Tune In: Whakarongo ki ngā Rangatahi

Poipoia te kākano kia puawai

Nurture the seed and it will blossom

Māori are a youthful population, brimming with potential (Cameron et al., 2013; Ministry of Health, 2020). Historically, rangatahi (Māori youth) were revered as aspiring leaders who played a significant role in the continuation of heritage (Hamley & Grice, 2021). As such, rangatahi were treasured. Today, assuring that future generations inherit the highest quality of life remains a priority for many, especially Māori. Meanwhile, rangatahi confront higher deaths by suicide, depression, anxiety, and poorer general well-being than tauiwi (non-Māori) (Government Inquiry into Mental Health and Addiction, 2018; Williams et al., 2018). Research suggests that early detection and treatment of mental health issues protects the psychological and social development of rangatahi across the life course. However, barriers to receiving care must be overcome (Martel et al., 2020).

Despite their high prevalence, there is an unmet need for treating mental health issues among rangatahi. Barriers to care have been attributed to limitations in healthcare access and a lack of culturally relevant services (McClintock et al., 2016; Williams et al., 2018). Given that adolescence is an optimal time to develop emotional well-being and resilience, early intervention during this period can assist in establishing positive patterns that endure well into adulthood (Martel et al., 2019). Consequently, there is increased support for developing effective and accessible services that guide young people toward well-being.

However, rangatahi have been rarely questioned about their experiences with psychological treatment (Gibson et al., 2016). Given the vital role of autonomy and motivation in treatment effectiveness (Ryan et al., 2011), any intervention made for rangatahi should foster their response to exercise control, interact on a personal level, and, most significantly, be themselves (Gibson & Cartwright, 2013; Gibson & Trnka, 2020; The Center for Generational Kinetics, 2020). Fundamentally, rangatahi Māori navigate a diverse continuum of life as tangata whenua (Indigenous people) in the context of Aotearoa/New Zealand’s colonial history, which remains impacted, in part, by widespread catastrophic loss and the charge of new technologies (Pīhama et al., 2015).

The youth of today are at the forefront of technology (Anderson & Jiang, 2018). Accordingly, their expression of identity is informed through both physical and digital dimensions, as is their relationship with peers and the environment (Sussman & DeJong, 2018). As specialists investigate creative ways to reach youth at risk (Merry et al., 2020), they are turning increasingly to digital tools that draw on the apparent readiness of young people to interact with this media. Global research has yielded promising results for the strength of Behavioural Intervention Technologies (BITs) in the delivery of health care (Hermes et al., 2019). Embedded in behavioural and psychological intervention strategies, BITs intend to expand access and effectiveness of care through cutting-edge technologies. However, research suggests that implementation be evaluated across several domains, including acceptability and appropriateness (Hermes et al., 2019). Concerning rangatahi, such factors remain critical to their sustained engagement (Fox et al., 2018).

Locally, TuneIn has emerged as a recent e-health application that guides users on a journey of positive change (Christie & Hetrick, 2019). Based on behavioural intervention technology, users are encouraged and rewarded by imagining, activating, and achieving their well-being goals. Developed in Aotearoa/New Zealand, researchers produced the interface in collaboration with rangatahi, communities, clinicians, and software engineers. While the prototype intervention is open for development, currently, the design infuses culturally significant values that reflect Māori identity. However, rangatahi identity aptly evolves alongside the rapid change of technology in which their identity is shared (O’Carroll, 2013). Therefore, future developments should routinely revise and improve features of significance to primary intended users (Peiris-John et al., 2020).

Looking forward, the study aims to improve rangatahi engagement with eHealth service, TuneIn. Specifically, this research will explore the diverse realities of rangatahi to align the application with their needs. To that end, the following sections of this report will further outline critical considerations and barriers to ensure engagement with rangatahi in e-health care appropriately centres rangatahi as agents of change and active participants in their journey of well-being. Findings will provide context for the current research while centralising an approach that respects the unique worldview and mātauranga of rangatahi under the protection of te Tiriti o Waitangi.

