View Article PDF

Choosing Wisely is an international health quality improvement campaign that originated in 2012 in the United States. Its aims are to improve clinical outcomes by reducing low-value and inappropriate clinical interventions and to promote well-informed conversations about treatment options between patients and health professionals to improve decision-making.[[1]] Choosing Wisely was launched in New Zealand by the Council of Medical Colleges (CMC) in 2016. Initially, colleges and specialty societies reviewed a raft of standard medical practices and, by the end of the year, had issued a list of 50 recommendations around low-value tests, treatments or procedures.[[2]] The other strategy, promoting shared decision-making, is central to reducing unnecessary interventions and is a significant marker of quality practice in its own right.[[3]]

In 2019, determined not to exacerbate inequity across the range of health outcomes[[4,5,6]] for an already-underserved Māori population,[[7]] the CMC sought a collaborative relationship with the Māori Medical Practitioners Association (Te ORA). Choosing Wisely New Zealand primarily intended to contribute to shared decision-making between healthcare practitioners and Māori health consumers. The US-initiated Choosing Wisely campaign had never deployed an Indigenous lens to look at its programme.

Consequently, a Te ORA research team was commissioned to scope the perspectives of Māori health consumers and Māori health practitioners around the Choosing Wisely NZ campaign and its messages. Te ORA also wanted to examine the experience of (shared) decision-making between Māori and their medical practitioners and make recommendations to better inform an equity-focused Choosing Wisely campaign in Aotearoa New Zealand. This research produced the report[[8]] from which this paper is derived.

Methods

This qualitative research seeks to be transformative in the identification of structural issues within Choosing Wisely NZ that are inconsistent with the promotion of equity for Māori. We deployed a Kaupapa Māori Research methodology—that is, one conducted by, with and for Māori that centres the values and aspirations of Māori whānau, hapū and iwi.[[9]] The study was initiated and led by Māori researchers (DTL and AA) and guided by a small reference group of two Māori health practitioners and three Māori consumers, who provided advice and feedback throughout the study’s design, implementation and analysis. Ethics approval was obtained from the New Zealand Ethics Committee, Te Rōpu Rapu i te Tika, on 15 October 2019 (ref 2019_46).

Māori healthcare consumers and Māori health practitioners were purposively recruited for this small qualitative study through community and professional networks. All 17 consumers and practitioners who were approached agreed to participate, although two pulled out. Fifteen participants (eight consumers and seven practitioners) were subsequently interviewed between November 2019 and February 2020. Participants were predominantly based in the North Island and urban areas. The consumers were from across the age range (20s–70s), and the health practitioners were doctors, nurses, midwives, pharmacists or Māori health provider managers. Interviews were conducted according to participants’ preferences: one by telephone, one by Zoom and the majority in person at locations chosen by the participants. Participants gave written consent to participate and were assured of anonymity in any written or oral reporting.

The interview schedule was semi-structured. The Choosing Wisely campaign was explained using the Choosing Wisely resource Communicating with your health professional: patients and consumers (available from https://choosingwisely.org.nz/patients-consumers/), which illustrates how health consumers might better participate in decision-making by asking questions of the practitioner around the need for, and the risks of, a test, treatment or procedure and whether other options, including doing nothing, are viable. On this basis, and after and further discussion, participants were asked to share perspectives on Choosing Wisely, such as its principles, aims and potential value for Māori, and to critique the usefulness of the Communicating with your health professional resource for use with Māori consumers. Participants were then asked about their own experiences of shared decision-making in healthcare settings and for recommendations to improve what they had experienced.

Each interview took between 25 and 90 minutes and, with the participant’s consent, was audio-recorded and transcribed. The data were analysed thematically, which entailed reading the transcripts closely, coding the data inductively and then creating, refining and finalising themes of participant talk.[[10,11]] All the coding and most of the thematic analysis was undertaken by AA. DTL and DS reviewed early themes and provided input into reorganisation and development of the final themes.

As well as being reviewed by the reference group, a summary of research findings and draft report was produced and sent to participants, who were encouraged to provide feedback (either in person, by telephone or by email) before the a formal report[[8]] was finalised. Input on the preparation of findings and the discussion for this paper was sought from SA, an experienced qualitative researcher.

Results

The results are presented in two sections. The first, “Feedback on the Choosing Wisely campaign,” includes three themes: the importance of Māori governance; the need to be careful with messaging; resources should be engaging for Māori. The second section, “Shared decision-making between Māori and their medical practitioner,” is presented in four domains[[12]]: consumer, practitioner, organisation and health system. Each domain has 2–3 themes (Table 1).

Feedback on Choosing Wisely

The importance of Māori governance

All practitioner participants and one consumer raised concerns that Choosing Wisely had originated in the United States and that it had not been adapted well for local circumstances. Participants said that, due to a lack of engagement with Māori communities or Māori health professional groups until three years after its launch, the campaign lacked any reflection of Māori knowledge systems, practices and customs.

The recommendations that emerged included that the campaign should move to involve Māori in key governance and decision-making positions and incorporate a “Māori lens” across all activities. The conversation needed to empower shared decision-making could then include a practitioner-led focus on holistic models of health and wellbeing and incorporate rongoā (Māori medicines) and karakia (prayers/incantations) as reasonable treatment options.

The need to be careful with messaging

Both practitioners and consumers were critical of the campaign and its subsequent messaging that focused on the reduction of tests, treatments and costs associated to the health system when Māori were already under-served by that health system. Better messaging would be around the deployment of evidence-based medicine to provide equitable care, rather than any “cutting back” of care.

“I think that the explicit focus on over-treatment and over-utilisation of resources can overshadow the other important aspects that make up good quality care for any person… So how about shifting it towards being about the right thing, at the right time, and the right way, for the right person?” –  Health practitioner 5

After reading Communicating with your health professional, some participants felt that the campaign placed the onus for change on consumers rather than health professionals and that, although a focus on consumer autonomy in decision-making was important, there needed to be more emphasis on the practitioner creating welcoming environments and taking responsibility for facilitating shared decision-making and providing appropriate care.

“I hate going to the doctors. I would never ask any of those other things because I would just assume that the doctor is right… I don’t think the onus should be on the patient to ask all these things, I think the doctor should definitely be telling you all these things.” – Consumer 1

Resources should be engaging for Māori

Feedback on Communicating with your health professional was mixed. Both groups considered some of the language in the resource to be too complex, confusing or wordy.

“If I were to pick this up it would just be hard for me to be interested in reading it… You gotta make sure you can relate to it, be informative.” – Consumer 7

The resource advises consumers “to be honest” about their health issues, which some felt was insinuating they might be dishonest. In addition, asking consumers to make a longer appointment if their health issues are complex assumed that people understood whether their health issues are in fact complex. In addition, participants thought longer appointments would be unfeasible for most because of cost.

Both groups recommended that resources needed to be simple and realistic, to cater to different levels of health literacy, and both socially and culturally engaging for Māori (ie, incorporating the target audience into the design of the resource).

Shared decision-making between Māori and their medical practitioner

Health consumer

Trust and autonomy

Trust and autonomy were identified as key to shared decision-making, and this included knowing one’s rights to question, to not feel coerced, to be informed, to have clear explanations and to be treated as an equal. On the other hand, it was noted that a lack of trust in health services creates anxiety, which in turn discourages participation and communication. Participants emphasised that health practitioners are responsible for ensuring whānau are supported to make positive health decisions and for promoting health literacy in strengths-based ways. A consumer participant talked about the sense of whakamā (shyness/reticence) that some Māori feel in health settings, for fear of coming across as unknowledgeable. Likewise, a health practitioner emphasised the need for whānau to be guided to engage in shared decision-making.

“From the patient’s perspective, from the whānau perspective, they’ve always been taught that they’re passive. And then they’re encouraged to be another way, which is great, to take control. But you have to give them some tools so you don’t set them up to fail.” – Health practitioner 7

Appropriate shared decision-making resources

Appropriate shared decision-making resources were described as culturally appropriate and friendly. They would include text and graphics or visuals that are relevant and engaging for Māori. Both practitioners and consumers frequently discussed the lack of access to resources for consumers as a barrier to shared decision-making. This is compounded by barriers to accessing healthcare in the first place because of cost, lack of transport and childcare, and the negative impact of trauma and life stresses on health-seeking behaviour.

“Because of the emotional overload in people’s lives due to housing problems, stress, domestic violence, past history of trauma... prioritising health issues [is] very difficult.” – Health practitioner 5

Importance of advocacy and support

Good advocacy and support within healthcare settings, such as from whānau members, representatives, nurses and community support workers such as Whānau Ora navigators, were also considered important for shared decision-making. The benefits included having another person to contribute and interpret information and to ensure that rights and wishes were met. As one health provider stated, “even just an extra face in the room makes a difference” (Health practitioner 7). Similarly, a consumer reflected on the importance of whānau support.

“[To] have someone to advocate for you when you aren’t necessarily in that right frame of mind to ask those questions, when you’re just vulnerable… I had my Mum with me and so she was asking a lot of these questions.” – Consumer 3

Health provider

Competence and communication

Clinical competence and efficacious communication were described by both groups as critical for shared decision-making. Consumer participants reported feeling able to make good decisions when health providers were thorough and informative. This included going through different scenarios to demonstrate their knowledge of health issues and treatment options. Health provider participants emphasised the importance of demonstrating competent judgement and providing opportunities for shared decision-making with all consumers regardless of whether their conditions were acute or chronic.

