Te Mauri—whānau mana motuhake: supportive care for whānau Māori living with cancer

Abstract

This article describes the origins and development of Te Mauri (the life essence), a unique Māori (Indigenous people of New Zealand) public health and well-being programme aimed at addressing critical gaps in knowledge about supportive cancer care for whānau (families) living with cancer in Aotearoa (New Zealand). Te Mauri is a kaupapa Māori (Māori philosophy) public health initiative having a whānau ora (family well-being) approach, so is based not on the individual, or patient, but within whānau and the core role of communities in relation to the provision of cancer care, the promotion of recovery from cancer, and the maintenance of well-being for current and future generations. Te Mauri makes an important contribution to expanding mātauranga Māori (Māori knowledge) and the range of Indigenous models of care so that cancer service provision is improved for the benefit of all those who are on a cancer journey.

Keywords

Indigenous knowledge kaupapa Māori mātauranga Māori public health whānau well-being

Introduction

The burden of cancer has been steadily increasing over the past decades both worldwide and in Aotearoa (New Zealand) (Blakely et al., 2011; Bray et al., 2018). The burden of cancer is not equal, however, with clear ethnic differences in cancer incidence and mortality evident for Māori (Indigenous people of New Zealand) compared to non-Māori (Gurney et al., 2020a; Ministry of Health, 2015; Robson et al., 2005). In addition to inequities in the burden of disease it is also well documented that differential access to cancer care services (Ellison-Loschmann et al., 2015; Hill et al., 2013; Priest et al., 2010) are likely to be important mediators of cancer survival disparities (Gurney et al., 2020b; Hill et al., 2013; Seneviratne et al., 2015).

Health inequities between Indigenous and non-Indigenous peoples are part of a common legacy of colonisation (Anderson et al., 2016; Robson & Harris, 2007). Health is a social justice and human rights issue and Indigenous people’s rights to health have been clearly articulated and recognised (Braveman & Gruskin, 2003; United Nations, 2007). In Aotearoa, Te Tiriti o Waitangi (Treaty of Waitangi), signed in 1840 between Māori leaders and the British Crown, affirms the right to collective self-determination, recognised in contemporary Māori health policy as inclusive of the rights to health care provision (Ministry of Health, 2014) and for equitable health outcomes (Robson & Harris, 2007).

A universal approach to health care has not led to improved health outcomes for Māori (Waitangi Tribunal, 2023). Recent reviews of the health system found Māori health outcomes continue to be significantly worse than those for other New Zealanders and that this represented a failure of the health system and lack of commitment by successive governments to Te Tiriti o Waitangi (Ministry of Health, 2020; Waitangi Tribunal, 2023). Experiences of racism and discrimination (Harris et al., 2012; Robson & Harris, 2007) also contribute to major systemic factors which have ongoing historical and current day impacts on Māori health and well-being alongside differential access to the determinants of health which also disproportionately affects Māori who are exposed to very different education, employment, income and housing opportunities compared with non-Māori (Robson & Harris, 2007).

Since their establishment in the 1990s, Māori health providers (MHPs) have played a crucial role in facilitating access to services for Māori in a range of ways, from the provision of Māori-specific services in the primary care environment through to playing an advocacy role in the interface with general service providers at the secondary care level. MHPs have also consistently highlighted the major impacts of social determinants and racism on Māori health inequities (Ellison-Loschmann & Pearce, 2006; McLeod et al., 2011; Slater et al., 2015) and the need to promote the use of Māori models of health and well-being as more likely to address inequity and result in better health outcomes (Wilson et al., 2021). Māori models of health draw on mātauranga Māori (Māori knowledge) as a core foundation which is consistent with other Indigenous models of care built around holistic understandings of health (Durie, 2001; Wilson et al., 2021). Traditional knowledge in terms of values and practices arising from Indigenous worldviews recognise varying levels of mental, spiritual family/relationships and environmental, alongside physical elements, as being vital to the promotion and maintenance of well-being (Allen et al., 2020; Cavanagh et al., 2015; Gifford et al., 2023).

There is growing evidence that primary care plays a key role in facilitating access to services, and continuity of care throughout the cancer care journey (Burge et al., 2003; Kendall et al., 2006). Primary care is the first point of connection with the health system, and influences cancer prevention, early detection, access to specialist treatment and patient support following discharge from hospital (Campbell et al., 2002). A few New Zealand studies have highlighted the importance of relationship building between MHPs and their communities which can enhance cancer prevention activities, for example, cancer screening (Thomson et al., 2009), as well as strengthen networks in the provision of support for whānau (families) during cancer treatment (Robson et al., 2019; Slater et al., 2013; Walker et al., 2008). In addition to barriers to care (Cormack et al., 2005; Paterson et al., 2023), there is an identified gap in cancer support service provision that meet the needs of whānau Māori (Māori families) experiencing the effects of cancer (Signal et al., 2013, 2023).