Rangatahi Māori

Whānau

            In Māori society, Te Pā Harakeke (the flax plant) is an expression of whānau and security (Pīhama et al., 2015). Rangatahi are seens as the rito (centre shoot) within larger leaves portayed as whānau, the protective mechanism of continuity (Pihama et al., 2015). Accordingly, there is mounting evidence that whanaungatanga (relationship) benefits the growth and well-being of rangatahi (M. H. Durie, 1985; Fox et al., 2018; Webber & Macfarlane, 2020). A recent analysis by Roy et al. (2021) confirmed that of 1,528 rangatahi Māori surveyed, the majority described favourable home, family, and support networks, including a high degree of cultural connection. These findings demonstrate the resilience of rangatahi and their whānau in a colonial system that is adverse to their needs and interests (Hamley & Grice, 2021). Additionally, it emphasises the importance of relationship, environment, and cultural identity in sustaining and enhancing rangatahi well-being.

Identity

Research suggests that rangatahi who possess strong cultural identities have better mental health outcomes (Williams et al., 2018). To illustrate, Fox et al. (2018) discovered that cultural embeddedness, a predictor of positive coping strategies, resulted in a greater degree of well-being and resilience in a longitudinal study of over 400 rangatahi. Nevertheless, Māori are complex and diverse. Far from homogenous, different whānau, hapū, and iwi have different tikanga (customs), dialects, and beliefs (Durie, 1995). Further, Māori participate across an intersection of traditional and contemporary identities, thoughts, and values within tribal structures and urban settings. Consequently, how rangatahi situate themselves within Te Ao Māori can elicit diverse cultural expressions (Roy et al., 2021). Despite their strengths, rangatahi are not invulnerable to circumstances that expose them to discrimination, social isolation, poverty, and distress (Rivera-Rodriguez et al., 2021).

Mental Health

A national shame, Aotearoa/New Zealand has the highest rate of youth suicide globally, with rangatahi Māori being twice as likely to die by suicide than non-Māori (Government Inquiry into Mental Health and Addiction, 2018). While the prevalence of mood, peer, and self-harming disorders rise (Fleming et al., 2020; Martel et al., 2020), rangatahi often go untreated (Mariu et al., 2012) or face stigma and discrimination when help is anticipated (Williams et al., 2018). Numerous factors influence whether rangatahi seek help for their needs. Research indicates the importance of understanding the determinants of mental health issues in providing greater access to care and prevention strategies (Ministry of Health, 2020). For rangatahi Māori, mental health issues are compounded by colonisation’s ongoing effects, including cultural alienation, socio-economic deprivation, and institutional racism (Arahanga-Doyle et al., 2019; Came et al., 2018).

Acknowledging the Impacts of Colonisation

The impact of historical trauma on rangatahi remains challenging to quantify (Williams et al., 2018). However, it is essential to consider that Aotearoa/New Zealand remains a colonised nation in the context of healthcare. It is well recognised that the process of colonisation, along with loss of lands, culture, and identity, has had damaging effects, including the overrepresentation of Māori in negative mental health statistics (M. H. Durie, 1985; Government Inquiry into Mental Health and Addiction, 2018; Rolleston et al., 2020). As a result, many Māori face preventable health inequities associated with poverty, inadequate living conditions, low educational achievement, and involvement with the criminal justice system (Came et al., 2018; Roy et al., 2021). Notably, soul wounds, defined as trauma caused by historical events, continue to impact Māori communities (Pihama et al., 2017). Such inequities provide ample evidence for transformative healthcare. However, Came et al. (2019) argue that institutional racism (a critical determinant of health disparities) must be addressed within the health system to achieve health equity for Māori.

