Summary: My excuse for attempting this thesis is firstly, that I am a graduate in medicine of the University of New Zealand and secondly, that my mother was a Maori. It seems to me that with a young university such as that of New Zealand, without the facilities for research work provided by older and richer homes of learning, the scope for original work, which it is the duty of every University to encourage and foster, is somewhat limited. In the philology, history and ethnology of the Polynesian Race, however, is provided a wide field for research work which it is the bounden duty of this University to explore and lead the way. As an obligation to my �alma mater� I take up the subject nearest to my family - medicine amongst the Maoris, in ancient and modern times. As another reason, I have the honour through my mother of belonging to the Maori race. As a result of four years work amongst them as an officer of Health, I am much struck by the different view-point with which the two races, European and Maori, approach the subject of disease. As a member of the Race I am perhaps enabled to understand my mother�s people more intimately than the more progressive but some what forgetful Anglo-Saxon. My experience of Maori ideas and customs dates from beyond the time of graduation in medicine. In childhood�s days, I experienced the bitter taste of the decoction prepared from phorium tenex and I heard around me the whispered diagnosis of �makutu� and �mate Maori�. Constantly throughout youth and early manhood, I have seen the European doctor wax impatient with what he terms prejudices or superstitions which retard or prevent the recovery of Maori patients. I have understood and sympathised with him. At the same time, with the priveledge of the half-breed inheriting the blood and ideas of both races I have been able to detach myself from European thought and look at the question of disease from my Maori countryman�s viewpoint. I understood the burden of the neolithic man�s fears and I symathise with him more deeply still. There are deep holes in the Urenui river which flows through our tribal territory wherein, so my Maori mother taught me, dwelt �taniwhas� or �dragons of slime� who destroyed the transgressor of the multitude of Maori laws and observances. Years of College and University education, combined with the unbelief inherited from a European father, have not been able to suppress the involuntary shudder and contraction of the erector pilae which the suggestion of bathing in those dark holes gives rise to. We inherit our fears in our blood, we imbibe them at our mother�s breast. The schools and teaching of a father appeal to us as we grow older. We subject customs and faiths to the light of comparative criticism and we ridicule the ideas of more primitive races as absurd. But in times of stress, despondency and lowered vitality, there is a tendency to revert to the mother�s fears which slumber within beneath the veneer of civilisation. How much more so in the case of the full Maori who has not had the advantage of even primary education! Clodd says, "In structure and inherited tendencies each of us is recent". The Maori has not been civilised for a century yet. As a duty to my kin, I have attempted to put on record their view of disease, in the hope that though anthropologist�s and others have done so much in collecting the ideas and customs of races on a lower culture stage, this thesis may serve as a small contribution to ethnology.

This research was designed to see whether the clinical method espoused by Moira Stewart et al in the book "Patient-Centered: Transforming The Clinical Method" is appropriate for Pakeha general practitioners to use in clinical consultations with Maori patients. This thesis uses qualitative methodology. One of my supervisors and I selected from the kuia (old women) and kaumatua (old men) of Hauraki those whom I would approach to be involved. Nearly all responded in the affirmative. The kuia and kaumatua talked about their tikanga, about the basis of tikanga, about the spirituality of their Maori worldview. They talked about the need to maintain their tikanga, about qualities that they respect. They described different roles within Maoridom, especially those of the kuia, whaea (mothers) and Tohunga (experts). They refer to a GP as a Tohunga because of the GP�s special expertise. The GP is able to use his or her special expertise to heal Maori patients, but needs to be able to get through barriers to do so. They are also clear that Maori and Pakeha live in two different worlds which can merge in some circumstances. I came to two conclusions. The first is that the elements of Patient-Centered Medicine are relevant to the consultation of a Pakeha GP and Maori patient, and provides a framework that is productive. The second conclusion is that there is a better framework for working with Maori patients, within which Patient-Centered Medicine can be practiced more effectively. Maori already have a framework (tikanga) in which they function, and if in their settings, especially the marae, he or she is welcomed and has a place in their world; tikanga accommodates the GP as a Tohunga and Maori respond to him or her as such. In summary, a Pakeha GP who has some knowledge of tikanga or Maori culture and who has a basic knowledge of the Maori language of tikanga of Maori culture and who has a basic knowledge of the Maori language can work very well for his or her Maori patients by working within the framework of Tikanga Maori and by being patient-centered in consultation.

