A level playing field? Sport and racism

At the weekend it was my parents’ wedding anniversary. They got married in Dar es Salaam and one of the distinguishing features of their wedding was the hockey stick “guard of honour” that their friends created for them outside the church after the service (my Mum played hockey for Tanzania). The family capability and Goan cultural propensity to excel at sport (take Seraphino Antao the first Kenyan athlete to win a gold medal at the 1962 Commonwealth Games) skipped right past me. Mostly I enjoy the social, political and cultural issues in relation to sport like the national anthems, the medals and the underdog winning. The recent completion of a PhD (yes really) has also given me some confidence and time to begin to explore questions like the neocolonial exploitation of African players by European football clubs and how raw materials in the form of players are sourced, refined and exported for consumption and wealth generation in Europe leaving the African periphery impoverished. But that’s another blogpost. This post is about racism and sport, but I needed to do a geneaological manouevre and trace my own relationship with sport through my experience of being a Goan via East Africa now resident in Aotearo New Zealand. I’ve mapped some of the ways in which sport has been mobilised such as the re-shaping of personhood for colonised peoples and in turn the ways in which western sport has been appropriated by diasporic and marginalised communities as a form of resistance. I then talk about the prevalence of racism in sport, the contributing factors and what can be done.

Photo of Goans in Dar es Salaam via Jo Birkmeyer-submitted to Mervyn A Lobo’s blog 

The establishment of sport in colonial contexts was linked with Western Christian church activity and colonialism. Sports were introduced to meet both the needs of churches and colonial governments in transforming bodies into desirable shapes and capabilities so imperial reform could be undertaken by locals thereby creating physical and moral reform against existing less palatable indigenous norms. Games like cricket and football were intended to reinforce the superiority of colonial culture and transmit a particular moral order and values that were seen lacking in the colonised group such as team spirit, commitment, the sacrifice of individual aspirations to the group, bravery and so forth. Particular versions of masculinity were also being promulgated in a context where many Asian men were seen as effeminate.

In the diaspora, Goans formed clubs and institutions replicating village ties and loyalties back home which helped to allay loneliness, cultural alienation and the challenges of navigating a new country. In 1921 it was estimated that almost half a million Goans lived in Goa, Dama and Diu and that up to 200,000 Goans lived in British India, East Africa or Mesopotamia (James Mills, 2002). One quarter of that number lived in Bombay. Expatriate sports confirmed ties with the homeland, created a sense of community and provided an oasis from the demands of navigating belonging in racially stratified communities. Every Saturday after mass at the Holy Family Cathedral in Nairobi my parents would make their way with us to the Railway Goan Institute founded in 1909 which later became the Railway Institute in 1967. I have great memories of hurtling around (we seemed to do a lot of running along those wooden floors) and being spoiled rotten by my parent’s friends who would provide us with bottomless supplies of coke and crisps. Goans in Kenya also formed other clubs like The Goan Institute Mombasa in 1901, Goan Institute Nairobi in 1905 and the Goan Gymkhana in 1936 with sports an important focus of diasporic life.

Closer to where I live now in New Zealand, Indians in Wellington formed their own hockey team in 1936, which also marked the year that the Auckland Indian Sports Club (AISC) was established.

Photo reproduced with permission from Te Ara. Original article: Nancy Swarbrick. ‘Indians’, Te Ara – the Encyclopedia of New Zealand, updated 1-Sep-11
URL: http://www.TeAra.govt.nz/en/indians/5/5

Many other communities also made sport a focus of their activities, for example the New Zealand Chinese Association Annual Sports Tournament (AKA Easter Tournament) started in 1947 and runs every Easter Weekend. It consists of a sports tournament and cultural event for Chinese members and competitive sports like basketball, volley ball, touch rugby, netball, lawn bowls and golf are enjoyed. Similarly pan-ethnic events like the Ethnic Soccer Cup at the Auckland International Cultural festival are eagerly awaited and full of good natured fun and tough competition.

Photo by the Localist

Sport seemingly offers a transcendent space, where cohesion and connection is possible not only within and across diasporic communities, but also across dominant and minority communities. A phrase bandied around frequently last year was the way in which hosting the Rugby World cup in New Zealand “brought us together as a nation”.  Who of us will ever forget the ferocious and irrepressible passion of the Tongan community in New Zealand supporting their team? I love the ideal that sport can be a place where people with diverse interests, histories and values can be unified in one setting. I’ve watched with growing feelings of warmth the ways in which our Pacific players have infused “the game” of rugby with flair and energy and increased the ratio of tattoos, dreadlocks and eye-liner.

This illusion that sport can be a connecting force is challenged in Sara Ahmed‘s critique of the “happy” multicultural film Bend it Like Beckham. Directed by Kenyan-born, Punjabi British filmmaker Gurinder Chadha, Ahmed suggests that the central message of the film is that “the would-be- citizen who embraces the national game is rewarded with happiness”. The feel good vibe of this film ignores the negative affects surrounding racism and unproblematically represents visibly different migrants as patriarchal, closed, traditional, fixed and unchanging. White people can be inspired and warmed by Jess’ migrant success, as she bends the ball (a metaphor for disrupting cultural barriers) without needing to feel guilty about racism. The film plays into the notion that success is the reward for integration and is also proof that racism can be overcome.

My fantasy that the arrival of the first Asian All Black will give Asians more street cred and admiration has taken a battering with the racist responses to the “Linsanity” phenomenon. Jeremy Lin, the Asian American son of Taiwanese immigrants and graduate of Harvard has experienced spectacular NBA basketball success but the headline “Chink in the Armor,” or the tweet by Jason Whitlock referring to “two inches of pain” have deeply hurt many Asian Americans. Understandable, given the limited representation of Asian Americans in mainstream media and because the blatant racism provided a barometer reading of how this group are viewed in a racially charged landscape. But as Long, Tongue, Spracklen and others have noted, we live in a racist society so why should there not be racism in sport? Racist taunts and chants at matches and the throwing of banana skins at players have been supplemented by attacks via social media adding a new viciousness. A Welsh student was recently been imprisoned for using twitter to spread racist rants about acritically ill footballer Fabrice Muamba and locally, unhappy fans took to twitter to racially denigrate Blues coach Pat Lam.

Sport media coverage contributes to inequity by not reflecting social and cultural diversity. The MARS – Media against racism in sport programme– developed by The Council of Europe and the European Union recognises the following inequalities in representation in sports news stories:

  • Gender under-representation -where women comprise only one quarter of all stories despite making up half the population.
  • Migrants making up around 10% of the EU population but representing less than 5% of the main actors in the news in Europe.
  • Lesbian, Gay, Bisexual and Transgender (LGBT) people representing roughly 6% of the population of the United Kingdom but accounting for less than 1% of the population seen on TV.
  • 20% of the British population has an impairment or disability but less than 1% are represented on British TV.

These inequalities in sports media coverage reflect broader societal inequalities. The New Zealand Human Rights Commission’s annual review of race relations Tūi Tūi Tuituiā, Race Relations in 2011 released in March 2012 noted a “continuing degree of racial prejudice, significant racial inequalities, and the exclusion of minorities from full participation in all aspects of society”. The Commission identified racial prejudice in the form of: “negative attitudes to the Treaty, to indigenous rights, to Māori, Pacific peoples, Asians, migrants and refugees”. The report noted that these prejudices were implicated in discrimination, marginalisation, and inequalities, ultimately proving a barrier to the realisation of the social and economic benefits of diversity.

The racist soup of Pakeha media culture not only excludes particular groups but it also reproduces pathological, deficient and destructive representations of groups that are already discrimiinated against and marginalised. Take the “common sense” racism of Paul Henry, Michael Laws and Paul Holmes who all compete for New Zealand’s top racist.Take the comments by the former All Black and World cup Rugby Ambassador Andy Haden, who referred to a “three darkies”selection policy by rugby franchise The Crusaders. When Haden made an apology it was “to anyone who was offended” by the comments. He received a smack on the hand with a wet hanky from our Prime Minister John Key despite the outrage and I don’t think he had to resign. Key defended Haden’s actions as having a precedent in Paul Holmes‘ “cheeky darkie” comments in 2003. The gutless and useless Broadcasting Standards Authority refused to uphold 10 complaints over the  comments on Radio station Newstalk ZB. They acknowledged that the comments went beyond the limits of acceptability and breached broadcast standards, but they were happy that the actions taken internally by broadcaster were adequate. Thank goodness for writers with a conscience like Tapu Misa who is my only reason for continuing to purchase the morning newspaper and the long missed Karlo Mila from the Dom Post who can still remind us through her poetry that words scar.

Poster by Dudley Benson (2012)

Where there is power, there is resistance (Thanks Foucault). Racism (and anti-Semitism) in sport have also provided a space for protest and resistance. American sprinters Sam Stoller and Marty Glickman who were the only two Jews on the USA Olympic team, were pulled from their relay team on the day of the competition in the 1936 Berlin Olympics,. There was speculation that the American Olympic committee did not want two Jews to win gold medals in the context of Nazi Germany and Hitler’s Aryan pride. These are the same games where Jesse Owens won four gold medals.  Fast forward to the 1968 Olympics when Tommy Smith and John Carlos powerfully raised their fists on the podium in a Black power salute. The symbolism of this gesture referenced the black American community (black gloves); black American poverty (black socks, no shoes), black American lynching (Smith wore a scarf and Carlos a bead necklace).