Cultural responsiveness

Cultural safety and cultural competency, which develop when trusting relationships are established and nurtured, were also identified as crucial. Being non-judgemental, genuine, supportive and understanding of context sat alongside acknowledging the validity of the Māori world and the importance of whanaungatanga (connecting/relationships) and holistic models of health. A consumer participant described this as creating a comfortable and safe environment. A health practitioner emphasised the importance of being a role model.

“As a health professional you’re taught to not show too much of yourself. But what we’re talking about is cultural safety, and realising how you can impact on people… For Māori it’s really important—engaging and encouraging them to be part of the planning and decision-making… You have to establish and maintain trust for it to be effective… Health professionals sometimes don’t realise how much they can be a role model by being a nice, caring person.” – Health practitioner 7

Health organisation

Model of primary care

The pervasive model of primary care that results in short appointment times and workforce shortages that disrupt continuity of care were considered barriers to shared decision-making by both participant groups. Consumers and health practitioners frequently discussed feeling rushed to get through consultations due to short appointment times, leaving needs unmet.

“There have been times I’ve gone to the doctor and they’ve just kind of skipped over a whole bunch of detail… but I felt out of line to question, I felt a bit rushed…” – Consumer 8

Detrimental impact of high practitioner turnover and burnout

High rates of practitioner turnover and burnout, and the subsequent reliance on casual or temporary staff, were frequently discussed by both groups. Consumer participants talked about the importance of seeing the same health provider and developing a relationship over time, and the disruption that change can cause. Similarly, the health practitioners reflected on nationwide general practitioner shortages and the detrimental impact on continuity of care for whānau.

“There’s GP shortages all over the country so whānau are struggling to get in, and the other thing is about the consistency of the GP you’re seeing. [If you’re] seeing locums there’s no consistency in what the messages will be.” – Health practitioner 2

Health system

Tiriti o Waitangi obligations

Both groups of participants identified that health practitioners and the wider providers failed to fulfil Te Tiriti o Waitangi obligations. In particular, they highlighted health inequities for Māori and the lack of Māori input into issues that affect them. Participants advocated for a tino rangatiratanga (self-determination/autonomy) approach, whereby communities and whānau are able to determine their own healthcare needs and control services.

Increasing and supporting Māori health workforce

There was concern about the lack of Māori in the health workforce. The implication was that addressing systemic inequities in health and improving Māori access to appropriate care and shared decision-making required placing Māori and Te Tiriti o Waitangi in the centre of the health system.

Discussion

Choosing Wisely’s intention of approaching Te ORA was to mitigate the increase in inequity for Māori, given that new initiatives are more readily taken up by the privileged.[[13]] Te ORA identified that the promotion of shared decision-making between healthcare practitioners and Māori health consumers were vital components of an improved Choosing Wisely.[[7]] Our participants rightly raised concerns about governance issues and decisions that saw Māori consultation begin only in year three and blamed the subsequent failure to deploy messages informed by Māori knowledge and cultural practice. Further, they critiqued the messaging focused on the reduction of tests, treatments and costs to the health system when Māori were already under-served, noting that a better messaging focus would have been around the deployment of evidence-based medicine to provide equitable care. At a more detailed level, they found Choosing Wisely to use “deficit” language overly focused on consumer behaviour change. Their comments indicated that Choosing Wisely resources needed to be health-literacy appropriate and engaging for Māori.[[14]] It has been shown,[[15]] and the Waitangi Tribunal WAI2575 enquiry has more recently argued,[[16]] that the principles of the Tiriti o Waitangi—that is, partnership, participation, protection, equity and options—are the basic building blocks for health promotion. Choosing Wisely had not lived up to those principles.

However, participants did recognise the value of the aim to promote better communication between the Māori consumers and their health practitioners, as well as clearly articulating the changes required. At the consumer level, trust, appropriate resources and advocacy and support were identified as significant. At the three provider levels, these required changes were identified: at the individual health practitioner level, cultural competence and safety; at an organisational level, a model of primary care that was Māori inclusive with adequate staffing; and at the health system level, appropriate levels of Māori in the workforce and Tiriti o Waitangi compliance.

Systematic reviews on shared decision-making among Indigenous peoples demonstrate that there is limited literature in this field.[[17]] Some decision-making tools have been developed in other jurisdictions, with First Nations, Inuit and Metis peoples,[[18]] particularly for cancer care.[[19]] But  tools and messages that focus narrowly on reducing tests and treatments, or on Indigenous patients posing the questions around medical advice, are problematic. These strategies also fail to acknowledge that individuals from under-served populations are the lesser partner in the power relationship of a medical consultation.[[20]] Other work with under-served consumers has found that the systematic training of health providers to work in ways that are culturally, linguistically and health-literacy appropriate, and that empower consumers, is required.[[21]]

This research highlights several broad strategies considered optimal for shared decision-making with Māori that can be applied across nearly all Māori health contexts. Firstly, Māori health equity must be prioritised, which includes a commitment by health programmes and health practitioners to privilege the knowledge, practices and customs of Māori in these contexts. Secondly, both individual and systems levels must recognise that developing connections and relationships is of central importance to the development of the trusting environment in which shared decision-making can occur. Supporting consumer trust and autonomy is appropriate in the consultation and at the systems level. Any national health campaign, including Choosing Wisely, would benefit from centring on Te Tiriti o Waitangi commitments and prioritising equity and the needs and aspirations of Māori from the outset.

Our participant recommendations cover systems issues, such as participation in programme governance, and practical and everyday issues that hamper quality improvement, such as literacy-appropriate health messaging. These findings are significant and an important contribution to the literature.

Although consumer participants covered a range of age groups and health providers were from a range of disciplines, the main limitation of this work was that the majority of participants were urban based. Further research exploring the views of more diverse Māori consumers and health practitioners would be beneficial.

In conclusion, this work has identified some structural issues in Choosing Wisely NZ that have limited the campaign’s ability to mitigate health inequities for Māori and helped to define a potentially transformative way forward. There was wide agreement among our participants that shared decision-making is not just a quality practice, but that it also has the potential to address health inequity among Māori by facilitating participation in healthcare that better meets self-identified need. Others have thought similarly for other Indigenous populations.[[22]] Many of the ingredients for improved shared decision-making identified by our participants are supported by the literature: consumer trust,[[23]] autonomy,[[24]] good relationships and rapport with health providers,[[25]] culturally appropriate resources,[[26]] provider clinical competence and efficacious communication[[27]] and health provider cultural safety.[[28]] These “practitioner dependent” factors are important and are as demanding of attention as systemic causes of health inequity such as inadequate access to services, the social determinants of health[[29]] and the structural determinants of health, including racism.[[30]]

Summary

This work identified some structural issues in Choosing Wisely New Zealand that have limited the campaign’s ability to mitigate health inequities for Māori and helped to define a potentially transformative way forward. There was wide agreement among our participants that shared decision-making is not just a quality practice, but that it also has the potential to address health inequity among Māori by facilitating participation in healthcare that better meets self-identified need. “Practitioner dependent” factors like consumer trust, autonomy, good relationships and rapport with health providers and culturally appropriate resources are important and are as demanding of attention as systemic causes of health inequity, such as inadequate access to services, the social determinants of health and the structural determinants of health, including racism.

Abstract

Aim

Choosing Wisely seeks to prevent harm by reducing the number of unnecessary tests, treatments and procedures, and by promoting shared decision-making. This article scopes perspectives of Māori patients/consumers and Māori health practitioners around Choosing Wisely and explores shared decision-making between Māori and their medical practitioners.

Method

Eight Māori consumers and seven Māori health practitioners participated in a qualitative, semi-structured, in-depth interview study with an inductive thematic analysis.

Results

Participant feedback spanned issues from lack of Māori participation in programme governance through to practical issues like meaningful and literacy-appropriate health messaging, traversing consumer, practitioner, organisational and health-system aspects. Feedback further focused on the patient having trust in the practitioner, a sense of autonomy and the availability of advocacy and support in the consultation.

Conclusion

Despite a late campaign collaboration with Māori, Choosing Wisely New Zealand is the first of the international programmes to acknowledge the possibility that their initiative might increase inequity for Indigenous populations. This enquiry highlights the need to consult Māori early and to infuse Treaty principles and Māori knowledge and custom at every stage of the programme.

Author Information

David Tipene-Leach: Public Health Physician, Research Professor, Eastern Institute of Technology. Anna Adcock: PhD candidate, Victoria University of Wellington. Sally Abel: PhD, Independent researcher, Kaupapa Consulting. Derek Sherwood: Ophthalmologist, Nelson-Marlborough District Health Board, Braemar Campus.

Acknowledgements

We would like to acknowledge all our consumer, health practitioner and Māori health provider participants and reference group advisors who gave so generously of their time.

Correspondence

David Tipene-Leach, Eastern Institute of Technology, 501 Gloucester St, Napier 4112, 06 8301090 (DDI)

Correspondence Email

dtipene-leach@eit.ac.nz

Competing Interests

Professor Tipene-Leach is Chair of Te ORA. Dr Sherwood was Chair of Council of Medical Colleges in New Zealand during the conduct of the study and received personal fees from them. Anna Adcock and Sally Abel were paid by Choosing Wisely Aotearoa New Zealand as contract researchers.