Honouring Te Tiriti o Waitangi

Under te Tiriti o Waitangi, health is a taonga (treasure) that demands protection (Came et al., 2019). Further, article two of the agreement between Māori and the British Crown enables Māori to exercise tino rangatiratanga (sovereignty) while maintaining individual and collective control of their future. However, health agencies and officials maintain a considerable amount of power to dominate health policy and the allocation of services (Government Inquiry into Mental Health and Addiction, 2018). Came et al. (2018) found that of 49 public health strategies, 75% of health policies substantively ignored Māori rights as laid down in te Tiriti o Waitangi. In response to their findings, Māori, when engaged in research, should be protected under the principles of te Tiriti o Waitangi to ensure that their culture, values, and beliefs receive due recognition (Martel et al., 2019).

Digital Health Interventions

Despite recent energy and innovation in Māori youth mental health, there continues to be a shortage of rangatahi-specific policies, services, and resources (Fleming et al., 2020). However, digital health interventions have been demonstrated to be increasingly effective in improving adolescent health and well-being given their accessibilty, adaptability and cost-effectiveness (Gibson & Trnka, 2020; Hermes et al., 2019; Peiris-John et al., 2020). With safety and security in mind, researchers frequently recruit young people with the aim of enhancing youth health outcomes within digital settings (Merry et al., 2020; Peiris-John et al., 2020). As such, digital health interventions provide an opportunity for rangatahi Māori to engage in accessible and culturally responsive healthcare services (Merry et al., 2020).

TuneIn

            TuneIn assists rangatahi in setting and achieving well-being objectives individually or with support people. Within the app, rangatahi identify a purpose they are willing to work toward. The objectives are behavior-specific and divided into activities that rangatahi can pursue to reach their desired outcome (Christie & Hetrick, 2019). The application sends daily notifications to encourage rangatahi toward their objective. When rangatahi achieve their goal, they are rewarded with a song and message from an Aotearoa/ New Zealand musician. The digitally delivered approach supports a body of knowledge that has been shown to be effective across a wide variety of behaviour change levels (Ozer et al., 2020). Further, researchers created the interface in collaboration with rangatahi to increase efficacy. Meanwhile, collaboration with health specialists meant that evidence-based treatment was embedded while also being simple to use for laypeople such as friends and whānau (Christie & Hetrick, 2019). 

A Kaupapa Māori Approach

Kaua e takahia te mana o te tangata; do not trample on the dignity of people (Smith, 2012). This proverb highlights the essence of Kaupapa Māori (Māori-led research for the benefit of Māori) in respect of mātauranga (indigenous knowledge), tikanga (values), te reo Māori (Māori language), customs, and worldview (Haitana et al., 2020). Kaupapa Māori recognises self-determination in identifying challenges, resolving issues, and creating new information through research processes (Barnes, 2000; Rolleston et al., 2020). Durie (1994) acknowledged that “Māori health development is essentially about Māori defining their own priorities for health and then weaving a course to realise their collective aspirations” (p.1). Accordingly, young people insist that when seeking help, their autonomy be respected (Gibson & Cartwright, 2013). Given that respect for self-determination underpins the therapeutic relationship, rangatahi should be empowered to recognise their strengths and autonomy (Martel et al., 2019).

Co-Design

Co-design is congruent with kaupapa Māori in that it involves collaborative research (Mark & Hagen, 2020; Martel et al., 2019). Fundamentally, the process is conducted by and with people where participants actively engage as respected creators and developers of the wider research team (Martel et al., 2019). Contributions include expertise, abilities, and ideas that broaden the scope of development and resolution. As experts in their own experience, young people often outperform researchers and therapists in terms of knowledge and understanding of digital activities (Gibson & Trnka, 2020; Peiris-John et al., 2020). Prior research involving young people in developing digital treatments has demonstrated the importance of user-centred design by allowing for meaningful participation and focusing on user needs (Hagen et al., 2012; Peiris-John et al., 2020). Accordingly, young people’s understanding of digital technology is critical for this investigation. Additionally, co-design enables researchers to analyse their own culture, perspective, ideas, and values and, as a result, acknowledge, validate, and respect those of collaborators (Martel et al., 2019). With this approach, co-design promotes cultural safety through active and collaborative participation.