Source Jonny Weeks:The Guardian

Closer to home, look at the stand many New Zealanders took against the Springbok rugby tour of 1981. 150,000 people took part in over 200 demonstrations in 28 centres and 1500 people were charged with protest related offences. The protests were in response to New Zealand opposition to the apartheid and segregation practiced in South Africa. These apartheid policies had impacted on team selection for the All Blacks, and Māori players had been excluded from touring South Africa by the New Zealand Rugby Football Union (NZRFU) until 1970. I take my inspiration from this event that “New Zealanders” might take their history into account and challenge the unacceptable comments against Pat Lam and show leadership over such behaviour.

So what are we to do about racism in sport? How can we use the values of sport, ostensibly fairness, teamwork, a fair go, equal opportunity, respect and care for each other to help us create a real level playing field, locally and globally? We can protest the sponsorship of the London Olympics by Dow (Union Carbide was merged into Dow and responsible for the tragedy at Bhopal not least 25,000 deaths and much much suffering). We can ask much more of our junk food media and not consume it as Jennifer Sybel suggests.  We can ask that the groups in our communities that are under-represented (disabled, women, LGBTQ, visibly different) get a fairer go and that  stories that purport to represent them contribute positively to our cultural and social diversity. We can take more responsibility for the actions of racist tweeters and taunters and recognise their actions come from consuming the same junk food media that we do. Rather than individualising their behaviour we can ask questions about what kind of playing field we have created and whether we want to put any effort into creating an alternative.

Illustration by Jim Sillavan for the Guardian

 

 

When helping does not help: Invisible children and colonialism

In almost thirty years of being a nurse I’ve learned that what one person thinks is helpful can be coercive to another. “Help” is complex, raising questions such as: how has the helper negotiated the relationship? Does the helper understand the problem? Do the people being helped agree with the helper’s framing of the problem? There is also the issue of power in the helping relationship. How did the helper get the power to help? What access to resources and knowledge does the helper have? Does helping disempower the helped?

The film and campaign KONY 2012 by Invisible Children and directed by Jason Russell about the Lord’s Resistance Army (LRA) led by the “monster” Joseph Kony has generated passionate pleas from a range of “friends” to support the “people” of Uganda. I am excited about the democratisation of information through social media, but I’ve been frustrated that this video has made us all “experts” about Africa. There is a bigger social and political backdrop to this story which has been tracked by Blackstar news and Akena Francis Adyanga.

My concern with this video is that it valorises the story being told by Invisible children (and other white people) at the expense of African leaders, without access to the same power structures or resources. The  documentary repeats the colonial imperative for Africa to be saved by white people. This video smacks of yet another colonial “civilising” project,  where the old binaries of colonialism are revived. These frame Africa as backward, while the west is modern; “we” are positioned as free while “they” are oppressed and so on. In this binary of good and bad, Africans are represented on the not so good side of the binary. Therefore, the solution must be a good one, a white one, and in this hierarchy Africans lose out. Local efforts and voices go unacknowledged in favour of the white saviour complex, which as Teju Cole suggests “supports brutal policies in the morning, founds charities in the afternoon, and receives awards in the evening”. Even the name  “Invisible Children” as the Sojourner project points out “denies and co-opts the agency of Ugandans – many of whom have organized to protect child soldiers”.

I have a stake in this propaganda video on several fronts. One is my personal experience of being born in Tanzania to parents who were also born in Tanzania and and having two sisters who were born in Kenya. My own life has been shaped by three versions of colonialism: German, Portuguese and British, and continues to be shaped by colonialism’s continuing effects in the white settler nation of Aotearoa/New Zealand. Secondly, in my doctoral studies, I investigated the colonial legacies of health and nursing in the context of migrant maternity. My profession of nursing is not only an altruistic and caring enterprise, but is also complicit with biomedicine in the advancement of colonialism and imperialism. Medicine has used imperial claims to modernity and universalism, while the concept of “health” has in turn has lent moral credibility to the colonial enterprise. Consequently, one of my theoretical and political commitments is the resistance to imperial cultural analysis. I abhor the white saviour narrative, where vulnerable children or women of colour must be rescued from men of colour by “culturally superior” white men or women.  We need less individualising narratives, where the full social, political and historical contexts of a situation can be considered.

So what does a process such as colonialism have to do with this video? European colonialism put in place hierarchies of superiority/inferiority and structures of domination and subordination. The conquest and control of other people’s land and goods has recurred throughout human history, but European colonialism in the 19th century allowed for the growth of European capitalism and industry through the economic exploitation of raw materials, cheap, indentured or slave labour and profitable land in the colonies. Profits always returned to the imperial centres. Domination and authority were supported by defence and foreign policies and internalised so that ordinary “indeed decent men and women accepted their almost metaphysical obligation to rule subordinate, inferior, or less advanced people” (Said, 1993, p.10). These imperial ventures were justified on the basis of developmental and pedagogical notions of progress and improvement. They created the template for contemporary production under globalisation. So none of us are outside of or immune from postcolonial relations, values and belief systems whether our ancestors were colonisers or colonised. We are all influenced by colonialism.

Narratives produced about the colonies have historically defined the West in contrast with the “Orient”. The Orient was represented in a denigrating and negative way, in order to represent a civilised and positive Britain. Generalisations were made about groups of people who were treated as a homogenous mass (rather than communities of individuals) about whom knowledge could be obtained or stereotypes created – for example ‘the inscrutable Chinese’. The video plays into this oppositional dichotomy of “us” and “them”, constructing two social groups as distinct and internally homogenous. It begins with a sense of connection, it targets our desire to belong and connect by talking about social media, emphasising what we have in common. However, the “we” that it refers to is white. The video then moves to the “other” and the mobilisation of social movements that social media allows in the form of the Arab Spring. The director Russell then shares a very personal experience of the birth of his son and how his son takes part in his father’s film work and activism. The son embodies Russell’s desire for a better world than the one he came into “because he [my son] is here, he matters”. Russell then takes us to Uganda and the experience of another young man who has had a different life from that of his son. A young man who has experienced loss and unimaginable suffering, who has no future because of Joseph Kony. Russell says something like “you mean this has been happening for years? If this happened in America for one day it would be on the cover of Newsweek”. How can we fail not to be moved? Rusell takes us through the journey he makes with his friends of trying to raise the attention of the United States government of the plight of this young man and eventually through the advocacy and donations of lots of young people who donate small amounts of money every month, the government takes action. Of course this might have nothing to do with the fact that oil was found in Uganda in 2009. Russell in his voice over says they did not wait for governments, they’ve built schools, created jobs, created warning systems to keep people safe. All funded by young people.  Russell invokes liberal humanist arguments (the very ones that were central to colonial capitalism) about the right of the individual to have a good life. As Teju Cole righly points out “the White Savior Industrial Complex is not about justice. It is about having a big emotional experience that validates privilege”.

The video enacts the binary colonial script of the civilised and liberated white person who rescues Ugandan children, thereby affirming the superiority of the former. Russell reproduces the narrow representations of people of colour as a mass of oppressed people who live in a world without freedom, ruled by oppressive vain tyrants (oops that sounds like the West!). He reproduces a flattened and familiar “single story” of Africa. As Chimamanda Ngozi Adichie says “the single story creates stereotypes, and the problem with stereotypes is not that they are untrue, but that they are incomplete. They make one story become the only story.”  In the process, the complexity and diversity of people’s lives are lost and local activism is hidden from view in favour of camera crews with resources and magnanimity. Think about Binyavanga Wainana’s essay, How to Write about Africa:

Never have a picture of a well-adjusted African on the cover of your book, or in it, unless that African has won the Nobel Prize. An AK-47, prominent ribs, naked breasts: use these. If you must include an African, make sure you get one in Masai or Zulu or Dogon dress

The effect is that we focus on the other, instead of looking at the monsters in our own communities. Rather than offering our support to the efforts of indigenous people who are quietly attempting to right wrongs without a television camera present, we get carried away in a tide of righteous indignation about “stopping the monster”.The video provides a depository for our own feelings of powerlessness and frustration. It demands very little of us. We don’t need to be accountable to a faceless mass, because we can trust Russell, we’ve seen the birth of his boy child, we’ve seen him in his kitchen, we’ve seen him in the family bed with both his children. He is trustworthy. Never mind facts such as Kony is no longer in northern Uganda, that the Ugandan army have also contributed to the violence meted out to civilians, that General Museveni used child soldiers way back in 1986 or that only 31% of funds that Invisible children receive go into this charity work.

So what does helping really mean in a different social context? How does sharing a link to a video to an organisation that is barely transparent about its funding, that uses the bodies of children to make a point, that carries us away with the injustice of it all, help? How does the fact that the focus now in Northern Uganda is about repatriating child soldiers who are being held in DRC, Sudan and the Central African Republic, on postconflict rehabilitation and the reintegration of child soldiers? What impact will this film have on former child soldiers who have now reintegrated into  their communities? Can something with good intentions lead to misconceived interventions? Hell yes! The history of modern Africa is replete with aid failures and poorly allocated resources.

I am not against standing up and fighting for what is right, but only when we really understand what we are standing up for, not on “zero knowledge and maximum hysteria” as Elliot Ross argues. So we must make the most of this technology that is available to us and to critically interrogate the sources of this new media, their motivations and their operations . We need to do the research, to ask questions about our own complicity in contemporary geopolitics and to support the people who understand the problem.

