Experiences of whanau/families when injured children are admitted to hospital: a multi-ethnic qualitative study from Aotearoa/New Zealand

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Experiences of whanau/families when injured children are admitted to hospital: a multi-ethnic qualitative study from Aotearoa/New Zealand
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   PLEASE SCROLL DOWN FOR ARTICLE This article was downloaded by: [University of Auckland]  On: 7 April 2009  Access details: Access Details: [subscription number 907452848]  Publisher Routledge  Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House,37-41 Mortimer Street, London W1T 3JH, UK Ethnicity Health Publication details, including instructions for authors and subscription information:http://www.informaworld.com/smpp/title~content=t713421971 Experiences of whnau/families when injured children are admitted to hospital: amulti-ethnic qualitative study from Aotearoa/New Zealand Brooke Arlidge a ; Sally Abel b ; Lanuola Asiasiga b ; Sharon L. Milne b ; Sue Crengle a ; Shanthi N. Ameratunga ca  Te Kupenga Hauora Maori (Department of Maori Health), School of Population Health, University ofAuckland, Auckland, New Zealand b  (Former) Department of Maori & Pacific Health, Faculty of Medical &Health Sciences, University of Auckland, Auckland, New Zealand c  Section of Epidemiology & Biostatistics,School of Population Health, University of Auckland, Auckland, New ZealandFirst Published:April2009 To cite this Article  Arlidge, Brooke, Abel, Sally, Asiasiga, Lanuola, Milne, Sharon L., Crengle, Sue and Ameratunga, ShanthiN.(2009)'Experiences of whnau/families when injured children are admitted to hospital: a multi-ethnic qualitative study fromAotearoa/New Zealand',Ethnicity & Health,14:2,169 — 183 To link to this Article: DOI: 10.1080/13557850802307791 URL: http://dx.doi.org/10.1080/13557850802307791 Full terms and conditions of use: http://www.informaworld.com/terms-and-conditions-of-access.pdfThis article may be used for research, teaching and private study purposes. Any substantial orsystematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply ordistribution in any form to anyone is expressly forbidden.The publisher does not give any warranty express or implied or make any representation that the contentswill be complete or accurate or up to date. The accuracy of any instructions, formulae and drug dosesshould be independently verified with primary sources. The publisher shall not be liable for any loss,actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directlyor indirectly in connection with or arising out of the use of this material.  Experiences of wha¯nau/families when injured children are admitted tohospital: a multi-ethnic qualitative study from Aotearoa/New Zealand Brooke Arlidge a , Sally Abel b , Lanuola Asiasiga b , Sharon L. Milne b ,Sue Crengle a , & Shanthi N. Ameratunga c, * a Te Kupenga Hauora Ma¯ ori (Department of Ma¯ ori Health), School of Population Health,University of Auckland, Auckland, New Zealand;  b (Former) Department of Maori & PacificHealth, Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand; c Section of Epidemiology & Biostatistics, School of Population Health, University of Auckland,Auckland, New Zealand (Received 22 September 2007; final version received 16 June 2008) Objectives.  Several quantitative studies in the international literature havedescribed disparities in the provision of and access to health services for a varietyof health conditions among ‘minority’ populations. This New Zealand qualitativestudy aimed to explore and describe the experiences of indigenous Ma¯ori andPacific families (both minority populations) and Pa¯keha¯ (New ZealandEuropean) families when their children were admitted to hospital for anunintended injury. Design.  Twenty-three children (eight Ma¯ori, eight Pacific and seven Pa¯keha¯) whowere admitted to hospital following an injury were selected using maximumvariation sampling from a trauma database and snowball sampling. In-depthindividual and group interviews undertaken with the child’s wha¯nau/familyexplored the issues they encountered in the hospital setting. The data wereanalysed by key ideas and coded into main themes. Each strand was analysedseparately by lead researchers of the same ethnic group prior to a comparativesynthesis of the overall findings. Results.  While many families praised the dedication of the staff, the interviewsrevealed important concerns regarding their encounters with hospitals and relatedhealth and support services. These could be broadly characterised as (a)inadequate communication and information; (b) difficulties negotiating anenvironment perceived as foreign; (c) the stress of conflicting demands placedon families; and (d) issues relating to ethnicity and cultural miscommunication.Of note, many Ma¯ori and Pacific wha¯nau/families felt particularly alienatedwithin the hospital setting and did not appear to see themselves as being entitledto high-quality information or services. Conclusion.  