The first national survey of cancer services delivered by MHPs in 2011 found that MHPs provide a wide range of services including cancer prevention through health promotion, advocacy, information and support (Slater et al., 2016). Important and understudied areas within systems of cancer care were identified including the critical role of information and how the quality of, and reception to, information, is interrelated with the support structures of patients, with MHPs and general practitioners identified as being central to supportive care for those whānau experiencing the effects of cancer (Slater et al., 2015; Slater et al., 2013). Support was also relevant for whānau both during treatment but also on discharge home in terms of adequate follow-up care and services (Koia, 2019; Slater et al., 2013). This is consistent with findings from overseas studies of the importance of family support among Indigenous cancer survivors as well as recognition of spirituality as central to coping with, and understanding, the cancer experience (Cavanagh et al., 2015; Garvey et al., 2020). However, in a systematic review of the types of interventions that have been utilised by Indigenous peoples living with cancer, Gifford et al. (2021) did not find strong evidence of relevance between participating Indigenous communities and the interventions in the 27 studies included in the review. In addition, none of the studies addressed all four—physical, mental, social, and spiritual—dimensions of holistic wellness.

There has been an identified need for culturally safe education and support programmes catering to Māori cancer patients and whānau. Originally developed in North America (McLeod et al., 1993) and then brought to Aotearoa via the Victoria Cancer Council, Australia in 1990 (Roberts et al., 2002), the Living with Cancer Education programme was first offered by the Cancer Society of New Zealand in 1991 (Jasperse et al., 2012). The name was changed to the Living Well programme in 2009 to reflect recent developments in cancer survivorship and then subsequently adapted to become Kia ora—E te iwi (be well—everyone) in 2011, with the content essentially unchanged and the only significant difference being the delivery setting taking place on the marae (a Māori meeting house and the complex of buildings around it) (Neser & Wharerau, 2011). The Cancer Society was established in 1929, as an independent charity funded by donations and is the main provider of supportive care in Aotearoa. Māori are underrepresented in those who access the Cancer Society telephone service (Murphy et al., 2010) and Māori attendance in the Living Well programme is low (Neser & Wharerau, 2011).

Recognising the need for and importance of cancer support as being critical for Māori, we undertook a research project with the overall objective being to develop, deliver and evaluate a Māori support programme which uses te ao Māori (the Māori world) as its basis for those experiencing cancer and their whānau.

Research aims

The aims of the research were to

(a) develop a cancer support programme for whānau Māori living with cancer;

(b) train programme facilitators who would obtain specific skills in the delivery of a cancer support programme and contribute to building the cancer education and health promotion workforce capacity in their regions;

(d) evaluate the effectiveness of a cancer support programme for whānau Māori living with cancer.

This article addresses the first aim (a) only with findings related to the other research aims to be presented in subsequent papers. Ethics approval for the study was sought first, through hui (meeting) with kuia (female elders) and kaumātua (male elders) to discuss the tikanga (the customary system of values) regarding how the process of the study would be initially undertaken and developed throughout its progress; and second through an application to the New Zealand Central Health and Disability Ethics Committee the programme received approval for the study (ref: 16/CEN/154) in November 2016.

The research proposal was developed by MHPs and researchers from Massey University. The study team was co-led by the kaiwhakahaere (manager) of Mana Wāhine (empowered women), a collective of MHPs from the lower half of the North Island of New Zealand with expertise in the delivery of cancer screening and health education services to whānau. Three MHPS organisations from Mana Wāhine were research partners on the study together with two Māori community workers with extensive experience caring for whānau with cancer. The other co-lead of the research was a Māori public health researcher based at Massey University. The remaining research team members, also from Massey University, comprised a Māori post-doctoral fellow who was the project manager and a Pākehā (New Zealander of European descent) senior researcher with experience in community-based research.

One of the deliberate intentions of the project was in structuring the language in ways that privileged Māori worldviews as tangata whenua (people born of the land) and the therapeutic healing nature of engaging whānau Māori in te ao Māori and te wairua (spirit of a person). The research team recognised this to be important while also being regardful of the devastating impacts that colonisation has had on Māori in so many ways including the loss of connection with te ao Māori, te reo Māori (the Māori language) and mātauranga Māori. Indigenous peoples of the world have their own customs and knowledge base systems; with mātauranga Māori being that system of Indigenous knowledge within Aotearoa. Drawing on this continuum of knowledge together with the recognised healing potential within whakapapa (genealogy) and the use of wānanga (environments of knowledge exchange) honoured the importance of te hono ki te wairua (the spiritual dimension) as core elements of whānau ora (family well-being). Any Māori person would be able to pick up this model and implement it from their reality of being Māori; one of the Māori research team members described it in these terms:

That was the intention, alongside celebration of te ao Māori, mātauranga Māori, our world, our worldview of life that comes from a mauri ora [flourishing life force] and a wairua [spiritual] orientation. We realised we were being asked to be present, to be pono [to be true; honest; genuine] to our tūpuna [ancestors] mātauranga, as a way in which our whānau would have the mana [power, essence or presence] to reclaim their mātauranga Māori while on their cancer journey of participating in Te Mauri [the name of a unique Māori public health and wellbeing programme; literally, living essence].