This study examines the �Kai o te Hauora� Maori Community nutrition training delivered by Maori Provider, Te Hotu Manawa Maori as a means of bringing about nutritional change in a Maori community. The aim of the Kai o te Hauora Training is to empower iwi and Maori communities with the skills, knowledge and resources to enable them to make informed decisions about their nutritional health. The research methods were grounded in Kaupapa Maori research methodology. Three community members who have taken part in the Kai o te Hauora training were interviewed as well as those people with whom they have networked within the wider community. Formal unstructured interviews were carried out with a total of twenty-three people over a twenty month period from November 1998 to June 2000. The interviews were each transcribed and analysed for key themes. The results of the interviews documented the changes in behaviour and attitudes toward nutrition for the Maori community in the Whakatane region, through the stories of the three community members who had taken part in the training. Their successes and difficulties in attempting to influence change were also recorded. The success of the Kai o te Hauora training in relation to the literature is discussed. The importance of working from a Kaupapa Maori framework in both nutrition interventions and research relating to Maori is emphasised. This framework inherently acknowledges the importance of Maori networks, values and concepts. The importance of the Kai o te Hauora training principle of empowerment is also acknowledged as being fundamental to the programmes success. The need for further research to measure the impact of the Kai o te Hauora programme, and Maori women�s contributions to their communities is noted, as is the need for this research to have been carried out within a Kaupapa Maori framework.

This thesis is concerned with cervical cancer amongst New Zealand women, particularly Maori women. Maori women have an alarmingly high incidence of cervical cancer, approximately three times higher than non-Maori women. Maori women experience one of the highest rates of cervical cancer in the world. Chapter one, two and three form the introductory section of the thesis, Section A. Chapter one provides an overview of cervical cancer incidence in the world, followed by a more detailed analysis of the occurrence of cervical cancer in New Zealand and a discussion of the aetiological factors of cervical cancer. Cervical screening is discussed in Chapter two. The ethnic differences in incidence and mortality of cervical cancer between Maori and non-Maori and possible reasons for these differences are studied in Chapter three. Section B consists of the original work undertaken. A pilot study (Chapter four) was conducted to trial the methods for the national study (Chapter five). The national study was a retrospective review of the cervical smear histories of Maori women first diagnosed with invasive cervical cancer over a recent two year period in order to investigate why Maori women have not had their disease detected by screening and treated at the intraepithelial stage. Maori women�s knowledge of and attitudes towards cervical screening were obtained in a survey in Ruatoria (Chapter six). Section C concludes with a chapter (Chapter seven) on the conclusions and recommendations based on the material reviewed and the work undertaken.

Throughout the twentieth century, Maori life expectancy for both men and women has increased significantly. For most health conditions however, medical statistics show that the Maori mortality rate remains significantly higher than the rate for the NZ non-Maori population. The results of epidemiological studies show that some of these health conditions may be environmentally induced. There appears to be a high incidence of obesity in the Maori population which has been related to dietary intake, with an associated high incidence of diabetes, heart disease and hypertension. These conditions appear to be particularly prevalent among Maori women. It is thought that the Maori population are gentically susceptible to obesity; a trait which manifests itself when there is a plentiful food supply in the population. At present, there is very little information available about the dietary intake of the Maori population, or the effect of diet upon obesity and associated health disorders in this group. The aim of this survey was to obtain information about the dietary intake of a sample of Dunedin Maori women using the diet history method of assessment. Also to determine the incidence of obesity and other dietry related health conditions in this group. Chapter 2 reviews the change in food habits and health status of the Maori population over the last two centuries, as well as reviewing the different methods by which information for dietary surveys is obtained. After setting out the methods and findings of the survey, Chapter 5 discusses the results in light of information obtained from similar dietary studies of NZ women. The samples intake is compared to recommended nutrient allowances for NZ women and the incidence of dietary related health disorders is also discussed. Overall, Dunedin Maori women�s diet was not deficient in any of the recorded nutrients. Dunedin Maori women, in their middle years, exhibited substantially higher energy intakes than middle years non-Maori women in the 1977 National Dietary Survey. The level of Dunedin Maori women�s carbohydrate intake was the main contributing factor for this higher energy intake. Dunedin Maori women over 50 years of age exhibited substantially higher energy intakes than NZ women aged 50-54 years in the 1985 Timaru Health District Survey, with an overall higher consumption of carbohydrate, protein and fat. Over half of Dunedin Maori were classified as overweight or very overweight. Hypertension and diabetes were reported, and obesity was commonly found among women with these health conditions. Over half of Dunedin Maori women used cigarettes, the majority using between ten and thirty cigarettes per day. Dunedin Maori women are relatively isolated from the more densely populated areas of North Island Maori. As a result, the survey results cannot be interpreted as characteristic of NZ Maori women in general. The significance of these findings is rather the elucidation of a regional situation. Further studies of Maori women in both rural and urban areas of the North and South Island are necessary to determine if an overall pattern of high intake exists with a deleterious impact upon the health of Maori women.