Power relations

Hot off the press! I’ve just had this chapter on power relations published in S. Shaw, A. Haxell & T. Weblemoe (Eds.), Communication and lifespan development. Melbourne: Oxford University Press

Many practitioners see themselves as apolitical and powerless, particularly with regard to their relationships with the structures of medicine and management. However, in reality practitioners are powerful both as individuals and as members of the groups with which they identify. The structures and cultures within which most health and disability practitioners exist and work are based on beliefs and practices that constrain autonomy. These constraints are at work through a number of mechanisms, such as the market, the infusion of targets and performance measures and quality programmes (Newman & Vidler, 2006). In addition, the changing role of consumers or service users from passive recipients of care in the past to people who may be informed, empowered, articulate and ‘demanding’ poses a threat to the ‘knowledge–power knot’ on which professional power rests.

When practitioners view themselves as people who are doing good, they tend to lack awareness of their complicity and embeddedness in relations of power that structure inequality. Yet, power is embedded in everyday practices and interactions (Bradbury Jones, Sambrook & Irvine, 2008). Practitioners within the wider health and disability sectors contribute to social regulation through their roles as employees of the state. They enact government policies for the benefit of the health of the citizens of the state; so they are both governed and governing. Members of recognised professional groups are provided with a moral authority by their capacity to define problems and pose solutions, and their role in defining and evaluating good or normal behaviour and health practices through surveillance of the population and the criteria for interventions on behalf of the state (Gilbert, 2001, p. 201).

These ambivalent relationships with power that are evident among health professionals require exploration. This can be done by considering the various ways in which power is conceptualised and the micro and macro definitions of empowerment. Some shifts in power have occurred in the last few decades, largely influenced by various social movements. Maternity and mental health are two particular examples of professional practice and service delivery in which power can be recognised and ideas of empowerment can be translated meaningful engagement between service delivery and those who engage with the service.

People of colour decolonisation hui

The Decolonise Your Minds! Hui on February 5th in Tamaki Makaurau, Aotearoa provided a great opportunity to present my PhD work to awesome folks with similar theoretical and political commitments. Outside a professional or academic context and supported by fabulous vegan food and great korero and creativity, the radical space provided a great opportunity to not have to explain everything!

In my presentation, I talked about the ways in which the people who are supposed to care in institutions can engage in subtle coercions and “do” violence. This violence works through the reproduction of taken for granted norms and values, such that pressure is exerted on those whose personhood sits outside the accepted norms and values and reshapes their personhood. Reflecting an assimilatory process similar to the colonial process of moral improvement. Hardly a surprise considering that institutions like health and education are colonial, having been transplanted from the metropole to the colony and super-imposed over indigenous ways of learning and maintaining health.

Using the example of maternity I talked about the ways in which heath professionals draw on culturally and socially available repertoires of care that can be less than helpful when imposed on women of colour. This is because so often these repertoires are drawn on the basis of an implicit ideal user who tends to be cis-woman, heterosexual, white, middle class and one who takes up the ‘imperative of health’. That is the ideal neoliberal consumer who makes herself an expert through her consumption of self-help books and its acceptable accoutrements, who takes responsibility by attending ante-natal classes and who labours naturally with her loving and supportive partner present. She obeys the edicts of the health professional and makes reasonable requests that align with the dominant discourse of maternity as an empowering experience (if you are “informed” and “take responsibility”).

You can listen to the audio which is hosted by the Pride New Zealand website. I take the audience through the idea of discourses and how they shape subjectivity and practice.

Please note I have a tendency to swear when I am speaking passionately about something!

Adapting to New Zealand’s super-diversity

Originally published in  Contact: Newsletter for members of the Pharmacy Guild of New Zealand, December 2011-January 2012  (Issue 11), Pages 8-9.

New Zealand has earned the right to call itself super-diverse. this term refers to an unprecedented level and kind of complexity that surpasses anything previously experienced in a particular society. This super-diversity leads to new conjunctions and interactions, and outcomes that extend beyond the usual ways of understanding diversity.

Super-diversity is a relatively new phenomenon given the relative homogeneity of the New Zealand population. The arrival of super-diversity, its impacts and the relevance of super-diversity to pharmacy are the focus of this article.

Why is ethnic diversity and super-diversity relevant to pharmacy? And why is a nurse with a PhD writing about it? Perhaps it is because nurses and pharmacists have a lot in common. We see a lot of people and we tend to have very regular, intimate and long- term relationships with people (if we are doing something right). If we are not, people vote with their feet. Given this ubiquity, how can we ensure that we make a difference in the context of super-diversity?

New Zealand’s super-diversity kicked in with Asian migration in the 1990s. Prior to that, New Zealand had preferred particular “source countries” to select migrants from (Great Britain and Ireland). This homogeneity of migrants was altered by Polynesian Pacific migration from the 1960s, but it was the migration policy changes of 1987 that paved the way for skilled migrants from a range of countries to arrive, notably Asia.

These demographic changes led to a philosophical shift from assimilation to multiculturalism in the context of biculturalism. The expectation of newcomers to assimilate (give up their ways to fit into a new culture) was changed to reflect the notion of New Zealand as an inclusive society where the integration of newcomers was supported by “responsive services, a welcoming environment and a shared respect for diversity”.

But the effects of assimilation can be seen on the health of Maori and Pacific people who experience health inequalities and a lower life expectancy than Pakeha. We are beginning to see these same trends in Asian and MELAA (Middle-Eastern, Latin American and African) communities. It is easy to write-off the poor health of particular groups to their individual behaviour or their culture. But there is growing evidence that health professional behaviour contributes to creating and reproducing disparities as seen by the differential quality of healthcare different racial and ethnic groups receive.

Cultural competence is a strategy for reducing health disparities and activating health gain. The American Society of Health-System pharmacists (ASHP) suggests that medication therapy management is central to many health disparities including diabetes or end-stage renal disease which disproportionately affects particular groups (for example, Maori) that pharmacists are in a position to directly address these disparities or to change the language away from deficit to health benefit or gain.

The Health Practitioners Competence Assurance Act 2003 requires that all health professionals are competent and fit to practice. There are seven standards for New Zealand pharmacists that articulate the knowledge, skills, attitudes and behaviours necessary for competence. The standard that is most relevant to cultural competence is Standard One which requires that pharmacists practice pharmacy in a professional and culturally competent manner.

Cultural competence approaches require the health professional and the institutional system of health to adapt the ways in which they deliver services in order to accommodate difference. these require the health professional to focus on three main areas.

  • The first is to be aware of how the patient or client’s health beliefs, values and behaviours are shaped by their culture or religion.
  • The second is a focus on learning about what shapes health behaviours, disease epidemiology, ethno-pharmacology and complementary health practices located in different groups.
  • The final area is that of communication where the role of the health professional is to elicit the client’s health beliefs, develop a therapeutic alliance and utilise strategies that enhance communication such as working with professional interpreters (funded in some areas) or using the pharmacy translation Kit developed by the guild, for example.

New Zealand also has an indigenous strategy called cultural safety. The emphasis, here, is on the beliefs and attitudes of the health professional rather than that of the client. Careful reflection on the assumptions that underpin the culture of the profession or the service is required because these very assumptions can be assimilatory and disempowering for people who are not invested in them. Such assumptions as the belief that the individual is solely responsible for their own health, that Western medicine is the only valid mechanism for dealing with ill-health require conforming to the system, rather than the system adapting to the needs of the patient or client. These assumptions might pose a barrier to caring for someone who does not hold those beliefs.

Instead of doing what we’ve always done, we might be inspired to develop new ways of thinking and practicing that could benefit all people and communities in this super- diverse New Zealand.

 

Becoming informed health care consumers: Asian migrant mothers in NZ

Presented at the Prevention, protection and promotion. Second International Asian Health and Wellbeing Conference, November 11,2006.

Cite as: DeSouza, R. (2006). Becoming informed health care consumers: Asian migrant mothers in New Zealand. In S. Tse, M.E. Hoque, K. Rasanathan, M. Chatterji, R. Wee, S. Garg, & Y. Ratnasabapathy (Eds.), Prevention, protection and promotion. Proceedings of the Second International Asian Health and Wellbeing Conference, November 11, 13-14, (pp. 196-207). Auckland, New Zealand: University of Auckland.

Abstract
A central tenet of New Zealand’s midwifery and maternity services is the emphasis on a partnership between two equals namely the midwife and the woman. However, such a partnership rests on the notion of an informed consumer who is independent. When the consumer is a migrant who has experienced social upheaval, lost their knowledge resources and is experiencing isolation and language barriers, they may take up a more dependent role rather than the autonomous and self-determining consumer that midwives are prepared for. This imbalance can mean that health professionals are challenged to take up less facilitative and more authoritative positions and in turn migrant mothers and their partners are challenged to develop more proactive roles. This paper presents partial and preliminary findings from a qualitative study of Asian mothers in New Zealand with regard to their information needs.