The research team had experience with undertaking projects consistent with a kaupapa Māori (Māori philosophy) theory approach which prioritises Māori values, Māori worldviews and Māori processes as essential for guiding and informing research (Mahuika, 2008; Smith, 2012). Importantly, all three MHPs share a common commitment to working within a kaupapa Māori framework where use of Māori models of health, taking a strengths-based approach, promotion of positive Māori development and recognition of the contribution of mātauranga Māori to effect change, are all core philosophies underpinning their services. Māori processes are also used as a basis for developing and delivering health services that support Māori control and autonomy. In addition, each MHP has their own expertise in kaupapa Māori knowledge and having worked with cancer patients within their respective services over a number of years, could draw on this information to contribute to the development of a supportive care programme.

We present here first the programme structure of Te Mauri before going on to describe the core foundational elements of the programme and the ways in which those foundations support the content and delivery of Te Mauri.

Te Mauri programme structure

The development of Te Mauri occurred over a 7-month period in 2017. Te Mauri was designed to be mana enhancing for whānau experiencing cancer as well as for those kaitiaki (trusted workers; guardians) involved as programme facilitators. The initial development of Te Mauri drew from interviews undertaken with whānau experiencing cancer and the experiences of the three MHPs organisations with expertise in the delivery of cancer screening and health education services to whānau who have been on a cancer journey. Building on relationships established over a number of years, Mana Wāhine organised a series of wānanga to bring together experts of mātauranga Māori who could contribute to the development of a programme based in te ao Māori.

Aki aki te ti o te tangata: through movement there is life

The kaupapa (philosophy) that begins the relationships within the support programme is based on the pōwhiri (welcome ceremony) process. Pōwhiri starts from the waharoa (gate) across the marae atea (the land in front of the meeting house) up and into the wharenui (meeting house) creating the safe space for pūrākau (stories) to be heard and to establish the transformative power of these pūrākau to provide the connections to tūpuna knowing and guidance through matangireia (afterlife journey). A deep engagement with the pōwhiri process requires an understanding of the separation of Papatūānuku (Earth Mother) and Ranginui (Sky Father) as it illuminates the transformation from the world of darkness to the world of light and can be applied by whānau as they navigate their journey through cancer (Robson et al., 2005). The marae represents the atea (realm) of Tūmatauenga (Māori God of Courage or War) which is significant because this is where Māori can discuss and debate issues freely and openly, followed by entering the wharenui within which there is the opportunity for reconciliation and further illumination and enlightenment.

Matangireia is a Tainui (tribal name of the Waikato, Hauraki and King Country areas of Aotearoa) kōrero (to speak, say, talk) of the afterlife that traces the journey of wairua to te hono ki te wairua through several purification rituals, and eventually leading to the realm of Io (Supreme Being) where we all must eventually journey (Jones, 2013). The significance of matangireia is that it provides hope and the understanding of a Māori view of the afterlife which is threaded throughout the programme. Te Mauri is a wairua journey and te haerenga mai (the journey back) is about returning back to the wairua that is on a journey and returns to the realms of Io. Spirituality here is positioned in a Māori worldview allowing for the journey of wairua, which can be experienced by anyone regardless of their religious affiliation. Te Mauri acknowledges that many whānau will take that wairua journey to matangireia.

The ritual and symbolism associated with pōwhiri and the various areas of the marae are critical to setting the foundation of establishing the supportive relationship within Te Mauri. The kaitiaki role represents the haukāinga (local people) or mana whenua (people who occupy tribal lands) as they welcome the whānau participants to the physical location and the programme. The kaitiaki roles are maintained throughout the process of pōwhiri, providing participants with the tikanga and kawa (protocols) surrounding whakapapa, mana and manaakitanga (process of showing respect and care) (McClintock et al., 2012).

Whānau mana motuhake: autonomy

Te Mauri is constructed around the sharing and exchange of knowledge through four konae (baskets) with eight wānanga within each konae. Each konae addresses a significant process of ritual and symbolism in which the whānau journey strives to achieve a flourishing state of mauri (life force or essence). The programme content draws on pūrākau as both ancient stories and present day whānau stories, within each session and uses these pūrākau as a basis from which whānau information needs are generated.