Summary: My excuse for attempting this thesis is firstly, that I am a graduate in medicine of the University of New Zealand and secondly, that my mother was a Maori. It seems to me that with a young university such as that of New Zealand, without the facilities for research work provided by older and richer homes of learning, the scope for original work, which it is the duty of every University to encourage and foster, is somewhat limited. In the philology, history and ethnology of the Polynesian Race, however, is provided a wide field for research work which it is the bounden duty of this University to explore and lead the way. As an obligation to my �alma mater� I take up the subject nearest to my family - medicine amongst the Maoris, in ancient and modern times. As another reason, I have the honour through my mother of belonging to the Maori race. As a result of four years work amongst them as an officer of Health, I am much struck by the different view-point with which the two races, European and Maori, approach the subject of disease. As a member of the Race I am perhaps enabled to understand my mother�s people more intimately than the more progressive but some what forgetful Anglo-Saxon. My experience of Maori ideas and customs dates from beyond the time of graduation in medicine. In childhood�s days, I experienced the bitter taste of the decoction prepared from phorium tenex and I heard around me the whispered diagnosis of �makutu� and �mate Maori�. Constantly throughout youth and early manhood, I have seen the European doctor wax impatient with what he terms prejudices or superstitions which retard or prevent the recovery of Maori patients. I have understood and sympathised with him. At the same time, with the priveledge of the half-breed inheriting the blood and ideas of both races I have been able to detach myself from European thought and look at the question of disease from my Maori countryman�s viewpoint. I understood the burden of the neolithic man�s fears and I symathise with him more deeply still. There are deep holes in the Urenui river which flows through our tribal territory wherein, so my Maori mother taught me, dwelt �taniwhas� or �dragons of slime� who destroyed the transgressor of the multitude of Maori laws and observances. Years of College and University education, combined with the unbelief inherited from a European father, have not been able to suppress the involuntary shudder and contraction of the erector pilae which the suggestion of bathing in those dark holes gives rise to. We inherit our fears in our blood, we imbibe them at our mother�s breast. The schools and teaching of a father appeal to us as we grow older. We subject customs and faiths to the light of comparative criticism and we ridicule the ideas of more primitive races as absurd. But in times of stress, despondency and lowered vitality, there is a tendency to revert to the mother�s fears which slumber within beneath the veneer of civilisation. How much more so in the case of the full Maori who has not had the advantage of even primary education! Clodd says, "In structure and inherited tendencies each of us is recent". The Maori has not been civilised for a century yet. As a duty to my kin, I have attempted to put on record their view of disease, in the hope that though anthropologist�s and others have done so much in collecting the ideas and customs of races on a lower culture stage, this thesis may serve as a small contribution to ethnology.