Whakarongo ki ngā Rangatahi: Listen to the Youth

Rangatahi are requesting “a way for our voice to be heard and accepted” (Fleming et al., 2020, p. 4). In a national survey, over 2,700 youth responded to open text questions regarding better well-being support (Fleming et al., 2020). When asked what should be altered to improve assistance for young people in Aotearoa/New Zealand, Fleming et al. (2020) discovered that rangatahi want to be heard, considered, and included in decisions that affect their future. Additionally, partcipants requested social, emotional, and practical support from parents, friends, and mentors, as well as leaders who can serve as a medium to maximising their potential. Notably, early intervention mental health treatments that are accessible and relevant were recommended. Such findings accord with observations from He Ara Oranga (Government Inquiry into Mental Health and Addiction, 2018), which demonstrates that dimensions and hopes of Māori, particularly within well-being, lead the way for all people of Aotearoa/ New Zealand.

References

Anderson, M., & Jiang, J. (2018). Monica Anderson and Jingjing Jiang. In Pew Research (Issue May). http://assets.pewresearch.org/wpcontent/uploads/sites/14/2018/05/31102617/PI_ 2018.05.31_TeensTech_FINAL.pdf

Arahanga-Doyle, H., Moradi, S., Brown, K., Neha, T., Hunter, J. A., & Scarf, D. (2019). Positive youth development in Māori and New Zealand European adolescents through an adventure education programme. Kotuitui, 14(1), 38–51. https://doi.org/10.1080/1177083X.2018.1508479

Barnes, H. M. (2000). Kaupapa maori: explaining the ordinary. Pacific Health Dialog : A Publication of the Pacific Basin Officers Training Program and the Fiji School of Medicine, 7(1), 13–16.

Came, H., Cornes, R., & McCreanor, T. (2018). Treaty of Waitangi in New Zealand public health strategies and plans 2006–2016. New Zealand Medical Journal, 131(1469), 32–37.

Came, H., McCreanor, T., Manson, L., & Nuku, K. (2019). Upholding Te Tiriti, ending institutional racism and crown inaction on health equity. New Zealand Medical Journal, 132(1492), 61–66.

Cameron, N., Pihama, L., Leatherby, R., & Cameron, A. (2013). He Mokopuna He Tupuna: Investigating Māori Views of Childrearing Amongst Iwi in Taranaki (Issue December).

Christie, G., & Hetrick, S. (2019). Evaluation of an app to support adolescents with managing behavioural change.

Durie, M. (1995). Ngā Matatini Māori Diverse Māori Realities (pp. 1–19).

Durie, M. H. (1985). A Maori perspective of health. Social Science and Medicine, 20(5), 483–486. https://doi.org/10.1016/0277-9536(85)90363-6

Fleming, T., Ball, J., Kang, K., Sutcliffe, K., Lambert, M., Peiris-John, R., & Clark, T. (2020). Youth19 – Youth Voice Brief Youth19 Youth Voice Summary Q1 “ What do you think are the biggest. https://www.youth19.ac.nz/

Fleming, T., Tiatia-Seath, J., Peiris-John, R., Sutcliffe, K., Archer, D., Bavin, L., Crengle, S., & Clark, T. (2020). Youth19 Rangatahi Smart Survey, Initial Findings: Hauora Hinengaro / Emotional and Mental Health. In The Youth19 Research Group, The University of Auckland and Victoria University of Wellington.

Fox, R., Neha, T., & Jose, P. E. (2018). Tū Māori mai: Māori cultural embeddeness improves adaptive coping and well-being for Māori adolescents. New Zealand Journal of Psychology, 47(2), 13–23.