1) Levinson W, Kallewaard M, Bhatia RS, et al. ‘Choosing Wisely’: a growing international campaign. BMJ Qual Saf. 2015;24:167-74. doi: 10.1136/ bmjqs-2014-003821.

2) Read D, Sherwood D, Ineson S. Choose Wisely - is more always better? NZ Med J. 2016;129(1447):10-1.

3) Stiggelbout AM, Van der Weijde, T, De Wit MPT, Frosch D, Légaré F, Montori VM, Trevena L, Elwyn G. Shared decision making: really putting patients at the centre of healthcare. BMJ. 2012;344:e256.

4) Ministry of Health. Tatau Kahukura: Māori Health Chart Book 2015 (3rd edition). 2015, Ministry of Health: Wellington.

5) Metcalfe S, Beyene K, Urlich J et al. Te Wero tonu - the challenge continues: Māori access to medicines 2006/07-2012/13 update. NZ Med J. 2018;131(1485):27-47.

6) Health Quality & Safety Commission. Patient Experience Wellington: Health Quality & Safety Commission, 2018. Available from: https://www.hqsc.govt.nz/our-programmes/health-quality-evaluation/projects/patient-experience/  

7) Loring B, Ineson S, Sherwood D, Tipene-Leach D. Choosing Wisely means choosing equity NZ Med J. 2019;132(1496):6-8.

8) Adcock A, Tipene-Leach D. Choosing Wisely Means Choosing Equity. Wellington: Choosing Wisely Aotearoa New Zealand, 2020.

9) Smith LT. Decolonizing Methodologies: Research and Indigenous peoples. 2nd ed. London & New York: Zed Books, 2012.

10) Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008;8(1):45.

11) Braun V, Clarke V. Using thematic analysis in psychology. Qualitative research in psychology. 2006 Jan 1;3(2):77-101.

12) Cram F. Improving Māori access to health care: Research report. Auckland: Katoa Ltd, 2014. Available from: https://www.moh.govt.nz/NoteBook/nbbooks.nsf/0/211DA45C5EA63205CC257DD8007AE977/$file/Access_ResearchReport.pdf

13) Rose G. Sick individuals and sick populations. Int J Epidemiol. 2001;30(3):427--32.

14) Reid S, White C, & Hoffman L. Health literacy and the prevention and early detection of gout. Auckland: Workbase Education Trust, 2014. Available from: https://www.healthliteracy.co.nz/site_files/13255/upload_files/Goutreport29.5.14-FINAL.pdf?dl=1

15) Berghan, G, Came, H, Coupe et al. Tiriti-based health promotion practice. 2017. STIR: Stop Institutional Racism Auckland, Aotearoa New Zealand. Available from: https://trc.org.nz/treaty-waitangi-based-practice-health-promotion  

16) HAUORA Report on Stage One of the Health Services and Outcomes Kaupapa Inquiry. Waitangi Tribunal Report 2019. Available from: www.waitangitribunal.govt.nz

17) Jull O, Crispo J, Welch V, et al. Interventions for indigenous peoples making health decisions: a systematic review. Pimatisiwin. 2013;11(3):539-54.

18) Jull J, Giles A, Boyer Y, et al. Cultural adaptation of a shared decision making tool with Aboriginal women: a qualitative study. BMC Med Inform Decis Mak. 2015;15(1):1.

19) Jull J, Mazereeuw M, Sheppard A, et al. Tailoring and field-testing the use of a knowledge translation peer support shared decision making strategy with First Nations, Inuit and Métis people making decisions about their cancer care: a study protocol. Res Involv Engagem. 2018;4(6):6.

20) Goodyear-Smith F, Buetow S. Power Issues in the Doctor-Patient Relationship. Health Care Analysis. 2001 9:449–462. Available from: https://doi.org/10.1023/A:1013812802937

21) The Connecticut Choosing Wisely Collaborative. Enhancing Patient/Clinician Communication: Leveraging Choosing Wisely as a Tool for Achieving Health Equity. Connecticut, The Connecticut Choosing Wisely Collaborative, 2017. Available from: https://largeuploads.blob.core.windows.net/uploads-lrg/EnhancePtComms.pdf

22) Jull J, Stacey D, Giles A, et al. Shared decision-making and health for First Nations, Métis and Inuit women: a study protocol. BMC Med Inform Decis Mak. 2012;12:146.

23) Palmer SC, Gray H, Huria T, et al. Reported Māori consumer experiences of health systems and programs in qualitative research: a systematic review with meta-synthesis. Int J Equity Health. 2019;18(163).

24) Edwards M, Davies M, Edwards A. What are the external influences on information exchange and shared decision-making in healthcare consultations: a meta-synthesis of the literature. Patient Educ Couns. 2009;75(1):37-52.

25) Groot G, Waldron T, Barreno L, et al. Trust and world view in shared decision making with indigenous patients: A realist synthesis. J Eval Clin Pract. 2020;26:503-14.

26) Reid S, White C, & Hoffman L. Health literacy and the prevention and early detection of gout. Auckland: Workbase Education Trust, 2014. Available from: https://www.healthliteracy.co.nz/site_files/13255/upload_files/Goutreport29.5.14-FINAL.pdf?dl=1

27) Jull J, Giles A, Boyer Y, et al. Cultural adaptation of a shared decision making tool with Aboriginal women: a qualitative study. BMC Med Inform Decis Mak. 2015; 15(1):1.

28) Nguyen, HT. Patient centred care: cultural safety in indigenous health [online]. Aust Fam Physician. 2008 37(12): 990-4. Available from: https://search.informit.com.au/documentSummary;dn=351890330015262;res=IELIAC  

29) Berwick, DM. The Moral determinants of health. JAMA. 2020; 324(3):225-6.

30) Crear-Perry J, Correa-de-Araujo R, Lewis Johnson T, McLemore MR, Neilson E, Wallace M. Social and structural determinants of health inequities in maternal health. Journal of Women's Health. 2021;30(2):230-5.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

Choosing Wisely is an international health quality improvement campaign that originated in 2012 in the United States. Its aims are to improve clinical outcomes by reducing low-value and inappropriate clinical interventions and to promote well-informed conversations about treatment options between patients and health professionals to improve decision-making.[[1]] Choosing Wisely was launched in New Zealand by the Council of Medical Colleges (CMC) in 2016. Initially, colleges and specialty societies reviewed a raft of standard medical practices and, by the end of the year, had issued a list of 50 recommendations around low-value tests, treatments or procedures.[[2]] The other strategy, promoting shared decision-making, is central to reducing unnecessary interventions and is a significant marker of quality practice in its own right.[[3]]

In 2019, determined not to exacerbate inequity across the range of health outcomes[[4,5,6]] for an already-underserved Māori population,[[7]] the CMC sought a collaborative relationship with the Māori Medical Practitioners Association (Te ORA). Choosing Wisely New Zealand primarily intended to contribute to shared decision-making between healthcare practitioners and Māori health consumers. The US-initiated Choosing Wisely campaign had never deployed an Indigenous lens to look at its programme.

Consequently, a Te ORA research team was commissioned to scope the perspectives of Māori health consumers and Māori health practitioners around the Choosing Wisely NZ campaign and its messages. Te ORA also wanted to examine the experience of (shared) decision-making between Māori and their medical practitioners and make recommendations to better inform an equity-focused Choosing Wisely campaign in Aotearoa New Zealand. This research produced the report[[8]] from which this paper is derived.

Methods

This qualitative research seeks to be transformative in the identification of structural issues within Choosing Wisely NZ that are inconsistent with the promotion of equity for Māori. We deployed a Kaupapa Māori Research methodology—that is, one conducted by, with and for Māori that centres the values and aspirations of Māori whānau, hapū and iwi.[[9]] The study was initiated and led by Māori researchers (DTL and AA) and guided by a small reference group of two Māori health practitioners and three Māori consumers, who provided advice and feedback throughout the study’s design, implementation and analysis. Ethics approval was obtained from the New Zealand Ethics Committee, Te Rōpu Rapu i te Tika, on 15 October 2019 (ref 2019_46).

Māori healthcare consumers and Māori health practitioners were purposively recruited for this small qualitative study through community and professional networks. All 17 consumers and practitioners who were approached agreed to participate, although two pulled out. Fifteen participants (eight consumers and seven practitioners) were subsequently interviewed between November 2019 and February 2020. Participants were predominantly based in the North Island and urban areas. The consumers were from across the age range (20s–70s), and the health practitioners were doctors, nurses, midwives, pharmacists or Māori health provider managers. Interviews were conducted according to participants’ preferences: one by telephone, one by Zoom and the majority in person at locations chosen by the participants. Participants gave written consent to participate and were assured of anonymity in any written or oral reporting.

The interview schedule was semi-structured. The Choosing Wisely campaign was explained using the Choosing Wisely resource Communicating with your health professional: patients and consumers (available from https://choosingwisely.org.nz/patients-consumers/), which illustrates how health consumers might better participate in decision-making by asking questions of the practitioner around the need for, and the risks of, a test, treatment or procedure and whether other options, including doing nothing, are viable. On this basis, and after and further discussion, participants were asked to share perspectives on Choosing Wisely, such as its principles, aims and potential value for Māori, and to critique the usefulness of the Communicating with your health professional resource for use with Māori consumers. Participants were then asked about their own experiences of shared decision-making in healthcare settings and for recommendations to improve what they had experienced.