Introduction
The notion of a partnership between the midwife and the woman underpins New Zealand midwifery models, where both parties are equal and make equally valuable contributions (Pairman, 2001). Midwives bring their knowledge, skills and experience and the woman brings her knowledge of herself and her family and her needs and wishes for her pregnancy and birth. However, for women become equal partners, they need to make informed decisions about their health and this in turn depends on having access to relevant and timely information. For mothers, biological knowledge about the pregnancy, birth and labour is only one form of knowledge. In addition, social knowledge and institutional knowledge are important (Lazarus, 1994). While biological knowledge can be obtained from authoritative sources like experts and electronic resources, social and institutional knowledge are more difficult to access for migrant women. AS access to these forms of knowledge is dependent on context and social networks which migrant mothers often lose in the social upheaval of migration. For many women who migrate, the separation from family and peers leads to ‘breaks in knowledge’ (Fitzgerald et al., 1998) and the loss of these knowledge resources which help prepare the mother for the processes of pregnancy, childbirth and parenting, creates what Liem (1999, p.157) calls a “vacuum of knowledge”. The vacuum of knowledge needs to be filled and most often this role falls heavily on health professionals (DeSouza, 2005).

This paper begins with a description of the dramatic population changes in New Zealand with a particular focus on Asian women. A discussion about receiving accurate and timely information follows suggesting that the quality of communication between women and their carers is critical for feeling safe and satisfied with care. An outline of research conducted in Auckland New Zealand follows and the findings are presented through the transition to parenthood. Strategies for managing the transition to parenthood and becoming an informed consumer are discussed with the paper concluding with practice, policy and research recommendations.

Literature Review
The following section contextualises the study by reviewing the changing demographics in New Zealand society with a focus on Asian women. This is followed by a discussion about the link between information and communication and satisfaction with care for migrants.

An increasingly diverse New Zealand
Service providers need to develop skills and competence for working effectively with diverse members of New Zealand society. International trends show that people of diverse racial, ethno-cultural and language backgrounds are underserved by health and social services, experience unequal burdens of disease, experience cultural and language barriers to accessing appropriate health care, and receive a lower quality of care when they do access health care services in comparison with members of the population (Johnstone & Kanitsaki, 2005). The 2001 Census revealed growing numbers of M␣ori (14.5%), Pacific Island people (5.6%), Chinese (2.2%) and Indian (1.2%), in addition to European/Pakeha who make up 79.6% of the population. There has been a 20% increase in the number of multilingual people and an increase in people whose religion was non-Christian. People who practice Hinduism increased by 56%, there was a 48% increase in Buddhists and a 74% of people practising Islam.

Asians are the fastest growing ethnic group; increasing by around 140% over the last ten years and predicted to increase by 122% by 2021 due to net migration gains rather than high fertility rates (Statistics New Zealand, 2005). The Asian community has the highest proportion of women (54%), (Scragg & Maitra, 2005) who are most highly concentrated in the working age group of 15-64 years compared to other ethnic groups, a reflection of a skills focused migration policy. 23% of New Zealand women were born overseas, predominantly in the UK and Ireland, Asia and the Pacific Islands. Some of the most dramatic demographic changes are evident in the Asian community, for example in the period between 1991 and 2001, the number of women originating from the Republic of Korea increased 23 times from 408 to 9,354, numbers of women from China quadrupled from 4,620 to 20,457 and women from South Asia doubled in the same time period (Statistics New Zealand, 2005). Such diversity has been unprecedented and present both unique challenges and opportunities to health and social service providers and policy makers.

Communication, caring and safety
Migration often results in the loss of reference points in the form of family networks, peer support and familiarity with health services. Such a loss amplifies the necessity for receiving accurate and timely information. Davies and Bath (2001) suggest that information provision during pregnancy and childbirth is critical for both supporting choices that are made but also in preparing women to manage uncertain outcomes. Citing a study by Kirkham (1989), Davies and Bath argue that women’s satisfaction with maternity services in secondary care is primarily dependent on the quality of communication between the women and their carers. Little is known about the health care experiences of migrant women, however, they are thought to report more acute concerns about communication and sensitivity of care than the population in general (Davies & Bath, 2001). Furthermore, language barriers can exacerbate isolation and promote dependency on health workers rather than enhancing self- determination, a dominant midwifery discourse. Small, Rice, Yelland, & Lumley (1999) found that Vietnamese, Turkish and Filipino women in Melbourne who were not fluent English speakers experienced problems in communicating with their caregivers and this made experiences of care less positive. Of more importance than knowledge about cultural practices, was care experienced as unkind, rushed, and unsupportive. Another Australian study found that migrant patients (and their families) did not feel safe when in hospital. Safety was undermined when effective communication with caregivers was compromised through being unable to access qualified health interpreters or being unable to have family members around to advocate and participate in decision-making (Johnstone & Kanitsaki, 2005).

The study
Migrants tend to maintain better health than the local population initially so often have little to do with hospitals (McDonald & Kennedy, 2004), but motherhood is a common aspect of migration requiring contact with the health system. The study took place in Auckland, New Zealand among White migrants (from South Africa, United Kingdom and the United States of America), Muslim Arab migrants (from Iraq and Palestine) and Asian women from three ethnic communities (Korean, Chinese and Indian) as part of a larger Families Commission funded study. Ethics approval was obtained from the Auckland University of Technology Ethics Committee and the Plunket Ethics Committee. Participants for the migrant mothers’ focus group were recruited though Plunket nurses who invited women to participate, selection criteria limited participation to migrant women who had become mothers within the last 12 months in New Zealand. Informed consent was obtained from all participants and consent forms were translated into Arabic, Korean and Chinese. Data collection involved focus groups using semi-structured interviews conducted in English, Chinese and Korean. The groups were facilitated by interviewers proficient in English and the language spoken by the women. These interviews were recorded and transcribed, translated into English if necessary and verified by an independent translator. The interview transcripts were then coded and analysed. The codes were clustered according to similarity and reduced. Similar phenomena were grouped into categories and named. The process was one of constant comparison, iteratively classifying and grouping the material to identify preliminary categories and sub- categories. This paper reports on a sub-theme about information needs and the findings focus on Asian women.

Findings
Midwives caring for migrant Asian parents are challenged to reconfigure their model of partnership and in turn migrant Asian parents experience a shift from birth being a social event to more of an individual responsibility. This shift requires a more proactive and self- sufficient role for women and their husbands, who become more involved than they might have been in their country of origin. In addition, language and communication drive experiences of care. This separation from knowledge resources places greater responsibility onto midwives to assume a more central role in information provision and support. In particular migrant mothers require detailed, individualised, stage specific information in order to take up the role of informed consumer.

Antenatal period
Not only are migrant mothers confronted with changing bodies and roles when they become pregnant, they also have to deal with an unfamiliar health system in the absence of a support network and knowledge resources they might have had in their countries of origin. In this study, Asian migrant women had to make decisions that required access to information in order to ascertain the choice of maternity carer and access to ante-natal classes. At this time women who were not fluent or confident English speakers had to contend with linguistic and cultural barriers to accessing services.

The loss of traditional sources of knowledge meant that pregnancy in a new country moved from being a social event and responsibility to being an individual one (DeSouza, 2005). This required the participants to become more involved and proactive in seeking out detailed, timely and specific information about the stages of their pregnancy. This allowed them to become more involved in the pregnancy than if they had been in their country of origin where this responsibility would have been shared. Husbands also became more involved in the processes of pregnancy, than they might have been in their countries of origin. Knowing where to begin the process was difficult:

I had no idea at all about the system here. It was through the pregnancy test kit that I found out I was pregnant, but did not know what the next step was. I wondered whether I had to show my test result to my GP. I had no knowledge of how to get the necessary information [Korean participant].

Obtaining language specific and precise information was important for many Korean women. Being given broad encouragement was not a substitute for specific information and was perceived as a laissez-fare attitude to their wellbeing.

I was given some information, but I didn’t read it, as it was not in Korean. I always felt that I was one step behind. It was not only the midwife who did not give enough information or necessary support. Everyone kept saying, “It is okay, you are doing well” but gave few information or specific support [Korean participant].

Pregnancy in a new country raised the need to develop active decision making strategies and to choose a health care provider. Many of the women were proactive about finding out about the New Zealand health system and turned to authoritative sources for information:

Luckily, I was attending school and the assignment from school was to complete a project. I chose ‘New Zealand’s maternity system’ and that was how I got some ideas about my situation [Korean participant].

For some women the absence of family members and the access to information meant that they could monitor themselves through the stages of pregnancy and this led to developing increased knowledge and greater self-sufficiency:

I have to take care of my own self. I found this good thing in New Zealand that you should take care of the baby and you should be aware of foods and what is going on each and every month, each and every week, what really is important [Indian participant].

One Indian woman found that she was more engaged in her pregnancy because her previous pregnancy was a joint responsibility with other family members while this time round she had to take more personal responsibility:

Why didn’t I get the feelings the first time? Time passed with families, mother in law, sisters, brothers and time passed like anything but here we are alone,  thinking about the baby early and so every moment for me was a first time moment, even though I’m a second time mother [Indian participant].

Many husbands become more involved during the pregnancy and were more in tune with what was happening to their partner’s bodies:

We used to wake up and the first thing we used to do was take a book and read ‘Okay, so now our baby’s doing that’ and he will pat me on my tummy saying ‘Oh my little one’ you know? So I doubt whether the same feeling would have come if my pregnancy was in India [Indian participant].

Language dictated the choice of LMC for many Chinese women and they, more than any other cohort, relied on their networks to find a care provider with Chinese newspapers also being a useful knowledge resource.

She speaks English and can speak Chinese. After I met her, I had a good impression of her. So I decided to have her as my midwife. My midwife has a partner who is also a Chinese (Malaysian Chinese). When I gave birth to my child, her partner delivered my child. The whole process was quite smooth [Chinese participant].