Narratives of 'being Maori in addiction' have developed in a context in which Maori have been constituted as both 'drunken savages' and 'traditionally' abstinent. Discourses of colonialism and ongoing marginalisation, not to mention resistance, have been most salient in Maori narratives, while those focused on 'cultural deficit' have been more prominent within hegemonic narratives. The goal of the current thesis was to increase understanding of the construction of being Maori in addiction' by: i) identifying key discursive resources used to constitute related subject positions; and ii) identifying the ways in which such resources were deployed to accomplish particular tasks. A review of influential texts identified several core discourses, which located Maori within 'traditions' of collectivity, spirituality and connection with the land. However, the ongoing impact of colonisation, including contemporary alienation from 'tradition', and construction of Maori as the inferior 'other' within hegemonic narratives were prominent. Discourses of addiction have characteristically been based on biological notions of 'disease' and 'disorder', however, psychosocial discourse has become prominent more recently. The '12 Steps' of Alcoholic Anonymous, which provided the primary resource for participants with regard to 'addiction', also includes explicit discourses of spirituality. The current thesis was implemented within a methodological framework, kaupapa Maori. In this context deconstructive discourse analysis was identied as the most appropriate means of analysing interview data gathered from 11 men attending a 'addiction treatment' programme. The results indicated that while 'tradition' was central to narratives of 'being Maori', dicources of alienation and loss were equally salient. In terms of 'addiction', discourses of genetic inheritance were most prominent, although psychosocially constituted 'underlying issues' were also clearly located as being important. Such 'issues' were linked to both general life experiences and 'being Maori'. 'Treatment' narratives revolved around transformative narratives of 'self'. As participants disconnected themselves from 'addiction' and 'underlying issues', they reconnected with their positive ;essential self', previously compromised by 'addiction'. Two main discourses were utilised in terms of the relationship between 'being Maori' and 'addiction'. The first, deployed in aetiological narratives, constituted an inevitable link between 'being Maori' and substance use. The second, more prominent in 'treatment' narratives, located substance use as antithetical to 'Maori culture'. While both Maori and 12 Step 'traditions' were highlighted in participants' narratives, the latter tended to be privileged. 'Being Maori' was identified as important, or at least relevant, however, the opportunity to engage with integrated indigenised narratives of 'addiction' appeared to be limited by several factors. Essentialist 'tradition', for example, tended to be uncritically privileged within discourses that failed to account for contemporary 'diverse Maori realities', ignoring the complexities of relations between and within Te Ao Maori and Te Ao Pakeha. Additionally, '12 Step' discourses of 'treatment' limited construction of more broadly focused narratives of 'recovery'. Overall, the results indicated a clear need for Maori 'addiction treatments' to avoid essentialist notions of 'tradition' and support integrated narratives of 'being Maori in addication', which reflect the varied needs, capacity and experiences of individuals and whanau.

Waka have a special place in the heart of many Maaori. The waka that brought the ancestors of the Maaori to Aotearoa and Te Waipounamu are valued symbols of identity, both culturally and metaphorically. With the effects of colonisation the use of waka as a means of transport disappeared leaving it to re-emerge in the 20th century as a symbol of the revitalisation of Maaori society. Through the construction of waka-taua, ocean going waka and the emergence of waka-ama as a sport, Maaori have endeavoured to reclaim their association to the seas and waterways of New Zealand. This research is a case study of Tupuwae, a kaupapa Maaori injury prevention project using traditional Maaori concepts regarding waka and applying it to a contemporary context. Tapuwae have used this attachment of Maaori to different forms of waka to associate the message of not drinking and driving using purpose-built waka-ama in the southern part of Te Waipounamu. This research identifies some of the wider outcomes that come from a kaupapa Maaori project, but, more importantly it identifies some of the processes that are important in implementing such a project by Maaori living in Otago, outside their tribal boundaries. This research also raises questions about the theoretical underpinnings of kaupapa Maaori theory and argues that there are two threads to this approach, one from a critical theory informed approach and the other from a native theory approach. Key words:Waka, Community Action, Community Development, Kaupapa Maaori, Maaori Development, Maaori Advancement, Native Theory.