The first konae, ngā pō (stages of potential), based upon the pōwhiri ritual, signifies the potential, knowing and the beginning of transition from darkness into light as whānau take in the news of a cancer diagnosis. Beginning with the creation of the supreme being, Io, and the significant aspects of the pō (stages) which are incorporated into the journey of the whānau. This creates an opportunity to connect to the innate mōhiotanga (knowledge) and mana of each participant. The topics of discussion lead whānau to more in-depth conversations concerning their own story, whakapapa, grief and trauma about their diagnosis.

The second konae, te whei ao (the realm of coming into being), based upon the idea of the marae atea, is the dawn where illumination brings an understanding of things as they are, a place to debate the challenges being faced and to find and connect with solutions. Practically these challenges usually surface as self-care, travel, finance and social issues and understanding their personal journey with a diagnosis of cancer. Clarity is sought to make decisions about treatment, support and key people or kaitiaki to contact.

The third konae, te ao mārama (coming into the light of understanding), which draws upon the concept of the wharenui, focuses on where light comes from darkness. Empowerment and mana illuminating and engaging with all those involved in the patient’s cancer journey during the remission stage. Whānau will go in and out of the pō as they go through the cancer journey—continuity of care is therefore critical so that whānau do not become confused and overwhelmed within the health care system and to ensure their mana is upheld. This in turn can also help guide the wairua and psychosocial needs of the whānau, through development of resilience and via the sharing of knowledge and learnings from each other.

The fourth konae, mauri ora, encompasses a sense of flourishing and maintaining a strong life essence to assist in the recovery from cancer, which may include encouraging whānau to connect or re-connect to pūrākau from within their iwi (extended kinship group; tribe; nation; people) to strengthen and support their recovery. Whānau are asked to consider what are the challenges and opportunities to support their mauri. How does one standing on the brink of eternity maintain a flourishing mauri? Whānau are asked to consider what are the challenges and opportunities to support their mauri. Equally, Mauri ora represents consideration of transition from one world to another—matangireia.

Foundational elements of Te Mauri

There are three foundational elements which inform and support the content and delivery of Te Mauri: nurturing the power of relationships through whānau connection; using pūrākau as a form of knowledge transmission and acquisition to promote spiritual well-being and a better understanding of cancer; and the establishment of a safe environment to support healing and transformation.

Whānau connection

The key aspiration heard from whānau was that they wanted a programme which spoke of traditional values and beliefs and systems of knowledge handed down by our ancestors, our mātauranga Māori. The programme was named Te Mauri.

Wānanga were chosen as the most appropriate way to begin the development of Te Mauri. Māori research practice draws on wānanga as an Indigenous method of knowledge construction and transmission (Mahuika & Mahuika, 2020). Wānanga are a creative activity and a conscious energy, for example, the te ao mārama paradigm advocates for moving past the acquisition of mātauranga Māori into a wānanga space that critically analyses and creatively applies this knowledge (Royal, 2009).

One of the four foundations for Māori health, as described by Durie (2001), is access to te ao Māori through our cultural heritage and whānau. Our first wānanga reminded us why a Māori specific programme was important for our people, including the need for something and somewhere for our whānau to be part of, to support them through their experience of cancer. Within the wānanga it was possible to explore what contextualising Māori health promotion might look like when blending two current Māori health models, Te Wheke (the octopus) (Pere & Nicholson, 1997) and Mātauranga Māori ā Iwi (the knowledge of the Māori people) (Royal, 2009). Broughton and McBreen (2015) notes that unless the survival of mātauranga is prioritised, it will cease to flourish. Wānanga thus invites critical reflection and active engagement (Nicholson, 2020), providing an important opportunity to celebrate, reclaim and centre mātauranga Māori, as an Indigenous knowledge worldview.

Pūrākau: knowledge transmission and spiritual well-being

The second foundational component of Te Mauri was the recognised importance of ancient stories or pūrākau that connect and support us in our relationship with atua (Māori gods). Atua and pūrākau give historical context to the journeys made and those that lay ahead, and provide a framework from which to draw strength, understanding and relationship. As a traditional form of narrative, pūrākau encompass philosophical thought, epistemological constructs, cultural codes, and worldviews that are fundamental to our identity as Māori. They are also dynamic and can be applied to better understand the experiences of our lives as Māori—including within a research context (Lee, 2009).

The development of Te Mauri was deeply committed to using te reo Māori, alongside English, to privilege a Māori worldview focused on mauri ora and wairua as key to facilitating a healing and therapeutic environment when engaging Māori whānau in te ao Māori. Our intention was to be pono to mātauranga Māori and not to reproduce a Pākehā programme with kupu Māori (Māori words). Te reo Māori is therefore a critical component of Te Mauri which can also contribute to the revitalisation of our language to counter the adverse effects of colonisation (Walker, 2016).