Gibson, K., & Cartwright, C. (2013). Agency in young clients’ narratives of counseling: “it’s whatever you want to make of it.” Journal of Counseling Psychology, 60(3), 340–352. https://doi.org/10.1037/a0033110

Gibson, K., Cartwright, C., Kerrisk, K., Campbell, J., & Seymour, F. (2016). What Young People Want: A Qualitative Study of Adolescents’ Priorities for Engagement Across Psychological Services. Journal of Child and Family Studies, 25(4), 1057–1065. https://doi.org/10.1007/s10826-015-0292-6

Gibson, K., & Trnka, S. (2020). Young people’s priorities for support on social media: “It takes trust to talk about these issues.” Computers in Human Behavior, 102(February 2019), 238–247. https://doi.org/10.1016/j.chb.2019.08.030

Government Inquiry into Mental Health and Addiction, 2018. (2018). He ara oranga : report of the Government Inquiry into Mental Health and Addiction.

Hagen, P., Collins, P., Metcalf, A., Nicholas, M., Rahilly, K., & Swainston, N. (2012). Participatory design of evidence-based online youth mental health promotion, intervention and treatment. In A Young and Well Cooperative Research Centre Innovative Methodologies Guide. http://www.academia.edu/download/29275573/Hagen_PD_Guide_12.pdf

Haitana, T., Pitama, S., Cormack, D., Clarke, M., & Lacey, C. (2020). The Transformative Potential of Kaupapa Māori Research and Indigenous Methodologies: Positioning Māori Patient Experiences of Mental Health Services. International Journal of Qualitative Methods, 19, 1–12. https://doi.org/10.1177/1609406920953752

Hamley, L., & Grice, J. Le. (2021). He kākano ahau – identity, Indigeneity and well-being for young Māori (Indigenous) men in Aotearoa/New Zealand. Feminism and Psychology, 31(1), 62–80. https://doi.org/10.1177/0959353520973568

Hermes, E. D. A., Lyon, A. R., Schueller, S. M., & Glass, J. E. (2019). Measuring the implementation of behavioral intervention technologies: Recharacterization of established outcomes. Journal of Medical Internet Research, 21(1), 1–15. https://doi.org/10.2196/11752

Mariu, K. R., Merry, S. N., Robinson, E. M., & Watson, P. D. (2012). Seeking professional help for mental health problems, among New Zealand secondary school students. Clinical Child Psychology and Psychiatry, 17(2), 284–297. https://doi.org/10.1177/1359104511404176

Mark, S., & Hagen, P. (2020). Co-design in Aotearoa New Zealand : a snapshot of the literature (Issue June).

Martel, R., Darragh, M. L., Lawrence, A. J., Shepherd, M. J., Wihongi, T., & Goodyear-Smith, F. A. (2019). Youthchat as a primary care e-screening tool for mental health issues among Te Tai Tokerau youth: Protocol for a co-design study. JMIR Research Protocols, 8(1). https://doi.org/10.2196/12108

Martel, R., Reihana-Tait, H., Lawrence, A., Shepherd, M., Wihongi, T., & Goodyear-Smith, F. (2020). Reaching out to reduce health inequities for Māori youth. International Nursing Review, 67(2), 275–281. https://doi.org/10.1111/inr.12565

McClintock, K., Tauroa, R., & Mellsop, G. (2016). An examination of Child and Adolescent Mental Health Services for Ma¯ori rangatahi [youth]. International Journal of Adolescence and Youth, 21(1), 56–63. https://doi.org/10.1080/02673843.2012.692658

Merry, S. N., Cargo, T., Christie, G., Donkin, L., Hetrick, S., Fleming, T., Holt-Quick, C., Hopkins, S., Stasiak, K., & Warren, J. (2020). Debate: Supporting the mental health of school students in the COVID-19 pandemic in New Zealand – a digital ecosystem approach. Child and Adolescent Mental Health, 25(4), 267–269. https://doi.org/10.1111/camh.12429

Ministry of Health. (2020). Whakamaua Māori Health Action Plan. https://www.health.govt.nz/system/files/documents/publications/whakamaua-maori-health-action-plan-2020-2025.pdf

O’Carroll, A. (2013). An analysis Of how Rangatahi Ma-ori use social networking sites. Mai Journal, 2(1), 46–59.