Each interview took between 25 and 90 minutes and, with the participant’s consent, was audio-recorded and transcribed. The data were analysed thematically, which entailed reading the transcripts closely, coding the data inductively and then creating, refining and finalising themes of participant talk.[[10,11]] All the coding and most of the thematic analysis was undertaken by AA. DTL and DS reviewed early themes and provided input into reorganisation and development of the final themes.

As well as being reviewed by the reference group, a summary of research findings and draft report was produced and sent to participants, who were encouraged to provide feedback (either in person, by telephone or by email) before the a formal report[[8]] was finalised. Input on the preparation of findings and the discussion for this paper was sought from SA, an experienced qualitative researcher.

Results

The results are presented in two sections. The first, “Feedback on the Choosing Wisely campaign,” includes three themes: the importance of Māori governance; the need to be careful with messaging; resources should be engaging for Māori. The second section, “Shared decision-making between Māori and their medical practitioner,” is presented in four domains[[12]]: consumer, practitioner, organisation and health system. Each domain has 2–3 themes (Table 1).

Feedback on Choosing Wisely

The importance of Māori governance

All practitioner participants and one consumer raised concerns that Choosing Wisely had originated in the United States and that it had not been adapted well for local circumstances. Participants said that, due to a lack of engagement with Māori communities or Māori health professional groups until three years after its launch, the campaign lacked any reflection of Māori knowledge systems, practices and customs.

The recommendations that emerged included that the campaign should move to involve Māori in key governance and decision-making positions and incorporate a “Māori lens” across all activities. The conversation needed to empower shared decision-making could then include a practitioner-led focus on holistic models of health and wellbeing and incorporate rongoā (Māori medicines) and karakia (prayers/incantations) as reasonable treatment options.

The need to be careful with messaging

Both practitioners and consumers were critical of the campaign and its subsequent messaging that focused on the reduction of tests, treatments and costs associated to the health system when Māori were already under-served by that health system. Better messaging would be around the deployment of evidence-based medicine to provide equitable care, rather than any “cutting back” of care.

“I think that the explicit focus on over-treatment and over-utilisation of resources can overshadow the other important aspects that make up good quality care for any person… So how about shifting it towards being about the right thing, at the right time, and the right way, for the right person?” –  Health practitioner 5

After reading Communicating with your health professional, some participants felt that the campaign placed the onus for change on consumers rather than health professionals and that, although a focus on consumer autonomy in decision-making was important, there needed to be more emphasis on the practitioner creating welcoming environments and taking responsibility for facilitating shared decision-making and providing appropriate care.

“I hate going to the doctors. I would never ask any of those other things because I would just assume that the doctor is right… I don’t think the onus should be on the patient to ask all these things, I think the doctor should definitely be telling you all these things.” – Consumer 1

Resources should be engaging for Māori

Feedback on Communicating with your health professional was mixed. Both groups considered some of the language in the resource to be too complex, confusing or wordy.

“If I were to pick this up it would just be hard for me to be interested in reading it… You gotta make sure you can relate to it, be informative.” – Consumer 7

The resource advises consumers “to be honest” about their health issues, which some felt was insinuating they might be dishonest. In addition, asking consumers to make a longer appointment if their health issues are complex assumed that people understood whether their health issues are in fact complex. In addition, participants thought longer appointments would be unfeasible for most because of cost.

Both groups recommended that resources needed to be simple and realistic, to cater to different levels of health literacy, and both socially and culturally engaging for Māori (ie, incorporating the target audience into the design of the resource).

Shared decision-making between Māori and their medical practitioner

Health consumer

Trust and autonomy

Trust and autonomy were identified as key to shared decision-making, and this included knowing one’s rights to question, to not feel coerced, to be informed, to have clear explanations and to be treated as an equal. On the other hand, it was noted that a lack of trust in health services creates anxiety, which in turn discourages participation and communication. Participants emphasised that health practitioners are responsible for ensuring whānau are supported to make positive health decisions and for promoting health literacy in strengths-based ways. A consumer participant talked about the sense of whakamā (shyness/reticence) that some Māori feel in health settings, for fear of coming across as unknowledgeable. Likewise, a health practitioner emphasised the need for whānau to be guided to engage in shared decision-making.

“From the patient’s perspective, from the whānau perspective, they’ve always been taught that they’re passive. And then they’re encouraged to be another way, which is great, to take control. But you have to give them some tools so you don’t set them up to fail.” – Health practitioner 7

Appropriate shared decision-making resources

Appropriate shared decision-making resources were described as culturally appropriate and friendly. They would include text and graphics or visuals that are relevant and engaging for Māori. Both practitioners and consumers frequently discussed the lack of access to resources for consumers as a barrier to shared decision-making. This is compounded by barriers to accessing healthcare in the first place because of cost, lack of transport and childcare, and the negative impact of trauma and life stresses on health-seeking behaviour.

“Because of the emotional overload in people’s lives due to housing problems, stress, domestic violence, past history of trauma... prioritising health issues [is] very difficult.” – Health practitioner 5

Importance of advocacy and support

Good advocacy and support within healthcare settings, such as from whānau members, representatives, nurses and community support workers such as Whānau Ora navigators, were also considered important for shared decision-making. The benefits included having another person to contribute and interpret information and to ensure that rights and wishes were met. As one health provider stated, “even just an extra face in the room makes a difference” (Health practitioner 7). Similarly, a consumer reflected on the importance of whānau support.

“[To] have someone to advocate for you when you aren’t necessarily in that right frame of mind to ask those questions, when you’re just vulnerable… I had my Mum with me and so she was asking a lot of these questions.” – Consumer 3

Health provider

Competence and communication

Clinical competence and efficacious communication were described by both groups as critical for shared decision-making. Consumer participants reported feeling able to make good decisions when health providers were thorough and informative. This included going through different scenarios to demonstrate their knowledge of health issues and treatment options. Health provider participants emphasised the importance of demonstrating competent judgement and providing opportunities for shared decision-making with all consumers regardless of whether their conditions were acute or chronic.

Cultural responsiveness

Cultural safety and cultural competency, which develop when trusting relationships are established and nurtured, were also identified as crucial. Being non-judgemental, genuine, supportive and understanding of context sat alongside acknowledging the validity of the Māori world and the importance of whanaungatanga (connecting/relationships) and holistic models of health. A consumer participant described this as creating a comfortable and safe environment. A health practitioner emphasised the importance of being a role model.

“As a health professional you’re taught to not show too much of yourself. But what we’re talking about is cultural safety, and realising how you can impact on people… For Māori it’s really important—engaging and encouraging them to be part of the planning and decision-making… You have to establish and maintain trust for it to be effective… Health professionals sometimes don’t realise how much they can be a role model by being a nice, caring person.” – Health practitioner 7

Health organisation

Model of primary care

The pervasive model of primary care that results in short appointment times and workforce shortages that disrupt continuity of care were considered barriers to shared decision-making by both participant groups. Consumers and health practitioners frequently discussed feeling rushed to get through consultations due to short appointment times, leaving needs unmet.

“There have been times I’ve gone to the doctor and they’ve just kind of skipped over a whole bunch of detail… but I felt out of line to question, I felt a bit rushed…” – Consumer 8

Detrimental impact of high practitioner turnover and burnout

High rates of practitioner turnover and burnout, and the subsequent reliance on casual or temporary staff, were frequently discussed by both groups. Consumer participants talked about the importance of seeing the same health provider and developing a relationship over time, and the disruption that change can cause. Similarly, the health practitioners reflected on nationwide general practitioner shortages and the detrimental impact on continuity of care for whānau.

“There’s GP shortages all over the country so whānau are struggling to get in, and the other thing is about the consistency of the GP you’re seeing. [If you’re] seeing locums there’s no consistency in what the messages will be.” – Health practitioner 2

Health system

Tiriti o Waitangi obligations

Both groups of participants identified that health practitioners and the wider providers failed to fulfil Te Tiriti o Waitangi obligations. In particular, they highlighted health inequities for Māori and the lack of Māori input into issues that affect them. Participants advocated for a tino rangatiratanga (self-determination/autonomy) approach, whereby communities and whānau are able to determine their own healthcare needs and control services.

Increasing and supporting Māori health workforce

There was concern about the lack of Māori in the health workforce. The implication was that addressing systemic inequities in health and improving Māori access to appropriate care and shared decision-making required placing Māori and Te Tiriti o Waitangi in the centre of the health system.

