori language), tikanga (Māori protocols) and whanaungatanga (Māori customary engagement rituals) to facilitate the interview process. Interviews ranged from 15 to 60 minutes in duration, were audio recorded and transcribed verbatim by a Māori researcher. A Kaupapa Māori thematic analysis was carried out by experienced Kaupapa Māori researchers to ensure that known Māori world views and realities were foregrounded, and a non-deficit approach was taken.[[17]] Researchers read and re-read transcripts and held in-depth discussions to identify, understand and refine results into themes. Data was collated into common themes and presented to the wider research team for review. The final themes were a consensus decision. Illustrative quotes are reported verbatim.
This study was categorised as low-risk (ie did not require full approval) by the New Zealand Health and Disability Ethics Committee review process. Additional ethical review was then completed and granted by the New Zealand Ethics Committee (NZEC)[[18]] on 20 November 2020.
Results
Fourteen participants including five Māori health professionals, six Māori telehealth patients, and six Māori in-clinic patients agreed to take part in the study. Note that three participants were eligible for more than one category (eg health professional and Telehealth patient). The results were categorised into three main themes: 1) benefits; 2) challenges; and 3) suggested improvements.
Benefits–Rangatiratanga (weaving components that benefit all)
Key benefits of Telehealth were identified by all participants and included time and economic savings, enabling of tino rangatiratanga and improved safety.
Health professionals and patients noted that Telehealth consultations minimised time needed to travel, to wait and to be seen at the clinic, and to process prescriptions, which was particularly useful for people who were working long hours, had lengthy travel or had young children to mind.
It was very efficient, it saved me a whole lot of time, and all of that [Telehealth consultation] took like half an hour. (Telehealth patient_10)
For some patients this [Telehealth consultation] was great, this was easier, this was faster, this was better. (Health professional_4)
All patients described Telehealth consultations as cost-effective because they were cheaper than in-person visits and reduced time off work. For example, some patients use Telehealth consultations during their lunch break at work. In addition, patients noted that there were no transport costs.
You definitely save time and effort and it’s cheaper, so I usually pay $18.00 to go in and that’s an enrolled patient but it was $10 over the phone… it saved time, saved energy, saved petrol, saved money. (Telehealth patient_6)
I’d recommend the phone consultations. It’s simple so it gets all the waiting and all that sort of stuff… out of the way. I could see it being really beneficial. (Telehealth patient_14)
Patients and health professionals described virtual consultations as a means for exercising tino rangatiratanga. The ability to self-determine aspects of the appointment, in ways that met their needs and made them feel in-charge.
You could go online on the website and then book in your appointment, but you could also select who you wanted to see … It was all very self-driven, so I didn’t have to ring anyone. I like that because I hate ringing people … you just book it in, you can see when you’re available … when they’re available … then she just called my phone. (Telehealth patient_10)
The de-centralisation of health clinics (ie no longer requiring patients to physically attend appointments at health clinics) resulted in improved flexibility of health service delivery. Patients were able to access doctors on their own terms, as well as increasing access to services and Māori health professionals who are otherwise inaccessible through their usual GP practice and local regions.
We could live wherever we wanted but we could still actually get consults from people [Māori doctors] we want to. (Telehealth patient_10)
My Kōhanga māmā … they've got multiple kids … trying to get one to the doctors and worry about the others is always a mission … having online or phone consultations can help counter those access barriers. (In-clinic patient_6)
I've already been back to the doctors … five times … had to tell [my] story to four men [doctors] … then this woman rang back [during COVID] … she's the only … wāhine Māori doctor … in the area that I live in … I've never seen her … and I’ve been there for years … that was the point of difference … she was Māori, she was caring, there was aroha in her tone … it was the first time I think someone heard me and it was on the phone.” (Telehealth patient_11)
The provision of telehealth platforms enabled patients and their whānau to stay safe in their homes from COVID-19. In addition, patients and health professionals noted that Telehealth mediums at times enabled an increased level of privacy and confidentiality, a concern in smaller communities.