We have been constantly reminded we are not here to treat cancer but to support whānau mana motuhake (autonomy, self-determination). This then becomes a programme inclusive of our history within our Māori philosophy, and our spirituality with reference to creation, ecology and the environment. Being enriched with mātauranga Māori, Te Mauri reached well beyond that of providing cancer support to also contributing to strengthened cultural identity, the positive enhancing of mana and the development of resilience among all those who were part of the programme.

Supporting healing and transformation

Preliminary discussions identified the need for kuia and kaumātua to be present within the design and ongoing structure of Te Mauri. What we gained by having them support us was their leadership within their community, an increased community connection, and the presence of experts of tikanga Māori from whom we could seek advice. They were the pou (pillars; support) and ancestral and oral knowledge wisdom holders (Nicholson, 2020) who held the mauri and kept everyone safe and grounded throughout the whole process of developing the programme from beginning to end.

The role of the facilitator or kaitiaki was recognised as a key element to ensuring the success of the programme in terms of guiding the collective mana and knowledge among participating whānau. It was also necessary that the kaitiaki be able to establish a te ao Māori perspective within Te Mauri that is inclusive of the diverse experience of whānau. To do this requires a range of qualities including recognition of the importance of wairua and mauri as well as other essential skills such as the ability to foster a sense of whānaungatanga (relationship; kinship; sense of family connection) and aroha (compassion). It was important to acknowledge our diverse abilities with regard to understanding and fluency in te reo. Kaitiaki and participants were supported in whatever level of knowledge they had in te reo Māori with all Te Mauri training documents and resources providing translations to ensure everyone could feel confident while fully participating in the programme.

In our interviews with whānau they identified the importance of being in an environment they felt belonged to them and where they were able to freely share their cancer experience with others, in some instances for the first time. One of the crucial ways we have provided an environment of manaakitanga for whānau has been the sharing of food together and the use of karakia (ritual chants; prayers), waiata (to sing; song) and whakawhānaungatanga (process of establishing relationships). Te Mauri seeks to contribute to the empowerment of whānau, to provide a safe space to reclaim their mātauranga Māori which can support a flourishing mauri through their experience of cancer.

Tohu Kaupapa: life’s journey

The Te Mauri framework and its underlying processes and structures are embodied by the tohu (logo), which represents the relationship between the research partner organisations and their respective strengths which are brought together through the collaborative nature of this study (Figure 1). It is also an invitation to Māori whānau affected by cancer to realise that Māori concepts have the ability to sustain our mauri when experiencing feelings of taumaha (burden). This tohu is an expression of the worldview of our tūpuna drawing on a range of interpretations and philosophical viewpoints as well as kōrero with mentors and colleagues.

Figure 1.

Te tohu o Te Mauri (The logo of the Te Mauri programme).

The design of this tohu signifies the journey each person must take in the physical world and in the spiritual world. Time does not dictate the life and death of an individual, it is irrelevant. What matters, and is reflected in the many histories, whakataukī (proverbs; significant saying) and waiata of our people, is the importance of striving to achieve excellence in life. The name of the programme Te Mauri recognises that all things created have a mauri, from animals, to trees, people, stones and dirt. Mauri exists in all forms and is present in both animate and inanimate objects, therefore, it is continuous and a part of the unbroken cycle of existence. We exist, we pass away, we continue to exist on another plane. We are connected via this whakaaro (understanding) to the world around us, and ultimately to the universe itself as a part of a continuous cycle.

The design is in the shape of the ihu (prow) of a waka (Māori canoe). Waka are not only used to move our people in this world, but are also used to send Māori to the spirit world. The poutama (pattern representing life and lifelong learning) at the bottom of the design represents the journey of life and lifelong learning. The two wheku (carved faces) at each side represent māreikura (female supernatural being) and whatukura (male supernatural being), the guardians of the uppermost heavens and gateway to the most sacred and sought-after knowledge. These elements are used here to symbolise the importance of valuing each day we have and striving to achieve our greatest potential in our time. Te tatau o te pō, the space between the Māreikura and Whatukura, that symbolises the threshold that separates the spirit world and te ao mārama. Once we cross this threshold, we are reconnected with the atua, the source of all creation. The only way to access this realm is for each of us to take the eternal sleep, and when we sleep, we also dream. Therefore, we must lose our physical essence to be able to experience not only the eternal slumber, but also an eternity of dream time. The kākano (circle) at the centre of the design represents eternity and the next stage in our journey, among other things.