Discussion

Choosing Wisely’s intention of approaching Te ORA was to mitigate the increase in inequity for Māori, given that new initiatives are more readily taken up by the privileged.[[13]] Te ORA identified that the promotion of shared decision-making between healthcare practitioners and Māori health consumers were vital components of an improved Choosing Wisely.[[7]] Our participants rightly raised concerns about governance issues and decisions that saw Māori consultation begin only in year three and blamed the subsequent failure to deploy messages informed by Māori knowledge and cultural practice. Further, they critiqued the messaging focused on the reduction of tests, treatments and costs to the health system when Māori were already under-served, noting that a better messaging focus would have been around the deployment of evidence-based medicine to provide equitable care. At a more detailed level, they found Choosing Wisely to use “deficit” language overly focused on consumer behaviour change. Their comments indicated that Choosing Wisely resources needed to be health-literacy appropriate and engaging for Māori.[[14]] It has been shown,[[15]] and the Waitangi Tribunal WAI2575 enquiry has more recently argued,[[16]] that the principles of the Tiriti o Waitangi—that is, partnership, participation, protection, equity and options—are the basic building blocks for health promotion. Choosing Wisely had not lived up to those principles.

However, participants did recognise the value of the aim to promote better communication between the Māori consumers and their health practitioners, as well as clearly articulating the changes required. At the consumer level, trust, appropriate resources and advocacy and support were identified as significant. At the three provider levels, these required changes were identified: at the individual health practitioner level, cultural competence and safety; at an organisational level, a model of primary care that was Māori inclusive with adequate staffing; and at the health system level, appropriate levels of Māori in the workforce and Tiriti o Waitangi compliance.

Systematic reviews on shared decision-making among Indigenous peoples demonstrate that there is limited literature in this field.[[17]] Some decision-making tools have been developed in other jurisdictions, with First Nations, Inuit and Metis peoples,[[18]] particularly for cancer care.[[19]] But  tools and messages that focus narrowly on reducing tests and treatments, or on Indigenous patients posing the questions around medical advice, are problematic. These strategies also fail to acknowledge that individuals from under-served populations are the lesser partner in the power relationship of a medical consultation.[[20]] Other work with under-served consumers has found that the systematic training of health providers to work in ways that are culturally, linguistically and health-literacy appropriate, and that empower consumers, is required.[[21]]

This research highlights several broad strategies considered optimal for shared decision-making with Māori that can be applied across nearly all Māori health contexts. Firstly, Māori health equity must be prioritised, which includes a commitment by health programmes and health practitioners to privilege the knowledge, practices and customs of Māori in these contexts. Secondly, both individual and systems levels must recognise that developing connections and relationships is of central importance to the development of the trusting environment in which shared decision-making can occur. Supporting consumer trust and autonomy is appropriate in the consultation and at the systems level. Any national health campaign, including Choosing Wisely, would benefit from centring on Te Tiriti o Waitangi commitments and prioritising equity and the needs and aspirations of Māori from the outset.

Our participant recommendations cover systems issues, such as participation in programme governance, and practical and everyday issues that hamper quality improvement, such as literacy-appropriate health messaging. These findings are significant and an important contribution to the literature.

Although consumer participants covered a range of age groups and health providers were from a range of disciplines, the main limitation of this work was that the majority of participants were urban based. Further research exploring the views of more diverse Māori consumers and health practitioners would be beneficial.

In conclusion, this work has identified some structural issues in Choosing Wisely NZ that have limited the campaign’s ability to mitigate health inequities for Māori and helped to define a potentially transformative way forward. There was wide agreement among our participants that shared decision-making is not just a quality practice, but that it also has the potential to address health inequity among Māori by facilitating participation in healthcare that better meets self-identified need. Others have thought similarly for other Indigenous populations.[[22]] Many of the ingredients for improved shared decision-making identified by our participants are supported by the literature: consumer trust,[[23]] autonomy,[[24]] good relationships and rapport with health providers,[[25]] culturally appropriate resources,[[26]] provider clinical competence and efficacious communication[[27]] and health provider cultural safety.[[28]] These “practitioner dependent” factors are important and are as demanding of attention as systemic causes of health inequity such as inadequate access to services, the social determinants of health[[29]] and the structural determinants of health, including racism.[[30]]

Summary

This work identified some structural issues in Choosing Wisely New Zealand that have limited the campaign’s ability to mitigate health inequities for Māori and helped to define a potentially transformative way forward. There was wide agreement among our participants that shared decision-making is not just a quality practice, but that it also has the potential to address health inequity among Māori by facilitating participation in healthcare that better meets self-identified need. “Practitioner dependent” factors like consumer trust, autonomy, good relationships and rapport with health providers and culturally appropriate resources are important and are as demanding of attention as systemic causes of health inequity, such as inadequate access to services, the social determinants of health and the structural determinants of health, including racism.

Abstract

Aim

Choosing Wisely seeks to prevent harm by reducing the number of unnecessary tests, treatments and procedures, and by promoting shared decision-making. This article scopes perspectives of Māori patients/consumers and Māori health practitioners around Choosing Wisely and explores shared decision-making between Māori and their medical practitioners.

Method

Eight Māori consumers and seven Māori health practitioners participated in a qualitative, semi-structured, in-depth interview study with an inductive thematic analysis.

Results

Participant feedback spanned issues from lack of Māori participation in programme governance through to practical issues like meaningful and literacy-appropriate health messaging, traversing consumer, practitioner, organisational and health-system aspects. Feedback further focused on the patient having trust in the practitioner, a sense of autonomy and the availability of advocacy and support in the consultation.

Conclusion

Despite a late campaign collaboration with Māori, Choosing Wisely New Zealand is the first of the international programmes to acknowledge the possibility that their initiative might increase inequity for Indigenous populations. This enquiry highlights the need to consult Māori early and to infuse Treaty principles and Māori knowledge and custom at every stage of the programme.

Author Information

David Tipene-Leach: Public Health Physician, Research Professor, Eastern Institute of Technology. Anna Adcock: PhD candidate, Victoria University of Wellington. Sally Abel: PhD, Independent researcher, Kaupapa Consulting. Derek Sherwood: Ophthalmologist, Nelson-Marlborough District Health Board, Braemar Campus.

Acknowledgements

We would like to acknowledge all our consumer, health practitioner and Māori health provider participants and reference group advisors who gave so generously of their time.

Correspondence

David Tipene-Leach, Eastern Institute of Technology, 501 Gloucester St, Napier 4112, 06 8301090 (DDI)

Correspondence Email

dtipene-leach@eit.ac.nz

Competing Interests

Professor Tipene-Leach is Chair of Te ORA. Dr Sherwood was Chair of Council of Medical Colleges in New Zealand during the conduct of the study and received personal fees from them. Anna Adcock and Sally Abel were paid by Choosing Wisely Aotearoa New Zealand as contract researchers.

1) Levinson W, Kallewaard M, Bhatia RS, et al. ‘Choosing Wisely’: a growing international campaign. BMJ Qual Saf. 2015;24:167-74. doi: 10.1136/ bmjqs-2014-003821.

2) Read D, Sherwood D, Ineson S. Choose Wisely - is more always better? NZ Med J. 2016;129(1447):10-1.

3) Stiggelbout AM, Van der Weijde, T, De Wit MPT, Frosch D, Légaré F, Montori VM, Trevena L, Elwyn G. Shared decision making: really putting patients at the centre of healthcare. BMJ. 2012;344:e256.

4) Ministry of Health. Tatau Kahukura: Māori Health Chart Book 2015 (3rd edition). 2015, Ministry of Health: Wellington.

5) Metcalfe S, Beyene K, Urlich J et al. Te Wero tonu - the challenge continues: Māori access to medicines 2006/07-2012/13 update. NZ Med J. 2018;131(1485):27-47.

6) Health Quality & Safety Commission. Patient Experience Wellington: Health Quality & Safety Commission, 2018. Available from: https://www.hqsc.govt.nz/our-programmes/health-quality-evaluation/projects/patient-experience/  

7) Loring B, Ineson S, Sherwood D, Tipene-Leach D. Choosing Wisely means choosing equity NZ Med J. 2019;132(1496):6-8.

8) Adcock A, Tipene-Leach D. Choosing Wisely Means Choosing Equity. Wellington: Choosing Wisely Aotearoa New Zealand, 2020.

9) Smith LT. Decolonizing Methodologies: Research and Indigenous peoples. 2nd ed. London & New York: Zed Books, 2012.

10) Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008;8(1):45.

11) Braun V, Clarke V. Using thematic analysis in psychology. Qualitative research in psychology. 2006 Jan 1;3(2):77-101.

12) Cram F. Improving Māori access to health care: Research report. Auckland: Katoa Ltd, 2014. Available from: https://www.moh.govt.nz/NoteBook/nbbooks.nsf/0/211DA45C5EA63205CC257DD8007AE977/$file/Access_ResearchReport.pdf

13) Rose G. Sick individuals and sick populations. Int J Epidemiol. 2001;30(3):427--32.

14) Reid S, White C, & Hoffman L. Health literacy and the prevention and early detection of gout. Auckland: Workbase Education Trust, 2014. Available from: https://www.healthliteracy.co.nz/site_files/13255/upload_files/Goutreport29.5.14-FINAL.pdf?dl=1

15) Berghan, G, Came, H, Coupe et al. Tiriti-based health promotion practice. 2017. STIR: Stop Institutional Racism Auckland, Aotearoa New Zealand. Available from: https://trc.org.nz/treaty-waitangi-based-practice-health-promotion  

16) HAUORA Report on Stage One of the Health Services and Outcomes Kaupapa Inquiry. Waitangi Tribunal Report 2019. Available from: www.waitangitribunal.govt.nz

17) Jull O, Crispo J, Welch V, et al. Interventions for indigenous peoples making health decisions: a systematic review. Pimatisiwin. 2013;11(3):539-54.