I just thought the [clinic] was the most unsafe space [for COVID-19 exposure]. (In-clinic patient_5)
In… a small community, they’re worried about… the word going around, so actually being able to offer that [Telehealth], where they don’t actually have to walk through the front door and go report to their cousins that are on reception. So being able to provide that [Telehealth] for that particular community. (Health professional_1)
Challenges–Tikanga Aukati (unfair practices)
Whilst multiple benefits of Telehealth consultations were identified, a number of challenges were also highlighted including access to the necessary resources (eg Telehealth software, internet capable devices and internet data) and unmet health needs (eg physical assessment) due to prioritisation of COVID-focussed care.
When the call came to deliver the majority of primary care consultations virtually, health providers scrambled to obtain the necessary equipment and training (eg Telehealth software, operational processes). Patients and whānau also had to adapt quickly, however; their support to access resources and information was limited.
The Kuia and Kaumātua (elders) that we were trying to screen [for health concerns during COVID-19 lockdown]. We literally phoned everybody… [but] some of them don’t even have mobile phones. (Health professional_2)
[We were having] a tutu [play] around with the internet [website of healthcare provider]… [so that we were prepared] if we needed to get in touch with somebody through that lockdown; because it [accessing healthcare online] was just something totally new to us. (Telehealth patient_8)
Health professionals reported that the health system did not provide funding for patients and whānau to access Telehealth. Insufficient provision of Telehealth system infrastructure meant that many patients were not yet familiar with using technology to access Telehealth. Further, health systems were not meeting the financial costs associated with whānau accessing telehealth, eg paying for IT devices and internet data.
We’re moving to a digital space; how do we cater for that? … If you go into a clinic there's usually a Samoan or Tongan nurse or someone that can translate at the clinic but … a whole lot of our people… they're not… computer literate or savvy. (Health professional_6)
I think we have to breakthrough on some of the digital technology stuff, so having access to devices and spaces and places where you can do [a Telehealth consultation], and the data requirements to be able to do it. (Health professional_4)
New communication and literacy barriers arose between whānau and health professionals when using Telehealth compared with face-to-face consultations. For example, participants often reported that doctor’s ‘terms’ were difficult to follow and understand without non-verbal communication. Accordingly, the need for both whānau and health professionals’ health literacy development in a Telehealth-specific context was evident.
Health literacy stuff … how we talk to patients about digital health … how we provide that information. Are we understandable to our patients? … Doing some work on ourselves … our community might benefit. (Health professional_4)
Particularly challenging communication and literacy barriers surfaced when health professionals asked questions about symptoms. For example, when health professionals asked whānau to assess basic health symptoms such as ‘temperature’, whānau often did not have a thermometer at home, and were not trained to ‘read their temperature’.
Health professional communication and interpretation of health needs via Telehealth at times seemed to require patients and whānau to have the ability to complete physical examinations, as articulated here:
For instance, if they say to you over the phone ‘have you got a fever, are you hot?’ Well yeah, I’m hot, but, like, is it because I’ve got a fever or because it’s a hot day? … Just sort of figuring out, would they be able to diagnose it just like that? Whether I’ve got a fever or not? (In-clinic patient_12)
At times, choosing between Telehealth and in-clinic options, whilst prioritising COVID-19 versus other health needs, was challenging for health professionals, patients and whānau. Despite needing in-clinic healthcare, some patients chose to stay home and self-administer medical procedures rather than prioritise their health needs over others during the COVID-19 pandemic. When patients did seek in-clinic consultations during lockdown, health professionals were focussed on COVID-19 testing, leaving other health needs unmet.
I just phoned up … I have an abscess growing up the back of my mouth. It’s quite swollen … What do I do? Do I pop it? Do I cut it? Do I cause I can’t come in there … so they gave me antibiotics … it did nothing for the pain, so I ended up popping it myself ... I just got a really big needle and … cracked it and squirted it all out. (Telehealth patient_9)
[During in-clinic consultation] there was no focus on my actual sickness. All he wanted to know was, do you have COVID and how far away can you stay from me? … All I wanted was my antibiotics … what about my body aches? He didn't, I remember, he didn't actually ask what my other symptoms are, all he asked was three COVID questions. (In-clinic patient_13)
Suggested improvements–Mana enhancing
Building on the identified benefits and challenges of Telehealth provision, and the immediacy of COVID-19, suggested improvements for long-term delivery were made.
Telehealth systems that were more user-friendly with language options were recommended.