Antenatal classes
Antenatal classes were a pivotal mechanism for acquiring knowledge:

When you know something it’s better than just going without knowledge and you’re worried. , Yeah and as a first time mother I didn’t really know what was going to happen or what to expect and then yeah, I learnt a lot from that [Indian participant].

And for gaining confidence about what was to come by having some broad knowledge about what was to come:

I felt it was not so relevant to my delivery. But I felt more at ease and more confident during delivery. There are Chinese people in the class. The midwife was also careful when teaching us. We could understand her. My husband’s English is very good. He escorted me to the class. It was about some basic ideas. I didn’t find it useful for my delivery. During delivery, you follow the instructions of your midwife and have no time to reflect on what was taught in the class. But you feel relieved and less anxious. You roughly know what is going to happen and what is what [Chinese participant].

But language barriers made classes inaccessible for some:

I felt frustrated because I could not understand everything [Korean participant].

Both my husband and I have poor English so only attended once [Korean participant].

This section highlighted the importance of receiving detailed and specific information in one’s own language and how this influences the choice of LMC or attendance at ante-natal classes. Knowing where to start can be difficult. For women and their husbands who want to take up an informed consumer role there are resources available which lead women and their husbands to be more self-sufficient, proactive and engaged in the process.

Labour and delivery
Labour and delivery was also a time when information, support and cultural needs were highlighted. Women wanted information that was specific to their stage of labour and that was individualised (some felt they had too much and others too little information to feel that they could make the best choice for themselves). The value of specific stage by stage information was supported by a Korean participant rather than broad encouragement:

In Korea mums are given lots of warning and feedback of what is happening during labour, and told by Dr’s what to do regularly. This was missing in NZ. It would be good to be given feedback of our progress of labour and how many cm we are at each stage after the vaginal examinations. I was not told this. Not enough explanation and only told that “You are doing well” [Korean participant].

The need for not only specific information but also to be told the best option or given enough information to make the best choice was also voiced. The facilitative role of health providers was called into question with some participants wanting a more authoritative role. The partnership between the midwife and the woman underpins the midwifery model in New Zealand maternity services and is based on equity and the acknowledgement that both parties make equally valuable contributions (Pairman, 2001). Midwives bring their knowledge, skills and experience and the woman brings her knowledge of herself and her family and her needs and wishes for her pregnancy and birth. Midwives have moved from authoritative sources of knowledge to models of partnership and collaboration in a bid to empower women and distinguish themselves from the more hierarchical professional models of medical, nursing and obstetric practise (Tully, Daellenbach, & Guilliland, 1998). However, this is predicated on the notion of the informed consumer:

In NZ different delivery options are given to mums and we are asked to choose by ourselves but unable to choose the best options for ourselves due to lack of sufficient knowledge. Want more advice and guidance and even want to be told which better option for us is. So in the end we have limited options due to not enough knowledge of all the pros and cons of delivery methods [Korean participant].

Information does need to be individualised, one participant who felt that she was given too much information:

During the labour the ladies said that I need an epidural because I can’t go through the pain anymore, the anaesthetist comes in the room and says out of 150 million there are 10% of cases with risk all that information beforehand [Indian Participant].

This section has highlighted the importance of detailed and specific information and the need for information to be individualised. The midwifery model of care which emphasises facilitative rather than authoritative relationships was challenged.

Post-partum
The postnatal period is a critical time for women but it is also a time when their needs are often not met (Baker, Choi, Henshaw, & Tree, 2005). In the postpartum, information needs were an issue, women needed to know how to handle an unpredictable and unknown baby, there were issues around feeding from a cultural point of view and what to feed and when, the amount and type of information became important too:

We need more information. Iron deficiency for example. We don’t know what to feed our babies for this. And solid feeding too. We don’t know how to begin solid feeding with Korean food. The information is only on Kiwi way of feeding [Korean participant].
I didn’t even know how to care for her after delivering baby. No knowledge. Had to cook and clean and do everything after delivering baby , had no one to help. Breastfeeding was hard, received no help. Got sore bones and joints. No Korean appropriate services available, so often missed out altogether on information and the right kind of help [Korean participant].

However, not everyone wanted to be an informed consumer:

Yeah, you just want to get out of that place and these people are giving you like the advantages and disadvantages of various things, you don’t want to hear all these things [Indian participant].

The post-partum period highlights the need for the expansion of the information agenda from New Zealand models of infant feeding to incorporating other cultural models and the need for language specific information about breastfeeding. Some women contested the pressure to be informed consumers. The following section provides some discussion and recommendations.

Discussion

This section focuses on five key areas where further exploration and consideration by both migrant mothers and health professionals would be beneficial, namely:

  • Providing detailed and individualised information;
  • Language support;
  • Preparing women for new discourses of maternity;
  • Developing fluency; and
    Developing health literacy.

Providing detailed and individualised information

Health-care providers have a responsibility to make available, accessible and up-to-date information. However this is not as easy as it sounds, when facilitating informed choice. Midwives and other health professionals are caught in a difficult position and have to strike other balances, such as between giving enough information for the woman to make a choice but not giving too much information and frightening her (Levy, 2006). They also have to delicately meet the needs of women and to appear neutral in their advice, when they might have strong feelings regarding certain issues. In this study, migrant mothers looked to health professionals to fill the vacuum of knowledge by being authoritative rather than facilitative. Increasingly research shows that information is more effective when it is tailored to the individual and their needs (Rapport et al., 2006) and relevant to the women’s current stage of pregnancy (Benn, Budge, & White, 1999). In addition detailed information rather than ‘big picture’ was valued. Therefore highlighting the need for individualised and detailed information when planning for the provision of maternity information (Soltani & Dickinson, 2005). Information that is available in ones own language or written information is important. While translated information is available about childbirth in New Zealand from the Maternity Services Consumer Council of New Zealand it is not clear how well this information is distributed or whether LMCs are aware of its existence.

Language support
Communication as a part of information support can be improved through implementing a two pronged strategy. First, health professionals and systems can become more skilful at information provision through linguistic competence and secondly through identifying and assisting in the extension of sources of information. Health providers can assist new migrants to identify information sources and encourage women to develop information seeking skills. Developing linguistic and cultural competence can be achieved by:

  • Providing bilingual /bicultural staff;
  • Providing foreign language interpreting services; Having link workers/advocates; and     Having materials developed and tested for specific cultural, ethnic, and linguistic
    groups;
  • Having translation services including those of:Legally binding documents (for example, consent forms); Hospital signage; Health education materials; and Public awareness materials and campaigns, including ethnic media in languages other than English. Examples include television, radio, internet, newspapers and periodicals (Szczepura, 2005).

In the USA, health care organisations are required to both offer and provide language services such as bilingual staff and interpreter servicesat no extra cost to clients who require it. It is recommended that information about services is provided both in writing and in a timely manner with credentialed interpreters and bilingual workers available (U.S. Dept. of Health and Human Services, 2003).

Lastly, research is needed to assess the level of unmet information needs among new migrant women in greater depth. To borrow from a recommendation from a recent study:
Research is needed on cross-cultural and intercultural communication in particular on the nature and impact on Culturally and Linguistically Diverse (CALD) people not being able to communicate with service providers; not being able to get information and explanations about ‘what is going on’; not being able to get information in a timely manner; not being given information in a culturally appropriate manner; not being given any information at all; being given too much information; being given unwanted information (Johnstone & Kanitsaki, 2005, p.15).

Preparing women for new discourses of maternity
The study findings highlight the need for health providers to assist women socialise into new discourses in particular the discourse of partnership and the informed consumer. A useful mechanism for socialising women into an informed consumer discourse is to provide multi- lingual antenatal classes. Many women in this study felt the need for specific and detailed information in order to make the best choice but some women also wanted to be told the best option. The facilitative role of health providers was called into question with some participants wanting their LMC to have a more authoritative style. The partnership model underpinning midwifery in New Zealand maternity services assumes that midwives bring their knowledge, skills and experience and women brings their knowledge of themselves and their families to the relationship. This is intended to be a collaborative and empowering relationship but it requires that the woman wants the responsibility of being an informed consumer. It appears that the notion of partnership cannot contain women who don’t want the equal responsibility that is required. In addition, one needs to be information literate in order to take this role on (Henwood, Wyatt, Hart, & Smith, 2003).

Developing fluency
Lack of English language proficiency impacts on access to health care, employment prospects, income levels and other factors which determine health status (Asian Public Health Project Team, 2003).The link between language and accessing health care is further strengthened by the findings of a New Zealand study where self-rated fair or poor health was found to be associated with Chinese-only reading knowledge, residency of more than five years and regretting having come to New Zealand (Abbott, Wong, Williams, Au, & Young, 2000). While a study of Chinese American women which found that lack of English language ability was a major barrier to access (Liang, Yuan, Mandelblatt, & Pasick, 2004). Ensuring that migrants are aware of Language line and encouraging them to take up their English for Migrants language courses, as proficiency is a key settlement enhancer. The migrant levy that migrants pay when coming to New Zealand entitles migrants to take up English language classes (English for Migrants). The Tertiary Education Commission pays for English language tuition on behalf of migrants to New Zealand who have pre-paid for their training, recent news reports indicate that few migrants take up these classes.