18) Jull J, Giles A, Boyer Y, et al. Cultural adaptation of a shared decision making tool with Aboriginal women: a qualitative study. BMC Med Inform Decis Mak. 2015;15(1):1.

19) Jull J, Mazereeuw M, Sheppard A, et al. Tailoring and field-testing the use of a knowledge translation peer support shared decision making strategy with First Nations, Inuit and Métis people making decisions about their cancer care: a study protocol. Res Involv Engagem. 2018;4(6):6.

20) Goodyear-Smith F, Buetow S. Power Issues in the Doctor-Patient Relationship. Health Care Analysis. 2001 9:449–462. Available from: https://doi.org/10.1023/A:1013812802937

21) The Connecticut Choosing Wisely Collaborative. Enhancing Patient/Clinician Communication: Leveraging Choosing Wisely as a Tool for Achieving Health Equity. Connecticut, The Connecticut Choosing Wisely Collaborative, 2017. Available from: https://largeuploads.blob.core.windows.net/uploads-lrg/EnhancePtComms.pdf

22) Jull J, Stacey D, Giles A, et al. Shared decision-making and health for First Nations, Métis and Inuit women: a study protocol. BMC Med Inform Decis Mak. 2012;12:146.

23) Palmer SC, Gray H, Huria T, et al. Reported Māori consumer experiences of health systems and programs in qualitative research: a systematic review with meta-synthesis. Int J Equity Health. 2019;18(163).

24) Edwards M, Davies M, Edwards A. What are the external influences on information exchange and shared decision-making in healthcare consultations: a meta-synthesis of the literature. Patient Educ Couns. 2009;75(1):37-52.

25) Groot G, Waldron T, Barreno L, et al. Trust and world view in shared decision making with indigenous patients: A realist synthesis. J Eval Clin Pract. 2020;26:503-14.

26) Reid S, White C, & Hoffman L. Health literacy and the prevention and early detection of gout. Auckland: Workbase Education Trust, 2014. Available from: https://www.healthliteracy.co.nz/site_files/13255/upload_files/Goutreport29.5.14-FINAL.pdf?dl=1

27) Jull J, Giles A, Boyer Y, et al. Cultural adaptation of a shared decision making tool with Aboriginal women: a qualitative study. BMC Med Inform Decis Mak. 2015; 15(1):1.

28) Nguyen, HT. Patient centred care: cultural safety in indigenous health [online]. Aust Fam Physician. 2008 37(12): 990-4. Available from: https://search.informit.com.au/documentSummary;dn=351890330015262;res=IELIAC  

29) Berwick, DM. The Moral determinants of health. JAMA. 2020; 324(3):225-6.

30) Crear-Perry J, Correa-de-Araujo R, Lewis Johnson T, McLemore MR, Neilson E, Wallace M. Social and structural determinants of health inequities in maternal health. Journal of Women's Health. 2021;30(2):230-5.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

Choosing Wisely is an international health quality improvement campaign that originated in 2012 in the United States. Its aims are to improve clinical outcomes by reducing low-value and inappropriate clinical interventions and to promote well-informed conversations about treatment options between patients and health professionals to improve decision-making.[[1]] Choosing Wisely was launched in New Zealand by the Council of Medical Colleges (CMC) in 2016. Initially, colleges and specialty societies reviewed a raft of standard medical practices and, by the end of the year, had issued a list of 50 recommendations around low-value tests, treatments or procedures.[[2]] The other strategy, promoting shared decision-making, is central to reducing unnecessary interventions and is a significant marker of quality practice in its own right.[[3]]

In 2019, determined not to exacerbate inequity across the range of health outcomes[[4,5,6]] for an already-underserved Māori population,[[7]] the CMC sought a collaborative relationship with the Māori Medical Practitioners Association (Te ORA). Choosing Wisely New Zealand primarily intended to contribute to shared decision-making between healthcare practitioners and Māori health consumers. The US-initiated Choosing Wisely campaign had never deployed an Indigenous lens to look at its programme.

Consequently, a Te ORA research team was commissioned to scope the perspectives of Māori health consumers and Māori health practitioners around the Choosing Wisely NZ campaign and its messages. Te ORA also wanted to examine the experience of (shared) decision-making between Māori and their medical practitioners and make recommendations to better inform an equity-focused Choosing Wisely campaign in Aotearoa New Zealand. This research produced the report[[8]] from which this paper is derived.

Methods

This qualitative research seeks to be transformative in the identification of structural issues within Choosing Wisely NZ that are inconsistent with the promotion of equity for Māori. We deployed a Kaupapa Māori Research methodology—that is, one conducted by, with and for Māori that centres the values and aspirations of Māori whānau, hapū and iwi.[[9]] The study was initiated and led by Māori researchers (DTL and AA) and guided by a small reference group of two Māori health practitioners and three Māori consumers, who provided advice and feedback throughout the study’s design, implementation and analysis. Ethics approval was obtained from the New Zealand Ethics Committee, Te Rōpu Rapu i te Tika, on 15 October 2019 (ref 2019_46).

Māori healthcare consumers and Māori health practitioners were purposively recruited for this small qualitative study through community and professional networks. All 17 consumers and practitioners who were approached agreed to participate, although two pulled out. Fifteen participants (eight consumers and seven practitioners) were subsequently interviewed between November 2019 and February 2020. Participants were predominantly based in the North Island and urban areas. The consumers were from across the age range (20s–70s), and the health practitioners were doctors, nurses, midwives, pharmacists or Māori health provider managers. Interviews were conducted according to participants’ preferences: one by telephone, one by Zoom and the majority in person at locations chosen by the participants. Participants gave written consent to participate and were assured of anonymity in any written or oral reporting.

The interview schedule was semi-structured. The Choosing Wisely campaign was explained using the Choosing Wisely resource Communicating with your health professional: patients and consumers (available from https://choosingwisely.org.nz/patients-consumers/), which illustrates how health consumers might better participate in decision-making by asking questions of the practitioner around the need for, and the risks of, a test, treatment or procedure and whether other options, including doing nothing, are viable. On this basis, and after and further discussion, participants were asked to share perspectives on Choosing Wisely, such as its principles, aims and potential value for Māori, and to critique the usefulness of the Communicating with your health professional resource for use with Māori consumers. Participants were then asked about their own experiences of shared decision-making in healthcare settings and for recommendations to improve what they had experienced.

Each interview took between 25 and 90 minutes and, with the participant’s consent, was audio-recorded and transcribed. The data were analysed thematically, which entailed reading the transcripts closely, coding the data inductively and then creating, refining and finalising themes of participant talk.[[10,11]] All the coding and most of the thematic analysis was undertaken by AA. DTL and DS reviewed early themes and provided input into reorganisation and development of the final themes.

As well as being reviewed by the reference group, a summary of research findings and draft report was produced and sent to participants, who were encouraged to provide feedback (either in person, by telephone or by email) before the a formal report[[8]] was finalised. Input on the preparation of findings and the discussion for this paper was sought from SA, an experienced qualitative researcher.

Results

The results are presented in two sections. The first, “Feedback on the Choosing Wisely campaign,” includes three themes: the importance of Māori governance; the need to be careful with messaging; resources should be engaging for Māori. The second section, “Shared decision-making between Māori and their medical practitioner,” is presented in four domains[[12]]: consumer, practitioner, organisation and health system. Each domain has 2–3 themes (Table 1).

Feedback on Choosing Wisely

The importance of Māori governance

All practitioner participants and one consumer raised concerns that Choosing Wisely had originated in the United States and that it had not been adapted well for local circumstances. Participants said that, due to a lack of engagement with Māori communities or Māori health professional groups until three years after its launch, the campaign lacked any reflection of Māori knowledge systems, practices and customs.

The recommendations that emerged included that the campaign should move to involve Māori in key governance and decision-making positions and incorporate a “Māori lens” across all activities. The conversation needed to empower shared decision-making could then include a practitioner-led focus on holistic models of health and wellbeing and incorporate rongoā (Māori medicines) and karakia (prayers/incantations) as reasonable treatment options.

The need to be careful with messaging

Both practitioners and consumers were critical of the campaign and its subsequent messaging that focused on the reduction of tests, treatments and costs associated to the health system when Māori were already under-served by that health system. Better messaging would be around the deployment of evidence-based medicine to provide equitable care, rather than any “cutting back” of care.

“I think that the explicit focus on over-treatment and over-utilisation of resources can overshadow the other important aspects that make up good quality care for any person… So how about shifting it towards being about the right thing, at the right time, and the right way, for the right person?” –  Health practitioner 5

After reading Communicating with your health professional, some participants felt that the campaign placed the onus for change on consumers rather than health professionals and that, although a focus on consumer autonomy in decision-making was important, there needed to be more emphasis on the practitioner creating welcoming environments and taking responsibility for facilitating shared decision-making and providing appropriate care.

“I hate going to the doctors. I would never ask any of those other things because I would just assume that the doctor is right… I don’t think the onus should be on the patient to ask all these things, I think the doctor should definitely be telling you all these things.” – Consumer 1

Resources should be engaging for Māori

Feedback on Communicating with your health professional was mixed. Both groups considered some of the language in the resource to be too complex, confusing or wordy.