I think having forms in different languages, or websites that talk, so you can just push a button and then someone talks to you saying in the different language you know ‘push here if you need a doctor’ … we could streamline it that way… or you can touch the screen, ‘press here for the receptionist’ or ‘for Samoan press here.’ (Health professional_6)
Some healthcare organisation Telehealth systems involved the of sharing whānau health information between and across health system organisations. This was seen as a key highlight of moving consultations online. Sharing of key information in real time across the health system inevitably removed barriers that were previously created by organisational healthcare silos.
One of the things that happened in our system is barriers fell away between different organisations, everybody would share anything that was needed… if you had some information, research … everybody consistently made that available across networks, different Primary Health Organisations were sharing. (Health professional_4)
Participants appreciated the ‘options’ to attend an in-clinic, online or phone call consultation and wanted to see these continued. In addition, health professional utilisation of cultural competencies remains essential in Telehealth settings.
Giving [the patient] the option to choose which one was better, and quite a few went for the video call. Just that kanohi ki te kanohi stuff. Even though some of them called it fake kanohi ki te kanohi, for some it was still powerful enough to be able to give the same mana they get from being in-person kanohi ki te kanohi. (Health professional_1)
Educating healthcare service staff around the communication and delivery of information digitally (ie understanding Māori patient health literacy, realities and experiences when accessing Telehealth, and learning how to assess patients online) would improve Telehealth services.
I think we should do better in some of our information health literacy stuff… health literacy in terms of how we talk to patients about digital health. (Health professional_4)
Health professionals and patients clearly noted that access to technology, devices, and knowledge around their use were critical components of a successful Telehealth system for whānau.
For me the important things were… ensuring that our patients had access to that … a lot of whānau we serve don’t actually have that sort of technology available to them… that’s why they’d come into the clinic because they couldn’t talk over the phone. (Health professional_1)
A sense of connection with their health providers was essential to fully engage and benefit from the Telehealth consultation and therefore patients recommended training in ‘building online rapport’ for providers.
It does take a bit of time to develop that trust because whānau aren't just going to say, ‘hey this is my problem, and this is what I need’, right. (Health professional_3)
It wasn’t easy, and she had to try and earn that trust from me over a telephone. (Telehealth patient_11)
Discussion
This article presents a qualitative scoping investigation of the experiences of Māori whānau and health professionals’ provision and use of Telehealth during the 2020 COVID-19 lockdown. Participants represented a range of experiences: use of Telehealth, opting for in-clinic consultation, and design and provision of Telehealth services. Given the barriers Māori whānau face when accessing primary healthcare, and the impacts of these barriers on increasing inequities, this Kaupapa Māori study explored how a culturally appropriate Telehealth system might mitigate access barriers for Māori whānau, and thereby reduce health inequities.
Māori participants in this study described multiple benefits to Telehealth consultations during the 2020 COVID-19 lockdown. Telehealth consultations were introduced in Aotearoa based on international pre-COVID-19 studies confirming their feasibility, safety, effectiveness and accessibility in general practice,[[19]] in adults with diabetes[[20,21]] and in mental health.[[22]] Some studies suggest that Telehealth clinics have the potential to keep important care pathways, particularly for cancer, moving during lockdowns.[[23]] Telehealth is therefore likely to be beneficial to Māori who experience higher rates of chronic conditions, cancer and mental illness.[[24]] Knowing that international research supports the use of Telehealth consultations in these key Māori health areas is important, but prior to this study, there was limited evidence of Māori experiences.
The patients and providers described ‘reduced cost’ as a reason for choosing Telehealth over face-to-face consultations, confirming previous research on the cost-benefits of Telehealth consultations.[[25]] Wider benefits identified in this study, such as savings on transport and improved waiting times have also been reported internationally.[[26]] In addition, having access to a wider range of Māori health professionals (without geographic barriers) aligns with whānau preferences for cultural concordance.[[27]] However, the participants also described hidden costs and barriers, particularly with regard to digital access (equipment and broadband availability). Such barriers have the potential to widen disparities, as demonstrated in studies with peoples living with social deprivation, limited digital access[[28,29]] and disabilities.[[30]]
Therefore, the introduction of Telehealth consultations requires a comprehensive approach that ensures equity in broadband coverage across New Zealand,[[31]] access to equipment similar to the way education providers have delivered devices to students[[10]] and culturally safe ‘Telehealth literacy’[[32]] for both providers and patients. Of considerable concern were descriptions of unmet need when providers prioritised COVID-19 in the consultation over other health issues. This may be true for both Telehealth and in-person consultations. Clear processes are required to ensure that Telehealth during COVID-19 lockdowns does not result in poorer care despite the convenience.