The findings have important implications for the structure, profes-sional and institutional practices in the delivery of health services. The researchalso indicates the need for wider societal policies that increase Ma¯ori and Pacificwha¯nau/families’ sense of entitlement to the full range of available supportservices, and reduce alienation within public institutions such as hospitals. Keywords:  injury; child; New Zealand; ethnic groups; Ma¯ori; Pacific; quality of healthcare; hospitalisation; cultural diversity; communication*Corresponding author. Email: s.ameratunga@auckland.ac.nz ISSN 1355-7858 print/ISSN 1465-3419 online # 2009 Taylor & FrancisDOI: 10.1080/13557850802307791http://www.informaworld.com Ethnicity & Health Vol. 14, No. 2, April 2009, 169    183  D o w nl o ad ed  B y : [ U ni v e r si t y  of  A u ckl a nd]  A t : 23 :37 7  A p ril 2009  Introduction Each year, unintentional injuries result in almost 14,000 hospital admissions andapproximately 100 fatalities (i.e., about 40% of deaths) among New Zealand childrenaged one to 14 years (Ministry of Health (NZ) 2004). Childhood injury death ratesare considerably higher than those in most other ‘rich nations’ (UNICEF InnocentiResearch Centre 2007). Furthermore, children of Ma¯ori or Pacific ethnicity, andthose from low-income families bear a disproportionately high burden of injury(Shaw  et al  . 2005, Stephen  et al  . 2005). Despite these acknowledged disparities in theoccurrence of significant injuries, little is known about the experiences of injuredchildren or their families.Ma¯ori, the indigenous population, and Pacific peoples, a diverse group who overgenerations have migrated from the various parts of the Pacific region, are minoritypopulations in New Zealand. In 2006, of the four million people residing in NewZealand, 15% were Ma¯ori, 7% were Pacific peoples and 67% were Pa¯keha¯ (NewZealand European) (Statistics New Zealand 2006). Both Ma¯ori and Pacificpopulations are positioned on the margins of the dominant European society, theformer as a consequence of colonisation and the latter due to its low socio-economicmigrant status. The marginalising impact of over 165 years of European colonisationincluding significant loss of land and language has resulted in profoundly negativesocial, cultural, economic and health consequences for Ma¯ori (Durie 1998). Pacificpeoples, primarily from Samoa, Tonga, Cook Islands and Niue, whose peakmigration occurred in the 1960s and 1970s in response to a need for manual labour,struggled economically, particularly following major economic restructuring in the1980s (Statistics New Zealand and Ministry of Pacific Island Affairs 2002). Despitesome educational, social and economic gains in recent times for these populations,both remain disproportionately represented in the lower socio-economic groups andthe health inequalities between them and Pa¯keha¯ remain marked (Ajwani  et al  . 2003,Jensen  et al  . 2006). Rates of unintentional childhood injury are no exception.The social inequities and disproportionately higher representation of Ma¯ori andPacific children among injury hospitalisations and among low-income families(Ministry of Health and Ministry of Pacific Island Affairs (NZ) 2004, Ministry of Health (NZ) 2006) also suggest that their experiences may be qualitatively andquantitatively different from those of other New Zealand families. Yet, apart from afew studies that have explored the concepts and perceptions relating to unintentionalinjuries among Ma¯ori and a Samoan community (Kudos Organisational DynamicsLtd. 1998, Broughton 1999), there is a dearth of information regarding the impact of injuries and hospitalisations on the wha¯nau/families of injured New Zealandchildren.Research conducted overseas has identified significant levels of psychologicaldistress among affected children and their families during and after hospitalisationfor an injury (Landolt  et al  . 1998, de Vries  et al  . 1999, Winston  et al  . 2002). A fewstudies have also explored the qualitative experiences of families whose childrenreceive hospital care (Aitken  et al  . 2004, Stratton 2004). Aitken  et al. ’s US study usedfocus groups to explore the perspectives of mothers of injured children admitted to atertiary care children’s hospital. Despite reporting a high level of overall satisfactionwith care, these families expressed major concerns regarding communication in thehospital setting, difficulties with access to care, and problems in negotiating170  B. Arlidge  et al.  D o w nl o ad ed  B y : [ U ni v e r si t y  of  A u ckl a nd]  A t : 23 :37 7  A p ril 2009  transitions across different medical services within hospital, and from hospital to thecommunity setting. The caregivers reported significant emotional, financial andsocial stressors, difficulties that often preceded the discharge from hospital.The considerable family disruptions surrounding the time shortly after dischargefrom the hospital or rehabilitation setting ‘when responsibility shifts from profes-sional care givers to family members’ have led some authors to call this phase ‘thesecond crisis of injury’ (Lash and Scarpino 1993). A study from the US found that38% of families with a child hospitalised for unintentional injury experienced at leastone work or financial problem six months after discharge (Osberg  et al  . 1996).Importantly, even families whose children had been hospitalised for only a day for aminor injury reported substantial difficulties.We found no studies exploring ethnic differences in families’ experiences of hospitalisation for childhood injury. However, a number of studies have documentedethnic disparities in children’s general healthcare (Flores 1999, Weech-Maldonado  etal  . 2001, Stevens and Shi 2003, Stevens  et al  . 