Developing health literacy
The development of health literacy among health care recipients is gaining prominence as a health promotion strategy. Health literacy is defined by the World Health Organisation as “ the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health” (World Health Organization, 1998, p.10). Health literacy is a stronger predictor of health status than socio-economic status, age, or ethnic background (Speros, 2005). Speros claims that the lack of health literacy can act as a barrier to navigating the system and functioning successfully as a consumer, presumably then the combination of socio-economic status, ethnic background and low health literacy compound the issues of access. Speros cites a large study by Williams et al. (1995) which found that one-third of English -speaking patients at two public hospitals in the USA could not read and understand basic health-related materials. Sixty per cent could not understand a routine consent form, 26% could not understand information written on an appointment slip, and 42% failed to comprehend directions for taking medications. While little is known about health literacy is known in New Zealand, overseas research suggests that being culturally and linguistically different magnifies the problem.

Conclusion
This study highlights the importance of information provision for health care consumers, in particular migrant mothers. The study shows that migrant women frequently experience a vacuum of knowledge that needs to be filled. Factors such as poor English language proficiency, limited networks and unresponsive health providers can all increase the likelihood of migrant mothers experiencing a problematic birth experience and poor outcomes. This research suggests that improving the quality and range of information for migrant mothers and the inter-cultural resources for health providers could improve outcomes.

Further research is needed into how maternity information is provided and it is suggested that more attention is paid to the information needs of migrant mothers and migrants in general. Language proficiency is vital not only with regard to access to services but also for being empowered and prepared for the dual transition of parenthood in a new country. The study highlights the need for further exploration of changing demographics on dominant health care discourses in New Zealand such as partnership and whether there is space for new discourses. There are several aspects that contribute to a satisfying experience of health care for migrant mothers and these appear to be the ability to access a service, being able to obtain relevant information and having a supportive relationship between themselves and providers. These appear to be mutually dependent factors.

Acknowledgements

Funding for this research was provided by grants from The Families Commission and the Plunket Society volunteers in Central Auckland. The following people are gratefully acknowledged for their contributions: The mothers, Elaine Macfarlane, Sheryl Orton, Michele Hucker, Dr Wanzhen Gao, Rose Joudi, Paula Foreman, Rezwana Nazir, Lorna Wong, Jane Vernon, Zahra Maleki, Nagiba Mohamed, Hyeeun Kim, Catherine Hong and Stephanie Shennan.

References

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Migrant Populations

DeSouza, R. (2004). Working with refugees and migrants. In D. Wepa (Ed.), Cultural safety (pp. 122-133). Auckland: Pearson Education New Zealand.

The art of walking upright here

Is the art of using both feet.

One is for holding on.

One is for letting go. (Colquhoun, 1999, p.32)

Glenn Colquhoun’s poetry captures the challenge dislocation from home and family. The migrant or refugee has to somehow hold on to their legacy and their heritage whilst simultaneously letting go of those things that cannot be maintained in a new country. They must let go to create new lives, so they can stake a new claim of belonging; a new place to stand.

One in five New Zealanders was born overseas. This rises to one in three in Auckland. For many, migration is seen as a way of obtaining a better life, particular for ones children. Whilst many migrants make informed decisions, this needs to be seen as a continuum between full choice and no choice. This can been viewed as a ‘pull’ effect (migrants are drawn to a new country for the opportunities available) or a ‘push’ effect (the motivation is simply to leave where they are). Migrants can be defined as people who were born in one country and then move to another under an immigration programme. In New Zealand this consists of three main streams:

  •  Skilled/Business: Which relates to attracting migrants with qualifications and skills, or the potential to create business opportunities in New Zealand.
  • Family sponsored: Where New Zealand citizens or permanent residents can sponsor family members to the country.
  • Humanitarian: This includes refugees and allows for family members to be granted residence if there are serious humanitarian concerns.

Refugees that have resettled in New Zealand mostly originate from Africa, the Middle East, South East Asia and Eastern Europe. Refugees differ from voluntary migrants because they were forced to leave their home and have little if any choice in selecting their destination. They are at the extreme end of the ‘push’ effect, often having fled from situations of conflict and human right abuses. This has important implications for the provision of  health care, as they might not have had access to preventative and treatment services. Most refugees arriving in New Zealand will spend six weeks at the Mangere Refugee Reception Centre (MRRC) in South Auckland. There are estimated to be 20.6 million refugees and displaced people in need of protection and help (UNHCR, 2003). Currently New Zealand accepts a United Nations-mandated quota of 750 refugees per year, plus approximately the same number again of asylum seekers. Asylum seekers are people seeking refugee status without legal documentation. They often experience depression, hopelessness and helplessness related to stress and socio-economic deprivation. Even where migration is an informed choice, the result can still be isolation and loss of financial independence. Before migration, one often only considers the positives; it can be difficult to understand the adjustment that is required and to come to terms with the losses of family, friends, culture and familiarity.

In this chapter I present a view of cultural safety and how it is relevant to health from the perspective of a migrant with a view to informing those who will be caring for the needs of migrants and refugees. I will briefly review the history and tensions around migration and migrants. Anecdotes from my clinical experience are woven through the text to present multiple layers to reflect the complexity of the experience and reflective questions are posed to increase self-awareness. I conclude by offering a range of strategies for working with diversity.

Improving collaboration between nursing professionals and support workers in the New Zealand mental health system– A position paper

In 1998 I began teaching the first mental health support work cohorts in New Zealand at Unitec Institute of Technology. I had the privilege of working with Maori and Pacific mental health workers, peer support workers and consumer providers until 2005. I wrote this position paper for the Australian and New Zealand College of Mental Health Nurses way back in 2003. I have taken it out of the vault in case it is of use. I have listed more up to date references at the end of the document for those who might want to do some further reading.

EXECUTIVE SUMMARY

The Mental Health Commission (1997) states that mental health is the concern of all. Support workers are a reality of today’s mental health system in New Zealand and this paper looks at their relationship with community mental health nurses. This paper is a response to the major changes in mental health care in New Zealand over the last decade, which have dramatically altered the landscape of the mental health workforce. It seems timely to look at a way forward and to develop guidelines for nurses working with support workers in the community. In this paper “support workers” include community support workers and consumers as providers and the term “nurses” refers to community mental health nurses.

No one group can meet the needs of consumers. Together these two groups can provide complimentary services to improve client care but a model of cooperation is necessary and further clarification of roles and overlap is required. Effective teamwork between nurses and support workers in the mental health community in New Zealand must occur so that the care delivered is flexible and responsive to the needs of consumers and their families. The changes in the socio-political context of mental health care in New Zealand are challenging nurses to re-define their scope of practice. These developments and their implications are summarised and options for the nursing profession are discussed and recommendations given.

ISSUES

Competition for funding

The creation of the Regional Health Authorities (RHA) in 1991 was part of a new system of purchasing health services which replaced Area Health Boards (Yegdich & Quinn, 1996). This new funder /purchaser /provider system encouraged competition between providers and led to many new services entering the health sector. These included non-governmental services who were now able to compete directly with Crown Health Enterprises (CHE), previously there was an obligation for boards to concentrate funding on their own services (Yegdich & Quinn, 1996). In 1996 the new coalition government initiated another review of the health system leading to funding being centralised under the Transitional Health Authority (THA). Competition for central funding begs the question of whether competing services with different philosophies and types of workers can cooperate with each other. When community support services were established in Auckland there was antagonism from nurses as these new services were seen as better resourced, with lower caseloads and were seen to be eroding the role of the professional nurse.

Culturally appropriate parallel services

The changes in funding have also lead to the development of specialised Maori and Pacific Island support work services. In Auckland, the Maori community support work (CSW) service has dramatically reduced the rate of admission and re-admission for Maori . Previous statistics had shown that Maori were entering the mental health system at the same rates as non-Maori but required longer stays and more frequent re-admissions (Te Puni Kokiri, 1993). Increased numbers of immigrants and refugees from Africa, Asia and Eastern Europe have led to the formation of specialised mental health services, for example the Refugees As Survivors (RAS) centre. However, a disadvantage of parallel services is that nurses in main stream services lose the opportunity to develop specialised skills for working with cultures other than their own.

Case management

Case management originated in the United States in the 1980’s in the context of deinstitutionalisation, normalisation and the development of community mental health centres (Sledge, Astrachan, Thompson, Rakfeldt & Leaf, 1995; Willis & Morrow, 1995). It was seen as a way of improving the connections between services and linking both clinical and rehabilitation services together to ensure that “severely mental ill” clients received adequate services (Sledge, et al. 1995). Versions of case management are used in New Zealand although little has been written about the experience locally. Universal agreement has not been achieved regarding the scope of practice of case managers and the level of education required. The assumption that nurses are the most suitable group to provide case management services is being challenged by the emergence of support work services and parallel ethnic mental health teams.

Role change

Yegdich and Quinn (1996) have observed that the role of nurses has extended with the move from institution to community. Needs of clients now include housing, income, employment and social networks. However, an audit of community services in Auckland found that the dominant activity of nurses was crisis intervention (Yegdich & Quinn, 1996). Support work services have evolved in recognition of the gaps in community care provision. This movement to the community has also resulted in an increased emphasis on tertiary prevention, rehabilitation and recovery. New postgraduate training courses in mental health nursing have been developed as a result of a growing dissatisfaction with comprehensive nurse training and what is seen as inadequate preparation for working in this area (Ministry of Health, 1996). This is also important from a case management perspective particularly as broader skills are necessary for this role, for example knowledge of community resources.