This Kaupapa Māori study investigated experiences of Māori within the Telehealth context during the 2020 COVID-19 lockdown. The findings indicate Telehealth is a viable long-term option that with additional resourcing can support Māori whānau access to healthcare. Telehealth removes practical barriers as well as providing reasonably safe access to health services when there is high COVID-19 risk in the community. Future provision of Telehealth requires robust investment in necessary resources, systems and capabilities for both patients and health providers.
Summary
Abstract
Aim
Māori experience barriers to accessing timely, quality healthcare. The March 2020 COVID-19 lockdown in New Zealand required provision of Telehealth consultation options in primary care. Telehealth consultations have the potential to improve access to healthcare for Māori, and thereby reduce health inequities. Conversely, Telehealth may present additional barriers that contribute to inequities overall. This scoping project investigated Māori experiences of Telehealth consultations during the March 2020 COVID-19 lockdown.
Method
Semi-structured key informant interviews were completed with five Māori health professionals, six Māori Telehealth patients, and six Māori in-clinic patients, about their healthcare consultation experiences during COVID-19 lockdown. Participants were asked about what worked, what did not work, and for suggestions to improve future Telehealth provision to Māori whānau.
Results
Key findings are presented in three overarching themes: benefits (safety, cost, time, options); challenges (health literacy, access to Information Technology (IT), supply and demand, limited physical assessment); and suggested improvements (systems fit for purpose, supporting IT and health literacy, Telehealth as a routine option, rapport building, and cross system efficiency and information sharing).
Conclusion
Telehealth is a viable long-term option that can support Māori whānau access to healthcare.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1) Robson B, Harris R. Hauora, Māori standards of health IV: A study of the years, 2000-2005. Wellington, N.Z.: Te Rōpū Rangahau Hauora a Eru Pōmare; 2007.
2) Ministry of Health. Tatau kahukura: Māori health chart book 2015 (3rd edition). Wellington: Ministry of Health;2015.
3) Waitangi Tribunal. Hauora: Report on Stage One of the Health Services and Outcomes Kaupapa Inquiry. WAI 2575. Waitangi Tribunal report 2019. Lower Hutt, New Zealand: Printlink;2019.
4) Blakely T, Ajwani S, Robson B, Tobias M, Bonne M. Decades of disparity: Widening ethnic mortality gaps from 1980 to 1999. NZ Med J. 2004;117(1191).
5) Curtis E, Jones R, Tipene-Leach D, et al. Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition. International Journal for Equity in Health. 2019;18(1):1-17.
6) Graham R, Masters-Awatere B. Experiences of Māori of Aotearoa New Zealand's public health system: a systematic review of two decades of published qualitative research. Australian and New Zealand Journal of Public Health. 2020;44(3):193-200.
7) Ministry of Health. Ministry of Health New Zealand Health Survey 2019/20. Explore indicators. 2020.
8) Lee R, North N. Barriers to Māori sole mothers' primary health care access. Journal of Primary Health Care. 2013;5(4):315-321.
9) Ministry of Health. Amenable mortality SLM data. Data to support system level measures. 2021; https://nsfl.health.govt.nz/dhb-planning-package/system-level-measures-framework/data-support-system-level-measures/amenable.
10) Gurney J, Fraser L, Ikihele A, Manderson J, Scott N, Robson B. Telehealth as a tool for equity: pros, cons and recommendations. The New Zealand Medical Journal (Online). 2021;134(1530):111-115.
11) Ministry of Health. Telehealth. 2017; https://www.health.govt.nz/our-work/digital-health/other-digital-health-initiatives/telehealth.
12) Gasteiger N, Anderson A, Day K. Rethinking engagement: Exploring women's technology use during the perinatal period through a Kaupapa Māori consistent approach. New Zealand College of Midwives Journal. 2019(55):20-26.