This research aims to assess the existing relationship and characteristics between Maori health providers (MHPs) and pharmacy services in New Zealand and to provide future direction, pathways and strategies for collaboration, planning and improving health outcomes for Maori within the primary health care environment. The characteristics of the relationship were identified and discussed before exploring strategies to strengthen the relationship and to improve Māori health outcomes. The assessment and analysis of the characteristics required an exploration of MHPs current knowledge of pharmacy services, the expectations of MHPs of pharmacy services and the current knowledge of pharmacists of MHP services and Maori health. Themes identified that characterised the relationship were related to knowledge, health philosophies, interaction, service and capacity issues. Knowledge issues incorporated themes of group dynamics, historical context, participant knowledge, pharmacy participant knowledge, MHP participant knowledge, solutions/ outcome knowledge, consideration of Maori. Health philosophies related to themes of paradigms/worldviews, kaupapa Maori, capacity, culture and delivery of services, Treaty of Waitangi, knowledge of culture, communication and te reo, rongoa Maori, environmental culture, access, tino rangatiratanga. Interaction issues discussed the themes of collaboration and communication, extent of collaboration, contact with Maori, community relationships, cost, benefits and opportunities. The pharmacy environment, cost and health service delivery were identified as themes relating to service issues. Capacity issues included themes of mana, direct workforce development (education, employment, promotion), indirect workforce development (education, environment, relationship building, funding), and the Maori Pharmacists Association. This research attempted to follow kaupapa Maori qualitative research methodology, methods and the epistemology of kaupapa Maori throughout the research and design process. One to one semi-structured interviews were conducted with participants from each group. The sample size was established based on the purposeful sampling strategy of maximum variation sampling (7 MHP participants, 8 pharmacy participants. Responses were directly related to differences in world-views and the historical context of the two health provider groups with respect to their roles in health. Variations within each group were related to knowledge, location and previous experience working with their counterparts. Recommendations were associated with themes/issues of environment, knowledge, communication, cultural awareness, collaboration, services and the increased awareness of the roles and responsibilities with respect to each health provider group. This dissertation also highlighted a number of key components that formed a collaborative, empowerment model of health created between organisations with different world-views, which can be adapted to a number of environments where there are different or opposing world-views within the overall same patient population. It is anticipated that the results and outcomes from this research will help develop Maori responsive pharmacy services based on health promotion and wellness to Maori locally, regionally, nationally and have a positive impact on Maori health in collaboration with MHPs. Areas of pharmaceutical care are highlighted which may encourage projects or initiatives in collaboration with MHPs to enhance health gains for Maori, while increasing professional practice roles and scope for pharmacy.

The consequences of drug use and benefits of methadone maintenance therapy (MMT) were investigated in a random sample of Maori and non- Maori injecting drug users in Christchurch, Aotearoa New Zealand. Eighty- five injecting drug users (IDUs) who had been on MMT for a mean time of 57 months were interviewed and followed up over an average 18 month period. Markov models were used to model cohorts of IDUs, changes in their health states and the effects of MMT and anti-viral therapy on morbidity and mortality. The savings in life from reductions in drug overdoses were used as the main outcome measure in cost-effectiveness analysis. Cost-utility and cost-benefit analysis were also used to provide additional information on the costs and outcomes of treatment. Comparisons were made between: (a) MMT alone; (b) MMT provided with conventional combination therapy for hepatitis C virus (HCV); and (c) MMT provided with anti-viral therapy with pegylated interferon. The monetary costs of drug use and benefits of MMT were similar for Maori and non-Maori. However, Markov modelling indicated that MMT is associated with greater savings in life for Maori than for non-Maori. Further, Maori IDUs identified the main personal costs of drug use as being loss of their children and loss of marriage or partners. Large reductions in use of opioids and benzodiazipines were reported at interview, compared with before starting MMT. The participants also reported large reductions in crime and stabilisation of their lifestyles. Improvements in the general health of IDUs om MMT were reported. However, 89% were positive for HCV infection, which was identified as the major physical health problem affecting IDUs in New Zealand. Few IDUs had received anti-viral therapy for HCV infections, despite having stabilised on MMT. This study investigated the benefits of providing anti-viral therapy for HCV to all patients meeting treatment criteria. The cost-effectiveness of MMT alone was estimated at $25,397 per life year saved (LYS) for non- Maori men and $25,035 for non-Maori women IDUs (costs and benefits discounted at 3%). The incremental effects of providing anti-viral therapy for HCV to all eligible patients were to save extra years of life, as well as to involve additional costs. The net effect was that anti-viral therapy could be provided, at a similar level of cost-effectiveness, to all patients who meet HCV treatment criteria. Cost-effectiveness could be improved if IDUs could be stabilised on MMT five years earlier at an average age of 26 instead of the current age of 31 years. The cost-effectiveness of treatment with pegylated interferon was similar to that for conventional combination therapy because there were incremental savings in life as well as increased treatment costs. Costs per LYS were estimated to be lower for Maori than for non-Maori, reflecting ethnic differences in mortality. Sensitivity analysis revealed that provision of MMT with anti-viral treatment remained cost-effective under varying assumptions of mortality, disease progression and compliance with treatment. the main problems that were not improved during MMT were continuing use of tobacco and cannabis, low participation in paid employment, only three participants had received specific treatment for their HCV infections. Cost-benefit analysis using a conservative approach showed a ratio of the benefits to the costs of MMT of 8:1. Benefits were demonstrated in terms of large reductions in crime. Benefit to cost ratios were similar for the different policy examined, as well as for both Maori and non-Maori IDUs.