Changing relationship with consumers

The consumer movement is influencing the movement of mental health service delivery from a medical to psychosocial rehabilitation model (Worley, 1997). New opportunities have arisen for consumers to interact with policy makers, professionals and others from a position of strength. Consumer operated programmes and initiatives have been developed due to the dissatisfaction with clinical mental health services. Consumers have found consumer-staffed organisations more empathetic, tolerant and understanding because of their own struggles with psychiatric disability (Worley, 1997). Consequently, guidelines have been developed as a result of increased consumer participation in professionally run mental health agencies (Ministry of Health, 1995). This has also led to changes in relationships between consumers and professionals. There is growing recognition on the part of professionals of the value of experiential knowledge and what consumers have to offer other consumers.

Safety and extended roles

  • Assessment by a nurse is required to detect changes in the mental state of a client. Where a support worker is the predominant contact, changes may be missed particularly if they have no clinical experience or assessment skills. In an article about extended roles, Rieu (1994) stated that discussion about accountability (“professional” and “legal”) and competency is needed. Other questions that need to be addressed include:
  • What preparation and training are support workers given?
  • What supervision do they get and how are they regulated?
  • How well are they resourced and supported?
  • Is their scope of practice clearly defined?

ADDRESSING THE ISSUES

Recognising the strengths of support workers

Support workers are seen as filling the gaps in community care, particularly in terms of work with clients with complex needs not met within the reductionist medical model (Davies, Harris, Roberts, Mannion, McCosker & Anderson, 1996). Other advantages include breaking the barrier of client-worker distance, providing a bridge between clients and mainstream staff and providing a role model for clients of similar background (Davies et al., 1996). Studies have shown that support workers are considered more effective than health professionals for several groups with varying mental health needs (Davies et al., 1996; Grant, Ernst, Streissgut, Phipps & Gendler, 1996). These include abused women, who have viewed the health system as sexist, fragmented and professionals as judgemental and insensitive (Davies et al., 1996). Other studies have shown that chronically drug-dependent women have become distrustful of “helping” agencies and in turn many professionals see these women as a hopeless population (Grant et al., 1996). They describe an advocacy model of case management using support workers, who worked intensively with women, who used drugs or alcohol heavily during their pregnancies and were alienated from community services. This alienation increased the risk of delivering children with serious medical, developmental and behavioural problems. It also prevented them from seeking assistance from agencies that were designed to help them. These ‘advocates’ were support workers experienced in social services with high-risk populations, had a variety of life experiences and came from a similar cultural background to their clients. They were seen as positive role models, providing hope and motivation. It was found after one year that clients now engaged with treatment agencies, decreased drug use, increased use of birth control and increased their involvement with supportive and skill building groups, such as parenting classes (Grant, et al., 1996).

Training and education of nurses

Nursing training must incorporate concepts such as recovery and consumer perspectives. Nurses need to be supported to work as case managers and build on their roles as more than adjuncts to the medical model. Mental health nurses working in the community must clarify their current roles and define what pathways they will follow.

Diversity in the workforce to provide culturally appropriate services

Reviews have shown that there are a paucity of culturally safe services for Maori and Pacific people (Ministry of Health, 1997). Furthermore, the provision of resources and devolution of resources have not supported other views of mental illness (Mental Health Commission, 1996). “Moving Forward” (Ministry of Health, 1997) national objectives states more trained mental health workers are needed before culturally appropriate services can be provided by mainstream and kaupapa Maori mental health services. A better partnership is needed between education and health sectors so that training can be specifically targeted to Maori. The Pacific Island objective also recommends that work be done so that mental health services become more responsive to the diverse needs of Pacific peoples. The national objectives recommend educating consumers as providers, community support workers and Maori and Pacific Island workers.

Better cooperation with ethnic support workers

In an Australian article, Fuller (1995) argued that health care practices by professionals continue to be predominantly monocultural despite recognition of the need to be responsive to the culturally diverse population. Fuller added that different ethnic groups practice illness prevention and health promotion differently. Some prefer direct, practical and immediate assistance from the Western care system rather than long term strategies. Fuller argued that nurses could not attain all the necessary cultural knowledge to provide total care to clients without a partnership with cultural intermediaries. According to Fuller, this expectation would result in lists of stereotypical traits being produced rather than an improved understanding of clients individual needs. Fuller added that the values and assumptions of primary nursing with contradictory notions of empowerment and autonomy have resulted in rigid professional boundaries which restrict multi-disciplinary team work, thereby increasing the need for an ethnic support worker.

Alternative structures and models

The Ministry of Health (1997) recommends that mental health promotion and prevention for Maori and Pacific Islanders be strengthened. They suggest using traditional (Pacific and New Zealand) structures to promote mental health including circulating Pacific language descriptions of key western mental illnesses. In addition, the Report of the National Working Party on Mental Health Workforce Development (Ministry of Health, 1996) suggested that Maori consumers become integrated into the provider culture of mental health services, so services reflect the wealth of Maori consumer experience. This is in line with the request by Maori consumers to have more Maori community support workers, patient advocates and crisis teams. This leads on to the next area for discussion about who can best provide services for those with mental health needs. Takeuchi, Mokuau & Chun (1992) found that the establishment of parallel services improved mental health for minorities and led to an increase in their use.

Multiskilled, multidisciplinary and comprehensive

According to Øvretveit (1993), it is rare that one profession alone is able to meet the needs of a person with a social or health need. Usually the skills and knowledge of a range of specialists are beneficial and coordination is crucial to prevent costs of duplication and staff frustration. This is echoed by the Report of the National Working Party on Mental Health Workforce Development (Ministry of Health, 1996). It suggests that the best way to deliver mental health services to consumers is by having a team of multi-skilled and multi disciplinary workers. This team would be able to address the many facets of care required by sufferers of mental illness and would include community support workers as well as Maori and Pacific Island workers. “Moving Forward’s” National objectives are to increase the Maori and Pacific Island mental health workforce. In addition, a flexible system is required where a case manager might need to spend more time with someone as the nature of mental illness changes rapidly.

A proposed model of cooperation

The mental health of consumers will be maximised if professionals and support workers are able to work in partnership and combine their skills, knowledge, life experience and expertise in a coordinated way. This would ensure that services are respectful, relevant, flexible, responsive and effective and that they are available to consumers to reduce the barriers that prevent them from achieving their full health potential. The framework for community service delivery for people with mental health problems needs to be comprehensive, health promoting and collaborative; a partnership that is committed to client empowerment and the elimination of barriers to access (Association of Ontario Health Centres, 1994).

RECOMMENDATIONS

Several recommendations are proposed:

Liaison

  • Adopt protocols for networking within all services so that inter-agency cooperation is maximised and clients receive a seamless service.
  • Improve the interface between clinical, cultural and psychosocial models to increase understanding and collaboration from both perspectives.

Training 

  • Educate support workers to understand the role of the nurse but not to the extent that traditional healing structures are negated in favour of psychotherapeutic methods.
  • Formalise traditional roles into the mental health system, for example the role of Kaumatua (Street & Walsh, 1996).
  • Train nurses in cultural and psychosocial models.

Role and Scope of practice

  • Develop job descriptions for support workers in cooperation with nurses to prevent role ambiguity, promote job satisfaction and decrease discontent.
  •  Support and safeguard support workers to ensure that their role does not compromise the safety of clients and staff or the role of the nurse.
  • Use nurses appropriately and ensure that they are not substituted by support workers for fiscal or political reasons.
  • Define core competencies for support workers at a national level and ensure on-going monitoring of standards.

Alternatives to the medical model

  • Recognise that the clinical model has limitations and cannot meet the needs of all clients.
  • Increase familiarity with alternative models of mental health amongst nurses, for example recovery and cultural models.
  • Review and clarify the role of nurses working in mental health.

Cultural safety 

  • Acknowledge the importance of spiritual issues, land rights, whanau reconstruction and physical health (Street & Walsh, 1996).
  • Resource nurses appropriately for the cultural component of their work.
  • Involve nurses in developing appropriate policy and healthcare services to Maori and ethnic minorities in New Zealand (Street & Walsh, 1996).
  • Familiarise nurses with the work of ethnic mental health workers and Maori support work services.

Consumer participation/consumer focused

  • Recognise the experiential and personal knowledge of consumers.
  • Ensure that consumers are key players in planning and accountability structures which are linked to outcome measures.

CONCLUSION

This paper has shown how support workers can reach clients who are lost to or fearful of the mental health system, whether this is because of social, ethnic or cultural reasons. In an evolving mental health system moving from institutionalisation to community-based care, these new roles provide a bridge between the clinician and the consumer. No one group can meet all the needs of consumers. Support workers can widen the focus of the mental health system in a way that better meets the needs of clients in the community at large, whatever their background. Friction has existed between nurses and support workers, the former often viewing the latter as eroding their role and of being unskilled. Alternatively support workers have sometimes viewed nurses as part of a system that they see as having failed them. Support workers are seen by some as being a political solution to eroded health care funding. Although there are several issues requiring on-going discussion, not least the legal and ethical requirements for support workers and their regulation, a synergy exists between nurses and support workers and together they can provide complimentary services to improve client care. For this to be successful a model of cooperation is necessary and further clarification of roles and overlap is required. Effective teamwork between nurses and support workers in the mental health community in New Zealand must occur so that the care delivered is flexible and responsive to the needs of consumers and their families. A guiding framework of principles for working in harmony should be developed.