“If I were to pick this up it would just be hard for me to be interested in reading it… You gotta make sure you can relate to it, be informative.” – Consumer 7

The resource advises consumers “to be honest” about their health issues, which some felt was insinuating they might be dishonest. In addition, asking consumers to make a longer appointment if their health issues are complex assumed that people understood whether their health issues are in fact complex. In addition, participants thought longer appointments would be unfeasible for most because of cost.

Both groups recommended that resources needed to be simple and realistic, to cater to different levels of health literacy, and both socially and culturally engaging for Māori (ie, incorporating the target audience into the design of the resource).

Shared decision-making between Māori and their medical practitioner

Health consumer

Trust and autonomy

Trust and autonomy were identified as key to shared decision-making, and this included knowing one’s rights to question, to not feel coerced, to be informed, to have clear explanations and to be treated as an equal. On the other hand, it was noted that a lack of trust in health services creates anxiety, which in turn discourages participation and communication. Participants emphasised that health practitioners are responsible for ensuring whānau are supported to make positive health decisions and for promoting health literacy in strengths-based ways. A consumer participant talked about the sense of whakamā (shyness/reticence) that some Māori feel in health settings, for fear of coming across as unknowledgeable. Likewise, a health practitioner emphasised the need for whānau to be guided to engage in shared decision-making.

“From the patient’s perspective, from the whānau perspective, they’ve always been taught that they’re passive. And then they’re encouraged to be another way, which is great, to take control. But you have to give them some tools so you don’t set them up to fail.” – Health practitioner 7

Appropriate shared decision-making resources

Appropriate shared decision-making resources were described as culturally appropriate and friendly. They would include text and graphics or visuals that are relevant and engaging for Māori. Both practitioners and consumers frequently discussed the lack of access to resources for consumers as a barrier to shared decision-making. This is compounded by barriers to accessing healthcare in the first place because of cost, lack of transport and childcare, and the negative impact of trauma and life stresses on health-seeking behaviour.

“Because of the emotional overload in people’s lives due to housing problems, stress, domestic violence, past history of trauma... prioritising health issues [is] very difficult.” – Health practitioner 5

Importance of advocacy and support

Good advocacy and support within healthcare settings, such as from whānau members, representatives, nurses and community support workers such as Whānau Ora navigators, were also considered important for shared decision-making. The benefits included having another person to contribute and interpret information and to ensure that rights and wishes were met. As one health provider stated, “even just an extra face in the room makes a difference” (Health practitioner 7). Similarly, a consumer reflected on the importance of whānau support.

“[To] have someone to advocate for you when you aren’t necessarily in that right frame of mind to ask those questions, when you’re just vulnerable… I had my Mum with me and so she was asking a lot of these questions.” – Consumer 3

Health provider

Competence and communication

Clinical competence and efficacious communication were described by both groups as critical for shared decision-making. Consumer participants reported feeling able to make good decisions when health providers were thorough and informative. This included going through different scenarios to demonstrate their knowledge of health issues and treatment options. Health provider participants emphasised the importance of demonstrating competent judgement and providing opportunities for shared decision-making with all consumers regardless of whether their conditions were acute or chronic.

Cultural responsiveness

Cultural safety and cultural competency, which develop when trusting relationships are established and nurtured, were also identified as crucial. Being non-judgemental, genuine, supportive and understanding of context sat alongside acknowledging the validity of the Māori world and the importance of whanaungatanga (connecting/relationships) and holistic models of health. A consumer participant described this as creating a comfortable and safe environment. A health practitioner emphasised the importance of being a role model.

“As a health professional you’re taught to not show too much of yourself. But what we’re talking about is cultural safety, and realising how you can impact on people… For Māori it’s really important—engaging and encouraging them to be part of the planning and decision-making… You have to establish and maintain trust for it to be effective… Health professionals sometimes don’t realise how much they can be a role model by being a nice, caring person.” – Health practitioner 7

Health organisation

Model of primary care

The pervasive model of primary care that results in short appointment times and workforce shortages that disrupt continuity of care were considered barriers to shared decision-making by both participant groups. Consumers and health practitioners frequently discussed feeling rushed to get through consultations due to short appointment times, leaving needs unmet.

“There have been times I’ve gone to the doctor and they’ve just kind of skipped over a whole bunch of detail… but I felt out of line to question, I felt a bit rushed…” – Consumer 8

Detrimental impact of high practitioner turnover and burnout

High rates of practitioner turnover and burnout, and the subsequent reliance on casual or temporary staff, were frequently discussed by both groups. Consumer participants talked about the importance of seeing the same health provider and developing a relationship over time, and the disruption that change can cause. Similarly, the health practitioners reflected on nationwide general practitioner shortages and the detrimental impact on continuity of care for whānau.

“There’s GP shortages all over the country so whānau are struggling to get in, and the other thing is about the consistency of the GP you’re seeing. [If you’re] seeing locums there’s no consistency in what the messages will be.” – Health practitioner 2

Health system

Tiriti o Waitangi obligations

Both groups of participants identified that health practitioners and the wider providers failed to fulfil Te Tiriti o Waitangi obligations. In particular, they highlighted health inequities for Māori and the lack of Māori input into issues that affect them. Participants advocated for a tino rangatiratanga (self-determination/autonomy) approach, whereby communities and whānau are able to determine their own healthcare needs and control services.

Increasing and supporting Māori health workforce

There was concern about the lack of Māori in the health workforce. The implication was that addressing systemic inequities in health and improving Māori access to appropriate care and shared decision-making required placing Māori and Te Tiriti o Waitangi in the centre of the health system.

Discussion

Choosing Wisely’s intention of approaching Te ORA was to mitigate the increase in inequity for Māori, given that new initiatives are more readily taken up by the privileged.[[13]] Te ORA identified that the promotion of shared decision-making between healthcare practitioners and Māori health consumers were vital components of an improved Choosing Wisely.[[7]] Our participants rightly raised concerns about governance issues and decisions that saw Māori consultation begin only in year three and blamed the subsequent failure to deploy messages informed by Māori knowledge and cultural practice. Further, they critiqued the messaging focused on the reduction of tests, treatments and costs to the health system when Māori were already under-served, noting that a better messaging focus would have been around the deployment of evidence-based medicine to provide equitable care. At a more detailed level, they found Choosing Wisely to use “deficit” language overly focused on consumer behaviour change. Their comments indicated that Choosing Wisely resources needed to be health-literacy appropriate and engaging for Māori.[[14]] It has been shown,[[15]] and the Waitangi Tribunal WAI2575 enquiry has more recently argued,[[16]] that the principles of the Tiriti o Waitangi—that is, partnership, participation, protection, equity and options—are the basic building blocks for health promotion. Choosing Wisely had not lived up to those principles.

However, participants did recognise the value of the aim to promote better communication between the Māori consumers and their health practitioners, as well as clearly articulating the changes required. At the consumer level, trust, appropriate resources and advocacy and support were identified as significant. At the three provider levels, these required changes were identified: at the individual health practitioner level, cultural competence and safety; at an organisational level, a model of primary care that was Māori inclusive with adequate staffing; and at the health system level, appropriate levels of Māori in the workforce and Tiriti o Waitangi compliance.

Systematic reviews on shared decision-making among Indigenous peoples demonstrate that there is limited literature in this field.[[17]] Some decision-making tools have been developed in other jurisdictions, with First Nations, Inuit and Metis peoples,[[18]] particularly for cancer care.[[19]] But  tools and messages that focus narrowly on reducing tests and treatments, or on Indigenous patients posing the questions around medical advice, are problematic. These strategies also fail to acknowledge that individuals from under-served populations are the lesser partner in the power relationship of a medical consultation.[[20]] Other work with under-served consumers has found that the systematic training of health providers to work in ways that are culturally, linguistically and health-literacy appropriate, and that empower consumers, is required.[[21]]

This research highlights several broad strategies considered optimal for shared decision-making with Māori that can be applied across nearly all Māori health contexts. Firstly, Māori health equity must be prioritised, which includes a commitment by health programmes and health practitioners to privilege the knowledge, practices and customs of Māori in these contexts. Secondly, both individual and systems levels must recognise that developing connections and relationships is of central importance to the development of the trusting environment in which shared decision-making can occur. Supporting consumer trust and autonomy is appropriate in the consultation and at the systems level. Any national health campaign, including Choosing Wisely, would benefit from centring on Te Tiriti o Waitangi commitments and prioritising equity and the needs and aspirations of Māori from the outset.

Our participant recommendations cover systems issues, such as participation in programme governance, and practical and everyday issues that hamper quality improvement, such as literacy-appropriate health messaging. These findings are significant and an important contribution to the literature.

Although consumer participants covered a range of age groups and health providers were from a range of disciplines, the main limitation of this work was that the majority of participants were urban based. Further research exploring the views of more diverse Māori consumers and health practitioners would be beneficial.