2003). Weech-Maldonado  et al  . (2001)found that Asian, black and Hispanic parents in six US states reported lower ratingsthan whites for many features of paediatric primary healthcare (e.g., access to care,timeliness of care, provider communication, staff helpfulness). Stevens and Shi(2002) found that, even after controlling for demographics, socio-economic statusvariables, and health system characteristics, minority children in the primary caresetting experienced poorer quality of care across a number of domains comparedwith white children.We use this paper to present information gathered from a qualitative study toexplore the experiences of Ma¯ori, Pacific and Pa¯keha¯ families when their childrenwere admitted to hospital for an unintended injury. We describe and discuss the keyissues encountered by these families in the hospital setting and make recommenda-tions to improve health services and policy. This work is part of a larger projectexploring the perceptions of injured children, their families, and health serviceproviders to better understand the social impact as well as the circumstances andissues that assist and/or hinder recovery following injury. Methods Like other indigenous and ethnic minority groups throughout the western world,Ma¯ori and Pacific peoples in New Zealand have felt disempowered and fatigued bybeing the objects of research where they have had no control, have feltmisrepresented and have seen no beneficial outcomes (Smith 1999). Importantaims for this project were that culturally appropriate processes were employed toensure participation was safe for families, data were interpreted appropriately andfindings were used to advance improvements in health service delivery and healthoutcomes for these populations.In accord with the multi-ethnic nature of the project the principal investigatorteam, which consulted, designed, sought funding for and oversaw the project,comprised Ma¯ori, Pacific, Pa¯keha¯ and Asian senior researchers. A project steeringgroup with a wide range of expertise, including cultural, was established at the outsetand cultural issues was a key domain on which the investigator team sought advice.Once funding was confirmed, a lead researcher and at least one research assistantfrom each of the three main ethnic groups were appointed to ensure cultural Ethnicity & Health  171  D o w nl o ad ed  B y : [ U ni v e r si t y  of  A u ckl a nd]  A t : 23 :37 7  A p ril 2009  consonance between the researcher and participant families and the option forMa¯ori and Pacific families to be interviewed in their own language. The co-authorsof this paper comprise the lead researchers and some of the principal investigatorteam, representing the major ethnic groups in the study.Qualitative research methods, using in-depth individual or group interviews withthe child’s wha¯nau/family, were chosen for this study to capture the richness of thepossible data in the most natural and unobtrusive manner (Patton 1990). Thisapproach was considered most appropriate and empowering for Ma¯ori and Pacificfamilies as it enabled them to raise unprompted issues and concerns and describetheir experiences in their own voice (Moewaka Barnes 2000). The study wasapproved by the Auckland Regional Ethics Committee and all participants providedinformed written consent. Setting and sampling procedure The study was conducted in two hospitals in the Auckland region and focussed onchildren admitted following an unintentional injury. The aim of the sampling processwas to select eight children (aged less than 15 years) in each of the following groups:Ma¯ori, Pacific, and Pa¯keha¯ or other ethnic groups. Children with head injuries, burnsand intentional injury were excluded because the complex issues associated with suchinjurieswerebeyondthescopeofthisinvestigation.Childrenunderfivewhohadfallenat home were also excluded due to a concurrent study focusing on this group.Using maximum variation sampling (Patton 1990), children were selected fromthe hospital trauma database of admissions in 2001 to include a range with respect togender, ages (pre-school, middle and adolescent age groups), lengths of hospital stay,and time since the injury.The initial recruitment method included sending letters to any potential familiesinviting them to participate in the study. These letters were followed up by a phonecall about four days later. Because of a poor response from Ma¯ori and Pacificinformants using that method of recruitment, snowball sampling was introduced as amore appropriate method until numbers were reached. Although there was a slightimprovement using this technique, engagement of Ma¯ori wha¯nau and Pacificfamilies was still slow causing a significant delay in the project.Between October 2001 and October 2002, the families of eight Ma¯ori, eightPacific Island (including Samoan, Niuean, Cook Island and Tongan families), sevenPa¯keha and one Indian family were recruited and interviewed. The analyses in thispaper are limited to the Ma¯ori, Pacific and Pa¯keha¯ families     three of the majorethnic groups in New Zealand. Interview process An in-depth individual or group family interview was undertaken at home withthe child’s wha¯nau/family to explore relevant issues and experiences. Twelveinterviews involved only mothers although in some cases other family memberswere around, one involved only the caregiver grandmother, nine involved bothparents and one involved both parents and a grandmother. In most cases theinjured child and occasionally siblings were present for some of the session. Theinterview schedule was developed from discussions with steering group members172  B. Arlidge  et al.  D o w nl o ad ed  B y : [ U ni v e r si t y  of  A u ckl a nd]  A t : 23 :37 7  A p ril 2009
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