Conclusion

Te Mauri is a wairua journey and by positioning the programme within pūrākau it allows and expands understanding of the physical, emotional and spiritual challenges faced by those with a cancer diagnosis from te ao Māori view. It provides an opportunity to create transformation and allow healing to occur drawing on the whānau mana motuhake. The intent of Te Mauri is to aki aki te tī o te tangata—to encourage and support the indescribable light that every person has within them. This programme allows us to reclaim our mātauranga Māori, our Indigenous cultural beliefs and values systems.

In the recent review of the New Zealand Health and Disability System (Ministry of Health, 2020), specific attention was given to mātauranga Māori and rangatiratanga (right to exercise authority) as core features needed within the health system, alongside recognition of the importance of Māori having a strategic role as commissioners to ensure an effective and responsive system and services. These were seen as fundamental requirements to address Māori health inequity (Ministry of Health, 2020). Sustained and effective change will only be achieved through the New Zealand government meeting their obligations to provide equitable health outcomes for Māori consistent with Te Tiriti o Waitangi (Waitangi Tribunal, 2023).

Involvement of whānau in the initial development stages of Te Mauri was an important step to ensure the programme was tailored to whānau needs, an approach which is consistent with other Indigenous developed programmes (Burhansstipanov et al., 2001; Cavanagh et al., 2015; Gifford et al., 2023; Santos et al., 2001). The utility and application of models which take a whānau and community focus, rather than an individual approach, and which emphasise the importance of relationship and building connections as demonstrated through the development of Te Mauri, highlights the significant role that Māori models of health and understanding of well-being can make to enhancing health service provision for everyone.

This has been increasingly important with the recent and ongoing COVID-19 response in Aotearoa where Māori providers were recognised as a critical workforce in ensuring access to vaccines and providing health, financial and food support to those with COVID-19 and their families (Gifford & Boulton, 2020). Drawing on the key principles of whānaungatanga, manaakitanga, kaitiakitanga (guardianship) and rangatiratanga, iwi leaders acted quickly to harness government and local resources and provide direction to strengthen preventive measures and plan or prepare for the management of COVID-19 in their communities, through a range of activities. These included the strategic mobilisation of community-based health and social services led by iwi, by marae and whānau and by Māori providers and organisations who designed, delivered and were responsible for the health and welfare needs of their communities, both Māori and non-Māori (Gifford & Boulton, 2020).

There has long been recognition by practitioners that current mainstream programmes do not address whānau mana motuhake in supporting whānau through the challenges of dealing with a cancer diagnosis (Koia, 2019; Slater et al., 2013). At the same time, while the majority of Māori continue to need to access mainstream health services, ensuring strong relationships between those health services and Māori organisations is critical to ensuring that support care needs for Māori experiencing cancer are maintained, given the scarcity of whānau centred Māori developed programmes such as Te Mauri (Ellison-Loschmann & Pearce, 2006; Koia, 2019). The importance of these kinds of relationships have also been recognised by other Indigenous peoples internationally (Allen et al., 2020; Thomas et al., 2023; Whop et al., 2012). For example, Allen et al. (2020) describe a range of Indigenous-led health service partnerships which show improved holistic health outcomes as well as access to care for Indigenous communities in Canada. Whop et al. (2012) emphasise how relationships between mainstream support services and Indigenous organisations are critical in meeting the supportive care needs of Indigenous cancer patients in Australia. Thomas et al. (2023) found that improving access to culturally safe and individualised health care for Indigenous peoples in Canada was critical and that spirituality, connection to the land and families and communities were important sources of healing and support for cancer survivorship.

While the cultural context and history of Māori are specific to Aotearoa, and hence too, the development of Te Mauri, some commonalities, for example, racism within the health system (Harris et al., 2012; Robson & Harris, 2007) and barriers to access (Cormack et al., 2005; Paterson et al., 2023; Slater et al., 2013) highlight oppression and racism as legacies of colonisation experienced by other Indigenous peoples (Anderson et al., 2016; Huang et al., 2023). Equally, the potential for system change, drawing on the examples of shared leadership, Māori innovation and collective strength, as witnessed during the COVID-19 response (Gifford & Boulton, 2020) for example, highlights the very real potential for improving health and equity outcomes for Māori.

Te Mauri is a unique Māori public health and well-being programme. Drawing on te ao Māori, it prioritises whānau and the core role of communities in relation to the provision of cancer care, the promotion of recovery from cancer and the maintenance of well-being for current and future generations. Te Mauri makes an important contribution to expanding mātauranga Māori and the range of Indigenous models of care so that cancer service provision is improved for Māori and potentially for the benefit of all those who are on a cancer journey.

