The shame of fat shaming in public health: moving past racism to embrace indigenous solutions.

OBJECTIVES: The aim of this article is to explore perceptions of weight and racism towards Maori, as an indigenous group, and the association between the two. We then propose indigenous solutions as pathways out of fat shaming. STUDY DESIGN: This is a conceptual article supported by a review of literature in the fields of weight stigma, racism and indigenous (Maori) health. METHODS: This article is taken from the perspective of three researchers involved in Maori health research, studies on institutional and societal racism and critical research on weight stigma and the weight loss industry. Indigenous peoples in developed nations are more likely to be overweight, obese and disproportionately affected by the comorbidities and physical disorders associated with weight when compared with their counterparts. Beyond the physical ailments are a variety of psychological, emotional and social issues, which are associated with being 'fat' and/or overweight and/or from subsequent stigmatisation. RESULTS: Long before this world's populations reached the current alarming level of obesity, indigenous peoples in colonised countries were stigmatised because of the colour of their skin, their beliefs and their culture. Stigma is nothing new to indigenous peoples, and so when Maori, or any other indigenous groups are told they are fat and less productive (or moral) because of 'fatness', there is no surprise because they have been told the same thing (albeit for a different reason) for generations. Considering the relatively high proportion of indigenous people in New Zealand, North America and beyond who do not fit the 'recommended weight range', the justification for racist sentiment is seemingly strengthened. CONCLUSIONS: A weight loss-centred approach to health has not improved the health of indigenous people. Initiatives that draw on, or are underpinned by local, traditional knowledge are more relevant for indigenous peoples and could lead to better health outcomes for these groups.

Realising the rhetoric: refreshing public health providers' efforts to honour Te Tiriti o Waitangi in New Zealand.

OBJECTIVES: New Zealand has a unique tool, Te Tiriti o Waitangi, the Treaty of Waitangi, for addressing health disparities. Indigenous Maori have compromised health status compared to other groups. This paper investigates ways in which public health units (PHUs) and non-governmental organisations (NGOs) use Te Tiriti o Waitangi in service delivery to Maori. DESIGN: A nationwide telephone survey of primary health providers (n=162) was conducted in 2014-15. Participants were asked about effectiveness and monitoring of their service delivery to Maori. RESULTS: PHUs reported actively working with Maori, and Te Tiriti o Waitangi to reduce health disparities. Direct Maori engagement with development and delivery of programmes was viewed as essential. Strategies included designated PHU staff in positions of responsibility, formal partnerships with Maori, and providing operational and strategic guidance. Some PHUs supported development of cultural competencies. NGO responsiveness to Maori was variable. Some NGOs described prioritising service delivery and programmes for Maori. Others reported the focus of their service was European or other non-Maori ethnicities. Lack of resources or past difficulties engaging with Maori were barriers. CONCLUSION: Public health has an ethical commitment to reduce health disparities. Advancing Te Tiriti obligations in everyday practice has the potential to address inequalities.

Using vignettes about racism from health practice in Aotearoa to generate anti-racism interventions.

Racism is a key modifiable determinant of health that contributes to health inequities in Aotearoa and elsewhere. Experiences of racism occur within the health sector for workers, patients and their whanau (extended family) every day. This paper uses stories of racism from nurses - reworked into vignettes - to examine the dynamics of racism to generate possible micro, meso and macro anti-racism interventions. A critical qualitative design was utilised, informed by kaupapa Maori approaches. The five vignettes in this paper were sourced from a pair of caucused focus groups with nine senior Maori (Indigenous peoples of Aotearoa) and Tauiwi (non-Maori) nurses held in Auckland Aotearoa in 2019. The vignettes were lightly edited and then critically analysed by both authors to identify sites of racism and generate ideas for anti-racism interventions. The vignettes illustrate five key themes in relation to racism. These include (i) mono-cultural practice, (ii) everyday micro-aggressions; (iii) complexity and the costs of racism, (iv) Pakeha (white settler) privilege and (v) employment discrimination. From analysing these themes, a range of evidence-based micro, meso and macro-level anti-racism interventions were derived. These ranged from engaging in reflective practice, education initiatives, monitoring, through to collective advocacy. Vignettes are a novel way to reveal sites of racism to create teachable moments and spark reflective practice and more active engagement in anti-racism interventions. When systematically analysed vignettes can be utilised to inform and refine anti-racist interventions. Being able to identify racism is essential to being able to effectively counter racism.

Diabetes podiatry services for Maori in Aotearoa: a step in the right direction?

Maori with diabetes are at a 65% greater risk of amputation compared to non-Maori with diabetes. Despite evidence to support the role of podiatrists in reducing diabetes-related lower limb amputations; the effectiveness of diabetes podiatry services at the community and secondary level to achieve this for Maori is largely unknown. Diabetes podiatry services need to be reorientated and be culturally applicable to Indigenous communities. Transforming diabetes podiatry services and practice may reduce Indigenous amputation rates and improve quality of life for an unserved community.

Institutional racism in public health contracting: Findings of a nationwide survey from New Zealand.

Public institutions within New Zealand have long been accused of mono-culturalism and institutional racism. This study sought to identify inconsistencies and bias by comparing government funded contracting processes for Maori public health providers (n = 60) with those of generic providers (n = 90). Qualitative and quantitative data were collected (November 2014-May 2015), through a nationwide telephone survey of public health providers, achieving a 75% response rate. Descriptive statistical analyses were applied to quantitative responses and an inductive approach was taken to analyse data from open-ended responses in the survey domains of relationships with portfolio contract managers, contracting and funding. The quantitative data showed four sites of statistically significant variation: length of contracts, intensity of monitoring, compliance costs and frequency of auditing. Non-significant data involved access to discretionary funding and cost of living adjustments, the frequency of monitoring, access to Crown (government) funders and representation on advisory groups. The qualitative material showed disparate provider experiences, dependent on individual portfolio managers, with nuanced differences between generic and Maori providers' experiences. This study showed that monitoring government performance through a nationwide survey was an innovative way to identify sites of institutional racism. In a policy context where health equity is a key directive to the health sector, this study suggests there is scope for New Zealand health funders to improve their contracting practices.