REFERENCES

Association of Ontario Health Centres (1994). Response to: “Implementation Vision” – Mental Health Reform. Toronto: Association of Ontario Health Centres

Davies, J; Harris, M; Roberts, G; Mannion, J; McCosker, H & Anderson, D. (1996). Community health workers’ response to violence against women. Australian and New Zealand Journal of Mental Health Nursing,5, 20-31.

Fuller, J. (1995). Challenging old notions of professionalism: how can nurses work with paraprofessional ethnic health workers? Journal of Advanced nursing, 22, 465-472.

Grant, T.M.; Ernst, C.C.; Streissgut, A.P.; Phipps, P.& Gendler, B. (1996).When case management isn’t enough: a model of paraprofessional advocacy for drug and alcohol abusing mothers. Journal of Case Management, 5, 1, , 3-11.

Mental Health Commission (1997). Discrimination against people with experience of mental illness: Discussion paper for the mental health commission. Wellington: Mental health commission.

Ministry of Health (1995). A guide to effective consumer participation in mental health services. Wellington: Ministry of Health.

Ministry of Health (1996). Towards better mental health services: The report of the national working party on mental health workforce development. Wellington: Ministry of Health.

Ministry of Health (1997). Moving forward: The National Mental Health Plan for more and better services. Wellington: Ministry of Health.

Øvretveit, J. (1993). Coordinating community care. Open University press: Buckingham. Rieu, S. (1994). Error and trial: the extended role dilemma. British Journal of Nursing, 3, 4, 168-174.

Street, A & Walsh, C. (1996). Community nursing issues in Maori Mental Health. Australian and New Zealand Journal of Mental Health Nursing, 5, 54-62. Te Puni Kokiri (1993).

Nga Ia O Te Oranga Hinengaro Maori trends in Maori Mental Health: A discussion document. Wellington: Te Puni Kokiri. Worley, N. (1997). Mental health nursing in the community. .Mosby: St Louis.

Yegdich, T & Quinn, J. (1996). Community mental health nursing. In Clinton, M & Nelson, S (Ed), Mental health & Nursing practice, (p335-353). Sydney: Prentice Hall.

 

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Barber, K. F. M. (2015). Realising Our Best Intentions: Vision, Values and Voice in Community Non-government Organisations of the Aotearoa$\backslash$ New Zealand Mental Health Sector. University of Waikato. Retrieved from https://waikato.researchgateway.ac.nz/handle/10289/9989

Cheng, R., & Smith, C. (2009). Engaging people with lived experience for better health outcomes: Collaboration with mental health and addiction service users in research, policy, and …. Toronto, Ontario: Minister’s Advisory Group,. Retrieved from https://www.researchgate.net/profile/Christopher_Smith27/publication/260589695_Engaging_People_with_Lived_Experience_for_Better_Health_Outcomes_Collaboration_with_Mental_Health_and_Addiction_Service_Users_in_Research_Policy_and_Treatment/links/0f317531a029393ce7000000.pdf

Hatcher, S., Mouly, S., Rasquinha, D., & Miles, W. (2005). Improving recruitment to the mental health workforce in New Zealand. Of New Zealand. Retrieved from http://www.tepou.co.nz/uploads/files/resource-assets/Improving-Recruitment-to-the-Mental-Health-Workforce-in-New-Zealand-2005.pdf

Hennessy, J. L., Smythe, L., Abbott, M., & Hughes, F. A. (2016). Mental Health Support Workers: An Evolving Workforce. Workforce Development Theory and Practice in the Mental Health Sector, 200.

 

Hennessy, J. L. (2015). The contribution of the mental health support worker to the mental health services in New Zealand: an Appreciative Inquiry approach. Auckland University of Technology. Retrieved from https://aut.researchgateway.ac.nz/handle/10292/9192

McMorland, J., Kukler, B., Murray, L., & Warriner, R. (2008). Partnerships in Development: developments in mental health service provision in New Zealand. A case study. New Zealand Journal of Employment Relations (Online), 33(1), 19.

Morrison, N., & Ronan, K. (2002). Assessment of Core Competency Status and Work Environment of Residential Mental Health Support Workers. The Australian Journal of Rehabilitation Counselling, 8(02), 114–126.

Morrison, N. (2000). Assessment of competency status of residential mental health support workers: a thesis presented in partial fulfilment of the requirements for the degree of Master of Arts in Psychology at Massey University. Massey University. Retrieved from http://mro.massey.ac.nz/handle/10179/6018

 

O’Neil, P., Bryson, J., Cutforth, T., & Minogue, G. (2008). Mental health services in Northland. Industrial Relations Centre, Victoria University of Wellington, July, 2–3.

O’Hagan, M. (2001). Recovery Competencies for New Zealand Mental Health Workers. Retrieved from http://eric.ed.gov/?id=ED457512

Pace, B. (2009b). Organisational views of the mental health support worker role and function. Unpublished Paper. Waikato Institute of Technology, New Zealand. Retrieved from http://www.psychosocial.com/IJPR_14/Organizational_Views_Pace.html

Pace, B. (2009a). How New Zealand community mental health support workers perceive their role. Journal of Psychosocial Rehabilitation. Vol 13 (2). 5. Retrieved from http://www.psychosocial.com/IJPR_13/New_Zealand_Comm_Mental_Health_Pace.html

Pace, B. (2010). Exploring support work: Examining the role of mental health support workers in New Zealand (p. 159). Wellington, New Zealand: B. Pace.

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Southwick, M., & Solomona, M. (2007). Improving Recruitment and Retention for the Pacific Mental Health Workforce. Auckland: The National Centre of Mental Health Research and Workforce Development. Retrieved from http://www.tepou.co.nz/uploads/files/resource-assets/improving-recruitment-and-retention-for-the-pacific-mental-health-workforce-feasibility-study.pdf

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The ‘small’ things count in caring

Editorial published in Kai Tiaki: Nursing New Zealand 8.10 (Nov 2002): p28(1).

KAI TIAKI Nursing New Zealand has recently carried narratives written by nurses discussing their experiences as recipients of health care, eg “My Journey of Pain” by Glenis McCallum (July 2002, p16). These experiences gave the nurses the opportunity to re-examine their practice and to reclaim their empathy.

Similarly, a personal experience provided the impetus to write this brief piece. I recently had the opportunity to re-evaluate my own beliefs about nursing and the importance of communication and caring when I witnessed my sister receiving care in a hospital maternity setting. What came across was the importance of the “small” things–the caring and the communication, and the importance of compassion and empathy. The sweetness of the person who opened the door to the unit and said “welcome to our world”. The rudeness, almost surliness, of the nurses who forgot to introduce themselves or tell us what was happening.

Rightly, there is much focus on nursing as a profession, yet is it possible that in this debate we have forgotten the small things that really matter to our clients -the things that make people feel safe and cared for?

This personal and professional interest was further piqued by two workshops held in Auckland recently that focused on maternal mental health issues. Both highlighted the important role nurses have to play when caring for women experiencing childbirth.

In the first workshop, organised by the education and support group, Trauma and Birth Stress (TABS), 170 consumers and health professionals gathered to explore post-traumatic stress disorder (PTSD) after childbirth. The group TABS was formed by women who had all experienced stressful and traumatic pregnancies or births that had negatively affected their lives for months or even years after the experience. One of TABS’s aims is to educate health professionals on the distinctions between PTSD and post-natal depression so the chance of misdiagnosis is lessened and correct treatment is started quickly.

Speakers at the workshop included an international nursing researcher from the United States, Cheryl Beck. A number of New Zealand women have shared their stories of PTSD with Beck and have found telling their stories and having someone understand and believe them has been very therapeutic. Other speakers included TABS member Phillida Bunkle and Auckland University of Technolgy midwifery lecturer Nimisha Waller who spoke on how mid wives can assist mothers with PTSD.

In my role at UNITEC Institute of Technology, I organised the second workshop, which also featured Beck. Entitled “Teetering on the edge: Postpartum depression–assessment and best practice”, the workshop attracted around 100 nurses, midwives, GPs and consumers. A professor in the School of Nursing at the University of Connecticut, Beck has for many years focused her efforts on developing a research programme on postpartum depression. Using both qualitative and quantitative research methods, she has extensively researched this devastating mood disorder that affects many new mothers. Based on the findings from her series of qualitative studies, she has developed the postpartum depression screening scale (PDSS). Currently Beck’s research is focused on PTSD after childbirth and she presented her work to date. In September, there were 27 participants in the study, 18 from New Zealand and the rest from the United States.

The themes of her presentation were a reminder of the dramatic negative consequences of occurrences we as health professionals deal with frequently. Emergency situations arise and we all do our job, often without a second thought as to the future impact of our actions (or inactions) on the woman and her family.

Beck also spoke at the TABS work shop. The response to both workshops was really positive. Workshops such as these, where the long-term impacts of the health care experience are discussed, can act as a reminder for anyone working with women at and around the time of childbirth to critically view their practice and that of their colleagues. Themes that feature in the research are around caring, communication and competence–the very things that were absent in my recent experience of the health system. Women in the study felt they were not shown caring, communication from health providers was poor, and they perceived their care as incompetent.

Through her research, Beck poses the question so many mothers ask: “Was it too much to ask to care for me?” As health professionals, we need to ask ourselves every day “how can I care for the needs of this client?”, because nursing is not just a profession, it is a caring profession.

* For further information on TABS http://www.tabs.org.nz/