Footnotes

Acknowledgements

Kua wheturangitia tō tātou pou a Matua Rackie Pahau. Moe mai rā e Pā. May the wairua of your tūpuna illuminate your pathway to matangireia. Haere, haere, haere atu rā. Hoki ki te hunga ora. Let us return to the living. We acknowledge and thank all of the people who gave their time and expertise to be involved in this research. We are especially grateful to Whaea Iris Pahau for being our pou kuia who held the Mauri of our wānanga alongside Matua Rackie Pahau. We acknowledge and thank the contributions from the Mana Wāhine collective Lucie Kennedy, Cherie Seamark, Teresea Olsen, Triny Ruhe, Waitohiariki Quayle and Tūkaha Milne for his mātauranga. We are deeply grateful to the Te Mauri whānau from Hora Te Pai Te Atiawa ki Whakarongotai Kapiti Coast, Kōkiri marae Te Awa Kairangi and Whaiora Whānui Ngāti Kahungungu ki Wairarapa for all that they shared and contributed to Te Mauri. Tihei Mauri Ora!

Authors’ note

Tira Albert (Te Whānau-A-Apanui, Ngāti Rāhiri Tumutumu Pare Hauraki me Te Waipounamu) (BMM) is Manager Mana Wāhine, Wellington, Aotearoa/New Zealand. She has extensive experience in Māori health promotion, working towards equity in Breast and Cervical screening programmes and providing Māori specific cancer support services. Tira is a researcher for Cancer Narratives Aotearoa—He Kahui Kōrero Taumahatanga o Te Mate Pukupuku: Aotearoa and an advisor in the C3 Research Group 5-year Research Programme Whakatōmuri, whakamua: Walking backwards into the future of Māori cancer care, with the University of Otago Wellington. The work that she has been part of in cancer research extends to being the primary investigator in developing the first Indigenous cancer support programme for Aotearoa. Tira’s most recent research was as co-investigator in Assessing supportive care needs for Māori with cancer in Aotearoa/New Zealand with the University of Otago Wellington. She has a personal and professional commitment to Te Tiriti o Waitangi as reflected in her work. Mauri Ora!

Lewis Stephens (Ngāti Raukawa, Ngāti Whawhakia) (MA) is the Establishment Coordinator for Ui Consultancy Ltd. He has had a varied career with experience in many aspects of organisational management and business. Lewis has managed iwi primary health care and social services. He has a master’s degree in adult education with more than thirty-five years’ experience in training, lecturing and education. Lewis has had extensive experience in private practice, health and social service sectors as an educator, trainer, and manager. He also has a Graduate Diploma of Guidance and Counselling, Bachelor of Social Science, Diploma of Community Services (Case Management) and is a member of the Australian Psychological Society. Lewis has a fervent desire to contribute to community mauriora.

Matewawe Pouwhare (Ngāi Tuhoe, Ngāti Awa) (MA (Distinction)) is a Kaupapa Maori practitioner of Kaitiakitanga, and has over 30 years of experience in education, matauranga Māori, child & adolescent psychotherapy. She is the Director of Te Mauri Consultancy Ltd a kaupapa Māori training organisation. Matewawe has designed and developed various training programmes focusing on Bi-cultural Trauma-informed education. She is a strong advocate on delivering learning based on Ako Pedagogy/Andragogy and delivers through Māori wananga methodology. The Te Mauri whanau mana motuhake support programme was named after Matewawe’s son.

John Kingi (Muaūpoko, Ngāti Porou) is Manager for Rangatahi Tū Rangatira, Kōkiri Marae Keriana Olsen Trust, Wellington, Aotearoa/New Zealand. He has many other connections that he is very proud of, including his non-Māori lineage. John is involved with a number of kaupapa, including artistic expression. As the designer of the Te Mauri tohu he has drawn on many sources of inspiration and knowledge bases, many of which far more learned than him. Without the help and input of others designing something of such depth to represent an important group as Te Mauri would not be possible. Cultural identity, retention and continuation of ancestral knowledge in all its forms is something that John has come to realise has been his life’s work. Seeing his people express themselves as unique Whānau, Hapū, Iwi through the rich narratives of their ancestors is what he is all about! Mauri ora!

Cheryl Davies (Ngāti Raukawa, Ngāti Wehiwehi, Ngāti Mutunga o te Wharekauri) is Manager of Tū Kotahi Māori Asthma Trust, Wellington, Aotearoa/New Zealand. She has managed the Tu Kotahi Māori Asthma and Research Trust—the first Māori asthma society in New Zealand—for over 30 years. Cheryl has worked alongside the University of Otago on several key research studies involving Māori communities over the past 23 years. One of these projects is He Tipu Manahau, a papakāinga housing project, a partnership between Wainuiomata marae, Kāinga Ora and He Kāinga Oranga to create a sustainable eco-housing development based around the marae to provide warm and healthy homes for the local community. It will incorporate a smart renewable energy microgrid to supply affordable power to residents. There are many other research projects that she continues to be an integral member of.