13) Pihama L. Kaupapa Māori Theory: Transforming Theory in Aotearoa. He Pukenga Kōrero. 2010;9(2):5-14.
14) Smith L. Decolonising Methodologies. Research and Indigenous Peoples. Dunedin: University of Otago Press; 1999.
15) Wikaire E. The past, present and future of traditional Indigenous healing: What was, is, and will be, rongoā Māori. Auckland: Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, The University of Auckland; 2020.
16) Smith L. Decolonizing methodologies: Research and Indigenous peoples. 2nd ed. Dunedin: Otago Univerity Press; 2012.
17) Wikaire E. Data speaks: Predictors of success in tertiary education health study for Māori and Pacific students. Auckland: Te Kupenga Hauora Māori, University of Auckland; 2015.
18) New Zealand Ethics Committee. Welcome. 2021; https://www.nzethics.com/.
19) Ebad R. Telemedicine: Current and future perspectives. IJCSI. 2013;10(6):242-249.
20) Quinn L, Olajide O, Green M, Sayed H, Ansar H. Patient and professional experiences with virtual antenatal clinics during the COVID-19 Pandemic in a UK tertiary obstetric hospital: questionnaire study. J Med Internet Res. 2021;23(8):e25549.
21) Armstrong N, Hearnshaw H, Powell J, Dale J. Stakeholder perspectives on the development of a virtual clinic for diabetes care: Qualitative study. J Med Internet Res. 2007;9(3):e23.
22) Berryhill B, Halli-Tierney A, Culmer N, et al. Videoconferencing psychological therapy and anxiety: A systematic review. Family practice. 2019;36(1):53-63.
23) Connor M, Winkler M, Miah S. COVID‐19 pandemic–is virtual urology clinic the answer to keeping the cancer pathway moving? BJU international. 2020;125(6):E3-E4.
24) Health Quality and Safety Commission New Zealand. He matapihi ki te kounga o ngā manaakitanga ā-hauora o Aotearoa 2019. A window on the quality of Aotearoa New Zealand's health care 2019. Wellington: Health Quality & Safety Commission;2019.
25) Jacklin P, Roberts J, Wallace P, et al. Virtual outreach: economic evaluation of joint teleconsultations for patients referred by their general practitioner for a specialist opinion. BMJ. 2003;327(7406):84.
26) Murphy R, Dennehy K, Costello M, et al. Virtual geriatric clinics and the COVID-19 catalyst: a rapid review. Age and ageing. 2020;49(6):907-914.
27) Wikaire E, Ratima M. Māori participation in the physiotherapy workforce. Pimatisiwin J Aboriginal Indigenous Commun Health. 2011;9:473-495.
28) Atherton H, Brant H, Ziebland S, et al. Alternatives to the face-to-face consultation in general practice: focused ethnographic case study. British Journal of General Practice. 2018;68(669):e293-e300.
29) Mold F, Hendy J, Lai Y-L, de Lusignan S. Electronic consultation in primary care between providers and patients: systematic review. JMIR Med Inform. 2019;7(4):e13042.
30) Brant H, Atherton H, Ziebland S, McKinstry B, Campbell J, Salisbury C. Using alternatives to face-to-face consultations: a survey of prevalence and attitudes in general practice. British Journal of General Practice. 2016;66(648):e460-e466.
31) Wilson N, Summers J, Grout L, Baker M. Bumper issue of COVID-19 pandemic studies of relevance to Aotearoa New Zealand. New Zealand Medical Journal (Online). 2021;134(1538):9-17.
32) Huuskes B, Scholes‐Robertson N, Guha C, et al. Kidney transplant recipient perspectives on telehealth during the COVID‐19 pandemic. Transplant International. 2021;34(8):1517-1529.
Contact diana@nzma.org.nz
for the PDF of this article
Reducing healthcare inequities for Māori using Telehealth during COVID-19 | OPEN ACCESS
Health inequities between Māori and non-Māori are due to differential access to the determinants of wellbeing including timely healthcare and differences in the quality of healthcare.
Subscriber Content
The full contents of this pages only available to subscribers.
Login, subscribe or email nzmj@nzma.org.nz to purchase this article.