In conclusion, this work has identified some structural issues in Choosing Wisely NZ that have limited the campaign’s ability to mitigate health inequities for Māori and helped to define a potentially transformative way forward. There was wide agreement among our participants that shared decision-making is not just a quality practice, but that it also has the potential to address health inequity among Māori by facilitating participation in healthcare that better meets self-identified need. Others have thought similarly for other Indigenous populations.[[22]] Many of the ingredients for improved shared decision-making identified by our participants are supported by the literature: consumer trust,[[23]] autonomy,[[24]] good relationships and rapport with health providers,[[25]] culturally appropriate resources,[[26]] provider clinical competence and efficacious communication[[27]] and health provider cultural safety.[[28]] These “practitioner dependent” factors are important and are as demanding of attention as systemic causes of health inequity such as inadequate access to services, the social determinants of health[[29]] and the structural determinants of health, including racism.[[30]]

Summary

This work identified some structural issues in Choosing Wisely New Zealand that have limited the campaign’s ability to mitigate health inequities for Māori and helped to define a potentially transformative way forward. There was wide agreement among our participants that shared decision-making is not just a quality practice, but that it also has the potential to address health inequity among Māori by facilitating participation in healthcare that better meets self-identified need. “Practitioner dependent” factors like consumer trust, autonomy, good relationships and rapport with health providers and culturally appropriate resources are important and are as demanding of attention as systemic causes of health inequity, such as inadequate access to services, the social determinants of health and the structural determinants of health, including racism.

Abstract

Aim

Choosing Wisely seeks to prevent harm by reducing the number of unnecessary tests, treatments and procedures, and by promoting shared decision-making. This article scopes perspectives of Māori patients/consumers and Māori health practitioners around Choosing Wisely and explores shared decision-making between Māori and their medical practitioners.

Method

Eight Māori consumers and seven Māori health practitioners participated in a qualitative, semi-structured, in-depth interview study with an inductive thematic analysis.

Results

Participant feedback spanned issues from lack of Māori participation in programme governance through to practical issues like meaningful and literacy-appropriate health messaging, traversing consumer, practitioner, organisational and health-system aspects. Feedback further focused on the patient having trust in the practitioner, a sense of autonomy and the availability of advocacy and support in the consultation.

Conclusion

Despite a late campaign collaboration with Māori, Choosing Wisely New Zealand is the first of the international programmes to acknowledge the possibility that their initiative might increase inequity for Indigenous populations. This enquiry highlights the need to consult Māori early and to infuse Treaty principles and Māori knowledge and custom at every stage of the programme.

Author Information

David Tipene-Leach: Public Health Physician, Research Professor, Eastern Institute of Technology. Anna Adcock: PhD candidate, Victoria University of Wellington. Sally Abel: PhD, Independent researcher, Kaupapa Consulting. Derek Sherwood: Ophthalmologist, Nelson-Marlborough District Health Board, Braemar Campus.

Acknowledgements

We would like to acknowledge all our consumer, health practitioner and Māori health provider participants and reference group advisors who gave so generously of their time.

Correspondence

David Tipene-Leach, Eastern Institute of Technology, 501 Gloucester St, Napier 4112, 06 8301090 (DDI)

Correspondence Email

dtipene-leach@eit.ac.nz

Competing Interests

Professor Tipene-Leach is Chair of Te ORA. Dr Sherwood was Chair of Council of Medical Colleges in New Zealand during the conduct of the study and received personal fees from them. Anna Adcock and Sally Abel were paid by Choosing Wisely Aotearoa New Zealand as contract researchers.

1) Levinson W, Kallewaard M, Bhatia RS, et al. ‘Choosing Wisely’: a growing international campaign. BMJ Qual Saf. 2015;24:167-74. doi: 10.1136/ bmjqs-2014-003821.

2) Read D, Sherwood D, Ineson S. Choose Wisely - is more always better? NZ Med J. 2016;129(1447):10-1.

3) Stiggelbout AM, Van der Weijde, T, De Wit MPT, Frosch D, Légaré F, Montori VM, Trevena L, Elwyn G. Shared decision making: really putting patients at the centre of healthcare. BMJ. 2012;344:e256.

4) Ministry of Health. Tatau Kahukura: Māori Health Chart Book 2015 (3rd edition). 2015, Ministry of Health: Wellington.

5) Metcalfe S, Beyene K, Urlich J et al. Te Wero tonu - the challenge continues: Māori access to medicines 2006/07-2012/13 update. NZ Med J. 2018;131(1485):27-47.

6) Health Quality & Safety Commission. Patient Experience Wellington: Health Quality & Safety Commission, 2018. Available from: https://www.hqsc.govt.nz/our-programmes/health-quality-evaluation/projects/patient-experience/  

7) Loring B, Ineson S, Sherwood D, Tipene-Leach D. Choosing Wisely means choosing equity NZ Med J. 2019;132(1496):6-8.

8) Adcock A, Tipene-Leach D. Choosing Wisely Means Choosing Equity. Wellington: Choosing Wisely Aotearoa New Zealand, 2020.

9) Smith LT. Decolonizing Methodologies: Research and Indigenous peoples. 2nd ed. London & New York: Zed Books, 2012.

10) Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008;8(1):45.

11) Braun V, Clarke V. Using thematic analysis in psychology. Qualitative research in psychology. 2006 Jan 1;3(2):77-101.

12) Cram F. Improving Māori access to health care: Research report. Auckland: Katoa Ltd, 2014. Available from: https://www.moh.govt.nz/NoteBook/nbbooks.nsf/0/211DA45C5EA63205CC257DD8007AE977/$file/Access_ResearchReport.pdf

13) Rose G. Sick individuals and sick populations. Int J Epidemiol. 2001;30(3):427--32.

14) Reid S, White C, & Hoffman L. Health literacy and the prevention and early detection of gout. Auckland: Workbase Education Trust, 2014. Available from: https://www.healthliteracy.co.nz/site_files/13255/upload_files/Goutreport29.5.14-FINAL.pdf?dl=1

15) Berghan, G, Came, H, Coupe et al. Tiriti-based health promotion practice. 2017. STIR: Stop Institutional Racism Auckland, Aotearoa New Zealand. Available from: https://trc.org.nz/treaty-waitangi-based-practice-health-promotion  

16) HAUORA Report on Stage One of the Health Services and Outcomes Kaupapa Inquiry. Waitangi Tribunal Report 2019. Available from: www.waitangitribunal.govt.nz

17) Jull O, Crispo J, Welch V, et al. Interventions for indigenous peoples making health decisions: a systematic review. Pimatisiwin. 2013;11(3):539-54.

18) Jull J, Giles A, Boyer Y, et al. Cultural adaptation of a shared decision making tool with Aboriginal women: a qualitative study. BMC Med Inform Decis Mak. 2015;15(1):1.

19) Jull J, Mazereeuw M, Sheppard A, et al. Tailoring and field-testing the use of a knowledge translation peer support shared decision making strategy with First Nations, Inuit and Métis people making decisions about their cancer care: a study protocol. Res Involv Engagem. 2018;4(6):6.

20) Goodyear-Smith F, Buetow S. Power Issues in the Doctor-Patient Relationship. Health Care Analysis. 2001 9:449–462. Available from: https://doi.org/10.1023/A:1013812802937

21) The Connecticut Choosing Wisely Collaborative. Enhancing Patient/Clinician Communication: Leveraging Choosing Wisely as a Tool for Achieving Health Equity. Connecticut, The Connecticut Choosing Wisely Collaborative, 2017. Available from: https://largeuploads.blob.core.windows.net/uploads-lrg/EnhancePtComms.pdf

22) Jull J, Stacey D, Giles A, et al. Shared decision-making and health for First Nations, Métis and Inuit women: a study protocol. BMC Med Inform Decis Mak. 2012;12:146.

23) Palmer SC, Gray H, Huria T, et al. Reported Māori consumer experiences of health systems and programs in qualitative research: a systematic review with meta-synthesis. Int J Equity Health. 2019;18(163).

24) Edwards M, Davies M, Edwards A. What are the external influences on information exchange and shared decision-making in healthcare consultations: a meta-synthesis of the literature. Patient Educ Couns. 2009;75(1):37-52.

25) Groot G, Waldron T, Barreno L, et al. Trust and world view in shared decision making with indigenous patients: A realist synthesis. J Eval Clin Pract. 2020;26:503-14.

26) Reid S, White C, & Hoffman L. Health literacy and the prevention and early detection of gout. Auckland: Workbase Education Trust, 2014. Available from: https://www.healthliteracy.co.nz/site_files/13255/upload_files/Goutreport29.5.14-FINAL.pdf?dl=1

27) Jull J, Giles A, Boyer Y, et al. Cultural adaptation of a shared decision making tool with Aboriginal women: a qualitative study. BMC Med Inform Decis Mak. 2015; 15(1):1.

28) Nguyen, HT. Patient centred care: cultural safety in indigenous health [online]. Aust Fam Physician. 2008 37(12): 990-4. Available from: https://search.informit.com.au/documentSummary;dn=351890330015262;res=IELIAC  

29) Berwick, DM. The Moral determinants of health. JAMA. 2020; 324(3):225-6.

30) Crear-Perry J, Correa-de-Araujo R, Lewis Johnson T, McLemore MR, Neilson E, Wallace M. Social and structural determinants of health inequities in maternal health. Journal of Women's Health. 2021;30(2):230-5.

Contact diana@nzma.org.nz
for the PDF of this article

Subscriber Content

The full contents of this pages only available to subscribers.
Login, subscribe or email nzmj@nzma.org.nz to purchase this article.

LOGINSUBSCRIBE