Ozer, E. M., Rowe, J., Tebb, K. P., Berna, M., Penilla, C., Giovanelli, A., Jasik, C., & Lester, J. C. (2020). Fostering Engagement in Health Behavior Change: Iterative Development of an Interactive Narrative Environment to Enhance Adolescent Preventive Health Services. Journal of Adolescent Health, 67(2), S34–S44. https://doi.org/10.1016/j.jadohealth.2020.04.022

Peiris-John, R., Dizon, L., Sutcliffe, K., Kang, K., & Fleming, T. (2020). Co-creating a large-scale adolescent health survey integrated with access to digital health interventions. Digital Health, 6, 1–13. https://doi.org/10.1177/2055207620947962

Pīhama, L., Lee, J., Te Nana, R., Campbell, D., Greensill, H., & Tauroa, T. (2015). Te pā harakeke whānau as a site of well-being. In R. E. Rinehart, E. Emerald, & R. Matamua (Eds.), Ethnographies in pan-Pacific research: Tensions and positionings (1st Editio, pp. 251–264). Routledge. http://ebookcentral.proquest.com/lib/auckland/detail.action?docID=3569701

Pihama, L., Smith, L. T., Evans-campbell, T., Cameron, N., Mataki, T., & Skipper, H. (2017). Investigating Māori approaches to trauma informed care. Journal of Indigenous Wellbeing, 2(3), 18–31. https://journalindigenouswellbeing.com/media/2018/07/84.81.Investigating-Māori-approaches-to-trauma-informed-care.pdf

Rivera-Rodriguez, C., Clark, T., Fleming, T., Archer, D., Crengle, S., Peiris-John, R., & Lewycka, S. (2021). National estimates from the Youth’19 Rangatahi smart survey: A survey calibration approach. PLoS ONE, 16(5 May). https://doi.org/10.1371/journal.pone.0251177

Rolleston, A. K., Cassim, S., Kidd, J., Lawrenson, R., Keenan, R., & Hokowhitu, B. (2020). Seeing the unseen: evidence of kaupapa Māori health interventions. AlterNative, 16(2), 129–136. https://doi.org/10.1177/1177180120919166

Roy, R., Greaves, L. M., Peiris-John, R., Clark, T., Fenaughty, J., Sutcliffe, K., Barnett, D., Hawthorne, V., Tiatia-Seath, J., & Fleming, T. (2021). Negotiating Multiple Identities : Intersecting Identities among Māori , Pacific , Rainbow and Disabled Young People. https://static1.squarespace.com/static/5bdbb75ccef37259122e59aa/t/60dd227e2226ae499706dd69/1625105031254/Youth19+Intersectionality+Report_FINAL_2021_print.pdf

Ryan, R. M., Lynch, M. F., Vansteenkiste, M., & Deci, E. L. (2011). Motivation and Autonomy in Counseling, Psychotherapy, and Behavior Change: A Look at Theory and Practice 1ψ7. The Counseling Psychologist, 39(2), 193–260. https://doi.org/10.1177/0011000009359313

Sussman, N., & DeJong, S. M. (2018). Ethical Considerations for Mental Health Clinicians Working with Adolescents in the Digital Age. Current Psychiatry Reports, 20(12). https://doi.org/10.1007/s11920-018-0974-z

The Center for Generational Kinetics. (2020). Generation Influence: Reaching Gen Z in the new digital paradigm. https://wpengine.com/resources/gen-z-2020-full-report/

Webber, & Macfarlane. (2020). Mana Tangata: The Five Optimal Cultural Conditions for Māori Student Success. Journal of American Indian Education, 59(1), 26. https://doi.org/10.5749/jamerindieduc.59.1.0026

Williams, A. D., Clark, T. C., & Lewycka, S. (2018). The associations between cultural identity and mental health outcomes for indigenous Māori youth in New Zealand. Frontiers in Public Health, 6(NOV), 1–9. https://doi.org/10.3389/fpubh.2018.00319