Pauline Wharerau (Ngāti Hako, Ngapuhi) is Whānau Ora Navigator New Zealand Police, Palmerston North Aotearoa/New Zealand. She is committed to making a difference in cancer support care for the Indigenous peoples of Aotearoa/New Zealand. Pauline has worked as a the Kaitakawaenga for Central Districts cancer society division, supportive care coordinator for Manawatu cancer society, and Māori cancer coordinator for Best Care Whakapai hauora charitable trust Palmerston North.

Janis Awatere (Te Atiawa Ngāti Te Whiti, Taranaki) is a social worker at Kōkiri Marae Keriana Olsen Trust, Wellington, Aotearoa/New Zealand. She has been the Kaitiaki of Te Mauri since its inception, as it was established on the heels of her losing her husband to cancer, and was integral to informing the development the kaupapa. Janis holds the mauri of the kaupapa and continues to develop deep connections with all our whānau who contribute to and take part in the Te Mauri Kaupapa. She has a social work background and has worked in the Hutt Valley region for over 40 years. Janis has been a Caregiver Coordinator and helped lead the establishment and management of the Pātaka for Kōkiri during COVID-19, supporting our communities across the Hutt Valley and wider Wellington regions. She is also Kaiārahi of the Matua Rautia (caregiver training programme) providing one-to-one support to our caregivers on the ground. Janis is a valuable member of the Kōkiri Marae whānau.

Lis Ellison-Loschmann (Kāi Tahu & Te Ātiawa) has a PhD in Public Health. Her research focuses on health inequities, health system performance and the epidemiology of chronic disease, particularly cancer and respiratory conditions.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship and publication of this article: This work was supported by a Health Research Council (HRC) of New Zealand project grant [HRC reference 16/415].

ORCID iD

Tira Albert

Glossary

aki aki te tī o te tangata to encourage and support the indescribable light that every person has within them

Aotearoa New Zealand

aroha compassion

atea realm

atua Māori gods

haukāinga local people

hui meeting

ihu prow

iwi extended kinship group; tribe; nation; people

Io Supreme Being

kaitiaki trusted workers; guardians

kaitiakitanga guardianship

kaiwhakahaere manager

kākano circle

karakia ritual chants; prayers

kaumātua male elders

kaupapa philosophy

kaupapa Māori Māori philosophy

kawa protocols

Kia ora—E te iwi name of a living with cancer education programme; literally, be well—everyone

konae baskets

kōrero to speak, say, talk

kuia female elders

kupu words

kupu Māori Māori words

mana power, essence or presence

mana motuhake autonomy, self-determination

Mana Wāhine a collective of Māori health providers; literally, empowered women

mana whenua people who occupy tribal lands

manaakitanga process of showing respect and care

Māori Indigenous people of New Zealand

marae a Māori meeting house and the complex of buildings around it

marae atea the land in front of the meeting house

māreikura female supernatural being

matangireia afterlife journey

Mātauranga Māori Māori knowledge

Mātauranga Māori ā Iwi a Māori health model; literally, the knowledge of the Māori people

mauri life force or essence

mauri ora flourishing life force

mōhiotanga knowledge

ngā pō stages of potential

Pākehā New Zealander of European descent

Papatūānuku Earth Mother

pō stages

pono to be true; honest; genuine

pou pillars; support

poutama pattern representing life and lifelong learning

pōwhiri welcome ceremony

pūrākau stories

rangatiratanga right to exercise authority

Ranginui Sky Father

taumaha burden

Tainui tribal name of the Waikato, Hauraki and King Country areas of New Zealand

Tāne Māori god of the forest

tangata whenua people born of the land

te ao Māori the Māori world

te ao mārama coming into the light of understanding

te haerenga mai the journey back

te hono ki te wairua the spiritual dimension

Te Mauri name of a unique Māori public health and wellbeing programme; literally, the life essence

te reo Māori the Māori language

te tatau o te pō the space between the Māreikura and Whatukura that symbolises the threshold that separates the spirit world and the world of light

Te Tiriti o Waitangi Treaty of Waitangi

te tohu o Te Mauri the logo of the Te Mauri programme

te wairua spirit of a person

te whei ao the realm of coming into being

Te Wheke a Māori health model; literally, the octopus

tikanga the customary system of values

tohu logo

Tūmatauenga Māori God of Courage or War

tūpuna ancestors

waharoa gate

waiata to sing; song

wairua spiritual

waka Māori canoe

wānanga environments of knowledge exchange

whakaaro understanding

whakapapa genealogy

whakataukī proverbs; significant saying

whakawhānaungatanga process of establishing relationships

whānau families

whānau Māori Māori families

whānau ora family well-being

whānaungatanga relationship; kinship; sense of family connection

wharenui meeting house

whatukura male supernatural being

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